Inspection Reports for
Edencrest at Riverwoods
2210 E Park Ave, Des Moines, IA 50320, United States, IA, 50320
Back to Facility Profile9 Reports
Inspection Report — Oct 23, 2025
Complaint Investigation
Date: Oct 23, 2025
Visit Reason
Investigation of Complaint #130070-C at Edencrest at Riverwoods Assisted Living.
Complaint Details
Complaint #130070-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Inspection Report — Jul 1, 2025
Complaint Investigation
Date: Jul 1, 2025
Visit Reason
Investigation of Incident #128683-I at Edencrest at Riverwoods Assisted Living.
Complaint Details
Investigation of Incident #128683-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive impairment: 15
Number of tenants with cognitive impairment: 19
Inspection Report — Nov 5, 2024
Plan of Correction
Date: Nov 5, 2024
Visit Reason
The visit was conducted to investigate Complaint #118332-C and Incident #124286-I and to perform the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
Complaint #118332-C and Incident #124286-I were investigated with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the complaint investigation and recertification visit.
Report Facts
Number of tenants without cognitive impairment: 11
Number of tenants with cognitive impairment: 18
Inspection Report — Nov 9, 2023
Complaint Investigation
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#116084-C and #116567-C) regarding medication administration and staff training at Edencrest at Riverwoods Assisted Living.
Complaint Details
The investigation involved complaints #116084-C and #116567-C. No regulatory insufficiencies were found for complaints #112126-C, 112550-C, 113739-C, and 116291-C. The deficiencies cited were related to medication administration and staff training issues.
Findings
The program failed to consistently implement medication policies, including missing narcotic count documentation and failure to ensure medications were administered by properly trained staff. Additionally, staff did not consistently receive required training within specified timeframes, including dementia-specific education and dependent adult abuse training.
Violations (6)
Failed to consistently implement medication policy; missing narcotic sheet documentation for 9/28/23-10/4/23.
Medications were not consistently administered by staff who had completed department-approved medication aide/manager training.
Failed to ensure tenants received medications as ordered; missing staff initials on medication administration records for multiple dates.
Failed to ensure staff received training by the Program's Registered Nurse within 30 days of employment.
Failed to ensure staff received required Dependent Adult Abuse training as mandated by Iowa Code section 235B.16.
Failed to ensure staff received eight hours of dementia-specific education and training within 30 days of employment.
Report Facts
Number of tenants without cognitive impairment: 19
Number of tenants with cognitive impairment: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to receive nurse delegation training within 30 days and lacked required Dependent Adult Abuse training. | |
| Staff B | Did not complete eight hours of dementia-specific training within 30 days of employment. | |
| Staff C | Lacked documentation of department-approved medication training and dementia-specific training. | |
| Staff D | Lacked documentation of department-approved medication training and dementia-specific training. |
Inspection Report — Jan 4, 2023
Complaint Investigation
Date: Jan 4, 2023
Visit Reason
Investigation of Complaint #109893-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #109893-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 20
Inspection Report — Sep 29, 2022
Renewal
Date: Sep 29, 2022
Visit Reason
The visit was a recertification survey to determine compliance with certification of an Assisted Living Program for People with Dementia and to investigate several incidents and complaints.
Findings
No regulatory insufficiencies were cited during the recertification visit or during the investigation of the specified incidents and complaints.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 26
Number of tenants with cognitive disorder in General Population Program: 8
Number of tenants with cognitive disorder in Memory Care Unit: 9
Inspection Report — Sep 16, 2020
Complaint Investigation
Date: Sep 16, 2020
Visit Reason
The inspection was conducted to investigate complaints #92422-C and #93117-C and to perform an onsite infection control survey.
Complaint Details
Investigation of Complaints #92422-C and #93117-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints or the infection control survey.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 28
Number of tenants with cognitive disorder in General Population Program: 4
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 15
Inspection Report — Jul 21, 2020
Complaint Investigation
Date: Jul 21, 2020
Visit Reason
The visit was conducted as an investigation of multiple complaints and an incident, as well as an onsite infection control survey.
Complaint Details
Investigation of Complaints #89228-C, 89358-C, 89869-C, 91770-C and Incident #91920-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies or deficiencies were cited during the investigation of complaints or the infection control survey.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 24
Number of tenants with cognitive disorder in General Population Program: 6
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 13
Inspection Report — Feb 10, 2020
Complaint Investigation
Date: Feb 10, 2020
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program and during investigations of Complaint #88316-C and Complaint #88429-C.
Complaint Details
The visit was triggered by complaints #88316-C and #88429-C. The report documents multiple regulatory insufficiencies related to tenant rights, staffing, nurse delegation, service plans, nurse review, food service, activities, and structural requirements. Substantiation status is not explicitly stated.
Findings
The facility failed to provide adequate and appropriate care, treatment, and services to tenants, particularly in the dementia unit. Deficiencies included failure to engage tenants, inadequate assistance with meals and toileting, insufficient staffing, poor infection control practices, failure to provide appropriate service plans, and failure to maintain cleanliness and sanitation in the memory care unit.
Violations (9)
Failure to provide adequate and appropriate care, treatment, and services to tenants in the dementia unit, including failure to engage tenants and assist with meals and toileting.
Insufficient staffing to meet tenants' needs, including failure to provide a sufficient number of trained staff at all times.
Failure to provide services in accordance with nurse delegation training, including improper medication administration and hand hygiene.
Failure to develop individualized service plans indicating tenants' identified needs and preferences.
Failure to conduct nurse reviews for tenants with significant changes in condition and refusals of care.
Failure to provide 100% of the daily recommended dietary allowances for three meals served per day, including failure to provide milk and appropriate food choices.
Failure to meet standards of state and local health laws for food service preparation and service, including cleanliness of food contact surfaces.
Failure to provide appropriate activities for each tenant, including failure to engage tenants in scheduled activities.
Failure to maintain buildings and grounds in a clean, safe, and sanitary condition, including failure to ensure furniture was clean and free of urine odor in the dementia unit.
Report Facts
Number of tenants without cognitive disorder in general population: 23
Number of tenants with cognitive disorder in general population: 6
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 12
Number of tenants affected by care deficiencies: 8
Number of tenants in memory care unit: 12
Number of staff reviewed for nurse delegation: 6
Number of tenants reviewed for service plans: 6
Number of meals per day required to meet dietary allowances: 3
Number of tenants affected by food service deficiencies: 12
Number of scheduled activities per day: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Hildreth | Monitor | Named as monitor for the Plan of Correction |
| Staff C | Involved in multiple findings including failure to engage tenants, medication administration errors, and infection control breaches | |
| Staff I | Failed to appropriately engage tenants and assist with toileting | |
| Health Care Coordinator | HCC | Involved in observations and interviews regarding tenant care and staffing |
| Assistant Manager | Failed to offer appropriate encouragement or assistance during lunch | |
| Manager | Confirmed staffing needs and furniture replacement | |
| Clinical Quality Manager | Confirmed need for more staff and schedule updates | |
| Staff A | Interviewed regarding staffing and tenant care | |
| Staff B | Interviewed regarding staffing and tenant care | |
| Staff E | Involved in tenant care and observations | |
| Staff F | Involved in tenant care and observations | |
| Staff G | Observed medication administration and interviewed | |
| Staff H | Observed tenant care | |
| Staff D | Confirmed tenant care observations | |
| Life Enrichment Coordinator | Responsible for activities and engagement | |
| Culinary Coordinator | Responsible for food service and menu planning |
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