Inspection Reports for
River Valley Place of Fort Madison

Complaint #130319-C, #130358-C, #130378-C, #130354-C, #131042-C, #131152-C; Incident #130859-I

Multiple deficiencies were cited related to incident reporting, medication administration, tenant rights, staffing, and service plan updates. Tenant #9 was sent to the emergency room due to aggressive behavior without an incident report being timely completed. Medication administration errors and omissions affected several tenants including failure to follow hospice medication orders. Staffing was insufficient to meet tenant needs, including repositioning and timely response to call pendants. Several tenants were retained despite being bed-bound. Service plans were not updated timely or signed by tenants. Nurse reviews were not conducted after significant changes in tenant conditions.

Investigations #130319-C, 130358-C, 130354-C, 130378-C, 130859-I, 131042-C, 131152-C

The program failed to provide adequate care and services to six current tenants and one discharged tenant, including medication errors, inadequate wound care, delayed staff response to emergency pendants, poor hygiene and cleanliness, and failure to meet tenants' individual needs. These deficiencies resulted in harm such as hospitalizations, pain, and distress.

The investigation was triggered by complaints #129246-C and #129601-C. The findings included failure to follow physician orders, inadequate staffing, inappropriate admission and retention of an aggressive tenant, lack of nursing documentation, and failure to update service plans after significant changes.

The program failed to ensure physician's orders were carried out for 2 of 8 tenants reviewed, failed to provide sufficient trained staff to meet tenants' needs, admitted and retained a tenant with aggressive behaviors inappropriate for the setting, failed to document nurses' notes by exception for 3 tenants, and failed to update service plans for tenants with significant changes in condition.

Investigation into Incident #123909-I found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation into the incident.

The investigation into Complaint #122221-C found no regulatory insufficiencies. However, complaints #122222-C, #122012-C, and #121996-C resulted in a deficiency related to service plans not addressing housekeeping needs for Tenant C1.

No regulatory insufficiencies were found for Complaint #122221-C, but a deficiency was cited for failing to address housekeeping needs in the service plan for one discharged tenant (Tenant C1), whose apartment was frequently messy and disorganized.

The visit was complaint-related due to concerns about door alarm response failure leading to a tenant's death, tenant rights violations including unauthorized video recording and visitation restrictions, inadequate tenant evaluations and service plan updates, and missing legal documentation for a tenant.

The program failed to follow door alarm response protocols leading to a tenant's death, violated tenant rights including unauthorized video recording and visitation restrictions, failed to evaluate and update service plans for tenants with significant changes in condition, and lacked required legal documentation for a tenant. Nurse reviews were not conducted as required for multiple tenants.

The complaint investigation found no regulatory insufficiencies. The incident investigation revealed that a tenant exited the building unnoticed for approximately 13 minutes in cold weather, with staff failing to properly respond to door alarms and conduct required elopement drills. Staff interviews indicated lack of knowledge and failure to follow procedures. No staff were disciplined for the failure.

No regulatory insufficiencies were found related to Complaint #111818-C. However, deficiencies were cited for failure to follow established door alarm and elopement drill procedures for one tenant who eloped from the facility, resulting in a safety risk. The facility had not conducted quarterly elopement drills for seven months prior to the incident.

The program failed to conduct required quarterly elopement drills and did not properly respond to a door alarm, resulting in Tenant #1 leaving the building unattended for approximately 13 minutes in cold weather. Staff were not disciplined for failing to follow door alarm procedures, and reeducation and drills were conducted after the incident.

The investigation was triggered by complaints #107639-C and #106970-C. The program did not report suspected dependent adult abuse incidents on 8/2/22 and 8/17/22 and failed to complete required written reports within 48 hours after oral reports.

The program failed to report suspicions of dependent adult abuse for two tenants, did not properly store discontinued medications, and failed to ensure an operating alarm system was connected to the main exit door during specified hours.

The program failed to update service plans to reflect identified needs and preferences for assistance for 3 of 5 tenants reviewed, including issues with bathing assistance, verbal and physical aggression, and management of urinary tract infections and anxiety.