Inspection Reports for
River Valley Place of Ottumwa

Incident #131027-I and Complaint #131692-C were investigated during the visit with no regulatory insufficiencies cited related to them.

No regulatory insufficiencies were cited during the investigation of the incident and complaint. However, regulatory insufficiencies were cited during the recertification visit related to tenant evaluations, service plans, and nurse reviews.

Investigations included Complaints #130280-C, #130300-C, #130477-C, and #130567-C. The deficiency was related to Complaint #130567-C.

No regulatory insufficiencies were cited during the investigations of Complaints #130280-C, #130300-C, and #130477-C. One regulatory insufficiency was cited during the investigation of Complaint #130567-C related to failure to follow the dependent adult abuse reporting policy.

Investigation into Complaint #121772-C and Incident #121992-I found no regulatory insufficiencies. The revisit to Complaint #117180-C showed progress with no deficiencies cited.

No regulatory insufficiencies were cited during the investigation of Complaint #121772-C, Incident #121992-I, or the revisit related to Complaint #117180-C completed on 3/26/24.

The inspection was triggered by complaints #115373-C, #117180-C, and #117812-C; incidents #117537-I and #118762-I.

The program failed to ensure policies on dependent adult abuse reporting were consistent with Iowa Code, failed to follow established policies related to abuse reporting and medication management, failed to provide adequate care to several tenants, failed to secure medications properly, lacked sufficient staffing to meet tenant needs, and failed to complete required tenant evaluations and service plan updates. Additionally, tenant records for discharged tenants were not retained as required.

The program failed to follow established policies for reporting potential dependent adult abuse involving medication thefts from multiple tenants. Several incidents of missing medications, including narcotics, were documented and reported to police, but the program did not investigate or report these cases to the department as required.

The investigation involved complaints #111738-C, #112596-C, #113634-C, #112787-C, and #113694-C. No deficiencies were found for the first three complaints. Deficiencies were found related to complaints #112787-C and #113694-C. Specific issues included improper disposal of sharps and inadequate care and medication administration, including late medications and insufficient staffing.

No regulatory insufficiencies were found for complaints #111738-C, #112596-C, and #113634-C. However, regulatory insufficiencies were cited during the investigation of complaints #112787-C and #113694-C, including failure to follow policies on disposal of sharps and failure to provide adequate and appropriate care, treatment, and services to tenants.

The visit was complaint-related, investigating complaints #108559-C, #109456-C, and #109480-C. The report documents substantiated issues including failure to report incidents, insufficient staffing, and fire safety procedure failures.

The investigation found failures including not completing an incident report when a tenant left the building without staff knowledge, insufficient trained staff to meet tenant needs, failure to follow fire safety procedures, and inadequate response to tenant care needs such as missed showers and delayed assistance calls.

Complaints #108559-C, #109456-C and #109480-C

The program failed to ensure a sufficient number of trained staff were available at all times to meet the identified needs of Tenant C1, resulting in a fall during a transfer that contributed to the tenant's death.

The investigation was triggered by complaints #101853-C, #102323-C, #104971-C, #104803-C, and #106549-C. The findings confirmed multiple regulatory insufficiencies related to COVID-19 policy noncompliance, medication administration, staffing, tenant discharge criteria, and service plan development.

The program failed to follow its COVID-19 mask policy affecting all 24 tenants, failed to provide medical treatments as ordered for one tenant, lacked sufficient staffing to meet tenant needs in the memory care unit, failed to discharge tenants with dangerous behaviors, and failed to update and individualize service plans for tenants with complex needs.

The inspection found regulatory insufficiencies related to evaluation of tenants, service plans, and dementia-specific education for personnel. No deficiencies were cited during the onsite infection control survey or previous investigations.