Inspection Reports for Edencrest at Riverwoods
2210 E Park Ave, Des Moines, IA 50320, USA, IA, 50320
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Oct 23, 2025
Visit Reason
Investigation of Complaint #130070-C at Edencrest at Riverwoods Assisted Living.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #130070-C was investigated and found to have no regulatory insufficiencies.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Jul 1, 2025
Visit Reason
Investigation of Incident #128683-I at Edencrest at Riverwoods Assisted Living.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #128683-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 15
Number of tenants with cognitive impairment: 19
Total census: 34
Inspection Report
Plan of Correction
Census: 29
Deficiencies: 0
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.
Findings
No regulatory insufficiencies were cited during the complaint investigation and recertification visit.
Complaint Details
Complaint #118332-C and Incident #124286-I were investigated with no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive impairment: 11
Number of tenants with cognitive impairment: 18
Total census: 29
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 6
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.
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.
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.
Deficiencies (6)
| Description |
|---|
| 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
Total census: 38
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
Complaint Investigation
Census: 42
Deficiencies: 0
Jan 4, 2023
Visit Reason
Investigation of Complaint #109893-C regarding the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #109893-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 20
Total census: 42
Inspection Report
Renewal
Census: 43
Deficiencies: 0
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
Total census of Assisted Living Program for People with Dementia: 43
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
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.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints or the infection control survey.
Complaint Details
Investigation of Complaints #92422-C and #93117-C found no regulatory insufficiencies.
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
Total census: 47
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
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.
Findings
No regulatory insufficiencies or deficiencies were cited during the investigation of complaints or the infection control survey.
Complaint Details
Investigation of Complaints #89228-C, 89358-C, 89869-C, 91770-C and Incident #91920-I found no regulatory insufficiencies.
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
Total census: 43
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 9
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.
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.
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.
Deficiencies (9)
| Description |
|---|
| 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
Total census of Assisted Living Program for People with Dementia: 41
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 |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
May 21, 2018
Visit Reason
The inspection was conducted as an investigation of Incident #75364 at Edencrest at Riverwoods Assisted Living.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #75364.
Complaint Details
Investigation of Incident #75364 with no regulatory insufficiencies cited.
Report Facts
Number of tenants without cognitive disorder: 5
Number of tenants with cognitive disorder: 14
Total population of Program at time of on-site: 41
Inspection Report
Renewal
Census: 39
Deficiencies: 0
Apr 16, 2018
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Dec 20, 2017
Visit Reason
Investigation of Complaint #72304 at Edencrest at Riverwoods Assisted Living.
Findings
No regulatory insufficiencies were cited during the investigation of Complaint #72304.
Complaint Details
Complaint #72304 was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population program: 7
Number of tenants with cognitive disorder in General Population program: 6
Total population of General Population program: 35
Number of tenants without cognitive disorder in Dementia-Specific program: 1
Number of tenants with cognitive disorder in Dementia-Specific program: 7
Total population of Dementia-Specific program: 8
Total census of Assisted Living Program: 43
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Aug 25, 2017
Visit Reason
Investigation of Incident #68449-I at Edencrest at Riverwoods Assisted Living.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #68449-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 14
Total Population of Program at time of on-site: 35
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Sep 14, 2016
Visit Reason
The inspection was conducted as an investigation of complaints #61478-C, #61708-C, and #62875-C related to regulatory insufficiencies in an assisted living program.
Findings
The investigation found multiple deficiencies including failure to consistently follow handwashing procedures, failure to ensure medications were administered as prescribed, and failure to respond to call lights in a timely manner.
Complaint Details
The visit was triggered by complaints #61478-C, #61708-C, and #62875-C. The report details observations and interviews supporting the substantiation of these complaints.
Deficiencies (3)
| Description |
|---|
| Facility staff failed to consistently follow handwashing procedures during care and medication administration. |
| Medications were not administered as prescribed by physicians, with discrepancies in medication administration records. |
| Program failed to ensure call lights were answered in a timely manner, with over 110 instances exceeding 15 minutes response time. |
Report Facts
Total census: 32
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 5
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 8
Instances of call light response times exceeding 15 minutes: 110
Instances of call light response times exceeding 30 minutes: 12
Medication administration days with discrepancies: 12
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Apr 21, 2016
Visit Reason
The inspection was conducted as a Final Recertification & Complaint/Incident Investigation Report following complaints regarding medications, structure, service plans, level of care, staffing, and food concerns at Edencrest at Riverwoods AL.
Findings
All allegations were found to be Not Substantiated. However, regulatory insufficiencies were cited related to program policies and procedures and service plans, specifically deficiencies in hand washing during medication administration and lack of person-centered planned and spontaneous activities in service plans.
Complaint Details
The complaint investigation involved allegations about medications being given late or not at all, concerns about the cleanliness and pets in the building, service plans related to TED hose and infections, level of care concerns, staffing issues, and food quality. All allegations were found Not Substantiated.
Deficiencies (2)
| Description |
|---|
| Program policies and procedures, including those for incident reports, were not followed, specifically hand washing protocols during medication administration. |
| Service plans for persons with dementia did not include a list of person-centered planned and spontaneous activities. |
Report Facts
Tenants without cognitive disorder: 33
Tenants with cognitive disorder: 3
Total Population of General Program: 36
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 8
Total Population of Dementia Program: 8
Total census: 44
Civil penalty amount: 500
Reduced civil penalty amount: 325
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to failure to follow hand washing procedures during medication administration | |
| Rose Boccella | Program Coordinator | Contact for questions and payment of civil penalty |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed demand letter |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Nov 4, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following an incident involving a tenant with dementia eloping from the facility.
Findings
The investigation found regulatory insufficiencies in service plans and structural requirements, specifically failure to develop adequate service plans for a tenant and failure to maintain a safe building, allowing a tenant to elope.
Complaint Details
Complaint Intake #: 55994-I. The complaint was substantiated as the program failed to maintain a safe building, allowing a tenant with dementia to elope.
Deficiencies (2)
| Description |
|---|
| Failure to develop service plans designed to meet the specific service needs of individual tenants. |
| Failure to maintain a safe building; the memory care unit door stayed unlocked for 30 seconds after staff left, allowing a tenant with dementia to elope. |
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Census: 35
Tenant count: 28
Tenant count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for questions regarding the letter and report. |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Oct 15, 2015
Visit Reason
The inspection was conducted as a final complaint/incident investigation following complaints #54768-C, #55226-C, #55463-C, and #55469-C regarding various allegations at Edencrest at Riverwoods AL.
Findings
The investigation found all allegations including staffing, tenant rights, food service, structure/life safety, level of care, nurse review, and service plans to be not substantiated. However, a regulatory insufficiency was noted related to tenant documents, specifically incomplete incident reports involving tenants and bed bugs.
Complaint Details
The complaint investigation involved multiple allegations including staffing, tenant rights, food service, structure/life safety, level of care, nurse review, and service plans. All allegations were found not substantiated except for a regulatory insufficiency in tenant documentation related to incident reports and bed bugs.
Deficiencies (1)
| Description |
|---|
| Incident reports involving tenants, including those related to medication errors, accidents, falls, and elopements, were not maintained as required, particularly regarding identification of tenants with bed bugs. |
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 27
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 8
Total Population of Program at time of on-site: 8
Total census of Assisted Living Program: 35
Number of tenants reviewed: 6
Number of open tenant files reviewed: 5
Number of closed tenant files reviewed: 1
Days to correct regulatory insufficiencies: 30
Days to submit Plan of Correction: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the final complaint/incident investigation report letter |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 5
Jun 17, 2015
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies found during a June 16-17, 2015 investigation at Edencrest at Riverwoods Assisted Living.
Findings
The facility was found to have regulatory insufficiencies in program policies and procedures, tenant documents, nurse review, food service, and structural requirements. The A-039 regulatory insufficiency was dismissed after an informal conference. Deficiencies included improper insulin administration, failure to protect tenant records, incomplete nurse reviews, food service violations, and lack of keys for emergency exit.
Complaint Details
Complaint/Incident Intake #: 52410-C. The A-039 regulatory insufficiency related to two-person transfers was dismissed after review by the Independent Reviewer.
Deficiencies (5)
| Description |
|---|
| Program policies and procedures not followed, including insulin administration and transfer policy. |
| Tenant records were not protected from unauthorized use. |
| Nurse reviews were not completed at least every 90 days to assess and document tenant health status. |
| Food service standards were not followed, including improper food temperature monitoring and contamination risk. |
| Structural requirement not met: staff did not have keys to the courtyard gate for emergency exit. |
Report Facts
Total census: 28
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 5
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Laudick | R.N. | Facility participant who provided feedback and was interviewed regarding tenant care and transfers |
| Pat Hanson | Administrator | Attending for facility at informal conference |
| Cybil Hines | Nurse Care Consultant | Attending for facility at informal conference |
| Rose Boccella | Program Coordinator | Attending for Department of Inspections and Appeals |
| Staff A | Observed administering insulin and transferring Tenant #2, involved in deficiencies |
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 0
Oct 14, 2014
Visit Reason
The visit was conducted as a Final Initial Certification Monitoring Evaluation and Complaint/Incident Investigation following a complaint alleging a tenant eloped from the program and staff were not trained.
Findings
No regulatory insufficiencies were found during the evaluation. The complaint investigation determined that staff responded appropriately to door alarms and program policies were followed. Tenant and family satisfaction was generally positive.
Complaint Details
The complaint alleged a tenant eloped and staff were not trained. The investigation found staff responded to door alarms within the proper timeframe and followed program policies. No regulatory insufficiencies were noted.
Report Facts
Number of tenants without cognitive disorder: 6
Number of tenants with cognitive disorder: 1
Total census: 7
Number of tenants attending community meeting: 5
Tenant #1 age: 87
Tenant #2 age: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy E. Kuhse | RN, BS | Monitor conducting the complaint/incident investigation |
| Rose Boccella | Program Coordinator | Author of the certification monitoring evaluation and complaint/incident investigation report |
| Pam Elbert | Manager | Facility manager named in the report |
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