Inspection Reports for Oakwood Place at Ridgecrest Village
4130 Northwest Blvd., Davenport, IA, 52806
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 21, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to medication administration, staff training, and documentation, with substantiated complaints regarding failures in these areas. Prior reports also noted issues with staffing levels, individualized service plans, and food safety training, along with some concerns about building cleanliness. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed previous issues, as the latest inspection did not identify any regulatory insufficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
37 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to investigate Incident #129120-I at the assisted living facility.
Complaint Details
Investigation of Incident #129120-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #129120-I.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
The inspection was conducted related to the investigation of Complaint #127859-C concerning medication administration and related care practices at Oakwood Place at Ridgecrest Village.
Complaint Details
Investigation of Complaint #127859-C revealed failures in medication administration and documentation for tenants receiving insulin and blood glucose monitoring. The complaint was substantiated based on interviews and record reviews.
Findings
The program failed to administer medications and treatments as ordered for 4 tenants receiving staff assistance with blood glucose monitoring and insulin administration. Documentation and nurse notification regarding blood glucose levels outside ordered parameters were lacking. Staff delegation and training deficiencies were also noted.
Deficiencies (2)
Program failed to administer medications and treatments as ordered for tenants receiving assistance with blood glucose monitoring and insulin administration.
Failure to ensure staff provided services in accordance with training, including blood glucose readings outside ordered parameters and lack of nurse notification.
Report Facts
Number of tenants without cognitive impairment: 37
Number of tenants with cognitive impairment: 2
Total census: 39
Number of tenants reviewed for medication administration: 4
Entries of blood glucose levels outside parameters: 8
Entries of blood glucose levels outside parameters: 9
Entries of blood glucose levels outside parameters: 6
Inspection Report
Renewal
Census: 35
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The recertification visit was conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 9
Date: May 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#102287-C) and a recertification visit to determine compliance with certification for an Assisted Living Program.
Complaint Details
The inspection was triggered by Complaint #102287-C, which led to the identification of multiple regulatory insufficiencies related to medication administration and staffing.
Findings
The Program failed to administer medications as prescribed for multiple tenants, lacked sufficient trained staff especially on third shift for medication administration, failed to provide timely nurse delegation training and training on activities of daily living and service plan tasks, did not provide services in accordance with training, had incomplete individualized service plans, failed to provide food safety training to staff handling food, and failed to maintain a clean and sanitary building.
Deficiencies (9)
Failed to administer medications as ordered for 2 of 3 current tenants and 1 of 3 discharged tenants.
Failed to provide sufficient trained staff at all times to meet tenants' needs, including medication administration on third shift.
Failed to provide nurse delegation training within 30 days of employment for 1 of 4 staff hired in the last six months.
Failed to provide training on activities of daily living for 2 of 2 non-certified staff reviewed.
Failed to provide nurse delegated training on service plan tasks including wound care for 2 of 2 staff reviewed.
Failed to provide services in accordance with training for 1 of 1 staff observed passing medications.
Failed to develop individualized service plans reflecting identified needs for 1 of 3 tenants reviewed.
Failed to provide orientation on safe food handling and annual in-service training on food safety for 6 of 6 staff reviewed.
Failed to maintain a clean and sanitary building, including stained carpet, full garbage, soiled floors, cabinets, sink, and dirty serving carts in beverage/serving area.
Report Facts
Census: 35
Tenants affected by medication administration issues: 3
Tenants affected by staffing issues: 24
Staff reviewed for nurse delegation training: 4
Non-certified staff reviewed for ADL training: 2
Staff reviewed for nurse delegated training on service plan tasks: 2
Staff reviewed for food safety training: 6
Tenants reviewed for individualized service plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Interviewed about lack of medication passer on third shift. | |
| Staff I | Interviewed about frequent absence of medication passer on third shift. | |
| Staff F | Staff hired 12/6/22 who did not receive nurse delegation training within 30 days. | |
| Staff A | Non-certified staff lacking complete ADL training and food safety training. | |
| Staff D | Non-certified staff lacking complete ADL training and food safety training. | |
| Staff B | Certified medication aide lacking nurse delegated training on wound care; lacked food safety training; reported beverage area cleanliness issues. | |
| Staff E | Certified medication aide lacking nurse delegated training on wound care; lacked food safety training. | |
| Staff G | Certified Medication Aide | Observed medication pass with improper procedures and failure to sign off medications timely. |
| Assisted Living Director | Interviewed multiple times confirming findings and training deficiencies. |
Inspection Report
Original Licensing
Census: 37
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
The inspection was conducted as an initial certification to determine compliance with certification rules for an Assisted Living Program, including an onsite infection control survey.
Findings
No regulatory insufficiencies were cited during the onsite infection control survey or the initial certification inspection for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 3
Total census: 37
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