Inspection Reports for River Valley Place of Fort Madison
5025 River Valley Road, Fort Madison, IA, 52627
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 11, 2025, identified deficiencies related to failure to follow physician’s orders, insufficient trained staffing, admission and retention of a tenant with aggressive behaviors, incomplete nursing documentation, and lack of updated service plans. Earlier inspections showed a pattern of similar issues, including service plan deficiencies, staffing concerns, and failure to follow policies related to tenant safety and rights. Complaint investigations were mostly substantiated when deficiencies were found, with notable concerns about tenant care, documentation, and safety protocols, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior complaint investigations often found unsubstantiated allegations, though some incidents involved tenant falls and medication errors. The inspection history indicates ongoing challenges with staffing and care plan management, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
26 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 5
Date: Aug 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies cited during the investigation of Complaint #129246-C and Complaint #129601-C at River Valley Place of Fort Madison.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failed to ensure physician's orders were carried out for 2 of 8 tenants reviewed (Tenant #4 and Tenant #5), including delays in medication administration and failure to assist with compression stockings.
Failed to provide sufficient trained staff to meet tenants' identified needs, resulting in missed showers, late medication administration, delayed response to call pendants, and inadequate care.
Admitted and retained a tenant (Tenant #2) displaying physical and verbal aggression, including threats, assaults on staff and tenants, and inappropriate behaviors.
Failed to document nurses' notes by exception for 3 tenants (Tenant #2, Tenant #5, Tenant #7) regarding hospital visits, incidents, and changes in condition.
Failed to update service plans for 3 current tenants (Tenant #2, Tenant #7, Tenant #3) and 1 discharged tenant (Tenant C1) after significant changes in condition, including aggressive behaviors, pain, mobility changes, and incontinence.
Report Facts
Total census: 26
Tenants without cognitive impairment: 21
Tenants with cognitive impairment: 5
Medication administration delays: 3
Bathing assistance missed: 6
Staffing ratio: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Reported issues with medication administration and lack of nurse presence; described Tenant #2's aggressive behaviors. | |
| Staff E | Reported lack of nurse presence, power outage affecting response time, and staffing shortages impacting care. | |
| Staff G | Recalled being glad Tenant #5 was starting antibiotic due to her condition. | |
| Vice President of Clinical Services | Provided information on nursing coverage and admitted Tenant #2 was appropriate based on assessments. | |
| Executive Director | Reported on nursing coverage, staffing, and communication issues; involved in adding orders to MAR. | |
| Staff A | Reported lack of awareness of urine sample order and limited nurse presence. | |
| Staff B | Reported delayed awareness of urine sample order. | |
| Staff C | Reported delayed awareness of urine sample order and communicated symptoms to Executive Director. | |
| Staff F | Reported Tenant #2 required multiple staff for toileting due to aggression. | |
| Regional Director of Operations | Confirmed findings and lack of nursing notes documentation. |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 5
Date: Aug 11, 2025
Visit Reason
The inspection was conducted as a result of investigations of Complaint #129246-C and Complaint #129601-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
The visit was complaint-related, investigating Complaint #129246-C and Complaint #129601-C.
Findings
The investigation found multiple deficiencies including failure to follow physician's medication orders for tenants, inadequate staffing affecting tenant care, admission and retention of a tenant with aggressive behaviors inappropriate for the setting, failure to document nursing notes by exception, and failure to update tenant service plans after significant changes in condition.
Deficiencies (5)
Failure to ensure physician's medication orders were carried out for 2 of 8 tenants reviewed, including delayed administration of antibiotics and failure to assist with compression stockings.
Insufficient number of trained staff to meet tenants' needs, resulting in missed showers, late medication administration, delayed response to call pendants, and inadequate housekeeping.
Admission and retention of a tenant displaying physical and verbal aggression requiring multiple emergency interventions and hospitalizations.
Failure to document nurses' notes by exception for 3 of 8 tenants reviewed, including lack of documentation of hospital visits and incidents.
Failure to update service plans for tenants after significant changes in condition, including behavioral issues, pain, mobility changes, and incontinence.
Report Facts
Tenant census: 26
Tenants with cognitive impairment: 5
Tenants without cognitive impairment: 21
Medication administration delays: 3
Bathing assistance completion: 6
Bathing assistance completion: 5
Shower assistance completion: 2
Shower assistance completion: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Reported issues with medication administration and staffing shortages affecting care | |
| Staff E | Reported lack of nurse presence and staffing shortages impacting tenant care | |
| Staff G | Recalled Tenant #5's antibiotic administration and condition | |
| Vice President of Clinical Services | Provided information on staffing and tenant care issues | |
| Executive Director | Involved in communication about medication orders and staffing | |
| Staff A | Interviewed regarding urine sample collection and staffing knowledge | |
| Staff B | Interviewed regarding urine sample collection | |
| Staff C | Interviewed regarding urine sample order awareness | |
| Staff F | Reported lack of nurse presence and staffing challenges | |
| Tenant #3's hospice nurse | Reported on Tenant #3's mobility status |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as an investigation into Incident #123909-I at the assisted living facility.
Complaint Details
Investigation into Incident #123909-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation into the incident.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 6
Total census: 26
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Sep 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (#122222-C, #122012-C, and #121996-C) regarding the facility's service plans and care.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The program failed to address the housekeeping needs in the service plan for 1 of 1 discharged tenants reviewed (Tenant C1), whose apartment was often messy and disorganized.
Report Facts
Number of tenants without cognitive impairment: 17
Number of tenants with cognitive impairment: 16
Total census: 33
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
Date: May 23, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to follow door alarm response policy, tenant rights violations, inadequate evaluations and service plan updates for tenants, and missing legal documentation for a tenant.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Failed to follow established policy regarding door alarm response affecting a discharged tenant.
Failed to ensure 3 of 5 tenants were treated with dignity and autonomy, including unauthorized video recording and improper visitation restrictions.
Failed to evaluate needs of tenants with significant changes, including a discharged tenant who experienced multiple health declines.
Failed to obtain legal documents for 1 of 5 tenants reviewed.
Failed to update service plans for tenants with significant changes, including hospice admission and increased care needs.
Failed to list identified needs and interventions in service plans, including tenant medication refusal and toileting needs.
Failed to conduct nurse reviews as required for tenants receiving medication and with significant condition changes.
Report Facts
Total census: 35
Medication refusal days: 13
Medication refusal days: 11
Medication refusal days: 18
Medication refusal days: 21
Medication refusal days: 13
Medication refusal days: 12
Falls: 2
Completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in findings for unauthorized video recording and agitating tenants | |
| Staff J | Involved in door alarm incident response | |
| Staff A | Reported on door alarm issues and tenant C1 incident | |
| Staff B | Witnessed tenant C1 condition and reported on tenant #2 toileting issues | |
| Staff C | Reported on door alarm and tenant #2 toileting issues | |
| Staff D | Reported concerns about staff interaction with tenants and tenant #2 toileting | |
| Staff E | Recalled Staff F's behavior and tenant medication refusal | |
| Staff G | Witnessed video involving tenants | |
| Staff H | Involved in tenant pendant removal and staff interaction concerns | |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Involved in tenant assessments, medication administration, and confirming findings |
| Executive Director | Executive Director | Confirmed visitation restrictions and staff education |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The inspection was conducted to investigate Complaint #111818-C and Incident #111565-I involving the assisted living program's compliance with policies and procedures related to door alarms and elopement drills.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow established policies and procedures for door alarms and elopement drills for one tenant who eloped from the facility.
Report Facts
Number of tenants without cognitive impairment: 32
Number of tenants with cognitive impairment: 8
Total census: 40
Temperature outside during elopement: 29
Duration tenant was outside: 13
Months without quarterly elopement drills: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Assistant | Named in failure to respond to door alarm and lack of knowledge of procedures |
| Staff B | Mentioned in employee investigation but no interview available | |
| Staff C | Mentioned in employee investigation but no interview available |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Jan 24, 2023
Visit Reason
The inspection was conducted as an investigation into complaints #107639-C and #106970-C regarding suspected dependent adult abuse and other regulatory concerns at the assisted living program.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to report suspicion of dependent adult abuse for 2 of 8 tenants reviewed.
Failed to properly store discontinued medication; medications were found unsecured.
Failed to ensure an operating alarm system was connected to the main exit door from 6:00 AM to 8:00 PM.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 8
Total census: 43
Missing cash amount: 4000
Missing check amount: 400
Petty cash discrepancy: 45
Dates alarm system was not operating: From 8/1/22 through 1/23/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named as suspected individual responsible for stealing Tenant #1's money | |
| Director | Current Director | Reported abuse suspicions and confirmed findings on 1/23/23 |
| Regional Director of Sales and Operations | Interviewed employees regarding missing funds | |
| Former Director | Aware of Tenant #1's report and suspected Staff A | |
| Former LPN | Reported access to HCC's desk and medication storage issues | |
| Health Care Coordinator | Former HCC | Had locked desk with discontinued medications |
| Regional Nurse Specialist | Reported medication cards found unsecured and accessed alarm system reports | |
| Staff B | Reported main exit door locked at 10:00 PM and lack of alerts | |
| Staff C | Reported main exit door unlocked from 6:00 AM to 10:00 PM without notifications | |
| Maintenance Supervisor | Reported alarm system was disabled between Feb and Oct 2022 and reset it on 1/23/23 |
Inspection Report
Renewal
Census: 41
Deficiencies: 1
Date: May 2, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
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.
Deficiencies (1)
The service plan was not individualized to reflect tenant needs and preferences for assistance, including failure to update plans for bathing refusals, aggression interventions, and anxiety management.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 2
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total Census: 41
Service plan review: 5
Service plan deficiencies: 3
Paging calls for assistance: 181
Paging calls for assistance: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Leis L. Morrison | Director | Signed the report |
Inspection Report
Renewal
Census: 33
Deficiencies: 0
Date: Oct 3, 2018
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit, indicating compliance with certification rules.
Report Facts
Number of tenants without cognitive disorder in general population: 26
Number of tenants with cognitive disorder in general population: 1
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 6
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Jun 12, 2018
Visit Reason
Investigation of Complaint #75542-C at Sunnybrook of Fort Madison.
Complaint Details
Investigation of Complaint #75542-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 29
Number of tenants with cognitive disorder in General Population: 1
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 6
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Nov 1, 2017
Visit Reason
Investigation of Complaint #70146-C at the assisted living facility.
Complaint Details
Complaint #70146-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 25
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 27
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: 35
Inspection Report
Renewal
Census: 35
Deficiencies: 3
Date: Oct 18, 2016
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
The program failed to meet requirements related to criminal background checks for employment, service plans not updated or signed properly, and occupancy agreements not signed prior to occupancy. Several deficiencies were noted regarding record checks, service plans, and policy adherence.
Deficiencies (3)
Failure to complete proper criminal background checks prior to employment for one staff member.
Failure to update service plans as tenant needs changed, including wound care and treatment.
Failure to develop and sign preliminary service plans prior to tenant occupancy.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 8
Total census: 35
Number of staff reviewed for background checks: 5
Stage II pressure ulcer size: 2
Antibiotic order frequency: 4
Antibiotic order duration: 10
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Mar 4, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations related to staffing at Sunnybrook of Fort Madison.
Complaint Details
Allegation: Staffing. Findings: Unsubstantiated. Tenant files and staff interviews indicated adequate nurse availability and on-call coverage.
Findings
The allegation of staffing issues was found to be unsubstantiated after review of tenant files, occupancy agreements, and interviews with staff including the Director of Nursing and Executive Director. No regulatory insufficiencies were identified.
Report Facts
Total census of Assisted Living Program: 42
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report |
| Jeff Holmes | Executive Director | Interviewed regarding staffing allegation |
Inspection Report
Monitoring
Census: 42
Deficiencies: 2
Date: Oct 27, 2014
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals following a survey on October 27 & 28, 2014, to evaluate regulatory compliance related to Dementia Specific Education for Program Personnel and Staffing at Sunnybrook of Fort Madison.
Findings
The report identified regulatory insufficiencies in dementia-specific education for program personnel and nurse delegation procedures. Several staff files lacked documentation of required dementia-specific training and nurse delegations were not completed within the required 30-day timeframe.
Deficiencies (2)
Staff files lacked documentation of required dementia-specific training hours.
Nurse delegation procedures were not completed within the 30-day timeframe for some staff.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 10
Total census of Assisted Living Program: 42
Required dementia-specific training hours: 8
Dementia-specific training completed: 4
Timeframe for nurse delegation completion: 30
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Aug 2, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant became agitated, swung a cane at staff, and subsequently fell and fractured a hip.
Complaint Details
The complaint involved Tenant #1 becoming agitated, swinging a cane at staff, falling, and fracturing a hip. The investigation included review of tenant files, staff and nurse notes, event reports, and EMS reports. The tenant was hospitalized and later transferred to a skilled nursing facility. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 had an incident involving agitation and a fall resulting in a hip fracture, but the program's service plans and staff interventions were deemed adequate and no violations were identified.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 31
Number of tenants with cognitive disorder in General Population Program: 1
Total Population of General Population Program: 32
Number of tenants without cognitive disorder in Dementia-Specific Program: 10
Number of tenants with cognitive disorder in Dementia-Specific Program: 0
Total Population of Dementia-Specific Program: 10
Total census of Assisted Living Program: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor during complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor during complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Apr 17, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation for Sunnybrook Assisted Living Program following a complaint regarding a tenant fall and medication errors.
Complaint Details
The complaint involved Tenant #2 falling while unattended by staff, resulting in a cervical spine fracture. The investigation found no other falls resulting in fractures and no safety concerns for other tenants. The complaint was reviewed through clinical records and interviews.
Findings
The investigation found no regulatory insufficiencies related to the tenant fall incident but identified multiple medication administration errors and deficiencies in service plans and dementia-specific education. The program had no prior regulatory insufficiencies during the certification period.
Deficiencies (3)
Medication administration errors including failure to sign medication records and missed doses for multiple tenants.
Service plans not updated to reflect changes in tenant needs and failure of staff to follow service plans.
Lack of required documentation of eight hours of dementia training for certain staff within 30 days of employment.
Report Facts
Tenant census: 43
Tenants without cognitive disorder: 30
Tenants with cognitive disorder: 1
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 12
Tenant meeting attendance: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccellia | Program Coordinator | Signed letter enclosing the Final Complaint/Incident Investigation & Recertification Monitoring Evaluation Report. |
| Maribeth Freland | RN | Monitor involved in complaint/incident investigation. |
| Joyce Kix | RN | Monitor involved in complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Jun 15, 2011
Visit Reason
A complaint investigation and on-site visit was conducted at SunnyBrook Assisted Living on June 15, 2011, to investigate allegations related to tenant falls and staff response.
Complaint Details
Complaint Allegation #33815-C involved a tenant fall where staff did not respond appropriately and the tenant was not assessed properly after the fall. Incident Allegation #34311-I involved a tenant found lying on the floor with complaints of pain and subsequent major injury. The complaint was substantiated with regulatory insufficiency noted.
Findings
The investigation reviewed tenant files, event reports, and staff statements regarding tenant falls and staff responses. One tenant sustained a major injury from a fall, and regulatory insufficiency was identified related to nurse review and tenant care.
Deficiencies (1)
Regulatory Insufficiency: If a tenant does not receive personal or health related care, but an observed significant change in the tenant's condition occurs, a nurse review shall be conducted.
Report Facts
Current number of tenants without cognitive disorder: 30
Current number of tenants with cognitive disorder: 0
Total Population of General Population Program (GPP): 30
Total Population of Dementia Specific Program (DSP): 12
Total Census of Assisted Living Program (ALP): 42
Tenant age: 87
Tenant age: 84
Tenant age: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Beardsley | RN Manager | Facility manager named in report header |
| Stephanie Cummins | MA | Monitor involved in investigation |
| Margaret Kaltefleiter | RN MS | Monitor involved in investigation |
| Rose Boccella | Program Coordinator | Author of cover letter |
Inspection Report
Monitoring
Census: 48
Deficiencies: 1
Date: Oct 27, 2010
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report and to evaluate compliance with Iowa Code and Administrative Code for assisted living programs.
Findings
The report indicates that the Plan of Correction was accepted by the Department of Inspections and Appeals. Tenant satisfaction was generally positive, housekeeping was adequate, and no regulatory insufficiencies were found during this certification period except one regulatory insufficiency related to tenant evaluations.
Deficiencies (1)
A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and annually thereafter; an annual functional evaluation was not completed as required.
Report Facts
Current number of tenants without cognitive disorder: 40
Current number of tenants with cognitive disorder: 1
Total Population of General Population Program: 41
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Beardsley | RN Manager | Facility manager named in the report |
| Stephanie Cummins | MA | Monitor for the evaluation visit |
| Lori Miner | RN BSN | Monitor for the evaluation visit |
| Rose Boccella | Program Coordinator | Author of the cover letter |
Inspection Report
Original Licensing
Census: 23
Deficiencies: 0
Date: May 26, 2009
Visit Reason
The visit was an initial certification monitoring evaluation conducted to assess regulatory compliance of the SunnyBrook Assisted Living Program in Fort Madison, IA.
Findings
No regulatory insufficiencies were found during the evaluation, demonstrating full compliance with applicable rules and regulations. The program certification will continue without interruption for two years.
Report Facts
Current number of tenants without cognitive disorder: 21
Current number of tenants with cognitive disorder: 0
Total Population of Dementia Specific Program: 2
Total Census of Assisted Living Program: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the on-site monitoring evaluation |
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