Inspection Reports for River Valley Place of Ottumwa
173 East Rochester Street, Ottumwa, IA, 525011125
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2024, found no deficiencies during complaint investigations and a revisit to prior concerns. Earlier inspections showed a pattern of deficiencies primarily related to staffing levels, tenant care including medication management, and updating service plans and evaluations. Several complaint investigations substantiated issues with adequate care, medication security, and policy compliance, though no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints in recent years were unsubstantiated or showed progress in correction. The facility’s inspection history indicates some improvement over time, with the latest report showing no cited deficiencies after prior citations.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
14 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as part of investigations into complaints #121772-C and #117180-C, including a revisit to determine progress in correcting previously cited regulatory insufficiencies.
Complaint Details
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.
Findings
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.
Report Facts
Number of tenants without cognitive impairment: 6
Number of tenants with cognitive impairment: 8
Total census: 14
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 10
Date: Mar 26, 2024
Visit Reason
The inspection was conducted during the investigation of multiple complaints and incidents as well as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The inspection was triggered by complaints #115373-C, #117180-C, and #117812-C; incidents #117537-I and #118762-I.
Findings
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.
Deficiencies (10)
Policies regarding abuse and exploitation were not consistent with Iowa Code chapter 235E regarding reporting requirements.
Failed to follow established policies related to reporting potential dependent adult abuse and medication counting and securing.
Failed to provide adequate care to tenants including assistance with feeding, medication administration, and monitoring health conditions.
Medications were not always kept in a locked place accessible only to authorized employees.
Insufficient number of trained staff to meet tenant needs, resulting in delayed assistance and inadequate care.
Failed to complete functional and health evaluations prior to admission for a tenant.
Failed to complete required tenant evaluations within 30 days of occupancy.
Failed to evaluate tenants with significant changes in condition.
Failed to retain tenant records for discharged tenants for the required minimum of three years.
Failed to update tenant service plans within 30 days of occupancy and as needed with significant change.
Report Facts
Total census: 27
Medication missing: 40
Medication missing: 12
Medication missing: 9
Medication missing: 13
Medication missing: 20
Medication count missing: 8
Medication count missing: 6
Medication count missing: 7
Incident response delay: 120
Temperature: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported missing alprazolam pills and medication cart unlocked | |
| Staff B | Reported missing trazodone pills for Tenant #2 | |
| Staff C | Reported morphine missing for Tenant C3 and described care issues | |
| Staff D | Reported medication thefts and care concerns | |
| Staff E | Reported awareness of medication thefts and staffing shortages | |
| Staff F | Reported medication administration issues and staffing shortages | |
| Health and Wellness Director | HWD | Interviewed multiple times regarding investigations, staffing, and care issues |
| Former Executive Director | Reported medication thefts to police | |
| Former Registered Nurse | RN | Failed to count narcotics and administer medications properly |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to investigate multiple complaints (#111738-C, #112596-C, #113634-C, #112787-C, and #113694-C) related to the assisted living program at River Valley Place of Ottumwa.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to follow policy on disposal of sharps for 1 of 1 tenant reviewed who received insulin injections (Tenant #4).
Failure to provide adequate and appropriate care, treatment, and services to 3 of 6 tenants reviewed (Tenant #1, Tenant #2, and Tenant #5).
Report Facts
Number of tenants without cognitive impairment: 12
Number of tenants with cognitive impairment: 8
Total census: 20
Number of tenants reviewed for care adequacy: 6
Number of tenants with inadequate care: 3
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as an investigation into complaints #108559-C, #109456-C, and #109480-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failed to complete an incident report when Tenant #3 left the building without staff knowledge.
Failed to ensure sufficient trained staff to meet the identified needs of tenants, including incidents leading to a tenant fall and inadequate assistance with bathing.
Failed to implement fire safety procedures properly, including evacuation protocols and tenant notification during fire alarms.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 6
Total census: 20
Pendant response calls: 463
Pendant response times 0-5 minutes: 192
Pendant response times 5:02-10:00 minutes: 142
Pendant response times 10:22-19:33 minutes: 84
Pendant response times 20:31-23:50 minutes: 15
Pendant response times over an hour: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in incident involving Tenant C1 fall and failure to follow fire safety procedures | |
| Staff B | Named in incident involving Tenant C1 fall and fire alarm response | |
| Regional Director of Sales and Operations | Confirmed incident report was not written and staff failed to meet tenant needs | |
| Assistant Director | Provided information on staff training and fire safety procedures | |
| Deputy Fire Chief | Discussed evacuation plan with staff and recommended tenants shelter in place |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 6
Date: Oct 11, 2022
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#101853-C, #102323-C, #104971-C, #104803-C, #106549-C) regarding regulatory insufficiencies at the assisted living program for people with dementia.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Failed to follow policy for COVID-19 precautions, including staff not wearing masks properly, potentially affecting all 24 tenants.
Failed to provide medical treatments as ordered by a physician for a tenant requiring daily INR checks.
Insufficient number of trained staff available to meet the identified needs of tenants in the memory care unit, affecting tenants requiring 15-minute safety checks.
Failed to discharge tenants who chronically displayed unmanageable elopement and aggressive behaviors.
Failed to update service plans based on required evaluations to meet specific needs for tenants, including those in hospice care.
Failed to develop individualized service plans indicating tenants' identified needs and preferences for assistance, particularly for tenants with aggressive behavior and elopement risk.
Report Facts
Total tenants: 24
Tenants without cognitive disorder: 18
Tenants with cognitive disorder: 1
Tenants with cognitive disorder: 5
Safety checks required: 32
Elopements documented: 2
Incidents of aggression: 6
Falls: 46
Staff scheduled: 3
Staff scheduled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Failed to wear mask at entrance; admitted to boycotting mask use | |
| Staff B | Worked in memory care unit with mask below chin near tenants | |
| Staff C | Served meals with mask below nose/mouth; confirmed mask policy | |
| Staff D | Dished food with mask below nose; failed to wear mask when transporting food cart | |
| Staff E | Reported Tenant #1's aggressive behavior and staffing challenges | |
| Staff F | Confirmed Tenant #1 required 15-minute checks and described care difficulties | |
| Regional Director of Sales and Operations | Confirmed findings related to medication and staffing | |
| Director | Confirmed findings on 10/11/22 |
Inspection Report
Renewal
Census: 35
Deficiencies: 4
Date: Aug 26, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
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.
Deficiencies (4)
Evaluation annually and with significant change was not properly conducted for tenants, including failure to evaluate functional, cognitive, and health status as needed.
Service plans were not updated when needs changed for tenants with significant health status changes.
Service plans failed to include outside providers for tenants receiving hospice services.
Program failed to provide 8 hours of dementia-specific continuing education annually for direct-contact personnel.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 3
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 12
Total Census: 35
Staff reviewed for dementia training: 4
Staff lacking annual dementia training: 2
Inspection Report
Renewal
Census: 41
Deficiencies: 2
Date: Jul 15, 2019
Visit Reason
The recertification visit was conducted to determine continued compliance with the certification rules for an Assisted Living Program for People with Dementia (ALP/D).
Findings
The program failed to request background checks prior to employment for 2 of 8 staff reviewed, and failed to ensure background checks were valid for 1 of 8 staff reviewed. These deficiencies were confirmed through record review and interviews.
Deficiencies (2)
Failed to request background checks prior to employment for 2 of 8 staff reviewed.
Failed to ensure background checks were valid for 1 of 8 staff reviewed.
Report Facts
Number of tenants without cognitive disorder (General Population): 25
Number of tenants with cognitive disorder (General Population): 6
Number of tenants without cognitive disorder (Memory Care Unit): 0
Number of tenants with cognitive disorder (Memory Care Unit): 10
Total Census of Assisted Living Program for People with Dementia: 41
Number of staff reviewed for background checks: 8
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
Investigation of Complaint #77294-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #77294-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: 22
Number of tenants with cognitive disorder in General Population: 7
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
Investigation of Incident #75076-I at the assisted living program for people with dementia.
Complaint Details
Investigation of Incident #75076-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #75076-I.
Report Facts
Number of tenants without cognitive disorder in general population: 19
Number of tenants with cognitive disorder in general population: 12
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 11
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Mar 29, 2018
Visit Reason
Investigation of Complaint #74570-C regarding the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #74570-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder in General Population: 18
Number of tenants with cognitive disorder in General Population: 11
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 12
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Mar 6, 2018
Visit Reason
Investigation of Incident #73853-I at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #73853-I with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder in general population: 18
Number of tenants with cognitive disorder in general population: 11
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 10
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Nov 29, 2017
Visit Reason
Investigation of Complaint #70695-C at Prairie Hills at Ottumwa Assisted Living Program.
Complaint Details
Investigation of Complaint #70695-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 31
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 9
TOTAL census of Assisted Living Program: 41
Inspection Report
Renewal
Census: 48
Deficiencies: 1
Date: Jul 26, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an assisted living program.
Findings
The inspection found a regulatory insufficiency related to dementia-specific education for program personnel, specifically that 4 of 7 staff did not complete the required minimum eight hours of dementia-specific training within 30 days of employment.
Deficiencies (1)
Dementia-specific education for program personnel was not met as 4 of 7 staff failed to complete the required minimum eight hours of training within 30 days of employment.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 40
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: 48
Staff reviewed for dementia-specific training: 7
Staff failed to complete training within 30 days: 4
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Date: Apr 5, 2017
Visit Reason
Investigation of Incident #65635-I at the assisted living facility.
Complaint Details
Investigation of Incident #65635-I; no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #65635-I.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 16
Total Population of Program: 36
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 8
Total Population of Program: 8
TOTAL census of Assisted Living Program: 44
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: Jun 6, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following an allegation of staff theft of a tenant's gift card at Prairie Hills of Ottumwa.
Complaint Details
The complaint involved alleged abuse where a staff person stole a tenant's gift card and used it for purchases. The allegation was investigated and found unsubstantiated as no regulatory insufficiencies were cited.
Findings
The investigation determined the tenant was not a dependent adult and no regulatory insufficiencies were identified. The staff member involved was terminated after the theft was confirmed.
Report Facts
Number of tenants without cognitive disorder: 36
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 39
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 8
TOTAL census of Assisted Living Program: 47
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jun 15, 2015
Visit Reason
A recertification visit and complaint investigation were conducted to determine compliance with certification for an Assisted Living Program and to investigate Complaint #53491-C regarding staffing.
Complaint Details
Complaint allegation of staffing was investigated and found unsubstantiated. Regulatory insufficiency related to staffing was identified during the investigation of Complaint #53491-C.
Findings
The complaint allegation of staffing was unsubstantiated; however, regulatory insufficiencies were identified related to program policies and procedures and service plans. Specifically, the program failed to complete incident reports and develop individualized service plans reflecting tenants' needs and preferences.
Deficiencies (2)
Program failed to follow policy and procedure regarding completion of incident reports for one tenant who eloped from the building.
Program failed to develop service plans that reflected tenants' identified needs and preferences for assistance, including falls, interventions related to falls, weight loss, and decreased appetite for three of five tenant files reviewed.
Report Facts
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 11
Total population of program at time of on-site: 49
Dates of tenant falls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Techel | Executive Director | Named in letter and involved in transporting Tenant #2 back to building after elopement incident |
| Rose Boccella | Program Coordinator | Author of complaint intake letter |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 0
Date: Jan 15, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations of level of care and staffing at Prairie Hills at Ottumwa.
Complaint Details
Allegations investigated included level of care and staffing. Both were found unsubstantiated based on review of tenant files, staff interviews, and program documents.
Findings
The investigation found the allegations of level of care and staffing to be unsubstantiated, with no regulatory insufficiencies identified. Tenant files, staff interviews, and program documents showed no concerns with care levels or staffing adequacy.
Report Facts
Number of tenants without cognitive disorder: 42
Number of tenants with cognitive disorder: 11
Total census of Assisted Living Program: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report and contact person for questions |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 5
Date: Oct 1, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations that staff failed to provide necessary care resulting in a tenant falling to the floor, and that medications were not passed correctly.
Complaint Details
The complaint alleged staff failed to provide necessary care resulting in tenant falls and improper medication administration. The complaint was partially substantiated with findings of regulatory insufficiencies in staffing, evaluations, and medication administration.
Findings
The investigation found no regulatory insufficiency related to staffing and falls, but identified regulatory insufficiencies related to staffing levels, evaluations, and medication administration policies and practices. Several tenants had incidents involving falls, and medication administration procedures were not fully followed.
Deficiencies (5)
Documentation of two-hour checks did not occur at the times required.
A sufficient number of trained staff shall be available at all times to fully meet tenants' identified needs.
A program shall evaluate each tenant's functional, cognitive and health status within 30 days of occupancy and as needed with significant change.
Each program shall follow its own written medication policy.
Medications shall be kept in a locked place or container not accessible to unauthorized persons.
Report Facts
Total census: 45
Number of tenants without cognitive disorder (General Population Program): 37
Number of tenants with cognitive disorder (General Population Program): 1
Total population (General Population Program): 38
Number of tenants without cognitive disorder (Dementia-Specific Program): 0
Number of tenants with cognitive disorder (Dementia-Specific Program): 7
Total population (Dementia-Specific Program): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kristi Wheeler | RN Director | Director of Prairie Hills Assisted Living named in report header |
| Jim Berkley | Program Coordinator | Signed letter transmitting the report |
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 53
Deficiencies: 0
Date: May 8, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review recertification documents and evaluate compliance with Iowa Administrative Code chapters 481—67 and 481—69 for the Assisted Living Program at Prairie Hills at Ottumwa.
Findings
No regulatory insufficiencies were found during the evaluation. The program was accepted, and the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans were received. Tenant satisfaction was positive, and the program did not receive any regulatory insufficiencies during this certification period.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 42
Number of tenants with cognitive disorder in General Population Program: 2
Total Population of General Population Program: 44
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 9
Total Population of Dementia-Specific Program: 9
Total census of Assisted Living Program: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Crouse-Spurgeon | Administrator | Administrator of Prairie Hills at Ottumwa, named in report |
| Stephanie Cummins | MA | Monitor for the evaluation |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation |
| Jim Berkley | Program Coordinator | Signed the report as Program Coordinator, Adult Services Bureau |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Apr 10, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation triggered by allegations of medication discrepancies and falsification of medication records at Prairie Hills at Ottumwa.
Complaint Details
The complaint alleged medication discrepancies and falsification of medication records by administrative staff. The investigation found no substantiated regulatory insufficiencies.
Findings
The investigation found no regulatory insufficiencies. Medication errors were reviewed and no issues with medication discrepancies or falsification of medication documents were identified. Observations of medication administration and narcotic counts revealed no discrepancies.
Report Facts
Number of tenants without cognitive disorder: 45
Number of tenants with cognitive disorder: 6
Total census: 51
Number of tenants reviewed: 3
Number of different narcotics observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Author of the cover letter and contact for questions regarding the report |
| Stephanie Cummins | MA | Monitor during the complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor during the complaint/incident investigation |
| Amy Crouse-Spurgeon | Administrator | Administrator of Prairie Hills at Ottumwa, named in the report |
Inspection Report
Monitoring
Census: 54
Deficiencies: 5
Date: Jul 12, 2011
Visit Reason
An on-site monitoring evaluation was conducted at Prairie Hills Assisted Living at Ottumwa to review the Plan of Correction in response to the Preliminary Recertification Monitoring Evaluation Report and to assess compliance with regulatory requirements.
Findings
The evaluation found several regulatory insufficiencies related to individualized service plans, medication administration, food service training, and staffing documentation. The Plan of Correction submitted by the facility was accepted by the Department of Inspections and Appeals.
Deficiencies (5)
The service plan shall be individualized and indicate the tenant’s identified needs and preferences for assistance.
Staff documented administration of medications prior to offering them to tenants and administered eye drops without reviewing Medication Administration Record or medication container.
Personnel responsible for food preparation or service lacked annual in-service training on sanitation and safe food handling prior to handling food.
Staff did not have documentation of nurse delegations for medication administration, blood sugar checks, insulin reminders, or activities of daily living.
A sufficient number of trained staff shall be available at all times to fully meet tenants’ identified needs.
Report Facts
Tenants without cognitive disorder: 45
Tenants with cognitive disorder: 1
Total Population of General Population Program: 46
Total Population of Dementia Specific Program: 8
Total Census of Assisted Living Program: 54
Tenants attending community meeting: 14
Date of report: Aug 18, 2011
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Apr 6, 2010
Visit Reason
The inspection was conducted as a final incident investigation following a reported incident involving a tenant with a history of falls who sustained a fractured elbow after being found on the floor and hospitalized.
Complaint Details
The complaint involved a tenant in the memory care unit who fell and sustained a fractured elbow. The incident was substantiated by observations and documentation, but no regulatory insufficiencies were noted.
Findings
The investigation found no regulatory insufficiencies. The tenant was admitted with multiple diagnoses and was transferring with supervision. Staff responded appropriately to the incident, and the tenant was transferred to the hospital. The program notified the Department as required.
Report Facts
Current number of tenants without cognitive disorder: 43
Current number of tenants with cognitive disorder: 4
Total Population of GPP: 47
Total Population of Dementia Specific Program (DSP): 8
Total Census of Assisted Living Program (ALP): 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the incident investigation |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 8
Date: Mar 24, 2009
Visit Reason
A complaint investigation on-site visit was conducted at Prairie Hills Assisted Living to review allegations related to tenant care, medication administration, and staff training.
Complaint Details
Complaint Intake #22368-C involved allegations of staff neglect in medication patch application, lack of medication administration training, and insufficient dementia training. The complaint was substantiated with multiple regulatory insufficiencies identified.
Findings
The investigation found substantiated regulatory insufficiencies in tenant evaluation, service plan updates, medication administration, nurse review, and staffing training documentation. Specific issues included failure to evaluate tenants' functional and cognitive status, incomplete service plans, medication errors, and insufficient staff training documentation.
Deficiencies (8)
The program did not evaluate each tenant’s functional, cognitive and health status as needed to determine eligibility and service modifications.
The program did not consistently update each tenant’s service plan as needed when a tenant requires personal or health related care.
The program did not consistently provide the administration of medications by an Iowa-licensed registered nurse or authorized agent according to standards.
The program did not complete nurse reviews to ensure physician orders were current and documented tenant health activities.
The program did not assess and document tenant health status, make recommendations, or monitor progress on health changes.
The program RN did not consistently sign, date, and time physician orders.
The program did not consistently provide sufficient trained staff to meet tenant needs.
The program did not maintain training documentation for staff.
Report Facts
Current number of tenants without cognitive disorder: 31
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 33
Total Population of Dementia Specific Program: 9
Total Census of Assisted Living Program: 42
Medication incident report date: Feb 28, 2009
Staff dementia training hours: 6
Staff dementia training days: 3
Staff dementia training period: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 6
Date: Mar 6, 2008
Visit Reason
A complaint investigation and initial certification on-site visit was conducted at Prairie Hills Assisted Living to evaluate compliance with regulatory requirements and investigate specific complaints.
Complaint Details
The complaint investigation was triggered by allegations of medication errors including incorrect dosing of Levaquin for Tenant #1 and incorrect medication amounts for Tenant #2, as well as concerns about medication documentation and nurse review practices. The complaint was substantiated with multiple regulatory insufficiencies identified.
Findings
The investigation found multiple regulatory insufficiencies including failure to complete required functional, cognitive, and health evaluations within 30 days of admission, medication errors including incorrect transcription of physician orders and improper medication administration documentation, and failure to complete consistent 90-day nurse reviews for tenants receiving program-administered medications.
Deficiencies (6)
The program did not complete functional, cognitive and health evaluations within 30 days and as needed to determine tenant eligibility and needed service modifications.
The program developed service plans not based on required evaluations and not designed to meet specific tenant service needs.
Medication errors occurred including incorrect transcription of physician orders leading to incorrect medication administration.
Medication documentation was incomplete with multiple doses not documented as given.
The program did not consistently follow acceptable medication protocols ensuring nursing professional judgment in medication administration.
The program did not consistently complete 90-day nurse reviews for tenants receiving program-administered prescription medications.
Report Facts
Current number of tenants without cognitive disorder: 40
Number of tenants at community meeting: 32
Dates of medication errors and documentation issues: Specific dates of medication administration errors documented in March 2008 MAR
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
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