River Hills Village in Keokuk

In the surveyor’s words

From the most serious findings on record at River Hills Village in Keokuk, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 16, 2024

  Based on clinical record review, facility policy, resident and staff interviews, and facility investigation documentation the facility failed to use the necessary transfer equipment when assisting a resident in the bathroom, resulting in a lower leg fracture for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 64 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The MDS assessed the resident as dependent on staff for toileting hygiene and chair/bed to chair transfers. The MDS listed diagnoses included: stroke, arthritis, and hemiplegia and hemiparesis (paralysis on one side of the body) affecting the right side. […]

• No harm, potential for more than minimal, patternF803Sep 18, 2025

  Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure dietary staff served the correct portion size to meet the nutritional needs of the 9 residents (Residents #2, #3, #13, #20, #28, #30, #36, #56, #62) with a mechanical soft or puree diet order for one of one meal service observation. The facility reported a census of 65 residentsFindings include: 1. During an observation on 9/16/2025 at 10:04 AM, observation of the lunch meal preparation for mechanical soft and pureed diets revealed the following: Staff N, Cook, placed eight servings, four ounces each serving, of beef pot roast into a machine that mechanically ground the meat and added beef broth. The total amount of ground meat measured seven cups. […]

• No harm, potential for more than minimal, patternF812Sep 18, 2025

  Based on meal services observation, facility policy review, review of the Federal Food and Drug Administration Code, and staff interview, the facility failed to ensure dietary staff served food under sanitary conditions for one of one meal service observations. The facility reported a census of 65 residents.Findings include:During an observation on 9/16/25 at 11:49 AM, Staff N, Cook, uncovered the pans on the steam table in the memory care dining unit, gloved, uncovered plates, and served the lunch meal to residents in the memory care unit. At 12:02 PM, Staff N completed the lunch service in the memory care unit. […]

• No harm, potential for more than minimal, patternF585Oct 13, 2022

  Based on interviews, record review, document review, and facility policy review, the facility failed to implement a system for filing and responding to grievances for 3 (Resident #22, Resident #38, and Resident #8) of 3 residents interviewed who were members of Resident Council. The deficient practice had the potential to affect all residents of the facility. Findings included: A review of a facility policy and procedure titled, Grievances, revised on 06/01/2022, revealed, The Facility shall ensure that the resident has the right to voice grievances to the facility without discrimination or reprisal and without fear of discrimination or reprisal. Grievances shall be addressed by the facility and resolved in a timely manner. The procedure portion of the policy indicated, 1. […]

• No harm, potential for more than minimal, patternF725Jul 1, 2021

  Based on observation, record review, resident and staff interviews, the facility failed to answer call lights in a timely manner for five out of seven residents reported during the Resident Council Meeting (Residents #8, #9, #17, #23, and #49), for one resident interviewed (Resident #3) and an observation of one resident who had a call light on for more than 15 minutes (Resident #29). The facility reported a census of 67 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]