River Valley Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at River Valley Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 11, 2025

  Based on observation, clinical record review, wound care provider and facility staff interviews, the facility failed to notify the physician of pressure ulcer deterioration and implement nutritional orders in an effort to promote healing for 1 of 3 residents (Resident #3) reviewed for pressure ulcers. The facility reported a census of 36 residents. Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. […]

• Actual harm, isolatedF686Sep 19, 2022

  Based on clinical record review, policy review, and staff interviews, the facility failed to carry out assessments and interventions to promote healing of an existing pressure ulcer, resulting in an infection and hospitalization for 1 of 5 residents reviewed for pressure ulcers (Resident #20). The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 12/21/21, listed an admitted [DATE] for Resident #20 and included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident required limited assistance of 1 staff for bed mobility, extensive assistance of 1 staff for transfers, dressing, toilet use, and personal hygiene, and depended completely on 1 staff for bathing. […]

• No harm, potential for more than minimal, widespreadF727Aug 20, 2026

  Based on facility record review, staff interviews and facility policy review the facility failed to provide registered nurse coverage 8 hours a day for 2 out of 30 days reviewed. The facility identified a census of 34 residents. Findings include: Review of the schedule for nursing staff on 7/18/26 and 7/19/26 revealed the facility had nurse coverage of licensed practical nurse only for both days in a 24 hour period. On 8/20/26 at 11:38 AM the Director of Nursing revealed the facililty should have a registered nurse (RN) on staff for 8 hours a day minnumum. She explained the weekend of 7/18/26 and 7/19/26 the RN who would have worked was out of town and they had agency staff cover for the weekend and it should have been an RN. […]

• No harm, potential for more than minimal, widespreadF725Sep 9, 2024

  Based on clinical record review, facility assessment review, and staff interviews the facility failed to employ sufficient numbers of staff to meet resident needs. The facility reported a census of 36 residents. Findings include: 1. A review of the Facility Assessment, updated 8/01/24 revealed the facility needed 3 (three) Certified Nursing Assistants (CNA) for first and second shift if the census was 30 or more in order to meet resident needs. A review of the staff schedules from 8/01/24-9/02/24 revealed there were two CNA's for either partial or whole shifts 8 (eight) times on first shift and 13 times on second shift. […]

• No harm, potential for more than minimal, widespreadF865Sep 9, 2024

  Based on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 36 residents. Findings include: Per review of the dia-hfd.iowa.gov website, the following deficiency had been previously identified per a Recertification Survey conducted from 2/19/23 to 2/16/2. The deficiency also cited during a Recertification Survey and Complaint Survey conducted from 9/3/2024 to 9/9/24: a. F725 - Sufficient Nursing Staff. […]