Inspection Reports for
Grand River Health Care
118 TRENTON RD, CHILLICOTHE, MO, 64601-4002
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
12.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
52% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Jan 5, 2026
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by the Director of Nursing and the Administrator on 01/05/2026.
Complaint Details
The complaint investigation was substantiated. The abuse involved physical restraint and verbal abuse by the DON and Administrator on 01/05/2026. The resident had bruises and arm pain. The facility delayed removing the alleged perpetrators from resident oversight. The Maintenance Director/Nurse Aide reported the abuse to the Social Service Director who instructed calling the abuse hotline. The facility failed to immediately report the abuse to the state survey agency as required.
Findings
The facility failed to protect Resident #1 from physical abuse when the DON and Administrator forcibly removed soiled clothing by restraining the resident and using verbal obscenities. The resident sustained bruises and arm pain requiring emergency room evaluation. The facility also failed to immediately remove the alleged perpetrators from oversight, delaying protective actions. The abuse was substantiated and immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (2)
Failed to protect resident from physical abuse by staff forcibly removing soiled clothing and using verbal obscenities.
Failed to timely report suspected abuse to the state survey agency.
Report Facts
Residents present: 31
Dates of abuse incident: Jan 5, 2026
Dates of report and investigation: Jan 6, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Nurse Aide | Witnessed abuse, reported incident to Social Service Director, refused to participate in abuse |
| Director of Nursing | Director of Nursing | Perpetrator of abuse, physically restrained resident and used verbal obscenities |
| Administrator | Administrator/Certified Medication Technician/Certified Nurse Assistant | Perpetrator of abuse, physically restrained resident |
| Social Service Director | Social Service Director | Received abuse report from Maintenance Director, instructed to call abuse hotline |
| Business Office Manager | Business Office Manager | Heard yelling and DON cursing, involved in reporting process |
| Acting Administrator | Acting Administrator/MDS Coordinator | Initiated investigation, suspended DON and Administrator |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Nov 21, 2025
Visit Reason
The inspection was conducted due to complaints regarding physical abuse between residents in the facility, specifically incidents where Resident #1 hit Resident #2 on two separate occasions.
Complaint Details
The complaint investigation found that Resident #1 hit Resident #2 on two occasions (10/27/25 and 11/9/25) in the dining room. Resident #2 denied pain and no injuries were noted. Staff and management were notified, and interventions including 15-minute checks and one-on-one observation for Resident #1 were implemented. Resident #1 exhibited aggressive and agitated behaviors, and Resident #2 was advised to stay separated from Resident #1.
Findings
The facility failed to protect Resident #2 from physical abuse by Resident #1, who exhibited aggressive behaviors including hitting and yelling at other residents. The facility implemented interventions such as increased supervision and care plan modifications to manage Resident #1's behaviors.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident.
Report Facts
Residents Affected: 2
Facility Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | Certified Nursing Assistant | Reported observations of Resident #1's aggressive behavior and need for supervision |
| Registered Nurse A | Registered Nurse | Reported on Resident #1's behavior and supervision status during incidents |
| Certified Medication Technician A | Certified Medication Technician | Reported on interactions between Resident #1 and Resident #2 and staff interventions |
| Administrator | Administrator | Provided statements regarding incidents and facility interventions |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Date: Mar 25, 2025
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse of Resident #2 by staff members, including Nurse Aide A and Licensed Practical Nurse A, and concerns about misappropriation of Resident #1's narcotic medications.
Complaint Details
The complaint investigation was triggered by allegations that Nurse Aide A verbally abused Resident #2 by cussing and holding the resident down, and Licensed Practical Nurse A yelled at Resident #2 and forced the resident to wear a Bi-Pap mask against their will. The investigation substantiated abuse and neglect by both staff members. Additionally, the facility investigated missing narcotic medications for Resident #1, which were not reported to law enforcement as required.
Findings
The facility was found to have failed to keep Resident #2 free from verbal and physical abuse, with staff holding the resident down and using inappropriate language. The facility also failed to ensure the security of Resident #1's narcotic medications, which were found missing. The investigation confirmed abuse and neglect by staff toward Resident #2 and identified missing narcotics for Resident #1, but the theft was inconclusive. Corrective actions included staff suspensions, terminations, education, and policy changes.
Deficiencies (3)
Failure to protect Resident #2 from verbal and physical abuse by Nurse Aide A and Licensed Practical Nurse A, including holding resident down and using abusive language.
Failure to assure Resident #1 was free from misappropriation of property when narcotic medications were found missing.
Failure to timely report suspected abuse, neglect, or theft to proper authorities, including failure to report missing narcotics to law enforcement.
Report Facts
Facility census: 26
Missing narcotic medication count: 30
Medication counts: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Named in verbal and physical abuse of Resident #2 |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in verbal and physical abuse of Resident #2 |
| Registered Nurse A | Registered Nurse | Reported missing narcotics and participated in investigation |
| Certified Medication Technician A | Certified Medication Technician | Had access to narcotics, involved in missing medication investigation, suspended and lost medication administration privileges |
| Business Office Manager | Business Office Manager | Reported observations of CMT A behavior and medication possession |
| Director of Nursing | Director of Nursing | Facility investigator and interviewee regarding abuse and missing narcotics |
| Administrator | Facility Administrator | Facility investigator and interviewee regarding abuse and missing narcotics |
Inspection Report
Routine
Census: 27
Deficiencies: 18
Date: Feb 27, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to provide dignified care, improper medication administration, inadequate care planning, environmental and maintenance issues, infection control lapses, food safety violations, and failure to ensure staff compliance with tuberculosis screening and professional standards.
Deficiencies (18)
Staff administered insulin and inhalers in the day room instead of a private area, violating resident dignity.
Staff vaping in resident rooms and unprofessional behavior towards residents.
Residents served meals on disposable plates and plastic utensils, and meals were not served simultaneously to residents at the same table.
Shared restrooms had light switches wired so only one switch could turn on the light, requiring residents to cross the restroom in the dark.
Facility failed to accommodate resident shower and shaving preferences, causing distress.
Residents did not have timely access to personal funds on weekends.
Facility environment was unclean and in disrepair, including cold shower room temperatures, peeling paint, damaged furniture, and dusty vents.
Resident #12 threatened harm to another resident; facility failed to protect residents from abuse.
Care plans were incomplete or not updated to reflect resident conditions such as code status and antibiotic use.
Facility failed to develop and update care plans consistent with residents' specific conditions and needs.
Medication errors occurred with a 19.23% error rate, including incorrect eye drop administration and missing insulin orders.
Facility failed to provide timely physician notification of resident change in condition.
Residents did not have fresh ice water readily available at bedside on all shifts.
Oxygen and nebulizer equipment was not properly maintained, tubing was undated and on the floor, humidifiers were not refilled daily.
Medication administration failures included expired medications, undated opened vials, food stored in medication refrigerator, and resident money and cigarettes stored in medication cart.
Staff failed to use enhanced barrier precautions during wound care and failed to perform proper hand hygiene between tasks.
Facility failed to complete two-step tuberculosis screening for newly hired employees.
Food service safety violations included expired foods, unlabeled and undated food items, improper storage of cups and glasses, uncovered garbage cans, lack of dishwasher chemical test logs, unclean kitchen and walk-in cooler maintenance issues.
Report Facts
Medication error rate: 19.23
Facility census: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in medication administration and resident care findings |
| CMT A | Certified Medication Technician | Named in medication administration and resident care findings |
| NA C | Nursing Assistant | Named in vaping and unprofessional behavior complaint |
| DON | Director of Nursing | Named in interviews regarding care and policy compliance |
| Administrator | Named in interviews regarding facility operations and resident issues | |
| BOM | Business Office Manager | Named in interviews regarding resident funds and medication issues |
| Dietary Aid A | Dietary Aid | Named in food service and kitchen condition findings |
| Dietary Manager | Dietary Manager | Named in food service and kitchen condition findings |
| RN B | Registered Nurse | Named in medication and respiratory care findings |
| HSK A | Housekeeper | Named in infection control and housekeeping findings |
Inspection Report
Census: 27
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, abuse prevention, food service safety, and overall facility care.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified care and privacy during medical procedures, failure to prevent resident abuse and threats, improper food service practices including use of disposable plates and improper food storage, and inadequate kitchen cleanliness and maintenance.
Deficiencies (3)
Failure to ensure staff cared for residents in a dignified and professional manner, including administering insulin and inhalers in a public area and ignoring resident requests for medical help.
Failure to protect residents from abuse when Resident #12 threatened harm to Resident #9.
Failure to prepare and serve food in accordance with professional standards, including failure to keep dishwasher chemical test logs, label and date foods, dispose of expired foods, properly store glasses and cups, maintain kitchen cleanliness, and maintain walk-in cooler.
Report Facts
Facility census: 27
Residents affected: 5
Residents affected: 12
Residents affected: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA (C) | Nursing Assistant | Named in unprofessional behavior and vaping in resident's room |
| RN A | Registered Nurse | Named in observation of insulin administration and interview about care practices |
| CMT A | Certified Medication Technician | Named in observation and interview regarding inhaler administration |
| RN B | Registered Nurse | Interviewed about meal serving practices |
| Dietary Aid A | Dietary Aid | Interviewed about food service and kitchen practices |
| Dietary Manager | Dietary Manager | Interviewed about food labeling and kitchen cleanliness |
| Dietician | Dietician | Interviewed about food service standards and kitchen maintenance |
| Administrator | Facility Administrator | Interviewed about multiple deficiencies including abuse, food service, and kitchen maintenance |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Dec 16, 2024
Visit Reason
The inspection was conducted due to a complaint alleging verbal and physical abuse of Resident #1 by a Certified Nursing Assistant (CNA A).
Complaint Details
The complaint investigation substantiated that CNA A verbally and physically abused Resident #1. The resident was scared and had a red mark on the inner elbow. The Administrator instructed CNA A to leave the facility and emphasized residents' rights to be free from abuse.
Findings
The facility failed to ensure Resident #1 was free from verbal and physical abuse when CNA A grabbed the resident's arm, jerked him/her back into the wheelchair, yelled, and cursed at the resident. The incident was witnessed by staff and resulted in a red mark on the resident's arm. The Administrator confirmed expectations for staff to treat residents with respect and be free from abuse.
Deficiencies (1)
Failure to protect Resident #1 from verbal and physical abuse by CNA A, including grabbing the resident's arm, jerking him/her back into the wheelchair, yelling, cursing, and kicking the wheelchair.
Report Facts
Residents present: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in verbal and physical abuse incident involving Resident #1 |
| NA A | Nurses Aide | Assisted Resident #1 and involved in incident at nurses' station |
| Laundry Aide A | Laundry Aide | Witnessed incident at nurses' station and reported to Activity Director |
| Laundry Aide B | Laundry Aide | Witnessed incident at nurses' station and reported to Activity Director |
| Activity Director | Activity Director | Responded to incident, calmed resident, and instructed CNA A to leave |
| Administrator | Administrator | Spoke with resident and staff about incident and enforced staff expectations |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Dec 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by the Director of Nursing (DON) at Grand River Health Care.
Complaint Details
The complaint investigation involved Resident #1 who was physically abused by the DON on 11/25/24. The abuse involved the DON grabbing the resident's arm and using the resident's hand to hit the resident's face. The resident reported feeling afraid of the DON. The incident was not reported immediately; the Housekeeping Aide reported the incident to a supervisor the next day and to the Administrator two days later. The DON was placed on leave and an investigation was initiated.
Findings
The facility failed to ensure one resident was free from abuse when the DON forcibly used the resident's own hand to hit himself/herself in the face multiple times. Additionally, the facility failed to report the alleged abuse immediately as required by state law, resulting in delayed notification to proper authorities.
Deficiencies (2)
Failure to protect a resident from abuse when the DON used the resident's own hand to hit the resident's face.
Failure to timely report suspected abuse to proper authorities within two hours as required by state law.
Report Facts
Residents affected: 1
Facility census: 28
Dates of incident and reporting: Incident occurred on 11/25/2024; reported to supervisor on 11/26/2024; reported to Administrator on 11/27/2024.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Aide A | Housekeeping Aide | Witnessed the incident, reported it to supervisor and Administrator. |
| Director of Nursing | Director of Nursing (DON) | Alleged perpetrator who abused Resident #1 and was placed on leave. |
| Social Service Director | Social Service Director (SSD) | De-escalated the situation and reported the incident. |
| Administrator | Administrator | Received report of the incident, initiated investigation and staff education. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
Date: Sep 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the use of physical restraints on a resident during the administration of an intramuscular injection and concerns about behavioral health care interventions.
Complaint Details
The complaint involved the use of physical restraint on Resident #1 during an intramuscular injection for aggressive behavior. The investigation found the resident was held down by staff, which was not authorized or appropriate. The resident exhibited escalating behaviors including yelling, slapping staff, and required antipsychotic medication. Staff interviews revealed lack of training on restraints and behavior management. The facility educated staff post-incident.
Findings
The facility failed to ensure one resident was free from physical restraints when staff held the resident's arms down during an injection. The facility also failed to provide adequate behavioral health interventions for the resident, who exhibited escalating behaviors culminating in the use of antipsychotic medication. Staff lacked formal training on restraints, behavior modification, and de-escalation.
Deficiencies (2)
Failure to ensure a resident was free from physical restraints during medication administration.
Failure to provide necessary behavioral health care and services for a resident exhibiting catastrophic reactions.
Report Facts
Medication dosage: 500
Medication dosage: 5
Resident census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Administered injection and involved in restraint of Resident #1 |
| Certified Nurse Aide A | Certified Nurse Aide | Assisted in holding Resident #1 during injection |
| Certified Nurse Aide B | Certified Nurse Aide | Assisted in holding Resident #1 during injection and was slapped by resident |
| Medical Director | Medical Director | Interviewed regarding restraint practices |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Ordered medications for Resident #1 and interviewed about treatment |
| Certified Nurse Aide C | Certified Nurse Aide | Interviewed about behavior management and training |
| Administrator | Administrator | Interviewed about staff training and behavior management policies |
Inspection Report
Routine
Census: 26
Deficiencies: 12
Date: Apr 18, 2023
Visit Reason
Routine inspection of Grand River Health Care to assess compliance with resident rights, care, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to deliver mail timely, failure to document advance directives, failure to provide timely transfer/discharge notices, inadequate perineal care, improper use of gait belts and fall reporting, improper gastrostomy tube care and medication administration, medication errors including insulin administration errors, improper medication storage and handling, poor infection control practices, and failure to implement an antibiotic stewardship program.
Deficiencies (12)
Staff failed to knock and announce themselves before entering residents' rooms, violating residents' rights to dignity and respect.
Facility failed to deliver Saturday mail to residents, delaying receipt of mail.
Facility failed to document residents' advance directives in an accessible manner.
Facility failed to provide timely written notice of transfer or discharge to residents or responsible parties.
Dependent residents did not receive complete perineal care; staff failed to separate and cleanse all perineal folds.
Staff failed to use proper gait belt techniques and failed to report and document when a resident was lowered to the floor.
Staff failed to assess gastrostomy tube placement, failed to follow infection control practices during medication administration via feeding tube, and used syringe plungers improperly.
Medication error rate was 20% due to insulin administration errors including failure to prime insulin pens, failure to hold pen in skin for required time, and failure to transcribe physician orders.
Medication was left at resident bedside without staff supervision, medication storage refrigerator temperatures were not logged consistently, staff drinks were stored in medication refrigerator, expired medication was not destroyed, and narcotic counts were not properly signed at shift change.
Dietary staff failed to wash hands after touching trash can lid multiple times, increasing risk of contamination.
Staff failed to follow infection control practices during medication passes including failure to wash/sanitize hands between residents, improper glove use, failure to disinfect feeding tube ports, improper placement and disinfection of glucometers and insulin pens, and improper disposal of wound supplies.
Facility failed to implement and monitor an antibiotic stewardship program; no monthly infection and antibiotic usage logs were maintained for several months, and infections and antibiotic use were not properly tracked or assessed.
Report Facts
Medication error rate: 20
Facility census: 26
Medication errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in multiple medication administration and infection control deficiencies. |
| NA A | Nurse Aide | Named in deficiencies related to perineal care and gait belt use. |
| CNA A | Certified Nurse Aide | Named in deficiencies related to perineal care and gait belt use. |
| DON | Director of Nursing | Provided interviews regarding multiple deficiencies including medication administration, infection control, and fall reporting. |
| Administrator | Administrator | Provided interviews regarding multiple deficiencies including medication storage and resident rights. |
| DM | Dietary Manager | Interviewed regarding handwashing practices in dietary. |
Inspection Report
Routine
Census: 37
Deficiencies: 19
Date: Feb 10, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey of Grand River Health Care to assess compliance with federal and state regulations related to resident rights, care, safety, nutrition, medication administration, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to promptly address resident grievances, failure to notify physicians and responsible parties of condition changes, failure to provide timely transfer/discharge notifications and bed hold information, failure to ensure follow-up appointments, failure to provide appropriate care and services including therapy, medication administration errors, infection control breaches, food safety and preparation issues, and maintenance of equipment and environment.
Deficiencies (19)
Failed to act promptly upon resident council grievances and failed to communicate back with residents regarding their concerns about staff treatment.
Failed to notify a resident's physician and guardian immediately of a significant change in condition.
Failed to ensure residents' grievances were fully addressed and documented for two residents.
Failed to provide timely transfer or discharge notification to residents and their representatives for three residents.
Failed to notify resident and representative in writing of bed hold policy at time of transfer/discharge for one resident.
Failed to ensure follow-up appointment was kept for one resident after hospitalization.
Failed to provide necessary care and services according to orders and respond timely to condition changes for two residents.
Failed to identify cause of injury and implement measures to prevent further injury for one resident with ankle bruising.
Failed to monitor weights, notify physician of dietitian recommendations and weight loss for one resident.
Failed to change oxygen tubing weekly, failed to date tubing and failed to obtain physician orders for oxygen therapy for two residents.
Failed to implement gradual dose reductions and limit PRN psychotropic medication orders to 14 days for two residents.
Failed to administer medications with less than 5% error rate; three medication errors out of 25 opportunities for two residents.
Failed to provide nourishing, palatable, well-balanced diet meeting residents' nutritional and special dietary needs; served mushy broccoli and pureed food with chunks.
Failed to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards; unlabelled and expired food items found; kitchen cleanliness issues including grease, dust, slime, peeling paint, and leaking drains.
Failed to develop a policy regarding use and storage of foods brought to residents by family and visitors.
Failed to assess and provide therapy services for two residents; no speech therapy for resident on pureed diet and no physical therapy after resident requested it.
Failed to provide care to prevent infection or possibility of infection; staff failed to change gloves and wash hands between dirty and clean tasks; failed to wear appropriate PPE in COVID-19 observation unit; dietary staff failed to wear facemask while preparing food.
Failed to maintain dishwasher in safe operating condition; dishwasher broken for several days requiring use of disposable dishware.
Failed to maintain safe, easy to use, clean and comfortable environment; shower drain cover not fastened and parking lot had multiple large potholes posing tripping hazard.
Report Facts
Medication errors: 3
Resident census: 37
Weight loss: 5
Dishwasher hours: 425000
Potholes: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in interview regarding resident condition change and care |
| CNA B | Certified Nurse Aide | Named in infection control observation and medication administration |
| NA A | Nurse Aide | Named in infection control observation |
| DON | Director of Nursing | Named in multiple interviews regarding medication, infection control, and care |
| DM | Dietary Manager | Named in interviews regarding food preparation and kitchen cleanliness |
| CMT B | Certified Medication Technician | Named in medication administration and respiratory care observation |
| NA B | Nurse Aide | Named in infection control observation |
| NA C | Nurse Aide | Named in infection control observation |
| CNA C | Certified Nurse Aide | Named in infection control observation |
| NA D | Nurse Aide | Named in infection control observation |
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