Inspection Reports for Great River Care Center
1400 West Main, IA, 571570370
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 2, 2025, identified a deficiency related to inadequate supervision and unsecured exit doors that allowed a cognitively impaired resident to elope, creating an Immediate Jeopardy situation that was resolved with corrective actions. Earlier inspections showed a pattern of deficiencies involving resident care issues such as feeding management, care plan updates, medication administration, and skin care assessment. Complaint investigations were mostly unsubstantiated except for the recent substantiated elopement case. No fines, license suspensions, or other enforcement actions were listed in the available reports. The facility’s record shows some recurring care-related issues, with recent actions addressing immediate risks and prior plans of correction accepted to maintain compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
31 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Dec 2, 2025
Visit Reason
The inspection was conducted following investigation of facility reported incidents and complaints, including complaint #2658415-C which resulted in a deficiency related to a resident elopement incident.
Findings
The facility failed to ensure adequate supervision and secure exit doors, resulting in a cognitively impaired resident eloping from the facility and walking approximately 0.8 miles on a busy highway. This incident created an Immediate Jeopardy situation that was later removed after corrective actions including wander guard placement and staff education.
Complaint Details
Complaint #2658415-C was substantiated and resulted in a deficiency. The Immediate Jeopardy began on 2025-11-02 and was removed on 2025-11-03 after corrective actions were implemented.
Severity Breakdown
SS = SQC-J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain secured exit doors and provide adequate supervision to prevent resident elopement. | SS = SQC-J |
Report Facts
Census: 31
Distance walked by resident: 0.8
MDS BIMS score: 11
Morse Fall Scale score: 80
Temperature at time of elopement: 41
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 11, 2025
Visit Reason
The document is a plan of correction acceptance following a survey ending August 21, 2025, certifying the facility in compliance effective September 5, 2025.
Findings
The facility submitted a credible allegation of substantial compliance and a Plan of Correction for the prior survey. No specific deficiencies are detailed in this document.
Report Facts
Survey end date: Aug 21, 2025
Inspection Report
Annual Inspection
Census: 29
Deficiencies: 1
Aug 21, 2025
Visit Reason
The inspection was conducted as an annual recertification survey of the Great River Care Center from August 18, 2025 to August 21, 2025.
Findings
The facility was found deficient in the management of tube feeding and restoration of eating skills for Resident #4, including failure to provide a water flush per physician order and improper feeding tube care. Staff were re-educated on the enteral feeding policy and competency was documented.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide a water flush per physician order, measure formula amount during feeding set up, and raise the head of the bed to 45 degrees during feeding for Resident #4. | D |
Report Facts
Resident census: 29
Completion date: Sep 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Obtained verbal physician order to send Resident #4 to emergency department |
| Staff B | Registered Nurse (RN) | Administered feeding and water flushes to Resident #4 |
| Staff C | Certified Nursing Assistant (CNA) | Reported Resident #4's inability to verbalize and carry a conversation |
| Director of Nursing | Explained physician orders and expected nurses to verify orders and competency |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 14, 2024
Visit Reason
The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective October 3, 2024. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 1
Oct 2, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from September 30, 2024 to October 2, 2024.
Findings
The facility failed to revise the comprehensive care plan to include hospice care for one resident (Resident #24) who was admitted to hospice. Interviews and policy review confirmed the care plan lacked a hospice focus area as of the survey date.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to revise the Care Plan to include hospice care for Resident #24. | SS=D |
Report Facts
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Consultant | In charge of updating Care Plans upon admission and as changes occur |
| Staff B | Nurse Consultant | Assisted with Care Plan updates and expected updates by next business day |
| Assistant Director of Nursing | Explained Staff A's role in updating Care Plans |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 7, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification effective November 3, 2023.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 2
Oct 26, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey from October 23, 2023 to October 26, 2023.
Findings
The facility was found to have deficiencies related to resident rights and dignity, including failure to maintain clean toileting facilities and failure to administer eye drop medications according to physician orders and manufacturer instructions. The facility also failed to ensure staff followed proper medication administration protocols.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to uphold resident dignity related to toileting assistance and cleanliness of the resident's toilet seat. | SS=D |
| Failure to administer medicated eye drops per physician orders and manufacturer's prescribing information. | SS=D |
Report Facts
Resident census: 27
Resident sample size: 6
Resident sample size: 1
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 5, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on April 4, 2023 through April 5, 2023 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. An investigation of a facility self-reported incident resulted in no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2022
Visit Reason
A complaint investigation was conducted for complaints #105833-C and #106695-C and a facility reported incident #106904-I from September 6 to 8, 2022.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Complaint investigation for complaints #105833-C and #106695-C and facility reported incident #106904-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 22, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and ensure compliance.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and the submitted plan of correction effective July 22, 2022.
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 1
Jul 21, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey from July 18, 2022 to July 21, 2022.
Findings
The facility failed to meet the quality of care requirement for one resident related to skin care concerns, including inadequate assessment and documentation of a large bruise. The facility reported a census of 26 residents during the inspection.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents receive treatment and care in accordance with professional standards, specifically related to skin care and assessment of bruising for Resident #5. | SS=D |
Report Facts
Resident census: 26
Medication doses: 2.5
Medication doses: 5
Bruise size: 10
Bruise size: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A RN | Registered Nurse | Interviewed regarding initiation of a new skin sheet and skin assessment |
| DON | Director of Nursing | Interviewed regarding resident bath and bruise observation |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 26, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification Survey in accordance with Medicare Requirements for Long Term Care Facilities.
Findings
The facility was found to be in compliance with all applicable Medicare requirements during the survey conducted from 2021-08-23 to 2021-08-26.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 19, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on November 18-19, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 23, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on September 21 - 23, 2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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