Inspection Reports for
Great River Care Center

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.

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.

The visit was complaint-related due to a resident elopement incident on 11/2/25. The Immediate Jeopardy was identified and removed after corrective actions were implemented. The resident was found safe but exposed to risk during the elopement.

The facility failed to ensure staff maintained all secured exit doors, allowing a cognitively impaired resident to exit the facility unnoticed and walk approximately 0.8 miles on a busy highway before being found and returned by police. The facility implemented corrective actions including wander guard placement, staff education, and missing resident drills to remove the Immediate Jeopardy.

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.

The facility failed to provide a water flush per physician order, measure the formula amount accurately during feeding setup, and raise the head of the bed to 45 degrees during feeding for Resident #4. Observations and interviews confirmed non-compliance with feeding tube care policies.

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.

The facility failed to revise the Care Plan to include hospice care for Resident #24 despite the resident being admitted to hospice. Interviews with nursing staff confirmed the expectation to update care plans promptly, but the hospice focus was missing. The facility policy requires comprehensive and regularly updated care plans.

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.

The visit was complaint-related, investigating allegations of undignified toileting care and improper medication administration. The complaints were substantiated with observations and staff interviews confirming the deficiencies.

The facility failed to maintain cleanliness of a resident's toilet seat, compromising dignity, and failed to administer eye drop medications correctly for another resident, not following physician orders or manufacturer guidelines. Both deficiencies were determined to cause minimal harm with few residents affected.

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.