Inspection Reports for
James River Nursing and Rehabilitation
3550 EAST BATTLEFIELD, SPRINGFIELD, MO, 65809-3400
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
7.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
80% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Nov 4, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to honor residents' shower preferences and provide the expected frequency of showers.
Complaint Details
Complaint #2649642 triggered the investigation into shower frequency and resident self-determination regarding bathing preferences.
Findings
The facility failed to provide two showers per week as preferred by residents, resulting in some residents feeling dirty and experiencing skin issues. Staffing shortages and turnover of shower aides contributed to the inability to meet shower frequency expectations.
Deficiencies (1)
F 0561: The facility failed to promote and facilitate resident self-determination by not honoring reasonable shower preferences for three residents. Staffing shortages led to residents not receiving two showers per week as preferred, causing discomfort and skin issues.
Report Facts
Facility census: 96
Number of showers received: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | CNA | Shower aide for 200 hall, reported staffing shortages and resident concerns |
| Certified Nursing Assistant B | CNA | Shower aide for 100 hall, reported being pulled to floor duties and shower shortages |
| Certified Nursing Assistant C | CNA | Reported residents not receiving two showers per week and management awareness |
| Licensed Practical Nurse D | LPN | Reported residents voice concerns about shower frequency and staffing challenges |
| Licensed Practical Nurse E | LPN | Reported uncertainty about residents receiving two showers per week and management review |
| Social Service Director | SSD | Reported resident concerns about shower frequency and staffing challenges |
| Director of Nursing | DON | Reported facility shower policy and staffing changes impacting shower frequency |
Inspection Report
Life Safety
Census: 101
Capacity: 120
Deficiencies: 5
Date: Jul 30, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related regulations, focusing on building construction, fire safety, smoke barriers, and exit signage.
Findings
The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations, lacked proper exit signage on doors leading outside, and did not maintain smoke barrier walls properly. These deficiencies had the potential to affect residents, staff, and visitors in the event of a fire.
Deficiencies (5)
K161: The facility failed to maintain the integrity of the building construction by allowing unsealed penetrations between the attic and areas below, compromising the one-hour fire rating of ceilings. This posed a risk of smoke passage affecting residents and staff.
K293: The facility failed to ensure doors leading outside had appropriate exit signage, including missing 'No Exit' signs on doors leading to an interior courtyard, risking confusion during evacuation.
K372: The facility failed to maintain the smoke barrier walls, allowing unsealed gaps and holes that could permit smoke passage between compartments, risking resident and staff safety during a fire.
A2054: Each smoke section must be separated by one-hour fire-rated walls and doors that self-close or close automatically upon fire alarm activation. This regulation was not met as referenced in K372.
A3001: The building must be substantially constructed and maintained in good repair. This regulation was not met as referenced in K161, with a Class II severity noted.
Report Facts
Facility capacity: 120
Census: 101
Inspection Report
Routine
Census: 101
Deficiencies: 14
Date: Jul 30, 2024
Visit Reason
Routine inspection of James River Nursing and Rehabilitation to assess compliance with regulatory standards including resident rights, care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, failure to support resident self-determination, privacy violations, environmental maintenance issues, failure to provide timely transfer notifications, incomplete PASARR screening, inadequate assistance with activities of daily living, inconsistent code status documentation, improper catheter care, lack of physician orders for CPAP use, improper bed rail maintenance, medication errors, unlocked medication carts, improper dish drying, and infection control lapses during medication administration and blood glucose testing.
Deficiencies (14)
F 0550: The facility failed to treat residents with dignity and respect, including inappropriate staff tone and public discussions, rough transfers, and use of disrespectful names.
F 0561: The facility failed to support resident self-determination by not providing requested baths/showers as care planned for two residents.
F 0583: The facility failed to protect resident privacy when staff failed to shut the door during personal care, exposing a resident to the hallway.
F 0584: The facility failed to maintain a safe, clean, and homelike environment including unrepaired wall damage, stained ceiling, debris under resident's bed, and unsafe electrical outlet use.
F 0623: The facility failed to provide timely written notification to residents and representatives of hospital transfers for three residents, with delays up to 47 days.
F 0645: The facility failed to complete required PASARR screening for one resident prior to or upon admission.
F 0677: The facility failed to provide adequate incontinent care for one resident, including failure to provide peri-care and changing urine-soaked items.
F 0690: The facility failed to ensure catheter use was supported by a documented diagnosis for one resident with an indwelling catheter.
F 0695: The facility failed to obtain a physician's order for CPAP use and failed to ensure consistent respiratory care for one resident with obstructive sleep apnea.
F 0700: The facility failed to ensure proper installation and maintenance of bed rails for one resident, with loose rails that could be moved several inches.
F 0759: The facility failed to ensure medication administration safety, including failure to prime insulin pens and improper mixing and stirring of medications administered via PEG tube.
F 0761: The facility failed to ensure medication carts were locked when unattended, exposing medications to potential unauthorized access.
F 0812: The facility failed to ensure cups and glasses were air dried before storage, resulting in trapped water and potential bacterial growth.
F 0880: The facility failed to maintain proper infection control during medication administration and blood glucose testing, including reusing spilled pills, stirring medications with fingers, and improper glucometer disinfection.
Report Facts
Facility census: 101
Medication error rate: 14
Delay in transfer notice: 47
Delay in transfer notice: 37
Delay in transfer notice: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN T | Licensed Practical Nurse | Named in medication administration and glucometer disinfection findings |
| CNA I | Certified Nursing Assistant | Named in incontinent care finding |
| CNA H | Certified Nursing Assistant | Named in incontinent care finding |
| ADON R | Assistant Director of Nursing | Named in dignity and incontinent care findings |
| LPN G | Licensed Practical Nurse | Named in incontinent care and CPAP findings |
| CMT M | Certified Medication Technician | Named in medication administration and infection control findings |
| LPN U | Licensed Practical Nurse | Named in medication cart and CPAP findings |
| LPN V | Licensed Practical Nurse | Named in glucometer disinfection finding |
| DON | Director of Nursing | Named in multiple findings including medication carts, CPAP, infection control |
| Administrator | Named in multiple findings including medication carts, CPAP, infection control | |
| Maintenance Director | Named in bed rail maintenance finding | |
| Admissions Coordinator | Named in insulin pen priming and medication mixing findings |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Jul 30, 2024
Visit Reason
The inspection was conducted due to complaints regarding staff behavior and treatment of residents, specifically allegations of disrespectful communication, rough transfers, and verbal abuse by staff toward residents.
Complaint Details
The investigation was complaint-driven based on allegations of verbal abuse and rough handling of residents by staff. The complaint was substantiated with multiple staff and resident interviews confirming disrespectful and abusive behavior.
Findings
The facility failed to treat residents with dignity and respect, as staff used inappropriate tone and language, discussed resident concerns in public areas, and transferred a resident roughly. Multiple interviews and record reviews confirmed incidents of verbal abuse and disrespectful behavior by staff toward residents.
Deficiencies (1)
F 0550: The facility failed to honor residents' rights to dignity and respect when staff used inappropriate tone and language, discussed resident concerns publicly, and transferred a resident roughly with verbal abuse.
Report Facts
Facility census: 101
Sample size: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings for rough transfers, verbal abuse, and disrespectful language toward residents |
| LPN L | Licensed Practical Nurse | Involved in managing the situation and interviewed regarding staff behavior |
| DON | Director of Nursing | Provided statements on staff treatment of residents and investigation follow-up |
| RN D | Registered Nurse | Reported verbal abuse incident and assessed resident |
| Administrator | Provided statements on staff behavior and investigation | |
| CNA B | Certified Nurse Aide | Witnessed and reported CNA A's behavior |
| CNA C | Certified Nurse Aide | Witnessed and reported CNA A's behavior |
| ADON R | Assistant Director of Nursing | Involved in discussion with resident and staff during incident |
| CMT M | Provided statements on appropriate staff behavior |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 3
Date: Feb 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation and medication errors involving a Licensed Practical Nurse (LPN) at James River Nursing and Rehabilitation.
Complaint Details
The investigation was substantiated as the facility failed to prevent misappropriation of medications by staff and failed to provide adequate pain management to residents. The arrest of LPN A for possession of controlled substances was part of the investigation.
Findings
The facility failed to keep all residents free from misappropriation when staff could not account for 17 doses of medication affecting twelve residents. Additionally, the facility failed to ensure effective pain management for residents, and there were issues with medication records and administration.
Deficiencies (3)
F602 Free from Misappropriation/Exploitation: The facility failed to keep residents free from misappropriation when 17 doses of medication were unaccounted for, involving multiple residents and staff.
F697 Pain Management: The facility failed to ensure effective pain management for residents, including failure to administer pain medication as ordered and document administration properly.
F842 Resident Records - Identifiable Information: The facility failed to maintain complete and accurate medical records for residents, including medication administration and documentation.
Report Facts
Medication doses unaccounted: 17
Resident census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Alleged perpetrator involved in medication misappropriation |
| LPN C | Licensed Practical Nurse | Involved in narcotics count and investigation |
| LPN D | Licensed Practical Nurse | Involved in narcotics count and investigation |
| ADON | Assistant Director of Nursing | Involved in investigation and narcotics count |
| DON | Director of Nursing | Provided statements and involved in investigation |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 3
Date: Feb 9, 2024
Visit Reason
Investigation of medication misappropriation by a Licensed Practical Nurse (LPN A) involving 17 missing doses affecting twelve residents, and investigation of pain management and treatment documentation concerns.
Complaint Details
The complaint investigation was triggered by allegations of medication misappropriation by LPN A and concerns about pain management and treatment documentation. The investigation confirmed missing medications were found in LPN A's possession and that Resident #8 did not receive pain medication as ordered. Documentation failures were noted for multiple residents.
Findings
The facility failed to keep residents free from misappropriation of medications when 17 doses were unaccounted for but later found in LPN A's pockets. Additionally, the facility failed to administer pain medication to Resident #8 as ordered and failed to document treatments for Residents #2, #4, #9, and #10 properly.
Deficiencies (3)
F 0602: The facility failed to protect residents from misappropriation of medications when 17 doses were missing and found in LPN A's pockets, affecting twelve residents.
F 0697: The facility failed to provide effective pain management when Resident #8 did not receive prescribed pain medication despite requesting it and showing signs of pain.
F 0842: The facility failed to maintain complete and accurate medical records and failed to ensure treatments were administered or documented for Residents #2, #4, #9, and #10.
Report Facts
Missing medication doses: 17
Residents affected: 12
Resident census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Alleged perpetrator of medication misappropriation. |
| LPN C | Licensed Practical Nurse | Witness and participant in narcotic count and medication identification. |
| LPN D | Licensed Practical Nurse | Witness and participant in narcotic count and medication identification. |
| ADON | Assistant Director of Nursing | Managed investigation, covered shifts, and documented medication administration issues. |
| DON | Director of Nursing | Oversaw nursing operations and commented on medication administration policies. |
| CNA B | Certified Nurse Aide | Reported resident pain and medication requests. |
Inspection Report
Plan of Correction
Census: 93
Deficiencies: 2
Date: Jan 4, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to resident self-determination and bathing/showering policies at James River Nursing and Rehabilitation.
Findings
The facility failed to promote resident self-determination by not providing routine baths or showers to four residents as required. Interviews and record reviews showed inconsistent showering schedules, short staffing issues, and lack of policy on shower frequency.
Deficiencies (2)
F561 Self-determination: The facility failed to promote resident self-determination by not providing routine baths or showers to four residents, resulting in resident discomfort and dissatisfaction.
A4077 Residents Groomed/Dressed Appropriately: Residents were not consistently well-groomed or dressed appropriately due to the bathing deficiencies noted under F561.
Report Facts
Resident census: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shower Aide A | Shower Aide | Interviewed regarding shower schedules and staffing |
| Shower Aide B | Shower Aide | Interviewed regarding shower schedules and staffing |
| Certified Nurse Aide C | Certified Nurse Aide (CNA) | Interviewed about resident shower refusals and shower scheduling |
| Licensed Practical Nurse Unit Manager D | Licensed Practical Nurse (LPN) Unit Manager | Interviewed about shower scheduling and documentation |
| Registered Nurse (RN) | Registered Nurse | Interviewed about shower schedules and resident complaints |
| Director of Nursing (DON) | Director of Nursing | Interviewed about shower policies and staff training |
| Administrator | Administrator | Interviewed about facility policies on shower frequency and resident preferences |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 3
Date: Sep 23, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing homes, including nurse staffing information and food safety requirements.
Findings
The facility failed to post daily nurse staffing information in a clear and accessible manner and did not meet food safety requirements related to the cleanliness of the ice machine and proper storage and labeling of food items.
Deficiencies (3)
F732 Nurse staffing information was not posted daily in a clear, readable format and was not readily accessible to residents and visitors. The facility census was 94 at the time of inspection.
F812 The facility failed to ensure food safety by not cleaning the ice machine properly and failing to store opened food items in a manner that protected them from contamination. The facility census was 94.
A7015 Food must be protected from potential contamination at all times, including during storage, preparation, and service. This regulation was not met as referenced in F812.
Report Facts
Facility census: 94
Potentially affected residents: 32
Potentially affected rooms: 15
Potentially affected rooms: 2
Inspection Report
Life Safety
Census: 94
Capacity: 120
Deficiencies: 2
Date: Sep 23, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the smoke resistive properties of corridor doors, with multiple resident room doors having gaps that could allow smoke passage. This deficiency posed a potential risk to all residents, staff, and visitors in the event of a fire.
Deficiencies (2)
K363 Corridor doors did not maintain smoke resistive properties as several resident room doors had gaps around latch edges and top edges, compromising fire safety. The facility failed to ensure all doors were latched and sufficiently sealed, risking smoke passage into exit corridors.
A3001 The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2), with deficiencies referenced to K363. This regulation was not met, resulting in a Class II violation.
Report Facts
Facility capacity: 120
Census: 94
Residents potentially affected: 32
Rooms potentially affected: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and stated unawareness of resident doors not fully sealing | |
| Administrator | Interviewed and stated unawareness of problems or gaps around resident room doors |
Inspection Report
Routine
Census: 94
Deficiencies: 2
Date: Sep 23, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse staffing postings and food safety practices in the facility.
Findings
The facility failed to post daily nurse staffing information in a clear and accessible manner. Additionally, the facility did not ensure food safety standards were met, including unclean ice machine components and improper storage of opened food items.
Deficiencies (2)
F 0732: The facility failed to post daily nurse staffing information in a clear, readable format in a prominent place accessible to residents and visitors. Multiple observations from 09/19/22 to 09/23/22 confirmed the absence of posted nurse staffing information.
F 0812: The facility failed to ensure food was protected from contamination due to an unclean ice machine reflector shield and improper storage of opened food items, including unsealed and unlabeled products.
Report Facts
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN M | Licensed Practical Nurse | Interviewed regarding nurse staffing posting |
| RN F | Registered Nurse | Interviewed regarding nurse staffing posting |
| DA K | Dietary Aide | Interviewed regarding ice machine cleaning and food storage |
| DA L | Dietary Aide | Interviewed regarding ice machine cleaning and food storage |
| DM | Dietary Manager | Interviewed regarding ice machine cleaning and food storage |
| Administrator | Interviewed regarding nurse staffing posting and food safety practices | |
| Director of Nursing | Interviewed regarding nurse staffing posting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 22, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 infection control and emergency preparedness. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with relevant CMS and CDC guidelines related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices related to COVID-19 infection control and emergency preparedness.
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 5
Date: Oct 9, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for James River Nursing and Rehabilitation facility.
Findings
The facility was found deficient in reasonable accommodations for resident needs, medication error rates exceeding 5%, improper storage and labeling of medications, food safety violations, and infection control deficiencies. Multiple observations, interviews, and record reviews documented these issues affecting resident care and safety.
Deficiencies (5)
F558 Reasonable accommodations needs/preferences were not met as staff failed to provide adequate lighting for a resident to engage in independent activities. The facility census was 106.
F759 Medication error rates exceeded 5 percent with two errors out of 27 opportunities affecting two residents. The facility census was 106.
F761 Facility failed to store medications according to professional standards and manufacturer guidelines, including unlocked medication carts and expired medications. The facility census was 106.
F812 Food safety requirements were not met as stove and fryer had grease and lint buildup risking contamination. The facility census was 106.
F880 Infection control program deficiencies included failure to use appropriate procedures during blood glucose testing on two residents. The facility census was 106.
Report Facts
Facility census: 106
Medication error rate: 7.4
Medication errors: 2
Number of residents affected: 2
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 9, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and licensure requirements for James River Nursing and Rehabilitation.
Findings
The facility met applicable provisions of the 2012 Life Safety Code with no deficiencies in emergency preparedness or licensure cited during this inspection.
Inspection Report
Routine
Census: 106
Deficiencies: 5
Date: Oct 9, 2019
Visit Reason
Routine inspection to assess compliance with regulatory standards including resident accommodations, medication administration, medication storage, food safety, and infection control.
Findings
The facility failed to provide reasonable accommodations for a resident's visual needs, had medication administration errors exceeding 5%, improper medication storage including expired and undated insulin, inadequate cleaning of kitchen equipment, and improper infection control practices during blood glucose testing.
Deficiencies (5)
F 0558: Facility failed to provide reasonable accommodations for a resident's visual needs by not replacing a broken overhead lamp, affecting independent activities.
F 0759: Medication error rate exceeded 5% with two errors out of 27 opportunities during insulin administration affecting two residents.
F 0761: Medications were not stored properly; expired medications were present, opened insulin vials were undated, and medication carts were left unlocked.
F 0812: Food safety compromised due to grease and lint build-up on stove and tilt fryer, and incomplete cleaning schedules.
F 0880: Infection control procedures were not followed during blood glucose testing, contaminating glucose test strips and risking resident infections.
Report Facts
Facility census: 106
Medication error rate: 7.4
Medication errors: 2
Medication opportunities: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Administered insulin with errors and observed during blood glucose testing with improper infection control | |
| Certified Medication Technician (CMT) F | Observed leaving medication cart unlocked and accessing medication without key | |
| Director of Nursing (DON) | Provided statements on medication administration, storage policies, and infection control expectations | |
| Licensed Practical Nurse (LPN) E | Interviewed regarding medication cart locking, insulin administration, and infection control procedures | |
| Dietary Manager (DM) | Discussed cleaning schedules and expectations for kitchen equipment cleanliness | |
| Dietary Aides and Cooks | Interviewed regarding cleaning duties and practices |
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 5
Date: Aug 10, 2018
Visit Reason
The inspection was conducted as an annual survey of James River Nursing and Rehabilitation to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found to have multiple deficiencies including failure to provide timely Medicaid/Medicare coverage notices, insufficient nursing staff to meet resident needs, inadequate incontinence care, failure to provide showers as scheduled, food safety violations, and issues with the resident call system and environmental sanitation.
Deficiencies (5)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notices or denial letters for Medicare Part A services to certain residents and did not ensure proper documentation of resident choices.
F725 Sufficient Nursing Staff: The facility failed to have sufficient nursing staff to meet resident needs, resulting in inadequate assistance with bathing, incontinence care, and timely clothing changes for multiple residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to serve food under sanitary conditions, including staff not washing hands properly and food contamination risks in the kitchen.
F919 Resident Call System: The facility failed to provide a functioning call light system in all resident toilet rooms, compromising resident safety.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain clean non-food contact surfaces in the kitchen and had food safety hazards such as food crumbs and splatter in food prep areas.
Report Facts
Facility census: 109
Residents affected: 5
Residents affected: 3
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK M | Housekeeping | Named in relation to failure to properly document two-step TB test |
| N | Licensed Practical Nurse (LPN) | Named in relation to failure to properly document two-step TB test |
| C | Certified Nurse Aide (CNA) | Named in relation to failure to properly document two-step TB test |
| Laundry O | Laundry Personnel | Named in relation to failure to properly document two-step TB test |
Inspection Report
Annual Inspection
Census: 109
Capacity: 120
Deficiencies: 10
Date: Aug 10, 2018
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and related fire safety regulations.
Findings
The facility failed to meet several Life Safety Code requirements including unsealed fire sprinkler penetrations, self-closing doors not functioning properly, presence of portable space heaters, improper use of power strips, and failure to conduct annual fuel quality testing for the emergency generator. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (10)
K161: Facility failed to maintain fire resistive properties of the ceiling by allowing fire sprinkler head penetrations to remain open to the attic. This posed a risk of fire spreading due to heat bypassing sprinkler activation.
K223: Doors with self-closing devices did not close automatically upon activation of the fire alarm, allowing smoke to pass from the kitchen to the exit corridor, increasing fire risk.
K781: Portable space heaters were found in resident rooms, which is prohibited and increased fire risk in the affected smoke compartments.
K918: Facility failed to assure proper operation of the emergency generator by not conducting an annual fuel quality test, risking generator failure during power outages.
K920: Improper use of power strips including piggybacking and overloaded strips in resident rooms increased fire hazard risk.
A2008: Hazardous areas were not properly separated by fire-resistant construction and self-closing doors as required.
A2018: Facility failed to install fire alarm pull stations at or near two nurses' stations, delaying fire detection and response.
A3001: Building was not maintained in good repair per construction standards, with references to K161 and K918 deficiencies.
A3027: Heating system did not comply with regulations restricting portable heaters; portable heater use was prohibited but found in use.
A3030: Electrical wiring and equipment were not properly maintained, with unsafe use of power strips and cords as detailed in K920.
Report Facts
Facility capacity: 120
Resident census: 109
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Mar 8, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident at James River Nursing and Rehabilitation.
Complaint Details
The complaint was substantiated as the facility failed to report an allegation of verbal abuse by a staff member against a resident within the required time frame.
Findings
The facility failed to report an allegation of abuse to the state licensing agency within the required timeframe for one resident. Documentation and interviews revealed verbal abuse by staff towards a resident was not reported immediately as required by policy and state regulations.
Deficiencies (2)
F609: The facility failed to report an allegation of abuse to the state licensing agency within the required time frame for one resident. Documentation showed verbal abuse by staff was not reported immediately as required.
A8025: The facility did not immediately report or cause a report to be made to the Department of Health and Senior Services when there was reasonable cause to suspect abuse or neglect of a resident.
Report Facts
Resident census: 109
Date of incident: Feb 27, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant A | CNA | Named in verbal abuse allegation and statement |
| Certified Nurse Assistant B | CNA | Named in verbal abuse allegation and statement |
| Certified Nurse Assistant C | CNA | Named in verbal abuse allegation and statement |
| Licensed Practical Nurse D | LPN | Informed Director of Nursing about incident |
| Administrator | Administrator | Interviewed regarding abuse reporting and investigation |
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