Deficiencies (last 4 years)
Deficiencies (over 4 years)
25 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
355% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
51% occupied
Based on a November 2025 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a deficiency related to the facility's failure to obtain a discharge order and provide a comprehensive discharge summary for a resident.
Findings
The facility failed to obtain a physician's discharge order and did not provide the resident or representative with a comprehensive discharge summary including all required information such as diagnosis, treatment, lab results, post-discharge care instructions, and medication reconciliation for one resident out of three sampled.
Deficiencies (1)
Failure to obtain a discharge order and provide a comprehensive discharge summary including diagnosis, treatment, lab results, post-discharge care instructions, and medication reconciliation.
Report Facts
Residents Affected: 1
Facility Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding discharge process and physician order | |
| Administrator | Interviewed regarding expectations for discharge process and documentation |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Oct 28, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to document medication administration for three residents and an injury caused by improper nail care resulting in infection and hospitalization.
Complaint Details
The complaint investigation substantiated that facility staff failed to document medication administration for three residents and that a nursing assistant caused an injury to a resident's finger with an electric nail file, resulting in infection and hospitalization.
Findings
The facility failed to document administration of medications as ordered for three residents, and a nursing assistant caused an injury to a resident's finger using an electric nail file, which led to infection, hospitalization, and surgery.
Deficiencies (2)
Failure to document medication administration for three residents as directed by the physician.
Failure to prevent injury to a resident when a nursing assistant used an electric nail file causing a finger injury, infection, and hospitalization.
Report Facts
Facility census: 44.1
Residents affected: 3
Residents affected: 1
Dates of missed medication documentation: 7
Date of injury onset: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nursing Assistant | Named in injury caused by use of electric nail file on resident's finger |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: May 6, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify the physician timely about an allegation of inappropriate touching between two residents and failure to document medication administration for three residents.
Complaint Details
The complaint involved failure to notify the physician timely about an allegation of inappropriate touching between Resident #1 and Resident #2, and failure to document medication administration for Residents #1, #2, and #3. The complaint was substantiated with findings of minimal harm or potential for actual harm.
Findings
The facility failed to notify the physician in a timely manner about an allegation of inappropriate touching between two residents and failed to document medication administration for three residents, including missed documentation of multiple medications and nutritional feedings. The administrator and Director of Nursing acknowledged these issues and concerns about weekend nursing staff.
Deficiencies (2)
Failed to notify the physician in a timely manner for two residents regarding an allegation of inappropriate touching.
Failed to document medication administration for three residents, including multiple missed documentation dates for various medications and nutritional feedings.
Report Facts
Facility census: 39
Medication documentation failures: 22
Medication documentation failures: 11
Medication documentation failures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Mentioned as weekend nurse with concerns about medication administration and needing more training |
| Administrator | Responsible for investigation and acknowledged failure to notify physician | |
| Director of Nursing (DON) | Responsible for notification of physician and acknowledged complaints about weekend nurse not giving medications |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with professional standards of care and nursing staffing requirements at River City Living Community.
Findings
The facility failed to meet professional standards in documenting neurological checks after unwitnessed falls for multiple residents. Additionally, the facility did not provide a registered nurse for at least eight consecutive hours per day, seven days a week, as required.
Deficiencies (2)
F658: The facility failed to ensure services met professional standards by not documenting neurological checks after unwitnessed falls for three residents. The facility census was 40 at the time of inspection.
F727: The facility failed to provide a registered nurse for at least eight consecutive hours per day, seven days per week, as required by regulation. The facility census was 40 at the time of inspection.
Report Facts
Facility census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janette Patton | LDHA | Signed the report as Director or Provider/Supplier Representative |
| Janette Patton | LDHA | Signed the plan of correction |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Date: Feb 13, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to document and complete neurological checks after unwitnessed falls and failure to provide adequate RN coverage.
Complaint Details
The complaint investigation found that staff failed to complete neurological checks after unwitnessed falls for three residents and failed to maintain required RN coverage. The Director of Nursing and administrator acknowledged these failures during interviews.
Findings
The facility failed to ensure professional standards of care by not completing neurological checks for three residents after unwitnessed falls and failed to provide a registered nurse on duty for at least eight consecutive hours daily on multiple dates.
Deficiencies (2)
Failure to document and complete neurological checks for three residents after unwitnessed falls.
Failure to provide a registered nurse on duty for at least eight consecutive hours per day, seven days per week.
Report Facts
Residents affected: 3
Facility census: 40
Dates without RN coverage: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations and oversight of neurological checks and RN coverage |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed about staff directions for documenting neurological checks |
| Administrator | Administrator | Interviewed about RN scheduling and responsibility for ensuring RN coverage |
| Physician | Physician | Interviewed about expectations for neurological checks after falls |
Inspection Report
Census: 60
Deficiencies: 2
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to accident hazards, supervision, and devices to ensure resident safety, specifically focusing on smoking residents and the management of smoking materials.
Findings
The facility failed to ensure the resident environment remained free of accident hazards as staff did not secure lighters for three sampled residents who smoked. The facility also failed to provide adequate protective oversight for residents on voluntary leave.
Deficiencies (2)
F689: The facility did not ensure the resident environment remained free of accident hazards as staff failed to secure lighters for three residents who smoked. This posed a risk of fire or explosion, especially for residents using oxygen.
A4074: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, including procedures to track residents' whereabouts and length of absence.
Report Facts
Facility census: 60
Inspection Report
Routine
Census: 60
Deficiencies: 1
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, specifically related to the secure storage of lighters for residents who smoke.
Findings
Facility staff failed to ensure lighters were kept secure for three out of three sampled residents who smoked, despite policies allowing only disposable safety lighters. Observations and interviews confirmed residents kept lighters in their rooms, which posed a safety risk, especially for residents with oxygen in their rooms.
Deficiencies (1)
Facility staff failed to ensure lighters were kept secure for three sampled residents, posing accident hazards.
Report Facts
Residents affected: 3
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide A | Certified Nurse Aide (CNA) | Interviewed regarding knowledge of residents keeping lighters in rooms and safety concerns |
| MDS Coordinator | Interviewed about policy allowing residents to keep disposable lighters in their rooms | |
| Administrator | Interviewed about policy and safety concerns related to residents keeping lighters on their person and oxygen use |
Inspection Report
Life Safety
Census: 39
Capacity: 87
Deficiencies: 28
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with life safety code regulations, including fire safety, emergency preparedness, and facility safety features.
Findings
The facility was found to have multiple deficiencies related to emergency preparedness communication, fire safety equipment maintenance, fire drills, and life safety code compliance. Several fire doors, sprinkler systems, and emergency procedures were not properly maintained or documented.
Deficiencies (28)
E030 Emergency preparedness communication plan failed to include names and contact information for all staff, potentially delaying emergency response. The facility census was 39 with a capacity of 87.
E037 Emergency preparedness training was not provided annually to all staff, risking delayed emergency response. Training records lacked documentation for the period September 2023 through September 2024.
E039 Emergency preparedness testing requirements were not met; the facility failed to document participation in required full-scale or functional exercises. The census was 39 with a capacity of 87.
K222 Access-controlled egress doors failed to open within 15 seconds of manual actuation, delaying evacuation. The facility census was 39 with a capacity of 87.
K271 Exit discharge areas were obstructed and not maintained free of hazards, impeding safe egress. The facility census was 39 with a capacity of 87.
K321 Hazardous areas were not equipped with self-closing doors, risking fire and smoke containment failure. Maintenance and preventative maintenance plans were incomplete.
K346 Fire alarm system was out of service for more than four hours without proper notification or fire watch, risking occupant safety. The facility census was 39 with a capacity of 87.
K353 Dry sprinkler system lacked complete and verifiable documentation of installation and maintenance, risking system failure during emergencies.
K355 Portable fire extinguishers were not inspected monthly as required, risking unavailability during fire emergencies. Maintenance records were incomplete.
K363 Corridor doors failed to maintain positive latching and containment of smoke and fire, risking occupant safety. Maintenance and inspection records were incomplete.
K374 Fire barrier doors had holes and were not maintained, risking fire and smoke spread. Maintenance and inspection records were incomplete.
K712 Fire drills were not conducted quarterly on all shifts, risking unpreparedness for emergencies. Documentation of drills was incomplete.
K761 Metal roll doors separating kitchen and dining areas failed to close during fire alarm activation, risking fire spread. Doors will no longer be used during meal service.
K918 Emergency electrical systems, including generator and circuit breakers, were not inspected or maintained as required, risking power failure during emergencies.
K920 Electrical equipment, including power cords and surge protectors, were not maintained or inspected properly, risking electrical hazards. The facility census was 39 with a capacity of 87.
K923 Oxygen storage areas were not properly secured or marked with required signage, risking fire hazards. The facility census was 39 with a capacity of 87.
A2008 Hazardous areas were not separated by fire-resistant construction and lacked self-closing doors, risking fire spread. This was a Class II deficiency.
A2010 Oxygen storage was not in accordance with NFPA 99 standards, risking fire hazards. This was a Class III deficiency.
A2016 Fire extinguishers were not properly maintained or inspected monthly, risking unavailability during fire emergencies. This was a Class III deficiency.
A2017 Range hood certification was not maintained as required, risking fire hazards. This was a Class III deficiency.
A2025 Fire alarm system was out of service for more than four hours without proper notification or fire watch, risking occupant safety. This was a Class II deficiency.
A2034 Sprinkler system was not inspected, tested, or maintained as required, risking system failure during emergencies. This was a Class II deficiency.
A2036 Sprinkler system was out of service for more than four hours without proper notification or fire watch, risking occupant safety. This was a Class II deficiency.
A2054 Smoke section walls and doors were not maintained to fire rating standards, risking fire spread. This was a Class II deficiency.
A2058 Fire drills and emergency preparedness plans were incomplete or missing required documentation, risking unpreparedness for emergencies. This was a Class II deficiency.
A2061 Fire drill requirements for resident evacuation were not met; drills were not conducted as required. This was a Class II deficiency.
A3037 Extension cords and duplex receptacles were not used or maintained according to standards, risking electrical hazards. This was a Class III deficiency.
A4022 Employee orientation and continuing education on infection control and emergency preparedness were not provided as required. This was a Class III deficiency.
Report Facts
Facility census: 39
Total capacity: 87
Deficiencies cited: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Mentioned in relation to emergency preparedness and fire safety findings and plan of correction | |
| Director of Nursing | DON | Mentioned in relation to emergency preparedness and oxygen safety training |
| Maintenance Director | Mentioned in relation to fire safety inspections and maintenance findings | |
| Maintenance Supervisor | Mentioned in relation to fire safety and maintenance reports | |
| Registered Nurse D | RN | Interviewed regarding emergency preparedness communication |
| Dietary Manager | DM | Mentioned in relation to fire door inspections |
Inspection Report
Annual Inspection
Census: 39
Capacity: 87
Deficiencies: 11
Date: Oct 4, 2024
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements including care planning, professional standards, activities, staff competencies, food service, infection control, antibiotic stewardship, and vaccination documentation.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans addressing resident needs, failure to maintain professional standards in obtaining physician ordered blood work, inadequate activity programming and lack of qualified activity director, insufficient staff training and competency documentation, improper food portioning and unsafe food storage, inadequate infection prevention practices including improper oxygen and nebulizer equipment storage and wound care hygiene, failure to implement an effective antibiotic stewardship program, and incomplete documentation of pneumococcal and COVID-19 vaccinations and education.
Deficiencies (11)
Failure to develop and implement complete care plans addressing oxygen use, medication self-administration, shower preferences, and fall prevention for sampled residents.
Failure to maintain professional standards by not obtaining physician ordered blood work for four sampled residents.
Failure to provide ongoing activity programs on weekends and evenings and failure to meet needs of dependent residents.
Failure to ensure the activities program was directed by a qualified professional; activity director was not certified.
Failure to ensure nursing staff had appropriate competencies and training, including required annual in-service education and documentation of skills and competencies.
Failure to serve food in accordance with nutritionally calculated menus; portions served were less than menu directed.
Failure to store food properly to prevent contamination and use of outdated food items; multiple food items were undated, open to air, or improperly stored.
Failure to maintain infection prevention and control program; oxygen and nebulizer equipment improperly stored, suction machine not cleansed, and improper hand hygiene during wound care.
Failure to implement an effective antibiotic stewardship program; no current and ongoing antibiotic log maintained for residents with active infections.
Failure to document administration or refusal of pneumococcal vaccine for three sampled residents.
Failure to provide and document education regarding COVID-19 vaccination benefits, risks, and side effects for facility staff.
Report Facts
Facility census: 39
Facility total capacity: 87
Deficiencies cited: 11
Blood work not obtained: 4
Residents affected by infection control issues: 6
Residents affected by wound care hand hygiene issues: 2
Residents affected by pneumococcal vaccine documentation issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Named in infection control and wound care hand hygiene findings |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including care plan oversight, blood work process, infection control, antibiotic stewardship, and vaccination documentation |
| Administrator | Facility Administrator | Named in oversight and responsibility for multiple deficient areas |
| MDS Coordinator | Minimum Data Set Coordinator | Named in care plan development and update deficiencies |
| Activity Director | Activity Director | Named in activity program and certification deficiencies |
| Certified Medication Technician C | Certified Medication Technician | Named in activity program deficiencies |
| Certified Nurse Aid G | Certified Nurse Aide | Named in staff training deficiencies |
| Certified Medication Technician D | Certified Medication Technician | Named in staff training deficiencies |
| Certified Nurse Aid F | Certified Nurse Aide | Named in infection control deficiencies |
| Registered Nurse A | Registered Nurse | Named in infection control deficiencies |
| Infection Preventionist | Infection Preventionist | Named in antibiotic stewardship and infection control deficiencies |
| Dietary Manager | Dietary Manager | Named in food service deficiencies |
| Cook [NAME] I | Cook | Named in food portioning and food storage deficiencies |
Inspection Report
Annual Inspection
Census: 39
Capacity: 87
Deficiencies: 11
Date: Oct 4, 2024
Visit Reason
The inspection was the annual survey of River City Living Community to assess compliance with federal and state regulations for nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to develop comprehensive care plans, maintain professional standards of care, provide adequate activity programs, ensure sufficient nursing staff competencies, and comply with infection control and immunization requirements. The facility census was 39 with a licensed capacity of 87 beds.
Deficiencies (11)
F656: The facility failed to develop and implement comprehensive, person-centered care plans for residents, including addressing oxygen use, shower preferences, and fall prevention. The facility census was 39.
F658: Staff failed to maintain professional standards of care by not obtaining physician-ordered blood work for four of six sampled residents. The facility census was 39.
F679: The facility failed to provide an ongoing activity program that met the needs of dependent residents on weekends and evenings. The facility census was 39.
F680: The activities program was not directed by a qualified professional as required. The census was 39.
F726: The facility failed to ensure nursing staff had the competencies and skills to meet residents' needs, including nurse aides not receiving required annual in-service education. The census was 39.
F803: The facility failed to serve food in accordance with nutritionally calculated menus and did not serve correct portion sizes. The census was 39 with a capacity of 87.
F812: Food safety requirements were not met as food was stored improperly, including undated and open food items. The census was 39 with a capacity of 87.
F880: The facility failed to maintain an effective infection prevention and control program, including improper storage of oxygen equipment and failure to perform hand hygiene during wound care. The census was 39.
F881: The facility failed to implement an effective antibiotic stewardship program to monitor and track antibiotic use and infections. The census was 39.
F883: The facility failed to properly administer and document influenza and pneumococcal immunizations for residents. The census was 39.
F887: The facility failed to develop and implement policies and procedures for COVID-19 immunizations for staff, including education and documentation. The census was 39.
Report Facts
Facility census: 39
Total capacity: 87
Deficiencies cited: 11
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 4
Date: Jun 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged sexual abuse incident involving a resident and a Certified Nurse Assistant (CNA).
Complaint Details
The complaint investigation substantiated an Immediate Jeopardy level violation due to sexual abuse of a resident by a CNA. The facility failed to protect the resident, failed to report the abuse timely, and failed to train staff adequately. The Immediate Jeopardy was removed on 05/30/2024 after corrective actions were implemented.
Findings
The facility failed to protect a resident from sexual abuse by a CNA, who assaulted the resident and continued to work additional shifts after the incident was observed. The facility also failed to report the abuse timely and did not ensure all staff were trained on abuse and neglect policies.
Deficiencies (4)
F600 Freedom from Abuse and Neglect: The facility failed to protect one resident from sexual abuse by a CNA and did not report the abuse immediately. The CNA continued to work additional shifts after the abuse was observed.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to ensure all staff were trained on abuse and neglect policies, with two out of four sampled CNAs not trained upon hire.
F609 Reporting of Alleged Violations: The facility failed to report an allegation of sexual abuse within the required two-hour timeframe to the Department of Health and Senior Services.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate allegations of sexual abuse, including interviewing residents and staff and completing a timely investigation.
Report Facts
Facility census: 52
Additional shifts worked by CNA A after abuse: 18
Number of sampled staff not trained on abuse policy: 2
Timeframe for reporting abuse: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Perpetrator of sexual abuse against resident |
| CNA D | Certified Nurse Assistant | Witnessed the sexual abuse and did not intervene or report immediately |
| Administrator | Administrator | Notified of Immediate Jeopardy and responsible for corrective actions |
| Director of Nursing | Director of Nursing (DON) | Directed staff to remove resident to safety and report abuse |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 4
Date: Jun 26, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged sexual assault by a Certified Nurse Assistant (CNA A) on a resident with dementia.
Complaint Details
The complaint involved an alleged sexual assault by CNA A on Resident #1, who has dementia. CNA D witnessed the assault but delayed reporting it for about a month, wanting proof. CNA A worked 18 additional shifts after the assault before the incident was reported to the administrator on 05/13/24. The administrator failed to report the abuse to the Department of Health and Senior Services within the required two-hour timeframe. The investigation was incomplete and did not include interviews with the resident or other residents, nor observation of behaviors.
Findings
The facility failed to protect a resident from sexual abuse by CNA A, who sexually assaulted the resident. CNA D witnessed the assault but did not intervene or report it immediately. The facility also failed to timely report the abuse to the state agency and did not ensure proper abuse and neglect training for staff. The investigation was incomplete as it lacked resident interviews and observation of behaviors.
Deficiencies (4)
Failure to protect a resident from sexual abuse by a staff member.
Failure to implement abuse and neglect policies and procedures to ensure all staff were trained on abuse and neglect policy upon hire.
Failure to timely report suspected abuse to the state agency within the required two-hour timeframe.
Failure to conduct a thorough investigation including interviewing residents and observing behaviors.
Report Facts
Facility census: 52
CNA A additional shifts worked after assault: 18
Date of inspection completion: Jun 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Perpetrator of sexual assault on resident |
| CNA D | Certified Nurse Assistant | Witness to sexual assault who delayed reporting |
| Administrator | Facility Administrator | Responsible for reporting abuse and overseeing investigation |
| Director of Nursing | Director of Nursing (DON) | Responsible for staff training and abuse investigation oversight |
| RN C | Registered Nurse | Interviewed regarding investigation procedures |
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
This inspection was conducted as a re-inspection following a previous finding of non-compliance related to misappropriation of resident medication by a Licensed Practical Nurse (LPN).
Findings
The facility failed to prevent misappropriation of a resident's pain medication by an LPN without authorization. The administrator was notified, the employee was terminated, and staff were re-educated on abuse and neglect policies.
Deficiencies (1)
F 602 Free from Misappropriation/Exploitation: The facility failed to prevent misappropriation when an LPN misappropriated a resident's pain medication without authorization. The administrator terminated the LPN and notified appropriate parties.
Report Facts
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in misappropriation of resident medication finding |
| Administrator | Administrator | Notified of non-compliance and involved in corrective actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Involved in investigation and notification |
| Certified Medication Tech B | Certified Medication Technician | Interviewed regarding LPN's behavior |
| Certified Nursing Assistant C | Certified Nursing Assistant | Interviewed regarding LPN's condition |
| Police Officer F | Police Officer | Responded to report of stolen morphine |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's pain medication by a Licensed Practical Nurse (LPN) without authorization.
Complaint Details
The complaint was substantiated. The investigation revealed LPN A was found asleep and impaired while providing care, had slurred speech, dilated pupils, and was unable to walk properly. A bottle of morphine was missing from the narcotic count, later found in LPN A's car bag. The police were notified, and the LPN was terminated and reported to the State Board of Nursing.
Findings
The facility failed to prevent misappropriation when LPN A took a bottle of morphine belonging to a resident without permission. The employee was found impaired at work, the medication was missing from the narcotic lock box, and the facility took corrective actions including termination of the LPN and notification of appropriate authorities.
Deficiencies (1)
Failure to protect residents from wrongful use of belongings or money, specifically misappropriation of resident's pain medication by LPN A.
Report Facts
Facility census: 52
Morphine bottles counted: 6
Morphine bottles remaining: 5
Morphine bottle size: 30
Morphine dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in misappropriation of resident's narcotic medication and found impaired during work |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified administrator of LPN A's impairment and involved in narcotic count and investigation |
| Administrator | Administrator | Notified of misappropriation, conducted investigation, terminated LPN A, and notified authorities |
| Certified Medication Tech B | Certified Medication Technician | Witnessed LPN A's impaired state and assisted during investigation |
| MDS Coordinator | Minimum Data Set Coordinator | Witnessed narcotic count, took photos of morphine in LPN A's car, and assisted in investigation |
| Certified Nursing Assistant C | Certified Nursing Assistant | Reported LPN A's impaired condition to ADON |
| Police Officer F | Police Officer | Responded to report of stolen morphine and attempted to contact LPN A |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with professional standards of care and regulatory requirements at River City Living Community.
Findings
The facility failed to meet professional standards in comprehensive care plans, medication administration, and wound assessment documentation. Specific deficiencies included failure to obtain physician orders for a resident's catheter, failure to document medication administration for one resident, and failure to document wound assessments for another resident.
Deficiencies (2)
F658: The facility did not meet professional standards of quality as staff failed to obtain physician orders for one resident's catheter, failed to document medication administration for one resident, and failed to document wound assessments for another resident.
A4075: Nursing care per resident condition was not met as residents did not receive personal attention and nursing care consistent with current acceptable nursing practice. Refer to F658 for details.
Report Facts
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Banks-Dutler | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Census: 42
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, wound care, and catheter management at the nursing facility.
Findings
The facility failed to obtain physician orders for a resident's catheter, failed to document medication administration for one resident, and failed to document wound assessments for another resident. The facility census was 42 at the time of inspection.
Deficiencies (3)
Failure to obtain physician orders for Resident #3's catheter.
Failure to document administration of medication to Resident #1, including missed doses and lack of documentation for seizure medication.
Failure to document wound treatments for Resident #2 on specified dates.
Report Facts
Facility census: 42
Medication doses not documented: 7
Wound treatments not documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Documented Resident #1's seizure and notified Director of Nursing and resident's doctor |
| DON | Director of Nursing | Interviewed regarding medication administration expectations and catheter order policies |
| RN A | Registered Nurse | Interviewed regarding medication administration, use of emergency medication kit, and catheter order requirements |
| LPN B | Licensed Practical Nurse | Interviewed regarding medication administration and use of emergency medication kit |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Jan 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse by a Certified Nurse Aide (CNA) towards a resident.
Complaint Details
The complaint investigation substantiated that a CNA verbally abused a resident by using profane and threatening language. The CNA was suspended pending investigation and later terminated. The facility took corrective actions including staff education and policy review.
Findings
The facility failed to ensure one resident remained free from verbal abuse when a CNA told the resident to 'shut the fuck up or I'll smack the fuck out of you.' The CNA was suspended and subsequently terminated. The facility's abuse policy was reviewed and staff were educated on abuse reporting.
Deficiencies (2)
F 600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent verbal abuse by a CNA towards a resident, violating resident rights to be free from abuse.
A4074 Protective Oversight, Voluntary Leave: The facility did not meet requirements for protective oversight and supervision for residents on voluntary leave.
Report Facts
Facility census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirla Buster | Administrator | Named in plan of correction and administrative actions |
Inspection Report
Routine
Census: 44
Deficiencies: 14
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, safety, care planning, medication management, infection control, staffing, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inadequate posting of abuse hotline information, failure to maintain a safe and homelike environment, incomplete background checks for staff, failure to notify residents of bed hold policies, incomplete Minimum Data Set (MDS) assessments and care plans, failure to meet professional standards in laboratory and oxygen orders, unsafe wheelchair use, improper storage of hazardous chemicals and sharps, failure to post nurse staffing information, incomplete pharmacist medication regimen reviews, lapses in infection prevention and control practices, and incomplete COVID-19 vaccination documentation for staff.
Deficiencies (14)
Failure to maintain resident dignity by not closing privacy curtains during care and not providing privacy curtains in some rooms.
Failure to post telephone numbers for Adult Abuse and Neglect Hotline and Long-Term Care Ombudsman in accessible locations.
Failure to provide a safe, clean, comfortable and homelike environment including lack of personalized decorations, debris in hallways, unclean resident room, and missing window screens.
Failure to check Employee Disqualification List (EDL), Family Care Safety Registry (FCSR), and complete Criminal Background Checks for several staff members.
Failure to notify residents or their representatives in writing of bed hold policy at time of hospital transfer.
Failure to complete and transmit Minimum Data Set (MDS) assessments for multiple residents within required timeframes.
Failure to develop and implement comprehensive care plans that accurately identify care areas and provide direction for resident needs.
Failure to meet professional standards by not obtaining ordered laboratory services, lacking physician order for oxygen use, and not documenting enteral feeding tube flush bag changes.
Failure to properly propel a resident in a wheelchair with foot pedals and failure to secure hazardous chemicals and sharps in locked cabinets.
Failure to post nurse staffing information daily including facility census and actual hours worked by licensed and unlicensed staff.
Failure to ensure drugs and biologicals are labeled and stored properly, including expired medications and supplies found in medication rooms and carts.
Failure to ensure licensed pharmacist monthly medication regimen reviews are documented as reviewed and completed by the physician for several residents.
Failure to maintain an infection prevention and control program including lapses in hand hygiene, glove use, cleaning and disinfecting glucometers, and incomplete tuberculosis screening for staff.
Failure to ensure staff are fully vaccinated for COVID-19 or have approved exemptions, and failure to maintain documentation of vaccination status.
Report Facts
Facility census: 44
Number of residents with incomplete MDS assessments: 12
Number of staff missing complete background checks: 6
Number of residents affected by care plan deficiencies: 8
Number of residents affected by pharmacist medication regimen review deficiencies: 4
Percentage of staff not fully vaccinated for COVID-19: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA O | Nurse Aide | Documented as partially vaccinated for COVID-19; vaccination status not verified |
| CNA F | Certified Nurse Aide | Failed to pull privacy curtain during resident care |
| RA B | Restorative Aide | Failed to pull privacy curtain during resident care |
| Activity Director | Observed privacy curtain not pulled during care and commented on staff failure | |
| LPN L | Licensed Practical Nurse | Commented on privacy curtain use, room cleanliness, enteral feeding tube care, and oxygen orders |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies, deficiencies, and corrective actions |
| CNA I | Certified Nurse Aide | Reported lack of abuse hotline posting and commented on care plan and infection control deficiencies |
| Business Office Manager | Business Office Manager | Responsible for checking Employee Disqualification List but failed to do so regularly |
| Medical Director | Medical Director | Provided clinical input on resident care and deficiencies |
| CMT C | Certified Medication Technician | Commented on medication storage and glucometer cleaning |
| Administrator | Administrator | Commented on nurse staffing posting and medication storage |
| Corporate Nurse | Corporate Nurse | Commented on nurse staffing posting and pharmacy medication review documentation |
Inspection Report
Routine
Census: 37
Deficiencies: 7
Date: Aug 2, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, wound care, dietary services, infection control, and facility safety.
Findings
The facility failed to update care plans for residents with changing needs, maintain proper wound documentation, provide pureed diets and thickened liquids as ordered, store food safely, and properly disinfect glucometers. Additionally, the facility lacked a Legionella water management program.
Deficiencies (7)
Failed to update care plans with changes in residents' needs for four sampled residents.
Failed to consistently assess, document, and maintain proper wound documentation for four residents with pressure ulcers.
Failed to follow menus by not offering all pureed food items to a resident on a pureed diet.
Failed to provide residents with pureed diets and thickened liquids as ordered by the physician.
Failed to store food safely, including undated and moldy food items, and failed to maintain ice machine drainage with proper air gap.
Failed to properly disinfect the resident glucometer before and after each use, not allowing disinfectant to remain wet for required time.
Failed to implement policies and procedures for inspection, testing, and maintenance of facility water systems to inhibit growth of waterborne pathogens including Legionella.
Report Facts
Residents affected: 4
Residents affected: 4
Residents affected: 1
Residents affected: 1
Facility census: 37
Weight loss: 9
BIMS scores: 14
BIMS scores: 4
BIMS scores: 0
BIMS scores: 13
BIMS scores: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Named in findings related to improper thickened liquids preparation and glucometer disinfection |
| Dietary Manager | Dietary Manager | Named in findings related to pureed diet substitutions and food storage |
| Director of Nursing | Director of Nursing | Named in findings related to care plan oversight and infection control expectations |
| NA C | Nursing Assistant | Named in findings related to feeding resident with pureed diet |
| CNA D | Certified Nursing Assistant | Named in findings related to feeding resident with pureed diet |
| DA A | Dietary Aid | Named in findings related to preparation of pureed foods and thickened liquids |
| Maintenance Director | Maintenance Director | Named in findings related to ice machine drainage and Legionella water management |
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