Inspection Reports for
River Oaks Care Center
1001 NORTH WALNUT, STEELE, MO, 63877-1355
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
74% occupied
Based on a August 2025 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 5
Date: Aug 8, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, environment, medication administration, and immunization policies at River Oaks Care Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing baseline care plans within 48 hours of admission, providing trauma-informed and culturally competent care for residents with PTSD, maintaining medication error rates below 5%, and documenting influenza vaccination education, consent, and administration for residents.
Deficiencies (5)
Failed to provide a safe, clean, and comfortable homelike environment, including issues with dust and rust buildup on ceiling vents, deteriorated exit door frames, electrical outlet hazards, and damaged flooring.
Failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
Failed to identify, assess, and provide supportive interventions for residents with PTSD, including lack of addressing past trauma and triggers in care plans.
Failed to maintain medication error rates below 5%, with an error rate of 38.46% for one resident and errors for another, including failure to administer medications and improper documentation.
Failed to provide and document influenza vaccination education, consent, and administration or refusal for five residents.
Report Facts
Facility census: 67
Medication error opportunities: 26
Medication errors: 10
Medication error rate: 38.46
Residents with missing influenza vaccination documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Named in medication error findings for failure to administer medications and improper documentation |
| Registered Nurse (RN) A | Registered Nurse | Interviewed regarding baseline care plan initiation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding baseline care plan, PTSD care plans, medication administration, and influenza vaccination policies |
| Administrator | Facility Administrator | Interviewed regarding maintenance concerns, medication administration expectations, and immunization audits |
| Laundry Aide A | Laundry Aide | Reported environmental concerns and safety hazards in laundry area |
| Housekeeper B | Housekeeper | Reported environmental concerns and safety hazards |
| Housekeeper C | Housekeeper | Reported environmental concerns and safety hazards |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding maintenance requisition process and repair documentation |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to complaints of physical and verbal abuse by staff against two residents at River Oaks Care Center.
Complaint Details
Complaint #MO245031 involved allegations that CNA A physically and verbally abused Residents #1 and #2. The allegations were substantiated by witness statements and resident interviews. The facility failed to investigate the allegations promptly and adequately. Immediate jeopardy was identified starting 11/07/24 and removed on 11/14/24 after corrective actions.
Findings
The facility failed to protect residents from abuse and did not thoroughly investigate abuse allegations. Certified Nurse Aide (CNA) A was found to have physically and verbally abused two residents, and the administrator failed to properly investigate or take timely corrective action. Immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (2)
Failure to protect residents from physical and verbal abuse by staff.
Failure to thoroughly investigate reports of abuse for two residents.
Report Facts
Facility census: 73
Bruise measurement: 5
Bruise measurement: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings for physical and verbal abuse of residents. |
| CNA B | Certified Nurse Aide | Witnessed abuse by CNA A and reported the incident. |
| LPN C | Licensed Practical Nurse | Reported abuse allegations and participated in addressing the incident. |
| LPN D | Licensed Practical Nurse | Assessed Resident #1 after abuse report and informed DON. |
| ADM | Administrator | Failed to properly investigate abuse allegations and was notified of immediate jeopardy. |
| DON | Director of Nursing | Informed of abuse allegations, took corrective actions including sending CNA A home. |
| SSW | Social Service Worker | Received abuse report from Resident #2 and reported to ADM. |
| HR | Human Resources | Involved in addressing abuse allegations and reporting. |
Inspection Report
Routine
Census: 74
Deficiencies: 6
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain a safe, clean, and homelike environment, with multiple observations of chipped and peeled paint, rotted flooring in a wardrobe cabinet, buildup of dust and debris on light fixtures, stained ceiling tiles, and cracked or missing floor tiles. Maintenance logs showed no documentation of repairs for these issues.
Deficiencies (6)
Long piece of decorative trim with several areas of chipped and peeled paint on the left side of the kitchen door entrance.
Soiled rolled towels placed around the front outside edge of the wardrobe cabinet; right side of the inside bottom flooring rotted out with an exposed hole.
Several areas of chipped and peeled paint on the outside surface walls of the nurse's station.
Buildup of dust and debris visible on the inside of multiple light fixture covers in hallways between rooms.
Several dark stained areas on ceiling tiles throughout the therapy/exercise room and multiple rooms with brown circles and dark stains on ceiling tiles near air vents.
Five 12-inch by 12-inch floor tiles cracked and/or missing in front of the shower stall in the 500-hall shower room.
Report Facts
Facility census: 74
Floor tiles cracked or missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Reported maintenance concerns verbally and via maintenance log | |
| Housekeeper B | Reported environmental concerns written in maintenance log and showed pictures to maintenance supervisor | |
| Maintenance Supervisor | Maintenance Supervisor | Expected staff to write down environmental concerns and responsible for replacing ceiling tiles |
| Administrator | Previous Administrator | Reported ceiling tiles have been ordered and makes rounds throughout the facility daily |
Inspection Report
Routine
Census: 74
Deficiencies: 5
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with health and safety standards at River Oaks Care Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper use of gait belts during resident transfers, correct procedures for feeding tube administration, accurate medication management including controlled substances, and infection control practices related to glove use during wound and incontinent care. Deficiencies were noted to have minimal harm or potential for actual harm affecting a few residents.
Deficiencies (5)
Failed to provide a safe, clean, and comfortable homelike environment with issues such as chipped paint, rotted flooring, dust buildup, stained ceiling tiles, and cracked floor tiles.
Failed to use gait belts as directed by therapy recommendations and care plans during resident transfers for two residents.
Failed to measure gastric residual volume prior to tube feeding and used a plunger to force feedings and medication through feeding tubes.
Failed to implement procedures to ensure accurate administration, documentation, disposal, and reconciliation of controlled medications for one resident.
Failed to use proper infection control techniques for glove use during wound care and incontinent care, including failure to change gloves between dirty and clean tasks and failure to remove gowns when leaving rooms.
Report Facts
Facility census: 74
Cracked/missing floor tiles: 5
Medication bottle volume: 29.5
Medication orders frequency: 4
Water flushes: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in feeding tube administration and medication management deficiencies |
| RN C | Registered Nurse | Named in feeding tube administration and resident transfer deficiencies |
| Director of Nursing | Director of Nursing | Provided interviews regarding expectations for gait belt use, feeding tube procedures, medication management, and infection control |
| CNA J | Certified Nurse Aide | Named in resident transfer and infection control deficiencies |
| CNA K | Certified Nurse Aide | Named in resident transfer and infection control deficiencies |
| Housekeeper A | Interviewed regarding maintenance and repair reporting | |
| Housekeeper B | Interviewed regarding maintenance and repair reporting | |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding maintenance reporting and repair follow-up |
| Certified Medication Technician F | Certified Medication Technician | Named in medication count deficiency |
| Physical Therapy Assistant | Physical Therapy Assistant | Interviewed regarding resident transfer requirements |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 3
Date: May 4, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, facility environment, medication storage, and care planning.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment with multiple issues such as damaged baseboards, stained and sagging ceiling tiles, and exposed sheetrock. Additionally, the facility failed to implement baseline care plans within 48 hours for new admissions and improperly stored medications at a resident's bedside without proper orders or secure storage.
Deficiencies (3)
Failure to provide a safe, clean, and comfortable homelike environment with damaged baseboards, stained ceiling tiles, exposed sheetrock, and peeling paint.
Failure to implement a baseline care plan with specific interventions within 48 hours of admission for one resident.
Failure to store medications in a safe, secure, and orderly manner; medications were found at the bedside of a resident without orders or secure storage.
Report Facts
Facility census: 68
Residents sampled: 17
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant A | CNA | Mentioned in relation to reporting maintenance repair needs |
| Certified Nursing Assistant B | CNA | Mentioned in relation to reporting maintenance repair needs |
| Licensed Practical Nurse C | LPN | Mentioned in relation to reporting maintenance repair needs |
| Maintenance Supervisor | MS | Discussed maintenance repair reporting process |
| Administrator | Discussed expectations for maintenance repair reporting and baseline care plans | |
| Licensed Practical Nurse D | LPN | Discussed baseline care plan expectations and medication storage requirements |
| Assistant Director of Nursing | ADON | Discussed baseline care plan expectations and medication storage requirements |
| Director of Nursing | DON | Discussed baseline care plan expectations and medication storage requirements |
| Certified Medication Technician E | CMT | Observed administering medications and discussed medication storage |
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