Inspection Reports for
River Oaks Care Center
1001 NORTH WALNUT, STEELE, MO, 63877-1355
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
74% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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
Complaint Investigation
Census: 73
Deficiencies: 5
Date: Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging abuse and neglect involving two residents at River Oaks Care Center.
Complaint Details
Complaint #MO245031 involved allegations of physical and verbal abuse by a Certified Nurse Aide (CNA) toward Residents #1 and #2. The complaint was substantiated as the facility failed to investigate and prevent further abuse. The facility was notified of an Immediate Jeopardy (IJ) on 11/14/24, which was removed the same day after corrective actions were implemented.
Findings
The facility failed to ensure residents were free from physical and verbal abuse by staff. The investigation found that a Certified Nurse Aide (CNA) physically abused Resident #2 and verbally abused Resident #1, and the facility did not properly investigate or report the incidents in a timely manner.
Deficiencies (5)
F600: The facility failed to protect residents from abuse and neglect, including physical and verbal abuse by staff toward Residents #1 and #2. The facility did not conduct a proper investigation or facility reported incident for the abuse allegations.
F610: The facility failed to thoroughly investigate reports of abuse for Residents #1 and #2 and did not prevent further potential abuse during the investigation.
A4074: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, resulting in an imminent danger Class I level violation.
A8022: The facility failed to ensure each resident was free from abuse, including verbal and physical abuse, as evidenced by abuse incidents involving Residents #1 and #2.
A8023: The facility failed to develop and implement policies and procedures prohibiting mistreatment, neglect, and abuse of residents, and failed to report allegations to the department as required.
Report Facts
Facility census: 73
Deficiencies cited: 5
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: 74
Deficiencies: 5
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as an annual survey of River Oaks Care Center to assess compliance with federal regulations and state requirements for nursing facilities.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring free of accident hazards and proper supervision for transfers, managing enteral nutrition and medication administration, pharmacy services, and infection prevention and control. Several environmental and procedural issues were identified that had the potential to affect all residents.
Deficiencies (5)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to provide a safe, clean, and comfortable homelike environment, including issues such as chipped paint, soiled towels, rotted flooring, dust buildup, stained ceiling tiles, and cracked floor tiles.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide safe transfer for two residents when staff did not use gait belts as directed by therapy recommendations and the care plan.
F693 Tube Feeding Mgmt/Restore Eating Skills: The facility failed to ensure gastric residual volume was measured prior to tube feeding and failed to follow standards of practice using a plunger during tube feeding for two residents.
F755 Pharmacy Services/Procedures/Pharmacist/Records: The facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of, and reconciled for one resident outside the sampled group.
F880 Infection Prevention & Control: The facility failed to use proper infection control techniques for glove use during wound care for two residents and during incontinent care for two residents.
Report Facts
Facility census: 74
Sampled residents: 18
Completion dates: Corrective actions planned with completion dates ranging from 08/13/2024 to 09/27/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Mentioned in relation to expectations for staff use of gait belts and medication administration |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Observed uncapping G-tube and medication administration; mentioned in infection control findings |
| Certified Medication Technician F | Certified Medication Technician | Mentioned in medication count and administration observations |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Interviewed regarding resident transfer needs and use of gait belts |
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 2
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on fire safety and portable fire extinguisher maintenance.
Findings
The facility failed to meet the applicable provisions of the 2012 Existing Edition of the Life Safety Code related to portable fire extinguishers. Monthly fire extinguisher inspections were not maintained, and the ANSUL system in the kitchen had not been inspected since April 2024.
Deficiencies (2)
42 CFR 483.90(a): The facility does not meet the applicable provisions of the 2012 Existing Edition of the Life Safety Code related to portable fire extinguishers. The facility failed to maintain monthly fire extinguisher system inspections, and the ANSUL system in the kitchen had not been inspected since April 2024.
19 CSR 30-85.022(8)(D): Fire extinguishers did not bear the label of the UL or FM Laboratories and were not maintained with documentation and dating of monthly pressure checks as required.
Report Facts
Facility census: 84
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 |
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 6
Date: May 4, 2023
Visit Reason
The document is a plan of correction submitted by River Oaks Care Center following a survey conducted on 05/04/2023 to address identified deficiencies.
Findings
The facility failed to provide a safe, clean, and comfortable homelike environment and did not implement a baseline care plan upon admission for sampled residents. Additionally, the facility failed to store medications securely, allowing medications to be accessible at the bedside of a resident.
Deficiencies (6)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a safe, clean and comfortable homelike environment, with multiple issues including damaged baseboards, ceiling tiles with stains and holes, and peeling paint in various rooms.
F655 Baseline Care Plan. The facility failed to implement a baseline care plan upon admission with specific interventions for one resident, lacking documentation of a baseline care plan with specified interventions.
F761 Label/Store Drugs and Biologicals. The facility failed to store medications in a safe, secure, and orderly manner by allowing medications to sit at the bedside of one resident, posing a risk to all residents.
A4059 Self-Administration of Medication. Self-administration of medication was not approved in writing by the resident's physician as required.
A6009 Air Ducts-Maintain. Intake and exhaust air ducts were not maintained to prevent entrance of dust, dirt, and other contaminants.
A6015 Walls/Ceilings/Doors/Windows Clean. Walls, ceilings, doors, and windows were not clean or maintained in good repair.
Report Facts
Facility census: 68
Sampled residents for medication storage: 17
Inspection Report
Life Safety
Census: 68
Deficiencies: 5
Date: May 4, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to provide adequate exit illumination and had non-compliant cooking equipment in resident sleeping quarters. Additionally, the use of temporary wiring and power strips was not restricted, potentially affecting all residents and staff.
Deficiencies (5)
K281: The facility did not provide adequate exit illumination in the facility, potentially affecting all residents and staff. Observation on 5/3/23 showed exterior exit ways lacked adequate emergency lighting.
K324: The facility staff failed to ensure sleeping quarters did not contain cooking equipment, which could affect all facility occupants. Multiple resident rooms contained microwaves and coffee pots.
K920: The facility failed to restrict the use of temporary wiring, including power strips, potentially affecting all residents and staff. Observations showed power strips in use in the MDS office and therapy room.
A2050: Emergency lighting requirements were not met as referenced by K281. The emergency lighting system lacked automatic transfer switch and battery backup compliance.
A3037: Extension cords and duplex receptacles did not meet UL approval or safety standards as referenced by K920. Extension cords were improperly used and placed.
Report Facts
Facility census: 68
Deficiencies cited: 5
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 2
Date: Aug 6, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse involving two residents at River Oaks Care Center.
Complaint Details
The visit was complaint-related due to allegations of abuse involving two residents. The complaint was substantiated as the facility failed to report the abuse within the required timeframe.
Findings
The facility failed to report an allegation of abuse involving two residents within the required two-hour timeframe. Documentation and reporting deficiencies were identified related to the failure to notify the department regarding potential resident abuse.
Deficiencies (2)
F609: The facility failed to report allegations of abuse involving two residents within two hours as required by regulation.
A8025: The facility did not immediately report or cause a report to be made to the department when there was reasonable cause to believe a resident was abused or neglected.
Report Facts
Facility census: 61
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 27, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and was found to be substantiated with no deficiencies 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 as a result of this investigation.
Inspection Report
Plan of Correction
Census: 66
Deficiencies: 8
Date: Oct 30, 2020
Visit Reason
The document is a Plan of Correction submitted by River Oaks Care Center following a survey conducted on 10/30/2020. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including failure to notify the State Long-Term Care Ombudsman of resident transfers, incomplete significant change assessments, inaccurate Minimum Data Set (MDS) coding, lack of policies for PASARR screening, inadequate professional standards in services provided, failure to provide proper incontinent care, and deficiencies in drug regimen review and psychotropic medication management.
Deficiencies (8)
F 623 Notice Requirements Before Transfer/Discharge: The facility failed to notify the Missouri State Long-Term Care Ombudsman when residents were sent to the hospital for five sampled residents. The facility census was 66.
F 637 Comprehensive Assessment After Significant Change: The facility failed to complete a significant change assessment within 14 days of discontinuation of hospice services for one resident. The facility census was 66.
F 641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) for two residents out of 17 sampled. The facility census was 66.
F 645 PASARR Screening for Mental Disorder and Intellectual Disability: The facility failed to ensure residents with mental disorders and intellectual disabilities had required screenings and documentation. The facility census was 66.
F 658 Services Provided Meet Professional Standards: The facility failed to obtain physician orders for dialysis for two residents and failed to ensure proper care and monitoring related to dialysis services. The facility census was 66.
F 677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate incontinent care for two residents. The facility census was 66.
F 756 Drug Regimen Review: The facility failed to ensure proper drug regimen review and documentation for one resident receiving antipsychotic medication. The facility census was 66.
F 758 Free from Unnecessary Psychotropic Medications/PRN Use: The facility failed to monitor and limit psychotropic medication orders to 14 days and failed to provide clinical rationale for PRN orders for one resident.
Report Facts
Facility census: 66
Sampled residents: 5
Sampled residents: 17
Sampled residents: 8
Sampled residents: 4
Sampled residents: 2
Sampled residents: 1
Inspection Report
Life Safety
Census: 65
Capacity: 90
Deficiencies: 2
Date: Oct 30, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to ensure that an emergency exit door on the 500 hall released upon fire alarm activation and failed to provide a portable fire extinguisher in the designated smoking room. These deficiencies posed potential safety risks to residents, visitors, and staff.
Deficiencies (2)
K222 Egress Doors: The emergency exit door on the 500 hall did not release upon activation of the fire alarm system, potentially affecting safe egress during emergencies.
K355 Portable Fire Extinguishers: The facility failed to ensure a portable fire extinguisher was located in the designated smoking room, a hazardous area, posing a fire safety risk.
Report Facts
Facility capacity: 90
Census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the emergency exit door and fire extinguisher deficiencies |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
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
Plan of Correction
Deficiencies: 2
Date: Sep 15, 2020
Visit Reason
The document is a Plan of Correction submitted by River Oaks Care Center following a deficiency cited during a survey completed on 09/15/2020.
Complaint Details
The deficiency F658 was related to complaints #MO173914 and #MO173795.
Findings
The facility failed to meet professional standards of care related to medication administration and nursing care per resident condition, specifically involving transcription errors of physician orders and medication administration records.
Deficiencies (2)
F658 Services provided did not meet professional standards as the facility failed to follow physician's orders and standards of practice for one resident, resulting in medication transcription errors and improper medication administration documentation.
A4074 Nursing care per resident condition was not met as each resident did not receive personal attention and nursing care consistent with current acceptable nursing practice, referencing deficiency F658.
Report Facts
Deficiency cited: 1
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Tech | CMT | Found medication error and reported it to Director of Nursing on 7/27/20 |
| Assistant Director of Nursing | ADON | Interviewed regarding medication prescription and administration process |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
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 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with federal regulations 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
Census: 50
Deficiencies: 1
Date: Oct 8, 2019
Visit Reason
The inspection was conducted in response to allegations of resident to resident sexual misconduct reported at the facility.
Complaint Details
Complaint #MO160936 regarding alleged resident to resident sexual misconduct was investigated. The facility's investigation and assessment process was found deficient.
Findings
The facility failed to complete a thorough investigation regarding the allegation of sexual misconduct between residents. Documentation and assessments related to the incident were incomplete or missing.
Deficiencies (1)
F610: The facility failed to thoroughly investigate an allegation of resident to resident sexual misconduct and did not immediately assess the involved resident. Documentation of assessments and investigations was incomplete or absent.
Report Facts
Facility census: 50
Inspection Report
Plan of Correction
Census: 53
Deficiencies: 11
Date: Feb 20, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction following a survey conducted on February 20, 2019, at River Oaks Care Center in Steele, MO. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility was found non-compliant in several areas including resident rights, financial security, safe environment, notice requirements before transfer/discharge, accuracy of assessments, infection control, mobility, accident prevention, dialysis care, food safety, and others. The facility census was 53 at the time of the survey.
Deficiencies (11)
F550 Resident Rights. The facility failed to ensure residents' dignity with properly covered urinary catheter bags for two residents. Catheter bags were observed without privacy bags and improperly positioned.
F570 Surety Bond-Security of Personal Funds. The facility failed to maintain a surety bond amount sufficient to cover one and one-half times the average monthly balance of residents' personal funds for the last twelve months.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a safe, clean, comfortable, and homelike environment, with multiple ceiling tile damages, peeling paint, and maintenance issues observed.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to notify residents and representatives in writing of transfers or discharges and failed to provide timely notices as required.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to inform residents and families of the bed hold policy at the time of transfer for ten sampled residents.
F641 Accuracy of Assessments. The facility failed to ensure accurate assessments for two residents, including updating MDS and reflecting use of wander guard alarms.
F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide restorative services and maintain mobility for two residents, missing multiple therapy opportunities.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, including failure to use wander guard devices properly.
F698 Dialysis. The facility failed to ensure coordination of care and communication with the dialysis center for one resident, missing communication records and policies.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to maintain sanitary conditions in food storage and preparation areas, including missing control knobs and debris.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention and control program, including improper blood glucose monitoring and cleaning procedures.
Report Facts
Facility census: 53
Surety bond amount: 35000
Average monthly balance: 25308.76
Required bond amount: 37500
Missed therapy opportunities: 10
Missed therapy opportunities: 11
Missed TAR opportunities: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding catheter bag placement and blood sugar monitoring |
| Quality Assurance (QA) Nurse | Quality Assurance Nurse | Interviewed regarding catheter bag placement and dialysis communication |
| Administrator | Administrator | Interviewed regarding surety bond, bed hold policy, and monitoring compliance |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding transfer notifications, bed hold policy, and dialysis communication |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and kitchen maintenance |
| Restorative Nurse Aide (RNA) | Restorative Nurse Aide | Interviewed regarding restorative therapy program participation |
Inspection Report
Life Safety
Census: 53
Deficiencies: 5
Date: Feb 20, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain an all-weather exit pathway, adequate exit illumination, exit signage, exterior horn and strobe notification, and proper mounting height for fire extinguishers. These deficiencies potentially affected all residents and staff.
Deficiencies (5)
K211 Means of Egress - General: The facility failed to maintain an all-weather exit pathway from the smoking courtyard to the public way, obstructing safe egress for residents and staff.
K281 Illumination of Means of Egress: The facility failed to maintain exit illumination from the smoking courtyard, lacking battery backup exit lighting leading to the public way.
K293 Exit Signage: The facility failed to have adequate exit signage at the smoking courtyard's exterior gate, making it difficult to identify the exit.
K343 Fire Alarm System - Notification: The facility failed to have exterior horn and strobe notification in the smoking courtyard, affecting emergency alerting.
K355 Portable Fire Extinguishers: The facility had fire extinguishers mounted above the required height limit of 5 feet, making them inaccessible.
Report Facts
Facility census: 53
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 5
Date: Mar 23, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with Medicare and Medicaid regulations at River Oaks Care Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare Non-Coverage notices, incomplete discharge summaries, improper administration of enteral feeding medications, inadequate labeling and storage of drugs, and lapses in infection prevention and control practices.
Deficiencies (5)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) timely to discharged residents and did not provide two days' notice of benefit end date.
F661 Discharge Summary: The facility failed to complete a comprehensive discharge summary for a discharged resident, including a recapitulation of stay and post-discharge plan of care.
F693 Tube Feeding Management/Restore Eating Skills: The facility failed to accurately administer medications and flushes through a gastrostomy tube as ordered for a resident.
F761 Label/Store Drugs and Biologicals: The facility failed to label and store medications in a safe and effective manner, including undated opened multi-use vials and improper documentation of medication expiration.
F880 Infection Prevention & Control: The facility failed to use proper infection control techniques to prevent cross-contamination for two residents and did not conduct an annual review of its infection prevention program.
Report Facts
Facility census: 50
Sampled residents: 16
Deficiencies cited: 5
Inspection Report
Life Safety
Census: 50
Deficiencies: 4
Date: Mar 22, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain ceilings free of penetrations to resist smoke passage, maintain the kitchen range hood to NFPA standards, maintain smoke barrier doors with proper fire resistance ratings, and maintain gas-fired equipment ventilation. These deficiencies potentially affected all residents, staff, and occupants in the event of a fire.
Deficiencies (4)
K161: The facility failed to maintain ceilings free of penetrations to resist the passage of smoke. Observations included damaged ceiling tiles with water spots and electrical conduit without fire block.
K324: The facility failed to maintain the kitchen range hood to NFPA standards. The kitchen range hood showed no grease drip pan below the lower edge of the range hood.
K374: The facility failed to maintain smoke barrier doors to National Fire Protection Association code. Smoke barrier doors lacked fire resistance rating (FRR) tags.
K522: The facility failed to maintain gas-fired equipment with proper intake air ventilation within 18 inches of the floor. Laundry room gas-fired dryers lacked proper venting.
Report Facts
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding correction of ceiling penetrations and other deficiencies | |
| Maintenance Supervisor | Interviewed regarding gas-fired equipment ventilation and smoke barrier door repairs |
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