Inspection Reports for
Riverdell Care Center
1121 11TH ST, BOONVILLE, MO, 65233-1419
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
6.4 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
16% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
77% occupied
Based on a December 2024 inspection.
Occupancy rate over time
Inspection Report
Life Safety
Census: 46
Capacity: 60
Deficiencies: 4
Date: Dec 13, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and fire safety regulations, including emergency lighting and fire drill requirements.
Findings
The facility failed to conduct the required 90-minute annual functional test of emergency lighting and did not provide complete and verifiable documentation of quarterly fire drills for each shift. The facility census was 46 with a capacity of 60.
Deficiencies (4)
K291 Emergency lighting testing was not conducted annually for 90 minutes as required, and records lacked documentation of testing for five exterior emergency lights. The facility was not equipped with a backup generator but had battery-powered emergency lighting fixtures.
K712 Fire drills were not documented quarterly for each shift as required, with missing documentation for a third shift drill from 3/28/24 through 9/28/24. Some drills were held too close together and not spaced properly.
A2050 Emergency lighting requirements were not met, including failure to conduct required battery-operated emergency lighting tests and annual functional tests.
A2061 Fire drill requirements were not met, including failure to conduct a minimum of twelve fire drills annually with at least one every three months on each shift, and failure to include required evacuation simulations.
Report Facts
Facility census: 46
Total capacity: 60
Fire drills required annually: 12
Fire drills required quarterly per shift: 1
Emergency lighting test duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Warner | Administrator | Signed the inspection report and plan of correction |
| Maintenance Director | Interviewed regarding emergency lighting and fire drill testing practices | |
| Administrator | Interviewed regarding maintenance responsibilities and fire drill scheduling |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 6
Date: Dec 13, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with health and safety standards in the nursing home.
Findings
The facility was found to have multiple deficiencies including failure to maintain a homelike environment, unsafe wheelchair and mechanical lift use, improper medication storage with expired drugs, inadequate dishwashing machine operation, incomplete Legionella water management plan, and improper infection control related to indwelling catheter positioning.
Deficiencies (6)
Failure to maintain walls, ceilings, and floors resulting in an unsafe and uncomfortable environment for residents.
Failure to use wheelchair footrests and improper mechanical lift transfers compromising resident safety.
Failure to store medications safely, including presence of expired medications in storage room.
Dishwasher machine operated below manufacturer's recommended temperature, risking cross contamination.
Incomplete Legionella water management plan and failure to implement required water system maintenance procedures.
Failure to keep indwelling catheters off the floor, increasing risk of infection.
Report Facts
Facility census: 46
Expired medications: 6
Dish machine temperature: 98
Dish machine temperature: 109
Water heaters observed: 3
Water heaters indicated in plan: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication storage and expired medications |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding medication storage responsibilities |
| Dietary Dish Aide M | Dietary Dish Aide | Observed and interviewed regarding dishwasher operation and temperature monitoring |
| Dietary Manager | Dietary Manager | Observed and interviewed regarding dishwasher operation and food preparation |
| Maintenance Director | Maintenance Director | Interviewed regarding facility maintenance, Legionella control, and dishwasher temperature |
| Administrator | Facility Administrator | Interviewed regarding facility operations, safety, and compliance oversight |
| Certified Nurse Aid E | Certified Nurse Aid | Observed and interviewed regarding wheelchair safety |
| Licensed Practical Nurse C | Licensed Practical Nurse | Observed and interviewed regarding mechanical lift transfers |
| Certified Nursing Assistant G | Certified Nursing Assistant | Interviewed regarding catheter care and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding catheter care and infection control |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage, mechanical lift training, and catheter care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
This document is a plan of correction form related to a health facility survey for Riverdell Care Center following a survey completed on 12/21/2023.
Findings
No Health Facility Survey Deficiencies were cited. No state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 51
Capacity: 60
Deficiencies: 2
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, focusing on electrical equipment and power cords in the facility.
Findings
The facility failed to maintain electrical wiring regarding power strips and extension cords in patient care areas, which could increase the risk of electrical fire hazards. Several resident rooms had refrigerators and CPAP devices improperly plugged into surge protectors instead of directly into wall outlets.
Deficiencies (2)
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to maintain electrical wiring regarding power strips and extension cords, with multiple resident rooms having medical equipment and refrigerators plugged into surge protectors instead of wall outlets.
A3037 Extension Cords/Duplex Receptacles. Extension cords were not UL-approved or compliant with electrical appliance approval standards, and multiple appliances were improperly connected to single extension cords.
Report Facts
Census: 51
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kaylyn Warner | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
Annual survey inspection of Riverdell Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 5
Date: Aug 12, 2022
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal and state regulations at Riverdell Care Center.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, meeting professional standards of care, infection control, and other regulatory requirements. Multiple deficiencies were cited related to care planning, resident safety, infection prevention, and documentation.
Deficiencies (5)
F656: Facility staff failed to develop comprehensive person-centered care plans for eleven residents, lacking measurable objectives and interventions for safety and health needs.
F658: Facility staff failed to meet professional standards of quality in care planning for four residents, including inconsistent documentation of advance directives and dialysis orders.
F677: Facility staff failed to provide appropriate care and services for activities of daily living to four residents, including bathing, grooming, and oral hygiene.
F689: Facility staff failed to ensure residents' environment remained free of accident hazards, including unlocked shower rooms and improperly stored chemicals, affecting seven residents.
F880: Facility failed to establish and maintain an infection prevention and control program, including hand hygiene and wound care, resulting in risk of infection for multiple residents.
Report Facts
Facility census: 49
Residents affected by care plan deficiency: 11
Deficiency counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Warren | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Melissa Temme | Surveyor | Named as surveyor in infection control deficiency |
Inspection Report
Life Safety
Census: 49
Capacity: 60
Deficiencies: 3
Date: Aug 12, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding the installation and maintenance of the sprinkler system and night lights in resident areas.
Findings
The facility failed to provide complete sprinkler coverage to the wooden exterior front porch canopy, which poses a fire safety risk. Additionally, the facility did not provide night lights in several resident rooms, bathrooms, and common areas as required by code.
Deficiencies (3)
K351 Sprinkler System - Installation: Facility staff failed to provide sprinkler coverage to the wooden exterior front porch canopy attached to the building, which could delay fire suppression and evacuation.
A2032 No Complete Sprinkler System Prior to 8/28/07: Facility did not meet the requirement for a complete sprinkler system as per NFPA 13 standards.
A3033 Night Lights Provided: Facility failed to provide night lights in eight resident rooms, two bathrooms, and three common toilet rooms as required by regulation.
Report Facts
Facility census: 49
Total capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Wren | Administrator | Signed the inspection report and plan of correction |
Inspection Report
Routine
Census: 49
Deficiencies: 5
Date: Aug 12, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, safety, infection control, and documentation, including review of care plans, advance directives, wound care, and environmental safety.
Findings
The facility failed to develop comprehensive person-centered care plans for multiple residents, did not consistently document advance directives or physician orders for dialysis and oxygen, failed to provide adequate assistance with activities of daily living including hygiene and grooming, did not ensure environmental safety by securing hazardous items and properly using wheelchair foot pedals, and failed to follow infection control practices including hand hygiene and wound care.
Deficiencies (5)
Failure to develop and implement complete, person-centered care plans addressing residents' medical, nursing, and safety needs including use of bed rails, facial hair preferences, medication management, smoking, wandering, falls, diet, and dialysis.
Failure to provide consistent documentation and obtain physician orders for advance directives, dialysis, oxygen use, and diet changes.
Failure to provide appropriate care and assistance with activities of daily living including personal hygiene, nail care, shaving, oral care, and grooming for residents requiring extensive assistance.
Failure to maintain a safe environment by leaving hazardous chemicals and razors unsecured in shower rooms and improper wheelchair propulsion without foot pedals, risking resident safety.
Failure to perform hand hygiene appropriately and provide perineal and wound care in a manner to reduce risk of infection, including use of soiled gloves and reusing wipes and gauze pads.
Report Facts
Residents affected: 11
Facility census: 49
Observation dates: 8
Number of residents with care plan deficiencies: 11
Number of residents with advance directive documentation issues: 4
Number of residents with dialysis order issues: 2
Number of residents with oxygen order issues: 1
Number of residents with diet order discrepancies: 1
Number of residents with ADL care deficiencies: 4
Number of residents improperly propelled in wheelchairs: 7
Number of residents with infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide C | CNA | Interviewed regarding care plan access, resident care, and wheelchair propulsion |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan expectations, resident care, and staff responsibilities |
| Director of Nursing | DON | Interviewed regarding care plan oversight, infection control, and resident safety |
| Licensed Practical Nurse E | LPN | Interviewed regarding care plan knowledge, resident care, and infection control |
| Certified Nurse Aide I | CNA | Interviewed regarding care plan use and wheelchair safety |
| Certified Nurse Aide F | CNA | Observed and interviewed regarding perineal care and hand hygiene |
| Licensed Practical Nurse A | LPN | Observed propelling resident in wheelchair without foot pedals |
| Administrator | Interviewed regarding environmental safety and staff responsibilities |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Dec 14, 2021
Visit Reason
The inspection was a COVID-19 Focused Emergency Preparedness survey conducted to assess infection prevention and control compliance and investigate a complaint related to COVID-19 testing and employee infection control practices.
Complaint Details
The complaint investigation substantiated that an employee (CNA C) who tested positive for COVID-19 was allowed to continue working during the infectious period, contrary to facility policy and CDC guidelines.
Findings
The facility was found to be in compliance with general COVID-19 emergency preparedness requirements but failed to maintain an effective infection prevention and control program, specifically failing to ensure timely removal of an employee who tested positive for COVID-19. The facility census at the time was 39 residents.
Deficiencies (2)
19 CSR 30-85.042(78) Infection Control/Communicable Disease: The facility failed to report a communicable disease within seven days as required and did not properly manage an employee who tested positive for COVID-19, allowing the employee to work while infectious.
§483.80 Infection Control: The facility failed to maintain an infection prevention and control program by not removing an employee who tested positive for COVID-19 in a timely manner, risking further spread of infection.
Report Facts
Facility census: 39
COVID-19 test dates: 2
Reporting timeframe: 7
Return to work exclusion period: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Assistant | Named in infection control deficiency for working while COVID-19 positive |
| Theresa June | Administrator | Named in relation to notification and handling of employee COVID-19 positive test results |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Feb 19, 2021
Visit Reason
The inspection was conducted due to a complaint investigation related to infection prevention and control practices, specifically regarding COVID-19 transmission and reporting.
Complaint Details
The complaint investigation substantiated that the facility failed to protect residents from COVID-19 transmission and failed to report positive COVID-19 cases for two residents to the state health department as required.
Findings
The facility failed to implement adequate infection control interventions for residents with COVID-19, including improper use of PPE and failure to separate infected residents. Additionally, the facility failed to report positive COVID-19 test results for two residents to the state as required.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to implement infection control practices for COVID-19, including improper PPE use, failure to isolate infected residents properly, and inadequate signage and supplies. The facility census was 45 at the time of inspection.
A4085 Infection Control/Communicable Disease: The facility failed to report positive COVID-19 test results for two residents to the state within the required timeframe as per Missouri regulations. The facility census was 45.
Report Facts
Facility census: 45
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Faye | Administrator | Named as signing official on the report and plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with related federal 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: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal 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: Aug 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal 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: Jul 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices related to COVID-19 infection control and emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Report Facts
Regulatory compliance references: 42
Inspection Report
Plan of Correction
Census: 48
Deficiencies: 2
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to assess compliance with food safety requirements related to food procurement, storage, preparation, and serving at Riverdell Care Center.
Findings
The facility failed to store food properly to prevent contamination and outdated use. Multiple observations showed unlabeled, undated, and improperly stored food items in refrigerators and freezers, and staff failed to monitor and clean refrigerators adequately.
Deficiencies (2)
F812 Food safety requirements were not met as facility staff failed to store food to protect it from contamination and outdated use. Numerous food items in refrigerators and freezers were unlabeled, undated, or improperly stored, and staff did not monitor or clean refrigerators properly.
A7015 Food must be protected from potential contamination and held at proper temperatures. This regulation was not met as referenced in F812.
Report Facts
Facility census: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Fyfe | Administrator | Signed the plan of correction and mentioned in interviews regarding food storage policies |
| Dietary Manager | Interviewed regarding responsibility for cleaning and labeling refrigerator items | |
| Certified Nursing Assistant A | Interviewed regarding food storage and resident food items in refrigerators |
Inspection Report
Plan of Correction
Census: 48
Capacity: 60
Deficiencies: 3
Date: Dec 5, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety and sprinkler system maintenance standards.
Findings
The facility failed to maintain the sprinkler system free of obstructions and foreign materials, failed to maintain nonrated egress doors, and failed to properly store oxygen cylinders and combustible materials in the oxygen storage room. These deficiencies have the potential to affect all facility occupants.
Deficiencies (3)
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain sprinklers free of foreign materials and obstructions, and failed to maintain the correct number and type of spare sprinklers. Observations included sprinklers loaded with lint and paint on sprinkler deflectors.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect, test, and maintain nonrated egress doors, including the door to the oxygen storage room which did not latch properly and had gaps.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen cylinders properly, with combustible materials stored within five feet of oxygen cylinders and the oxygen storage room door not latching to maintain fire separation.
Report Facts
Facility census: 48
Facility capacity: 60
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 2
Date: Nov 8, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to resident safety, medication storage, and labeling at Riverdell Care Center, including issues with wheelchair pedal use and expired medications.
Findings
The facility failed to ensure residents were properly supervised and assisted to prevent accidents related to wheelchair use. Additionally, expired medications were found in the medication room, and labeling and storage requirements for drugs and biologicals were not met.
Deficiencies (2)
F689: The facility did not ensure residents were adequately supervised and assisted to prevent accidents while being propelled in wheelchairs without foot pedals, resulting in residents' feet dragging on the floor.
F761: The facility failed to properly label and store drugs and biologicals, including expired medications found in the medication room and failure to discard expired stock medications.
Report Facts
Facility census: 47
Expired medication counts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Interviewed regarding wheelchair pedal use and medication cart checks |
| CMT K | Certified Medication Technician | Observed propelling residents in wheelchairs without foot pedals |
| CNA B | Certified Nursing Assistant | Observed propelling residents in wheelchairs without foot pedals |
| Administrator | Interviewed about staff expectations for holding residents in wheelchairs and notification about foot pedal use |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 7
Date: Feb 9, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including review of care plans, medication management, infection control, and resident safety.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, monitoring psychotropic medication side effects, medication storage and labeling, infection prevention and control, and ventilation requirements. Several residents' care plans lacked documentation of monitoring for medication side effects, and expired medications were found in storage.
Deficiencies (7)
F 656: The facility failed to develop and implement comprehensive care plans for five residents, lacking documentation of monitoring for adverse side effects of psychotropic and anti-psychotic medications.
F 658: The facility failed to meet professional standards of quality by not discarding expired medications and lacking a policy for checking expired medications regularly.
F 675: The facility failed to ensure one resident received care to attain or maintain the highest practicable well-being, including inadequate monitoring and documentation of psychotropic medication side effects and skin conditions.
F 758: The facility failed to ensure residents were free from unnecessary psychotropic medications and did not monitor or document side effects and effectiveness of these medications properly.
F 761: The facility failed to label drugs and biologicals properly, including missing expiration dates on insulin vials and medication containers.
F 880: The facility failed to establish and maintain an infection prevention and control program, including failure to remove soiled gloves and wash hands properly, increasing risk of infection.
F 923: The facility failed to maintain adequate ventilation and exhaust systems in the indoor smoke room, resulting in strong smoke odors affecting resident areas.
Report Facts
Facility census: 47
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Faye | Administrator | Signed the report and plan of correction |
| Director of Nursing | Interviewed regarding medication monitoring and resident behaviors | |
| Licensed Practical Nurse (LPN) D | Licensed Practical Nurse | Interviewed about documentation of resident behaviors and medication effectiveness |
| Certified Nursing Assistant (CNA) B | Certified Nursing Assistant | Interviewed about care plan instructions and resident care |
| Certified Medication Technicians (CMTs) | Responsible for checking medication carts and expired medications |
Inspection Report
Life Safety
Census: 47
Capacity: 60
Deficiencies: 2
Date: Feb 8, 2018
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and sprinkler system maintenance.
Findings
The facility failed to maintain required clearance around sprinkler heads, with storage items placed too close and above sprinkler heads in multiple areas. The maintenance storage shed also contained combustible materials stored too close to sprinkler heads, violating NFPA standards.
Deficiencies (2)
K353: The facility stored adult incontinence briefs and combustible materials too close to sprinkler heads, violating NFPA 13 clearance requirements. Storage above sprinkler heads exceeded the allowed limits, posing a fire hazard.
A2034: The sprinkler system maintenance and testing requirements were not met as evidenced by the deficiencies noted in K353. The facility failed to comply with inspection and maintenance regulations for sprinkler systems.
Report Facts
Facility census: 47
Facility capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rhonda Faye | Administrator | Signed the plan of correction document |
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