Inspection Reports for
Riverview Nursing Center
10303 STATE RD C, MOKANE, MO, 65059-1211
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
17.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
220% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
62% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 37
Deficiencies: 2
Date: May 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident financial management and medication storage and labeling at Riverview Nursing Center.
Findings
The facility failed to prevent commingling of residents' personal funds with operating funds and did not refund resident funds within the required 30-day timeframe after discharge. Additionally, expired insulin vials were stored with current medications, and loose pills were found in medication carts, indicating lapses in medication storage and labeling practices.
Deficiencies (2)
Failed to prevent commingling of 13 residents' personal funds with facility operating funds.
Failed to store medications safely; expired insulin vials were stored with current medications and medications were loose in one medication cart.
Report Facts
Residents affected: 13
Facility census: 37
Amount held in operating account: 23907.83
Loose pills found: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager (BOM) | Discussed lack of training and responsibility for refunding resident funds | |
| Recovery Specialist | Responsible for ensuring claims are paid and resident refunds are issued | |
| Director of Banking Services | Responsible for cutting refund checks upon request | |
| Administrator | Reviewed accounts receivable aging report and acknowledged delays in refunds | |
| Regional Director of Operations | Oversight of refund process and awareness of delays | |
| Director of Nursing (DON) | Discussed medication storage and insulin vial expiration oversight | |
| Licensed Practical Nurse (LPN) C | Acknowledged failure to check insulin vial open dates | |
| Assistant Director of Nursing (ADON) | Responsible for ensuring medication safety and insulin date checks | |
| Certified Medication Technician (CMT) D | Medication cart observed with loose pills |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 5
Date: May 21, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Riverview Nursing Center.
Findings
The facility was found deficient in managing residents' personal funds, medication storage, and labeling. Issues included commingling of resident funds with facility operating funds, failure to refund resident funds timely, and improper storage and labeling of medications including expired insulin vials and loose pills in medication carts.
Deficiencies (5)
F567 Protection/Management of Personal Funds: Facility failed to prevent commingling of 13 residents' personal funds with facility operating funds. The facility census was 37.
F761 Label/Store Drugs and Biologicals: Facility staff failed to store medications safely, including expired insulin vials and loose pills in medication carts. The facility census was 37.
A4064 Medication Storage: Facility failed to store all medications at appropriate temperatures in a safe, clean, and orderly manner, violating 19 CSR 30-85.042(55).
A8044 Resident Funds-Itemized Bill: Facility failed to submit a final itemized bill for goods and services within 30 days of resident discharge or death, violating 19 CSR 30-88.010(43).
A9004 Resident Fund, Monthly Interest: Facility failed to maintain separate accounts for resident funds and credit accrued interest monthly, violating 19 CSR 30-88.020(4).
Report Facts
Facility census: 37
Residents with commingled funds: 13
Total amount held in operating account: 23907.83
Loose pills in medication cart: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Cross | Administrator | Named in plan of correction signature and referenced in findings |
Inspection Report
Life Safety
Census: 37
Capacity: 60
Deficiencies: 4
Date: May 21, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association and related fire safety regulations, focusing on the maintenance and testing of the sprinkler system.
Findings
The facility failed to provide complete and verifiable documentation for quarterly inspections and testing of the sprinkler system. The inspection revealed missing quarterly sprinkler inspection records from October 28, 2024, through May 21, 2025, which poses a risk of system failure and delayed fire suppression.
Deficiencies (4)
K353: Facility staff failed to provide complete and verifiable documentation for quarterly inspection and testing of the sprinkler system, missing records from 10/28/24 through 05/21/25. This failure has the potential to affect all facility occupants due to risk of system failure and delayed fire suppression.
A4064: Facility failed to store all external and internal medications at appropriate temperatures in a safe, clean place, and secure all medications including refrigerated ones behind locked doors or cabinets. This regulation was not met as evidenced by Class III deficiency.
A8044: Facility failed to submit a final itemized bill for all goods and services rendered within 30 days after discharge or death of a resident, including accounting of resident funds. This regulation was not met as evidenced by Class II* deficiency.
A2034: Facility failed to inspect, maintain, and test sprinkler systems as required by regulations for facilities with sprinkler systems installed prior to August 28, 2007. This regulation was not met as evidenced by Class II deficiency.
Report Facts
Facility census: 37
Total licensed capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Cross | Administrator | Signed plan of correction related to sprinkler system deficiency |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
The inspection was conducted as an annual survey of Riverview Nursing Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
This document is a Plan of Correction related to a health facility survey and licensure inspection for Riverview Nursing Center.
Findings
No Health Facility Survey deficiencies or state licensure deficiencies were cited as a result of the inspections conducted on 04/04/2024.
Inspection Report
Life Safety
Census: 34
Capacity: 60
Deficiencies: 14
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with life safety code requirements, including emergency preparedness, fire safety, and related regulations.
Findings
The facility failed to maintain adequate emergency preparedness plans, including subsistence needs for staff and patients, tracking of staff and patients during emergencies, and emergency communication plans. Additionally, the facility failed to maintain fire safety measures such as monitoring vaping device use, emergency lighting, fire drills, fire barrier door assemblies, and combustible decorations.
Deficiencies (14)
E015: Facility failed to ensure emergency preparedness plan included subsistence needs for staff and residents, and alternate energy sources for fire detection and alarm systems during emergencies.
E018: Facility failed to maintain a system to track location of on-duty staff and sheltered patients during emergencies, delaying response procedures.
E031: Facility failed to develop and maintain an emergency preparedness communication plan including contact information for state long-term care ombudsman.
K100: Facility failed to monitor vaping device use by residents, risking fire hazards in one of five smoke zones.
K281: Facility failed to provide emergency lighting in stairway between basement and first floor, delaying evacuation procedures.
K374: Facility failed to maintain three of three double egress fire barrier door assemblies, risking containment of smoke and fire.
K712: Facility failed to conduct silent fire drills only between 9:00 P.M. and 6:00 A.M., risking delayed response to fire emergencies.
K753: Facility failed to prohibit flammable decorations such as candles with wicks, creating fire hazards in one of five smoke zones.
A1054: Facility failed to provide at least one tub or shower for every 15 beds as required, risking resident care needs.
A2003: Facility presented a fire hazard by failing to prevent vaping device battery charging in resident rooms.
A2050: Facility failed to provide emergency lighting of sufficient intensity for safety of residents and staff in exit areas.
A2054: Facility failed to maintain smoke section walls and doors with required fire-rated separation and self-closing doors.
A2058: Facility failed to conduct required fire drills and maintain emergency preparedness plans as required by regulation.
A2061: Facility failed to conduct required fire drills including resident evacuation simulations at least annually.
Report Facts
Facility census: 34
Total capacity: 60
Deficiencies cited: 14
Fire drills required: 12
Fire drills conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #6 | Named in vaping device use and fire hazard findings | |
| Registered Nurse C | Registered Nurse | Interviewed regarding smoking materials and vaping device policies |
| Director of Nursing | Director of Nursing | Interviewed regarding smoking policies and resident supervision |
| Administrator | Administrator | Interviewed regarding emergency preparedness plan and policy compliance |
| Maintenance Director | Maintenance Director | Interviewed regarding emergency lighting and fire door maintenance |
| Maintenance Supervisor/Designee | Maintenance Supervisor/Designee | Responsible for monitoring fire drills and fire barrier door maintenance |
| Activity Director | Activity Director | Responsible for vaping device storage and fire hazard education |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of money from a resident's checking account by a Certified Nursing Aide (CNA A). The visit aimed to investigate the suspected financial exploitation and related policy violations.
Complaint Details
The complaint investigation substantiated that CNA A misappropriated resident funds by stealing checks and cashing them without authorization. The local sheriff charged CNA A and spouse with financial exploitation and related crimes. The facility took corrective actions including staff in-service and termination of CNA A.
Findings
The facility failed to prevent the misappropriation of money from one resident's checking account by CNA A, who stole checks and had them cashed without authorization. The facility conducted an investigation, suspended and terminated CNA A, and reported the incident to law enforcement. The local sheriff charged CNA A and CNA A's spouse with multiple financial crimes involving approximately $4,195.00.
Deficiencies (1)
Failure to protect resident from wrongful use of belongings or money due to CNA stealing checks and unauthorized cashing.
Report Facts
Residents Affected: 4
Resident Census: 34
Amount misappropriated: 4195
Amount stolen from facility: 4000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Aide | Named in misappropriation of resident funds and termination for policy violation |
| Business Office Manager | Business Office Manager | Reported CNA A admitted to stealing resident funds and facility money |
| Administrator | Administrator | Notified of non-compliance and reported arrest to DHSS |
| Director of Nursing | Director of Nursing | Provided information on investigation and policy enforcement |
| Social Service Director | Social Service Director | Involved in investigation and reporting of stolen checks |
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
This document is a plan of correction related to a deficiency found during a survey completed on 03/13/2024 at Riverview Nursing Center.
Findings
The facility failed to prevent misappropriation of resident property by a Certified Nursing Aide (CNA), who stole checks and misused a resident's debit card. The facility conducted an investigation, in-serviced all staff on abuse, neglect, and misappropriation policies, and terminated the CNA involved.
Deficiencies (1)
F 602: The resident was not free from misappropriation of resident property. A CNA stole checks and used a resident's debit card without authorization. The facility failed to prevent this abuse despite multiple investigations and staff training.
Report Facts
Facility census: 34
Misappropriated amount: 4195
Stolen amount: 4000
Stolen amount: 750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Aide | Named in misappropriation and abuse findings |
| Director of Nursing | Director of Nursing | Reported Social Services Director's findings about stolen checks |
| Business Office Manager | Business Office Manager | Reported CNA A admitted misappropriating resident's funds |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Jul 13, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure of facility staff to document administration of physician-ordered medications and treatments for four residents.
Complaint Details
The complaint investigation found that staff failed to document medication administration and treatments for four residents, with multiple missed documentation dates on MAR and TAR. Interviews with nursing staff, Certified Medication Aides, the Director of Nursing, and the administrator confirmed that holes in MAR or TAR indicate missed or unsigned medication or treatment administration.
Findings
The facility failed to meet professional standards as staff did not document medication administration or treatments in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for four residents on multiple occasions, indicating incomplete or missing documentation of care.
Deficiencies (4)
Failure to document administration of Cephalexin, Aspirin, Lisinopril, Paroxetine, and Foley catheter care for Resident #1 as ordered.
Failure to document administration of Methocarbamol, wet to dry dressings, Foley catheter care, nephrostomy tube care, colostomy care, and stump dressing for Resident #2 as ordered.
Failure to document administration of multiple medications including Lisinopril, Quetiapine, Carvedilol, Gabapentin, Memantine, Atorvastatin, Donepezil, health shakes, Foley catheter care, and wound care treatments for Resident #3 as ordered.
Failure to document administration of Lidocaine patch and Foley catheter care for Resident #4 as ordered.
Report Facts
Residents affected: 4
Facility census: 33
Missed medication/treatment dates: 20
Inspection Report
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
The inspection was conducted as a regulatory survey of Riverview Nursing Center to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 35
Deficiencies: 9
Date: Jan 27, 2023
Visit Reason
Routine inspection of Riverview Nursing Center to assess compliance with regulatory requirements including resident rights, safety, infection control, staff training, food service, and COVID-19 vaccination status.
Findings
The facility was found deficient in multiple areas including improper management of resident funds, unsafe and unsanitary environmental conditions, unsafe storage of hazardous chemicals, improper use of mechanical lifts and wheelchairs, failure to provide oxygen as ordered, nurse aides not certified within required timeframe, inadequate meal alternatives, improper food storage and handling, failure to follow infection control procedures, and incomplete COVID-19 staff vaccination compliance.
Deficiencies (9)
Facility staff failed to keep eight residents from going into negative trust account balances and failed to maintain written authorization to manage funds for two residents.
Facility staff failed to maintain resident rooms, common areas, and building structure in a safe, clean, and homelike environment.
Facility staff failed to ensure hazardous chemicals were stored safely and failed to provide safe mechanical lift transfers and wheelchair propulsion.
Facility staff failed to provide oxygen as ordered by the physician for one resident.
Facility staff failed to ensure five nurse aides completed training within four months of employment.
Facility staff failed to provide alternative meals accommodating resident preferences beyond peanut butter and jelly sandwiches.
Facility staff failed to store food properly, failed to perform hand hygiene adequately, failed to allow sanitized dishes to air dry, and failed to wear hair restraints in food service areas.
Facility staff failed to follow infection control procedures including hand hygiene and glove use during resident care.
Facility staff failed to ensure 100% of staff were fully vaccinated for COVID-19 or had approved exemptions/delays.
Report Facts
Facility census: 35
Total staff: 58
Staff without second COVID-19 vaccine dose: 2
Staff fully vaccinated percentage: 96.6
Residents affected by fund mismanagement: 8
Nurse aides without completed training: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA H | Nurse Aide | Named in nurse aide training deficiency and improper mechanical lift use |
| NA J | Nurse Aide | Named in nurse aide training deficiency and improper mechanical lift use |
| NA M | Nurse Aide | Named in nurse aide training deficiency |
| NA N | Nurse Aide | Named in nurse aide training deficiency |
| NA O | Nurse Aide | Named in nurse aide training deficiency |
| CNA F | Certified Nursing Assistant | Named in improper mechanical lift use and wheelchair propulsion |
| LPN C | Licensed Practical Nurse | Named in infection control and mechanical lift use interviews |
| RN L | Registered Nurse | Named in infection control deficiency observation |
| Dietary Manager | Dietary Manager | Named in food storage, hand hygiene, and hair restraint deficiencies |
| Administrator | Facility Administrator | Named in multiple interviews regarding deficiencies and COVID-19 vaccination monitoring |
| Director of Nursing | Director of Nursing | Named in interviews regarding infection control, mechanical lift use, and nurse aide training |
| Infection Preventionist | Infection Preventionist | Named in interviews regarding infection control and facility safety |
| Business Office Manager | Business Office Manager | Named in resident funds management deficiency |
| Housekeeping Regional Director | Housekeeping Regional Director | Named in environmental cleanliness deficiency |
| Maintenance Director | Maintenance Director | Named in building maintenance and chemical storage deficiencies |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 9
Date: Jan 27, 2023
Visit Reason
Annual inspection survey of Riverview Nursing Center to assess compliance with federal and state regulations.
Findings
The facility was found to have multiple deficiencies including improper management of residents' personal funds, unsafe and unclean environment, inadequate supervision and accident prevention, failure to provide adequate respiratory care, improper hiring and training of nurse aides, food safety violations, and infection control issues. The facility census was 35 during the inspection.
Deficiencies (9)
F567 Protection/Management of Personal Funds: Facility staff failed to keep eight residents' funds from going into negative balances and lacked written authorization to manage funds for two residents.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility staff failed to maintain a safe, clean, and homelike environment with issues including ants, sticky floors, damaged flooring, and plumbing problems.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure hazardous chemicals were stored safely and failed to provide safe mechanical lift transfers for residents.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility staff failed to provide oxygen as ordered by a physician for one resident.
F728 Facility Hiring and Use of Nurse Aide: Facility failed to ensure nurse aides completed required training within four months of employment.
F806 Resident Allergies, Preferences, Substitutes: Facility failed to provide alternative meals accommodating residents' allergies and preferences.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to store food properly to prevent contamination and failed to label and date food items correctly.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program including hand hygiene and staff training.
F888 COVID-19 Vaccination of Facility Staff: Facility failed to ensure all staff were fully vaccinated or had exemptions for COVID-19 vaccination.
Report Facts
Facility census: 35
Staff vaccination rate: 96.6
Staff total: 58
Staff without second dose: 2
Inspection Report
Life Safety
Census: 35
Capacity: 60
Deficiencies: 6
Date: Jan 27, 2023
Visit Reason
The inspection was a Life Safety Code survey to evaluate the facility's compliance with fire safety and hazardous area regulations.
Findings
The facility failed to meet several Life Safety Code requirements including self-closing doors to hazardous areas, fire alarm system testing and maintenance, sprinkler system maintenance, and fire drills. Multiple deficiencies were identified related to hazardous areas, fire alarm system, sprinkler system, smoke barrier doors, and fire drills.
Deficiencies (6)
K321 Hazardous Areas - Enclosure: Facility staff failed to ensure doors to hazardous areas were self-closing, positively latched, and resisted smoke passage. Several doors had gaps, were not self-closing, or had loose hardware.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to inspect, test, and maintain the fire alarm system monthly and did not document testing of smoke dampers. Fire alarm system tests were incomplete for several months.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain wet pipe sprinkler systems, including prompt repairs to impairments and clearance around sprinklers. Corrosion and leaks were noted on the water storage tank.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: Facility staff failed to maintain fire barrier doors to ensure they closed properly and resisted smoke and fire passage. Multiple doors had unsealed holes and did not close properly.
K712 Fire Drills: Facility staff failed to conduct fire drills at expected and unexpected times on each shift quarterly. Documentation of fire drills was incomplete and some drills were cancelled due to illness outbreaks.
A1065 Drinking Fountains: Facility staff failed to provide accessible drinking fountains near recreation areas and nursing units. Some drinking fountains were unplugged or lacked plumbing.
Report Facts
Facility census: 35
Facility capacity: 60
Deficiencies cited: 6
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 2
Date: Aug 8, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations at Riverview Nursing Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to mold and black substance issues in multiple areas. Additionally, the facility failed to ensure residents were free of significant medication errors, specifically a resident missing six scheduled doses of Norco.
Deficiencies (2)
F584 Safe Environment: The facility failed to maintain a safe, clean, and homelike environment by not fixing a leaking roof timely and having an unknown black substance in multiple areas including the basement and resident rooms.
F760 Residents are Free of Significant Med Errors: Facility staff failed to ensure one resident was free of significant medication errors by missing six scheduled doses of Norco over two days.
Report Facts
Facility census: 37
Missed medication doses: 6
Number of affected rooms: 5
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Apr 8, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged sexual abuse between residents at Riverview Nursing Center.
Complaint Details
The complaint investigation substantiated that Resident #2 sexually abused Resident #1 by placing a hand under Resident #1's clothing. Staff interviews and documentation confirmed the incident and subsequent monitoring measures.
Findings
The facility failed to ensure a resident was free from sexual abuse when one resident inappropriately touched another resident. Staff failed to prevent and properly document the incident, and interventions to monitor the residents were implemented.
Deficiencies (2)
F600: The facility failed to prevent sexual abuse when Resident #2 touched Resident #1 inappropriately by placing a hand under Resident #1's clothing. Staff did not ensure Resident #1 was free from abuse as required.
A4074: The facility did not provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, failing to inquire about the resident's whereabouts and estimated length of absence.
Report Facts
Facility census: 37
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 2
Date: Dec 13, 2021
Visit Reason
The inspection was conducted to assess compliance with regulations regarding care for dependent residents, specifically focusing on activities of daily living and timely response to call lights.
Findings
The facility failed to provide timely responses to call lights for dependent residents and did not provide appropriate incontinence care. Staff did not return to residents promptly after turning off call lights, resulting in unmet resident needs.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents: Facility staff failed to answer call lights in a timely manner for two dependent residents and did not return to provide needed assistance. Staff also failed to provide appropriate incontinence care for one dependent resident.
A4074 Nursing Care per Resident: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as referenced by F677.
Report Facts
Facility census: 65
Inspection Report
Life Safety
Census: 30
Capacity: 60
Deficiencies: 21
Date: Nov 20, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to maintain exit corridors free of obstructions and unsecured furniture, failed to maintain emergency lighting and fire alarm notification appliances, and failed to maintain sprinkler systems and electrical safety in accordance with NFPA standards. Several deficiencies were identified related to means of egress, emergency lighting, fire alarm systems, hazardous areas, sprinkler systems, and electrical equipment.
Deficiencies (21)
K211 Means of Egress - General: Facility staff failed to maintain exit corridors free of obstructions and unsecured furniture, potentially delaying evacuation in an emergency.
K222 Egress Doors: Facility staff failed to maintain one of seven exit doors with proper locking devices, delaying evacuation in two smoke zones.
K291 Emergency Lighting: Facility staff failed to inspect, test, and maintain battery-powered emergency lighting fixtures and lacked documentation of monthly tests.
K321 Hazardous Areas - Enclosure: Facility staff failed to ensure doors to hazardous areas were self-closing, positively latched, and resisted smoke passage, risking containment failure.
K341 Fire Alarm System - Installation: Facility staff failed to provide a fire alarm notification appliance for a courtyard enclosed by the building and a locked gate.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain sprinkler systems free of corrosion and promptly repair impairments, risking system failure.
K363 Corridor Doors: Facility staff failed to ensure corridor doors were self-closing, positively latched, and free of gaps, risking smoke containment failure.
K712 Fire Drills: Facility staff failed to conduct and document fire drills at required intervals and under varied conditions.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to inspect and maintain nonrated egress doors, risking equipment failure and evacuation delay.
K920 Electrical Equipment - Power Cords and Extension Cords: Facility staff failed to maintain electrical wiring and surge protectors in compliance with NFPA standards.
A1023 Dietary Office: Facility staff failed to locate the dietary office next to the kitchen as required by regulation.
A1088 Door No Louvre/Transom, Solid-Core Wood/Metal: Doors between rooms and corridors lacked required fire resistance and construction standards.
A2008 Hazardous Areas: Facility staff failed to ensure hazardous areas were separated by fire barriers and self-closing doors.
A2010 Oxygen Storage: Facility staff failed to maintain oxygen storage areas in accordance with NFPA 99 standards.
A2018 Complete Fire Alarm: Facility staff failed to provide fire alarm notification appliances for courtyards enclosed by the building and locked gates.
A2034 Sprinkler System-Test/Maintain: Facility staff failed to properly maintain and test sprinkler systems as required.
A2041 Door Locks: Facility staff failed to ensure door locks met NFPA 101 requirements for emergency egress.
A2046 Corridor Requirements: Facility staff failed to maintain corridors free of obstruction and swinging doors into corridors.
A2050 Emergency Lighting: Facility staff failed to maintain emergency lighting systems and conduct required testing.
A2061 Fire Drill Requirements, Evacuation: Facility staff failed to conduct required fire drills and document participation.
A3037 Extension Cords/Duplex Receptacles: Facility staff failed to ensure extension cords and receptacles met electrical safety standards.
Report Facts
Facility census: 30
Facility capacity: 60
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 4
Date: Feb 19, 2020
Visit Reason
Annual survey inspection of Riverview Nursing Center to assess compliance with federal and state regulations regarding nutrition, hydration, and environmental safety.
Findings
The facility failed to ensure proper nutrition and hydration for a resident with significant weight loss and did not maintain a safe, functional, sanitary, and comfortable environment due to ceiling tile discoloration and water damage.
Deficiencies (4)
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure the physician's nutritional orders were followed and the correct diet was consistently served for a resident with significant weight loss.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a clean, functional, sanitary, and comfortable environment as evidenced by multiple ceiling tiles with discoloration, water damage, and mold concerns.
A3001 19 CSR 30-85.032(2) Substantially Constructed/Maintained: The building was not maintained in good repair, with issues noted in ceiling tiles and water damage.
A5001 19 CSR 30-85.052(1) Nutritional Needs Met, Assess Res, Inform Dr: Nutritional needs of residents were not met as evidenced by failure to follow physician orders and properly document dietary interventions.
Report Facts
Facility census: 37
Weight loss: 15
Completion date: Apr 3, 2020
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 2
Date: Dec 3, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving one resident with an injury of unknown origin.
Findings
The facility failed to complete a thorough investigation as required by policy and regulations regarding an incident involving a resident with a goose egg and scratches. The investigation process and reporting were not properly followed by staff and administration.
Deficiencies (2)
F610: The facility failed to investigate, prevent, and correct alleged violations related to abuse, neglect, or mistreatment. The investigation of a resident injury was incomplete and not reported timely to appropriate officials.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. This deficiency is linked to F610.
Report Facts
Facility census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Parker | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 10
Date: Apr 18, 2019
Visit Reason
The inspection was the annual survey of Riverview Nursing Center to assess compliance with federal regulations and state requirements.
Findings
The facility was found noncompliant with multiple federal regulations including resident privacy, safe environment, comprehensive assessments, care planning, nutrition and hydration, pain management, psychotropic drug use, and infection control. Deficiencies were documented with specific examples and observations.
Deficiencies (10)
F583 Privacy and Confidentiality. Facility staff failed to maintain resident privacy and personal medical information, including failing to close doors and knock before entering rooms. The facility census was 40.
F584 Safe/Clean/Comfortable Environment. Facility staff failed to maintain sound levels at a comfortable level, causing loud beeping from the Special Care Unit door that disturbed residents. The facility census was 40.
F637 Comprehensive Assessment After Significant Change. Facility staff failed to complete a federally mandated comprehensive assessment for residents with significant changes in condition. The census was 40.
F657 Care Plan Timing and Revision. Facility staff failed to update care plans timely to reflect changes in residents' needs and conditions. The facility census was 40.
F677 ADL Care Provided for Dependent Residents. Facility staff failed to provide necessary care for residents unable to carry out daily living activities, including grooming and nutrition. The facility census was 40.
F689 Free of Accident Hazards/Supervision/Devices. Facility staff failed to ensure residents' environment was free of accident hazards and failed to provide adequate supervision to prevent falls. The facility census was 40.
F692 Nutrition/Hydration Status Maintenance. Facility staff failed to provide adequate nutrition and hydration to residents, including failure to monitor fluid intake and provide water pitchers. The facility census was 40.
F697 Pain Management. Facility staff failed to provide adequate pain management and failed to notify physicians of residents' pain complaints. The facility census was 40.
F758 Free from Unnecessary Psychotropic Meds/PRN Use. Facility staff failed to ensure appropriate use and monitoring of psychotropic medications for residents. The facility census was 40.
F880 Infection Prevention & Control. Facility staff failed to establish and maintain an infection prevention program, including failure to change gloves, handle linens properly, and prevent spread of infection. The facility census was 40.
Report Facts
Facility census: 40
Inspection Report
Life Safety
Census: 40
Capacity: 60
Deficiencies: 6
Date: Apr 18, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements at Riverview Nursing Center.
Findings
The facility failed to develop and implement emergency preparedness policies for care at alternate sites under a waiver. The sprinkler system was not properly maintained or documented, and the smoke barrier walls had openings that compromised fire resistance.
Deficiencies (6)
E026: The facility failed to develop policies and procedures for emergency preparedness under a waiver for alternate care sites, risking delayed response in emergencies.
K353: The sprinkler system was not inspected, tested, or maintained according to NFPA 25 standards, with rust, corrosion, and combustible materials near sprinklers.
K372: The facility failed to maintain smoke barrier walls free of openings, with holes around pipes and wiring that compromised fire resistance.
A2034: The sprinkler system maintenance and testing requirements were not met as evidenced by K353.
A2054: Smoke section walls and doors did not meet fire resistance requirements due to openings, as evidenced by K372.
A2058: The facility lacked adequate fire drills and emergency preparedness plans, as referenced in E026.
Report Facts
Facility census: 40
Total capacity: 60
Age of sprinkler system: 43
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 6
Date: Jun 12, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse and neglect involving residents at Riverview Nursing Center.
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed in protecting residents from abuse and neglect and in timely reporting and investigating allegations of abuse.
Findings
The facility failed to ensure one resident remained free from verbal and physical abuse when staff forced the resident to shower against their will, resulting in bruising and verbal threats. The facility also failed to immediately report an allegation of staff verbal/mental abuse to the Department of Health and Senior Services within the required timeframe.
Deficiencies (6)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure one resident was free from verbal and physical abuse when staff forced the resident to shower against their will, causing bruising and verbal threats.
F609 Reporting of Alleged Violations: The facility failed to immediately report an allegation of staff verbal/mental abuse to the Department of Health and Senior Services within the required two-hour timeframe for one resident.
A8013 Right to Plan Care/Refuse Treatment: The facility did not meet the regulation ensuring residents' rights to participate in care planning and refuse treatment.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents and to report such incidents as required.
A8025 Report A/N to DHSS/DMH When Needed: The facility did not ensure timely reporting of suspected abuse or neglect to the appropriate authorities as required by regulation.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to initiate and complete a thorough investigation of an alleged violation of resident abuse affecting one resident.
Report Facts
Facility census: 40
Deficiencies cited: 6
Staff suspension duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to abuse incident and investigation |
| CNA B | Certified Nursing Assistant | Named in findings related to verbal abuse and termination |
| Administrator | Conducted facility investigation and involved in reporting and corrective actions | |
| Director of Nursing | Director of Nursing | Informed about incident and involved in investigation and corrective actions |
Inspection Report
Life Safety
Census: 38
Capacity: 60
Deficiencies: 15
Date: Mar 16, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness policies, procedures, and life safety code requirements at Riverview Nursing Center.
Findings
The facility failed to develop and implement adequate emergency preparedness policies and procedures, including the use of volunteers and staffing strategies during emergencies. Multiple life safety deficiencies were identified, including unsecured doors, blocked egress, malfunctioning fire alarm systems, and inadequate fire drills and emergency lighting.
Deficiencies (15)
E024 Policies and procedures. Facility staff failed to develop policies and procedures for the use of volunteers and emergency staffing strategies during emergencies.
E026 Facility staff failed to develop policies and procedures regarding the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.
E035 Facility staff failed to develop and implement a method for sharing emergency preparedness information with residents and their families or representatives.
E039 Facility staff failed to participate in a full-scale community-based emergency exercise and failed to contact state, local, and healthcare agencies for availability of such exercises.
K100 Facility staff failed to ensure access to all areas of the facility at all times, including administrative offices and the Director of Nursing's office.
K211 Facility staff failed to maintain exit corridors free of unsecured furniture and projections greater than six inches, blocking egress.
K222 Facility staff failed to maintain egress doors with proper locking arrangements and failed to post codes for special locking arrangements.
K291 Facility staff failed to conduct annual and monthly testing of emergency lighting equipment and failed to maintain emergency lighting fixtures.
K321 Facility staff failed to maintain hazardous areas with proper fire barriers and self-closing doors, including broken door knobs and missing self-closing devices.
K346 Facility staff failed to timely implement a fire watch and notify appropriate entities during a fire alarm system outage lasting more than four hours.
K355 Facility staff failed to maintain portable fire extinguishers in accordance with NFPA standards.
K372 Facility staff failed to maintain smoke barrier walls free of penetrations and failed to have policies for inspection and maintenance of smoke barriers.
K521 Facility staff failed to maintain ventilation units to provide negative airflow to vent odors in bathrooms and utility rooms.
K712 Facility staff failed to conduct and document fire drills quarterly and failed to maintain written policies for scheduling fire drills.
K761 Facility staff failed to inspect, test, and maintain fire doors and smoke barrier doors in accordance with NFPA standards.
Report Facts
Facility census: 38
Total capacity: 60
Deficiencies cited: 15
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 16
Date: Mar 16, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of abuse, neglect, and failure to provide adequate care and services to residents at Riverview Nursing Center.
Complaint Details
The complaint investigation was substantiated with findings of abuse, neglect, failure to report incidents, inadequate care planning, and insufficient staffing. The facility failed to protect residents from harm and did not comply with multiple regulatory requirements.
Findings
The investigation found multiple deficiencies including failure to conduct proper background checks, inadequate abuse and neglect policies, insufficient care planning and monitoring, improper handling of residents' behaviors, and failure to maintain adequate staffing and medication management. Several residents experienced neglect and inadequate care resulting in harm or risk of harm.
Deficiencies (16)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide required notices and documentation for Medicare Part A services and beneficiary protections for sampled residents.
F606 Background Checks: The facility failed to complete and maintain criminal background checks for newly hired staff prior to employment.
F609 Reporting of Alleged Violations: The facility failed to report allegations of abuse and neglect to the State Survey Agency and other officials within required timeframes.
F657 Care Plan Timing and Revision: The facility failed to update care plans timely and include interdisciplinary assessments for sampled residents.
F658 Pressure Ulcer Care: The facility failed to provide adequate care and monitoring for residents with pressure ulcers, including documentation and prevention measures.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide appropriate incontinence care and assistance with activities of daily living for dependent residents.
F679 Activities: The facility failed to provide an ongoing program of activities to meet the interests and needs of residents, including those in the special care unit.
F692 Assisted Nutrition and Hydration: The facility failed to provide adequate hydration and nutrition to residents, including monitoring and documentation.
F726 Nursing Services: The facility failed to provide sufficient nursing staff with appropriate competencies and training to meet residents' needs.
F740 Behavioral Health Services: The facility failed to provide adequate behavioral health services and interventions for residents with behavioral health needs.
F755 Pharmacy Services: The facility failed to establish a system of records for receipt and disposition of controlled drugs and ensure proper documentation.
F756 Drug Regimen Review: The facility failed to ensure monthly pharmacist review of each resident's drug regimen and follow-up on irregularities.
F758 Medication Labeling: The facility failed to ensure all prescription medications were properly labeled and stored according to regulations.
F801 Food Service: The facility failed to provide adequate food service management including menu planning, food preparation, and sanitation.
F812 Food Procurement/Storage/Preparation/Sanitation: The facility failed to maintain food safety requirements including proper storage and sanitation of food items.
F880 Infection Control: The facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases.
Report Facts
Facility census: 38
Completion dates for corrective actions: Various corrective actions due by 04/30/2018 as listed in the Plan of Correction
Viewing
Loading inspection reports...
