Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River City Living Community during CMS and state inspections, most recent first.
Staff failed to develop and implement person-centered care plans for three residents with cognitive impairment and behavior-related needs. The plans did not include resident-specific interventions for wandering, agitation, exit seeking, inappropriate room entry, or other documented behaviors, and staff interviews showed they did not know the care plan directions for these residents.
Failure to Protect Resident from Inappropriate Touching: Two cognitively impaired residents were found alone in one resident’s room with the door shut, where a visitor observed one resident with his/her mouth on the other resident’s chest. The residents were separated and neither recalled the incident. Staff described the residents as frequently together, with one resident intrusive and overbearing, but the event was not treated as sexual by staff and was not reported as such.
Staff failed to implement the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. Facility policy required completion of a Grievance Complaint Report for lost resident items, documentation on a grievance log, and provision of a written copy and timely resolution to the resident. The grievance log showed only that the tablet was reported missing and staff were searching for it, with no completed grievance form or written response provided to the resident or guardian. The resident reported the tablet had been missing for about a month without resolution. The SSD stated he/she did not consider a missing item to be a grievance, did not complete a grievance form, and confirmed the tablet was neither found nor replaced, while the administrator acknowledged the resident should have received a resolution but did not.
Staff did not follow the facility’s investigation policy after a cognitively intact resident reported a missing tablet. The concern was recorded in the grievance log and staff searched for the item, but no thorough investigation was documented, and required interviews and reporting steps were not completed. The resident reported not receiving a response to the grievance, and the administrator acknowledged knowing about the missing tablet, speaking only with staff, and not conducting a full investigation as required by the misappropriation of property policy.
Staff failed to report an allegation of misappropriation of property to the state agency within the required timeframe. A cognitively intact resident reported a missing tablet, which was documented in the grievance log, and staff began searching for it. The facility’s abuse reporting policy addressed timelines for reporting abuse but did not specify requirements for reporting misappropriation of property. The administrator stated that staff were told to report missing items internally and acknowledged not knowing that such allegations had to be reported to the state, noting that missing items were usually found.
Facility staff did not obtain a physician's discharge order or provide a comprehensive discharge summary for a resident discharged to the community. The medical record lacked required documentation, including a summary of the resident's stay, treatment, and post-discharge care instructions, as well as a signed copy of the discharge summary. Staff interviews indicated a lack of awareness regarding follow-up resources and incomplete documentation of the discharge process.
A resident with diabetes developed a severe finger infection requiring hospitalization after a nursing assistant, unaware of the resident's diagnosis and facility policy, used an electric nail file to apply acrylic nails. The resident's care plan and facility policy specified that only licensed nurses or podiatrists should perform nail care for diabetic residents, but this was not followed, leading to a MRSA infection and surgical intervention.
Staff did not document the administration of prescribed medications for three residents, including those with severe cognitive impairment, diabetes, and chronic pain. Medications such as insulin, anti-seizure drugs, tube feedings, and pain management were not recorded as given according to physician orders, and one resident reported only receiving insulin upon request. These lapses were identified through interviews and review of medical records.
Staff failed to document the administration of medications and tube feedings for three residents, including those with severe cognitive impairment, diabetes, and ALS. Medications such as anti-seizure drugs, insulin, and nutritional feedings were not recorded as given on multiple occasions, particularly on weekends. Both the DON and administrator were aware of complaints about a weekend nurse not administering or documenting medications, but no clear action had been taken.
Staff did not notify the physician after a resident reported being touched inappropriately by another resident. Although the administrator, DHSS, corporate, and police were informed, there was no documentation of physician notification, despite facility policy requiring it when a resident's condition changes.
Facility staff did not ensure an RN was present for at least eight consecutive hours per day as required, with multiple days lacking adequate RN coverage. Time-keeping records and staff interviews confirmed the absence of an RN on several dates, and there was no policy in place for RN coverage. The DON and administrator acknowledged the deficiency and lack of a back-up plan when scheduled RNs did not report to work.
Staff did not document or complete required neurological checks for three residents with cognitive impairment after unwitnessed falls, despite facility policy and expectations from the DON, LPN, and administrator that such assessments be performed and recorded for up to 72 hours post-fall.
Facility staff did not prevent accident hazards by allowing three residents with mild cognitive impairment, all identified as smokers, to keep disposable lighters in their rooms and on their person. One resident also had oxygen therapy equipment in their room. Staff interviews confirmed awareness of the policy permitting this practice, but also acknowledged the associated safety risks.
Facility staff failed to serve food according to nutritionally calculated menus, serving smaller portions than directed. Observations showed residents on regular and pureed diets received less food than specified, with pureed bread omitted. Interviews revealed a lack of appropriate measuring tools and knowledge among staff, with the dietary manager and administrator unaware of the issue.
Facility staff failed to store food properly, leading to potential contamination and outdated use. Observations revealed undated and open food items in the refrigerator, freezer, and dry goods storage, contrary to the facility's Safe Food Handling policy. Interviews with staff indicated that the Dietary Manager and cooks were responsible for labeling and dating food, but this was not consistently done, potentially affecting all residents.
The facility failed to maintain an effective infection prevention and control program, with improper storage and handling of oxygen and nebulizer equipment for several residents. Observations showed equipment left uncovered, undated, and improperly stored, with some found on the floor. Additionally, hand hygiene practices during wound care were inadequate, as a nurse failed to perform hand hygiene and change gloves between tasks, increasing infection risk. Interviews revealed a lack of training and awareness among staff regarding infection control protocols.
The facility failed to provide and document education on the COVID-19 vaccine for staff. Policies lacked direction for staff vaccination, and interviews revealed gaps in responsibility and awareness. The business office manager, responsible for new hire paperwork, had quit, and the Infection Preventionist was unaware of staff education efforts.
The facility failed to obtain physician-ordered blood work for four residents, including tests like Hemoglobin A1C, CBC, CMP, and Depakote levels. Interviews revealed a lack of clarity in the process, with the RN unsure of who uploads results and the DON unaware of the missed tests, citing a disconnect between agency nurses and facility processes.
The facility failed to provide an ongoing activity program during weekends and evenings, affecting two residents. One resident with mild cognitive impairment did not have their activity preferences assessed, while another comatose resident's care plan preferences were not consistently followed. Observations showed limited activities and a lack of staff engagement, partly due to reliance on agency staff.
The facility failed to ensure nursing staff had the necessary skills and competencies to meet residents' care needs, lacking regular in-services and documentation of skills. Nurse aides did not receive the required 12 hours of annual training. Staff interviews revealed inadequate training on essential care areas, with reliance on previous experience. The DON acknowledged inconsistency in training, especially with agency staff, and the administrator was unaware of past training practices.
The facility failed to implement an effective antibiotic stewardship program, as staff did not track residents on antibiotics for infections. The Infection Preventionist (IP) and Director of Nursing (DON) were unclear about their responsibilities, leading to incomplete tracking. The administrator was unaware of the program's lack of implementation.
The facility failed to document the administration or refusal of pneumococcal vaccines for three residents, despite having an immunization policy. The records lacked necessary documentation, and the CDC's vaccination guidelines were not followed. Interviews revealed a lack of clarity and consistency in the immunization process, with staff unsure of the procedures and tracking systems for ensuring residents were up to date.
Facility staff failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical and nursing needs. One resident's care plan lacked directions for oxygen use and medication self-administration, while another's did not include shower preferences. A third resident experienced multiple falls without updated fall prevention interventions. The MDS Coordinator and DON acknowledged the oversight, citing workload as a contributing factor.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director, in position since early 2024, was not certified and unaware of the requirement. The administrator also confirmed the lack of certification, only realizing it when asked for documentation.
A resident with dementia was sexually assaulted by a CNA, witnessed by another CNA who failed to report the incident immediately. The perpetrator continued working for 18 shifts post-assault. The facility's policy to protect residents from abuse was not enforced, leading to an Immediate Jeopardy situation.
A resident with dementia was allegedly sexually abused by a CNA, but the incident was not reported to the administrator until nearly a month later. The alleged perpetrator continued working additional shifts during this time. The facility's policy requires immediate reporting of such incidents, but the administrator failed to notify the DHSS within the required timeframe due to misinformation. The witnessing CNA delayed reporting, seeking proof, and was unaware of reporting protocols.
The facility failed to ensure that two CNAs received mandatory abuse and neglect training upon hire, as required by their policy. Personnel records lacked documentation of training for CNAs hired in 2020 and 2023. Interviews with facility staff, including the administrator, DON, and staffing coordinator, revealed a lack of oversight and documentation regarding the training of newly hired and agency staff.
Facility staff failed to thoroughly investigate an alleged sexual assault by a CNA on a resident with dementia. The investigation lacked interviews with the resident, other residents, and the charge nurse on duty, and did not include observations of behaviors. The former administrator delayed the investigation due to misinformation about prior reporting. The new administrator and DON acknowledged the investigation's incompleteness.
Incomplete Care Plans for Residents With Cognitive and Behavioral Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered comprehensive care plans for three residents with cognitive impairment and behavior-related needs. The facility’s policy stated that care plans should be ongoing and revised as resident conditions change, and should involve resident needs, direct care staff, and relevant care planning areas. However, the care plans reviewed for the three residents did not include resident-specific behavioral interventions or directions for staff related to the behaviors documented in the records and observed by staff. For one resident, the admission MDS showed cognitive impairment, daily wandering, and dementia with behaviors. The care plan identified wandering, difficulty understanding due to cognition, and the need for staff to anticipate needs, but it did not document interventions after an incident of inappropriate touching of a peer. Nurse notes documented the resident in another resident’s room with the door shut, and the physician ordered 15-minute surveillance. For a second resident, the MDS showed cognitive impairment without behaviors, but the referral packet documented severe dementia with agitation, mood swings, and a recent altercation with a peer. The care plan noted risk related to cognition, but did not document the need for a secure unit or staff direction when behaviors occurred. For a third resident, the admission MDS showed cognitive impairment without behaviors, but nurse notes documented agitation, confusion, exit seeking, going into peer rooms, applying peers’ clothing, and relocation to a secured memory care unit for increased supervision. The care plan again only noted risk related to cognition and did not include the secure unit placement or directions for staff when behaviors occurred. During interviews, CNA and medication staff stated they did not know what the care plans directed for these residents’ behaviors, and some said they did not have access to care plans. The MDS nurse stated the behaviors should have been included and that care plans were still being updated; the DON and Administrator also stated resident-specific behaviors should be included in the care plans.
Failure to Protect Resident from Inappropriate Touching
Penalty
Summary
Facility staff failed to protect a cognitively impaired resident from inappropriate touching by another cognitively impaired resident. Resident #1 had dementia with behaviors, wandered daily, and was documented as difficult to understand due to cognition and needing staff to anticipate needs. Resident #2 also had dementia and was assessed as cognitively impaired. The facility’s abuse policy stated residents would be free from abuse and protected from abuse, neglect, and harm, but staff did not prevent the two residents from being alone together in Resident #2’s room with the door shut. On 04/17/26, a visitor opened Resident #2’s room door and observed Resident #1 with his/her shirt up and Resident #2 with his/her mouth on Resident #1’s chest. The residents were separated and neither recalled the incident. Staff interviews showed the residents were often together and that Resident #2 could be intrusive, overbearing, flirtatious, and overprotective, while Resident #1 was described as a tag-a-long personality. The LPN documented no visible injuries after assessment, and the administrator stated staff did not construe the event as sexual, so it was not reported. The DON stated staff would have been expected to separate the residents and report the incident if inappropriate touching was observed.
Failure to Implement Grievance Process for Resident’s Missing Tablet
Penalty
Summary
Facility staff failed to follow the facility’s grievance protocol when a cognitively intact resident reported a missing tablet. The facility’s undated Grievance Protocol policy stated that the purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper follow-up through appropriate disciplines, with the Social Service Director (SSD) responsible for the program and the administrator ultimately responsible for its implementation. The policy specified that a Grievance Complaint Report should be used for situations involving lost or unlocatable resident articles, including ongoing concerns about lost items and laundry issues, and that the SSD would obtain the original report and forward a copy to the appropriate discipline. Review of the grievance log showed an entry indicating the resident had reported a missing tablet and that staff were searching for the item, but there was no documentation that a grievance form had been completed or that a copy had been provided to the resident or guardian. During interviews, the resident stated the tablet had been missing for about a month, that he/she had reported it to an unknown staff member, and that he/she had not been given a resolution. The SSD reported that staff were directed to report grievances to him/her or to direct residents to do so, but acknowledged not considering a missing item to be a grievance and therefore did not complete a grievance form or provide a copy to the resident. The SSD confirmed the tablet was not found or replaced and that the resident had not been provided with a resolution, and also stated being newer to the position and not recalling training on the grievance process. The administrator stated the SSD was responsible for completing a grievance form, providing it to the resident, and giving a resolution within twenty-four hours, and acknowledged that the resident’s tablet had not been replaced and that the resident should have had a resolution but it “slipped through the cracks.”
Failure to Investigate Allegation of Misappropriated Resident Property
Penalty
Summary
Facility staff failed to follow their 2017 Investigation policy requiring that every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriated resident property be thoroughly investigated and reported to the administrator and State Survey Agency within five days. The policy specified that residents, employees, family members, visitors, and others may be interviewed about their knowledge of events, and emphasized that all health care workers are mandatory reporters of abuse. Despite this, when a cognitively intact resident reported a missing tablet, staff only documented the concern in the grievance log and noted they were still searching for the item, without initiating or documenting a formal investigation as required by policy. The resident’s quarterly MDS showed the resident was cognitively intact and had been admitted earlier in the year. The grievance log entry indicated the resident reported the tablet missing, but the medical record for the relevant month contained no documentation of an investigation into the missing property. In an interview, the resident stated the tablet had been missing for about a month, that it had been reported to an unknown staff member, and that there had been no response to the grievance. In a separate interview, the administrator acknowledged awareness of the missing tablet and stated that staff searched for the item and that he/she spoke with staff, but admitted not conducting a full investigation, not following the misappropriation of property policy, and not interviewing other residents, believing instead that the item would likely turn up as missing items typically do.
Failure to Report Alleged Misappropriation of Resident Property to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of misappropriation of property to the state agency (DHSS) within the required 24-hour timeframe. The facility’s Abuse and Neglect Reporting Instructions policy directed staff to immediately report events of abuse, no later than one hour after the event, so the Administrator or designee could report abuse to the DHSS/Abuse Hotline within two hours, but the policy did not address reporting misappropriation of property within 24 hours. The facility census was 51.1. Record review showed a cognitively intact resident, admitted on a specified date, had a quarterly MDS completed on a specified date. The grievance log documented that on 01/16/26 the resident reported a missing tablet and staff noted they were searching for it. In an interview on 03/27/26, the resident stated the tablet was missing and that they had reported this to an unknown staff member. In a subsequent interview on 03/31/26, the Administrator stated staff were instructed to report missing items to the Social Service Director or to the Administrator, and acknowledged not knowing that missing items were required to be reported to DHSS, explaining that staff typically locate missing items and therefore reporting to DHSS had not been considered.
Failure to Obtain Discharge Order and Provide Comprehensive Discharge Summary
Penalty
Summary
Facility staff failed to obtain a physician's discharge order and did not provide a comprehensive discharge summary for a resident who was discharged to the community. The resident's medical record lacked documentation of a discharge order from the attending physician, and there was no evidence that a discharge summary, including a summary of the resident's stay, diagnosis, course of illness, treatment, therapy, pertinent lab and radiology results, pending lab results, special instructions for ongoing care, post-discharge plan of care, advance directive information, and medication reconciliation, was provided to the resident or their representative. Additionally, there was no signed copy of the discharge summary or post-discharge plan by the resident or their representative in the medical record. Interviews with staff revealed that the discharge process was initiated on the day of discharge, but staff were unaware of any follow-up resources being set up, such as home health services. The administrator confirmed that the facility's expectation was for the Social Services Director to arrange necessary resources and communicate them to the resident or representative, with documentation in the medical record. However, the administrator acknowledged that there was not a single form containing all required discharge information and confirmed the absence of a physician's discharge order in the resident's electronic medical record.
Injury and Infection Following Improper Nail Care for Diabetic Resident
Penalty
Summary
Facility staff failed to prevent an injury to a resident when a nursing assistant (NA) used an electric nail file to apply acrylic nails, resulting in a cut to the resident's finger. The resident had a diagnosis of diabetes and was assessed as cognitively intact, with a care plan indicating a risk for unstable blood sugars and a need for assistance with activities of daily living. According to facility policy, nursing assistants are not permitted to perform nail care on residents with diabetes or vascular disease; such care must be provided by a licensed nurse or podiatrist. Despite this, the NA performed nail care using an electric nail file on the diabetic resident, unaware of the resident's diagnosis and the associated restrictions. Following the nail care, the resident developed pain, redness, tenderness, and swelling in the right hand and arm, with symptoms rapidly progressing. Medical records documented that the resident was sent to the emergency department for probable intravenous therapy. The resident was subsequently admitted to the hospital for septic arthritis of the right index finger and underwent surgical intervention to remove infected tissue. Cultures revealed a Methicillin-resistant Staphylococcus aureus (MRSA) infection. The resident continued on antibiotics after returning from the hospital. Interviews with facility staff revealed that the NA was not aware of the prohibition against providing nail care to diabetic residents and did not realize the resident was diabetic. The NA admitted to using an electric nail file but denied causing injury or observing any immediate signs of harm. The administrator acknowledged that the NA was not supposed to perform acrylic nails or clip nails due to lack of certification. Both the facility and hospital physicians indicated that the use of the electric nail file could have contributed to the resident's infection and subsequent hospitalization.
Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility staff failed to document the administration of medications as directed by physicians for three sampled residents. According to the facility's medication administration guidelines, staff are required to promptly record medication administration, including the date, time, dosage, and signature, immediately after giving the medication. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke and epilepsy, staff did not document the administration of skin prep, tube feeding formula, several anti-seizure and psychiatric medications, or the required feeding tube flushes on multiple occasions as ordered by the physician. Another resident, assessed as cognitively intact with diabetes, had undocumented administration of prescribed insulin on two separate occasions. This resident reported that insulin was only given upon request and that staff sometimes claimed it was documented even when it was not received. A third resident, also cognitively intact and diagnosed with diabetes, chronic pain, and pneumonia, had no documentation of receiving prescribed pain medication, bronchodilator, and diabetes medication on a specified date. These failures were identified through interviews and record reviews, indicating noncompliance with established medication administration and documentation protocols.
Failure to Document Medication and Feeding Administration
Penalty
Summary
Facility staff failed to document the administration of medications for three residents, as required by the facility's medication administration guidelines. The guidelines specify that medications must be given as prescribed and promptly recorded in the medical record by the person administering them. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke, seizure disorder, depression, cerebral palsy, and anxiety, staff did not document the administration of several medications, including anti-seizure drugs, antidepressants, and vitamin supplements, across multiple dates in March, April, and May. Another resident, cognitively intact and diagnosed with diabetes, had undocumented administration of insulin on several occasions, particularly on weekends, and reported not receiving insulin doses unless requested. A third resident, also cognitively intact with ALS and a feeding tube, had undocumented administration of tube feedings on several dates, with the resident reporting missed feedings on weekends. Interviews with the DON and the administrator confirmed awareness of complaints regarding a weekend nurse not administering or documenting medications, with the DON stating that issues had been reported to administration but was unsure if any action had been taken. The administrator acknowledged concerns with the weekend nurse and emphasized the expectation that staff follow physician orders and document medication administration, stating that if it is not documented, it is considered not done.
Failure to Notify Physician After Allegation of Inappropriate Contact
Penalty
Summary
Facility staff failed to notify the physician in a timely manner after an allegation of inappropriate touching was made by one resident against another. According to the facility's policy, staff are required to observe, record, and report any change in a resident's condition to the attending physician. In this incident, staff documented the allegation, notified the administrator, the Department of Health and Senior Services, corporate, and the police department, but did not document that the physician was notified. The investigation records and nurse's notes for both residents involved did not show evidence of physician notification. The residents involved included one who was cognitively intact with a diagnosis of anxiety disorder, and another who was moderately cognitively impaired with a diagnosis of bipolar disorder. Following the accusation, the resident accused was placed on fifteen-minute checks, and the administrator conducted an investigation. During an interview, the administrator acknowledged that physician notification should have occurred but was missed during the process.
Failure to Provide Required RN Coverage
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week, as required. Review of the facility's policies revealed there was no policy in place for RN coverage. Examination of time-keeping records showed that on multiple dates in December 2024, January 2025, and February 2025, the facility did not have an RN present in the building for the required eight consecutive hours. Specifically, there were several days where no RN was present for the mandated time, and on some days, no RN was present at all. Interviews with the Director of Nursing (DON) and the administrator confirmed awareness of the requirement for RN coverage. The DON, who had only recently started at the facility, was not aware of who was previously responsible for ensuring RN coverage. The administrator acknowledged ultimate responsibility for ensuring eight hours of RN coverage daily and admitted there were days without adequate RN presence, including instances where the scheduled RN did not report to work and no back-up plan was in place.
Failure to Document and Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of practice by not documenting and completing neurological checks for three residents who experienced unwitnessed falls. According to the facility's policies, staff are required to assess and document neurological status after such events, with the expectation that neurological checks are performed for up to 72 hours following an unwitnessed fall or a fall with potential head injury. However, record reviews revealed that for three residents with cognitive impairments and a history of falls, there was no documentation in the electronic medical record (EMR) or on paper forms indicating that neurological checks were completed after their respective unwitnessed falls. Interviews with the DON, LPN, and administrator confirmed that the expectation was for staff to complete and document neurological checks after unwitnessed falls, and that these checks were to be recorded on paper and uploaded to the EMR. Despite these directives, the required documentation was missing for the identified residents, and the DON acknowledged that neurological checks should have been completed and documented for each unwitnessed fall. The facility's failure to follow its own policy and professional standards resulted in a deficiency related to the lack of post-fall neurological assessments and documentation.
Failure to Secure Lighters and Prevent Accident Hazards for Smoking Residents
Penalty
Summary
Facility staff failed to ensure the resident environment was free from accident hazards by allowing three residents, all assessed with mild cognitive impairment and identified as smokers, to keep disposable lighters in their rooms and on their person. Facility policy permitted residents with independent smoking privileges to retain cigarettes and disposable safety lighters, and staff documented these residents as safe smokers in their care plans and smoking assessments. Observations confirmed that each resident kept cigarettes and lighters in their rooms and on their person, and used them during smoking activities outside the facility. One resident had an order for oxygen therapy and an oxygen concentrator present in their room, while also keeping a lighter in their possession. Interviews with staff, including the MDS Coordinator, CNA, and administrator, acknowledged awareness of the policy but also recognized the safety concerns associated with residents keeping lighters in their rooms, particularly the risk of smoking in rooms and potential fire hazards, especially in the presence of oxygen equipment.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents, as observed during a survey. The facility's policy required measured utensils to serve portions as described on the menu. However, during an observation, it was noted that residents on regular diets were served less than the directed portions of stroganoff, noodles, and vegetables. Similarly, residents on pureed diets received smaller portions of stroganoff and noodles than specified, and pureed bread was not served at all. Interviews revealed that the cook responsible for setting serving utensils was unsure of the correct portion sizes due to a lack of appropriate measuring tools and knowledge. The dietary manager acknowledged that the cooks should serve food according to the menus but was unaware of the incorrect serving sizes. The administrator also stated that the dietary manager was responsible for ensuring correct portions were served but was not aware of the issue. The facility census was 39 with a capacity of 87.
Food Storage Deficiency in LTC Facility
Penalty
Summary
Facility staff failed to store food in a manner that prevents potential contamination and outdated use, as observed during a survey. The facility's Safe Food Handling policy requires all food, including bulk items, to be tightly sealed with an identifying label and date. However, during an observation, several food items in the reach-in refrigerator were found to be undated and open to the air, including a plastic container of pineapple, hot dogs, lettuce, tuna salad, and a zipper bag of meat. Additionally, a cardboard flat of eggs contained five broken eggs, and a one-gallon container of soy sauce was open to the air. Similar issues were observed in the reach-in freezer and dry goods storage room, where bags of beef patties, fish, pasta elbows, cookie crumbs, tortilla chips, and gravy mix were found open and undated. Interviews with facility staff, including the Dietary Manager (DM) and the administrator, revealed that the cooks and the DM were responsible for ensuring all food items were labeled, dated, and not open to the air. The DM stated that open canned items were good for seven days, and cooked items were good for three days, and no food items should be open to the air. The administrator confirmed that the DM was responsible for ensuring all food items were labeled and dated, and that prepared food items were good for three days. This failure to adhere to the facility's food storage policy has the potential to affect all residents, given the facility's census of 39 with a capacity of 87.
Infection Control Deficiencies in Equipment Handling and Hand Hygiene
Penalty
Summary
The facility staff failed to maintain an effective infection prevention and control program, as evidenced by improper storage and handling of oxygen and nebulizer equipment for several residents. Observations revealed that oxygen tubing and nebulizer masks were left uncovered, undated, and improperly stored, with some equipment found on the floor. This was noted for multiple residents, including those with cognitive impairments and respiratory conditions, indicating a lack of adherence to proper infection control protocols. Additionally, the facility's policies on oxygen administration and suctioning were found to be lacking in specific guidance on equipment storage and cleaning procedures. For instance, the suction machine used for a resident requiring tracheostomy care was observed with yellow contents inside, indicating it had not been cleansed after use. Interviews with staff, including registered nurses and certified medication technicians, revealed a lack of training and awareness regarding the facility's protocols for equipment storage and maintenance. The facility also demonstrated deficiencies in hand hygiene practices during wound care for residents with pressure injuries. Observations showed that a registered nurse failed to perform hand hygiene and change gloves between dirty and clean tasks, increasing the risk of infection spread. Interviews with the infection preventionist and director of nursing confirmed that proper hand hygiene was not consistently practiced, highlighting a significant gap in the facility's infection control measures.
Failure to Educate and Document COVID-19 Vaccine Information for Staff
Penalty
Summary
The facility staff failed to provide and document education regarding the COVID-19 vaccine's benefits, risks, and potential side effects for facility staff. The facility's Immunization policy dated February 26, 2022, and the COVID-19 for LTC policy dated May 15, 2023, did not include directions for the COVID-19 vaccine for staff. Interviews revealed that the business office manager, who was responsible for new hire paperwork including COVID-19 status review, had quit. The Infection Preventionist, new to the role since August, was unaware of any education being provided to staff and only tracked resident information. The administrator confirmed that the facility did not document education or offer guidance on obtaining the vaccine for staff.
Failure to Obtain Physician-Ordered Blood Work
Penalty
Summary
The report identifies a deficiency in the nursing facility's adherence to professional standards of care, specifically in obtaining physician-ordered blood work for four out of six sampled residents. The facility failed to provide a policy for obtaining blood work, which contributed to the oversight. Resident #1, diagnosed with diabetes, did not have a Hemoglobin A1C test conducted as ordered in August 2024. Resident #2, with heart disease and diabetes, lacked documentation for a complete blood count (CBC), complete metabolic profile (CMP), Depakote level, and Hemoglobin A1C, all of which were ordered every three months. Resident #4, diagnosed with hypertension, did not have a CBC or CMP conducted in September 2024 as ordered. Similarly, Resident #5, with hypertension, heart failure, and lung disease, did not have a CBC, CMP, or Depakote level test conducted in September 2024. Interviews with facility staff revealed a lack of clarity and responsibility in the process of obtaining and documenting blood work. RN D indicated uncertainty about who was responsible for uploading lab results into the electronic health record and suggested that the Director of Nursing (DON) should oversee the lab process. The DON, new to the role, was unaware of the missed blood work and acknowledged a disconnect between agency nurses and facility processes. The administrator, who recently hired a medical record staff member to manage document uploads, was also unaware of the issues with blood work completion and expected nursing staff to follow up on all physician orders.
Lack of Weekend and Evening Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program during weekends and evenings, which did not meet the needs of two dependent residents. The activity calendar for September and October 2024 showed limited activities, primarily consisting of bible study and occasional puzzles or coloring. Interviews with staff and residents revealed that organized activities were lacking, particularly on weekends, and staff often did not have time to engage residents in activities. Resident #6, who had mild cognitive impairment, did not have their activity preferences assessed or included in their care plan. The resident expressed a desire for more organized activities on weekends. Resident #1, assessed as comatose with a diagnosis of persistent vegetative state, had specific preferences documented in their care plan, such as enjoying looking out the window, listening to gospel music, and being taken out of their room. However, observations showed the resident was often left in a dark room with curtains closed, contrary to their care plan. Interviews with staff indicated a lack of consistency in following the resident's preferences, partly due to the use of agency staff who may not be aware of the activity requirements. The Activity Director acknowledged the challenges in providing consistent activities due to staffing issues.
Inadequate Staff Training and Competency Assessment
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate skills and competencies to meet the care needs of residents. This was evidenced by the lack of regular in-services, re-evaluation, and documentation of skills and competencies for each employee. Additionally, nurse aides did not receive the required 12 hours of in-service education annually. The facility's Orientation and Training policy did not specify the frequency of education, documentation methods, or a comprehensive list of necessary in-services, including critical areas such as abuse and neglect, dementia care, and specialized resident needs. The facility's assessment highlighted the need for initial training upon hire, ongoing professional development, and periodic competency assessments for staff. However, the review of the facility's in-service annual training revealed incomplete documentation, with no records of skills and competencies or the required 12-hour nurse aide training. Interviews with staff, including a Certified Medication Technician, RNs, and CNAs, indicated that they did not receive adequate training on essential care areas such as oxygen use, COVID-19 protocols, dementia care, and other specialized care techniques. Staff often relied on their previous experience or knowledge rather than facility-provided training. The Director of Nursing acknowledged the inconsistency in training, particularly with agency staff, and admitted that the facility assumed agency staff were competent without conducting their own assessments. The administrator, who had only been at the facility for a few months, was unaware of previous training practices and confirmed that CNAs are required to have 12 hours of training annually. The facility had recently received a list of yearly trainings from the corporate office, but there was no evidence of a structured training program in place prior to this.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an effective antibiotic stewardship program, as evidenced by the lack of tracking of residents on antibiotics for various infections. The facility's Antibiotic Stewardship Program outlined responsibilities for the Infection Preventionist (IP) and designee, including auditing clinical assessment documentation and tracking antibiotic-resistant infections. However, the review of the Antibiotic Tracking binder showed it was incomplete, with the most recent line blank. Interviews revealed that the IP had only recently assumed the role and was not fully aware of the tracking responsibilities, while the Director of Nursing (DON) acknowledged not tracking antibiotics despite having received a form to do so. The administrator was under the impression that the antibiotic stewardship program was reviewed during weekly risk meetings but was unaware that it had not been implemented. The DON admitted to planning to start tracking antibiotics but had not yet begun the process due to other pressing issues. This lack of action and communication among staff members led to the deficiency in the antibiotic stewardship program, as there was no current and ongoing log of residents with active infections being treated with antibiotics.
Failure to Document Pneumococcal Vaccinations
Penalty
Summary
The facility staff failed to document the administration or refusal of the pneumococcal vaccine for three of five sampled residents, despite having an immunization policy in place. The policy required a physician order, consent from the resident or legal representative, and documentation of the vaccine administration in the resident's medical record. However, the records for these residents did not contain the necessary documentation, indicating a lapse in following the established procedures. The CDC's guidelines for pneumococcal vaccination were also not adhered to, as the records lacked evidence of the required vaccinations being administered or refused. Interviews with facility staff revealed a lack of clarity and consistency in the immunization process. The Director of Nursing acknowledged that immunizations were a work in progress and expressed uncertainty about the process before their tenure. The Infection Preventionist, responsible for vaccine status since August, admitted to only reviewing new admissions and not having a system for tracking long-term residents due for vaccines. The administrator confirmed that the Infection Preventionist was in charge of vaccine tracking but was unsure of how the process was being managed to ensure residents were up to date.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical and nursing needs. For one resident, the care plan did not include directions for oxygen use or the ability to keep medication at the bedside, despite observations of the resident using oxygen and having medication on the nightstand. The MDS Coordinator was unaware of these needs and acknowledged that oxygen use and self-administration should be part of the care plan. Another resident's care plan lacked information on shower preferences and the level of assistance required, even though the resident was assessed as cognitively impaired and requiring supervision during showers. The resident expressed feeling unclean due to not having a bath or shower while on isolation. The MDS Coordinator admitted there was miscommunication regarding the resident's shower abilities and that the care plan had not been updated. A third resident experienced multiple falls, yet the care plan did not include new interventions or updates for fall prevention. The MDS Coordinator stated that falls are usually updated in the care plan after weekly at-risk meetings but could not explain why this had not occurred. The DON and administrator acknowledged the responsibility of updating care plans with changes in resident status, but both cited being busy with other duties as a reason for the oversight.
Unqualified Activity Director Leads to Deficiency
Penalty
Summary
The facility staff failed to ensure that the activities program was directed by a qualified professional. The facility's policy, dated March 2012, requires that the activity program be directed by a certified Activity Director who is directly responsible to the administrator. However, during an interview, the current Activity Director admitted to not being certified and was unaware of the certification requirement, despite having held the position since February 2024. Additionally, the administrator confirmed that the Activity Director was not certified and acknowledged being unaware of this until prompted to provide the certification.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility staff failed to protect a resident from sexual abuse when a Certified Nurse Assistant (CNA) sexually assaulted the resident. The incident was witnessed by another CNA, who did not intervene or report the abuse immediately. This failure allowed the perpetrator to continue working at the facility for 18 additional overnight shifts after the assault was observed. The facility's policy mandates that residents be free from abuse, neglect, and harm, but this policy was not effectively enforced in this case. The resident involved had a diagnosis of dementia, which impaired their ability to consent or understand the situation. The witnessing CNA documented the incident in a written statement and recorded a video of the assault, although the video quality was poor. Despite suspecting inappropriate behavior for some time, the witnessing CNA delayed reporting the incident due to a lack of concrete evidence and concerns about making false accusations. The local law enforcement was notified, and an investigation was conducted. The perpetrator admitted to having sexual intercourse with the resident, acknowledging the resident's dementia diagnosis. The facility's failure to act promptly and protect the resident from further abuse resulted in an Immediate Jeopardy situation, which was later addressed by the facility.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with dementia in a timely manner. The incident was witnessed by a Certified Nurse Assistant (CNA) on April 17, 2024, but was not reported to the administrator until May 13, 2024. During this period, the alleged perpetrator, another CNA, continued to work 18 additional shifts. The facility's policy requires that such allegations be reported to the administrator and the state survey agency within two hours if serious bodily injury is suspected. However, the administrator did not report the incident to the Department of Health and Senior Services (DHSS) within the required timeframe, as he/she was initially misinformed that the allegation had already been reported and investigated. The CNA who witnessed the incident did not intervene or report immediately because he/she wanted to gather proof by attempting to enhance a video recording of the event. The CNA was unaware of the timeframe for reporting abuse or neglect and had not attended recent abuse in-service training. Interviews with the current administrator and Director of Nursing revealed that staff are directed to remove residents to safety and report incidents immediately, but this protocol was not followed. The deficiency was identified as an immediate and serious jeopardy level violation, indicating a significant failure in the facility's abuse reporting procedures.
Failure to Implement Abuse and Neglect Training
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures effectively, as evidenced by the lack of training for two Certified Nurse Aides (CNA A and D) out of four sampled staff. The facility's policy required all new employees and volunteers to receive training on the abuse policy before having any resident contact. However, a review of personnel records showed that CNA A, hired on 10/03/23, and CNA D, hired on 10/23/20, did not have documentation of receiving this mandatory training. Furthermore, during an interview, CNA D was unable to recall when they last attended an abuse in-service or the timeframe for reporting abuse or neglect. The facility's administration, including the current administrator, Director of Nursing (DON), and Staffing Coordinator, acknowledged the oversight in training. The administrator and DON both stated that the staffing coordinator was responsible for conducting abuse and neglect training for all newly hired staff, including agency staff, and ensuring annual training for existing staff. However, they could not find documentation that agency staff received the required training. The staffing coordinator, who was not in the position when CNA A and D were hired, confirmed conducting an abuse and neglect in-service during orientation for agency staff but did not provide evidence of training for the CNAs in question.
Incomplete Investigation of Alleged Sexual Assault
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation of sexual assault by a Certified Nurse Aide (CNA) against a resident. The facility's policy mandates that reports of abuse be promptly and thoroughly investigated, including interviews with involved parties and observations of behaviors. However, the investigation into the alleged incident, which reportedly occurred between 4:30 A.M. and 5:30 A.M., lacked documentation of interviews with the resident involved or any other residents, and there were no observations of resident and staff behaviors. Additionally, the charge nurse on duty during the incident was not interviewed. The former administrator did not initiate the investigation promptly, as they were initially informed that the allegation had been previously reported and investigated. It was later revealed that the allegation had not been reported, leading to a delayed investigation. Interviews with the newly hired administrator and Director of Nursing (DON) revealed that they believed the investigation was incomplete due to the lack of resident interviews and the omission of the charge nurse's interview. The facility census at the time was 52, and the resident involved had a diagnosis of dementia.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 75 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Oak Tree | 0.1 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Healthcare Western Campus | 2.5 mi | ★★★★★ | 0 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Jefferson City Manor Care Center | 2.8 mi | ★★★★★ | 8 | 0 |
| Stonebridge Villa Marie | 2.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.