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 Crossing Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain professional standards for food service safety, with multiple instances of improperly stored and unlabeled food items in the kitchen. Observations revealed unsanitary conditions, including caked-on stains on kitchen equipment and debris on the floor. Staff did not follow proper sanitary practices during food preparation, using bare hands and inadequately cleaning equipment between uses. The Dietary Manager acknowledged these issues, highlighting a need for improved cleanliness and food labeling.
The facility did not maintain RN coverage for at least eight consecutive hours daily, as required. On several days, there was no RN present, and on others, the only RN was the DON, who was also acting as the DON due to a nursing shortage. The ADON, an LPN, often took on DON responsibilities. This deficiency had the potential to affect all 87 residents.
The facility failed to ensure proper communication with dialysis centers for residents receiving dialysis services. Three residents reported no paperwork or communication forms were used, and the facility did not check vital signs. Interviews with the DON and Administrator confirmed the lack of communication and documentation, contrary to the facility's policy.
The facility failed to follow standardized recipes for pureed meals, leading to inconsistent textures and potential safety risks for residents on pureed diets. Additionally, the facility did not maintain proper food temperatures during service, with hot foods not reaching the required 120 degrees Fahrenheit and cold foods exceeding 41 degrees Fahrenheit. Residents reported dissatisfaction with the quality and temperature of meals, particularly those served in their rooms.
A resident with communication difficulties due to a stroke was dismissed by a housekeeper who did not speak the resident's language, compromising the resident's dignity. The facility lacked a consistent communication strategy, relying on family visits for translation. Staff interviews revealed gaps in communication support, with the ADON acknowledging the lack of a communication board and attributing the incident to the housekeeper's inexperience.
A facility failed to document a resident's change in condition according to its policy. The resident, with a history of acute respiratory failure and other health issues, showed signs of facial drooping and drowsiness. An LPN contacted the physician and family, who decided to keep the resident in the facility. However, there was no follow-up documentation, and the resident passed away without further intervention. Interviews revealed an expectation for proper documentation, which was not met, leading to a deficiency.
A long-term care facility failed to maintain an effective infection prevention and control program. An LPN did not change gloves or perform hand hygiene after wound care, and catheter tubing was reconnected without disinfection. Additionally, staff did not wear appropriate PPE during high-contact activities with a resident on enhanced barrier precautions. These actions were contrary to the facility's policies, which emphasize hand hygiene, aseptic technique, and PPE use to prevent infection spread.
The facility failed to protect residents from physical abuse by not adequately educating staff on the risk of resident-to-resident physical assault and immediate interventions. This led to a resident physically assaulting another resident after a verbal altercation escalated. The staff was unaware of the resident's history of verbal aggression and potential for physical violence, contributing to the severity of the incident.
The facility failed to maintain complete and accurate medical records, including documentation of verbal and physical aggressive incidents, encounters with the SSD, and timely uploading of neurological checks. A resident with a history of aggression had significant gaps in their progress notes, and another resident's neurological checks were not uploaded promptly.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed over several days. Food items in the dry storage room and freezers were found improperly stored, with many items not labeled, dated, or covered. Specific items included bags of chocolate chips, tortilla chips, crispy onions, powdered sugar, bow noodles, croutons, chicken patties, and chicken nuggets, all lacking proper labeling and dating. Additionally, a bag of biscuit dough was found open and exposed to air. These practices were observed on multiple occasions, indicating a systemic issue with food storage and labeling. The kitchen environment was also found to be unsanitary, with heavy caked-on stains on the stove burners, the front of the stove, and the deep fryer, which also contained old grease. The kitchen floor was dirty, with debris and food particles present. Furthermore, staff failed to follow sanitary practices during food preparation. On one occasion, a dietary staff member rinsed a blending bowl with plain water, leaving chicken puree residue before preparing a carrot puree. Another staff member used bare hands to clean a blending bowl, leaving soup puree residue before preparing cornbread puree. The Dietary Manager acknowledged these issues, noting that deep fryers were cleaned monthly and that there was an expectation for all equipment and floors to be clean, with food properly labeled and stored.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. The nursing schedules from 12/30/24 through 1/23/25 revealed multiple days without RN coverage, specifically on 1/3, 1/4, 1/5, 1/6, 1/8, 1/12, 1/13, 1/20, and 1/22. On other days, the only RN scheduled was the Director of Nursing (DON), who was also serving as the acting DON due to a shortage of nurses. The Assistant Director of Nursing (ADON), an LPN, often assumed DON responsibilities, as the DON preferred to work on the floor. The facility acknowledged the shortage and had posted an ad for an RN, but the deficiency persisted, potentially affecting all 87 residents.
Lack of Communication Between Facility and Dialysis Centers
Penalty
Summary
The facility failed to ensure proper communication between the nursing home and the dialysis centers for residents receiving dialysis services. The facility's policy required written communication with the dialysis center, including pertinent information such as medication changes, recent changes in condition, and the resident's tolerance of dialysis procedures. However, the facility did not adhere to this policy, as evidenced by the lack of written communication for three sampled residents who received dialysis services. Resident #32, who was cognitively intact and diagnosed with end-stage kidney disease, reported that no paperwork was provided by the facility for the dialysis center, and there was no communication form used. Similarly, Resident #58, also cognitively intact and diagnosed with end-stage renal disease, had no documentation of being assessed before or after dialysis, and the care plan did not align with the physician's order for dialysis days. Resident #60, who was cognitively intact and received dialysis, also reported that neither the resident nor the driver took any paperwork to the dialysis appointments, and the facility did not check vital signs. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not use the dialysis communication forms, and there was a lack of documentation regarding the residents' dialysis treatments. The DON acknowledged the need for in-service training to implement the communication form, but it was not in use at the time of the survey. The Administrator confirmed that there should be communication between the facility and the dialysis centers, but this was not occurring as required by the facility's policy.
Inconsistent Food Preparation and Temperature Control
Penalty
Summary
The facility failed to adhere to standardized recipes for pureed meals, resulting in inconsistencies in food texture and potential safety risks for residents on pureed diets. Observations revealed that dietary staff did not measure ingredients accurately, leading to variations in the consistency of pureed chicken, bean soup, and cornbread. The dietary manager acknowledged that the cornbread should not have been thick and pasty, emphasizing the importance of following recipes to ensure nutritional value and safety for residents with swallowing difficulties. Additionally, the facility did not maintain proper food temperatures during service, with hot foods not reaching the required 120 degrees Fahrenheit and cold foods exceeding 41 degrees Fahrenheit. Observations showed that food temperatures were not checked before serving, and test trays revealed that meals were served at inadequate temperatures. Residents reported that meals served in their rooms were often cold, while those in the dining room were served promptly and warm. The facility's policy required food to be served at proper temperatures to ensure safety, but this was not consistently followed. Resident feedback from council meetings indicated ongoing issues with cold meals, particularly for those receiving trays in their rooms. Residents expressed dissatisfaction with the quality and temperature of the food, with some relying on family members to bring meals from outside. Interviews with residents confirmed that meals were often unappetizing and cold, regardless of where they were consumed. The administrator acknowledged the expectation for hot foods to be served hot and cold foods to be served cold, highlighting a gap between policy and practice.
Failure to Ensure Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident who was dismissed by a housekeeper when attempting to communicate. The resident, who primarily speaks Cantonese and has a communication problem due to a stroke, attempted to engage with Housekeeper E, who shrugged and stated they did not speak the resident's language before walking away. This interaction was observed by two CNAs who giggled at the situation, highlighting a lack of sensitivity and understanding of the resident's needs. The resident's medical history includes atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's Disease, and a stroke, which has resulted in aphasia. The resident's care plan indicates a need for an interpreter and anticipates communication challenges. Despite this, the facility did not have a communication board in place, and staff relied on the resident's family for translation, who visited three times a day. The CNAs admitted they were unsure how the resident would communicate pain, indicating a gap in the facility's ability to meet the resident's communication needs. Interviews with various staff members, including an LPN, CMT, and the ADON, revealed that while some staff attempted to use translators or simple questions, there was no consistent approach to ensuring the resident's communication needs were met. The ADON acknowledged the lack of a communication board and attributed the incident to the housekeeper's inexperience in long-term care. The facility's failure to provide adequate communication support and training for staff resulted in a situation where the resident's dignity and respect were compromised.
Failure to Document Change in Resident's Condition
Penalty
Summary
The facility failed to adhere to its policy and accepted professional standards for documentation when a resident experienced a change in condition. The policy required licensed nurses to document the date, time, and details of the incident, contact the attending physician and family, update the care plan, and maintain records in the resident's medical record and 24-hour report. However, the facility did not follow these procedures when a resident showed signs of a change in condition, including facial drooping and increased drowsiness. The resident, who had a history of acute respiratory failure with hypoxia, generalized muscle weakness, and other health issues, was observed by an LPN to have a disfigured mouth and facial drooping. The LPN contacted the physician and the resident's family, who decided to keep the resident in the facility as long as they remained responsive. Despite this, there was no follow-up documentation regarding the resident's condition change, and the resident passed away in their bed without further intervention or documentation of the change in condition. Interviews with facility staff, including the acting DON, ADON, and the physician, revealed that there was an expectation for staff to notify the physician and family of any changes in condition and to document these changes properly. However, the documentation was incomplete, and there were no follow-up notes, nurses' notes, or SBAR sheets regarding the resident's change of condition. The lack of documentation and follow-up actions led to a deficiency in the facility's adherence to its policies and professional standards.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. During wound care for a resident, an LPN did not change gloves or perform hand hygiene after completing the procedure. Instead, the LPN continued to handle the resident's personal items and bed controls with the same gloves used during wound care, which is against the facility's hand hygiene policy. This policy emphasizes that hand hygiene is the primary means to prevent the spread of infections and should always be performed after removing gloves. In another instance, a resident with a suprapubic catheter had their catheter tubing disconnected and reconnected without disinfecting the junction, contrary to the facility's catheter care policy. This policy requires aseptic technique and disinfection of the catheter tubing junction with alcohol or a chlorhexidine sponge before reconnection. The resident had a history of urinary tract infections and was receiving catheter care every shift, highlighting the importance of adhering to infection control protocols. Additionally, staff failed to wear appropriate personal protective equipment (PPE) during high-contact activities with a resident on enhanced barrier precautions (EBP) due to an MDRO. Despite the presence of PPE supplies and signage indicating EBP, CNAs did not wear gowns while transferring the resident from bed to wheelchair and during morning care. The facility's policy mandates the use of gowns and gloves during high-contact care for residents on EBP to minimize the risk of infection transmission.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by not adequately educating nursing staff on the risk of resident-to-resident physical assault and immediate interventions to deescalate verbal altercations. This deficiency was highlighted when Resident #1, who was cognitively intact, willfully physically assaulted Resident #2. The nursing staff was unaware of Resident #1's potential for physical aggression and did not intervene promptly when a verbal altercation between the two residents escalated to physical violence. Resident #1 had a history of verbal aggression, which was not adequately documented or communicated to the staff, leading to a lack of appropriate interventions to prevent the escalation. Resident #1's care plan indicated a history of verbal aggression and poor impulse control, with interventions to monitor behavior and intervene before agitation escalates. However, the staff was not informed of these risks or the necessary interventions. On the day of the incident, Resident #1 had a distressing phone conversation and attempted to go outside to smoke, leading to a confrontation with Resident #2, who was blocking the hallway. The situation escalated quickly, resulting in Resident #1 physically assaulting Resident #2 by pulling their hair and hitting them repeatedly. The staff's delayed response and lack of awareness of Resident #1's potential for physical aggression contributed to the severity of the incident. Interviews with staff members revealed that they were not aware of Resident #1's history of verbal aggression or the risk of physical violence. The facility's documentation practices were also found to be lacking, as behavior incidents were kept in soft files and not included in the resident's medical record. This lack of documentation and communication prevented the staff from being fully informed about Resident #1's behavior and the necessary interventions to prevent such incidents. The facility's failure to educate and inform staff about the risks and appropriate interventions for resident-to-resident altercations directly led to the physical assault on Resident #2.
Failure to Maintain Accurate Medical Records and Document Behavioral Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for its residents, specifically failing to document verbal and physical aggressive incidents, encounters with the Social Services Director (SSD) discussing behaviors, and when psychiatric services or counseling were offered to a resident. For Resident #1, there were significant gaps in the progress notes, missing documentation of verbal and physical altercations, and no records of psychiatric services or counseling being offered. The facility kept behavior investigations in soft files that were not uploaded into the resident's medical records, making it difficult to track and manage the resident's behavioral issues effectively. Resident #1 had a history of verbal aggression towards staff and other residents, including using racial slurs and cursing when denied pain medication or smoking outside of scheduled breaks. Despite these behaviors, there was no documentation of the SSD's counseling sessions or the resident's refusal of psychiatric services. The facility's practice of keeping behavior incidents in soft files and not expecting nurses or the SSD to document these incidents in the medical record contributed to the incomplete documentation. For Resident #2, the facility failed to upload neurological checks into the resident's medical record in a timely manner. After an altercation with another resident, Resident #2 sustained injuries and required neurological checks, which were documented on a paper flow sheet. However, there was no established timeframe for uploading these flow sheets into the medical record, and the facility kept them in soft files instead. This practice resulted in incomplete medical records and hindered the ability to provide comprehensive care to the resident.
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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.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Maryland Heights | 0.9 mi | ★★★★★ | 6 | 0 |
| Stonebridge Maryland Heights | 1 mi | ★★★★★ | 4 | 0 |
| Parkwood Skilled Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Avenir At Mark Twain | 2.1 mi | ★★★★★ | 40 | 0 |
| Bentleys Extended Care | 2.3 mi | ★★★★★ | 8 | 0 |
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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.