Great River Care Center

In the surveyor’s words

From the most serious findings on record at Great River Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 2, 2025

  Based on observation, clinical record review, staff interview, family interview, police officer interview and facility policy review the facility failed to ensure the staff maintained all secured exit doors resulting in 1 of 3 reviewed residents (Resident #1), identified as exit seeking, exiting the facility while a staff member who entered allowed the resident to exit. The staff member failed to notify any nursing and/or management staff. The resident then walked 0.8 miles from the facility down an identified highway on an incline from a bluff and into town. The resident had left the facility for approximately 45 minutes before the nursing staff realized he was missing, when the resident's family called the facility and informed the staff. […]

• No harm, potential for more than minimal, isolatedF693Aug 21, 2025

  Based on observation, clinical record review, policy review and staff interview, the facility failed to provide a water flush per the physician order, measure the formula amount during feeding set up and raise the head of the bed to 45 degrees in the provision of feeding tube care for 1 of 1 resident sampled (Resident #4). The facility identified a census of 29 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #4 with unclear speech (slurred or mumbled words), rarely/never able to make self-understood, and rarely/never able to understand others. […]

• No harm, potential for more than minimal, isolatedF656Oct 2, 2024

  Based on record review, staff interviews, and policy review the facility failed to revise the Care Plan to include hospice care for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 25 residents. Findings include: The Minimum Data Set (MDS) report dated 8/01/24 for Resident #24 indicated a Brief Interview for Mental Status (BIMS) score of 0/15, indicating severe cognitive impairment. The MDS further indicated diagnoses including: Alzheimer's disease, non-Alzheimer's dementia, and seizure disorder. The Progress Note dated 8/08/24 documented Resident #24 admitted to hospice on this date. […]

• No harm, potential for more than minimal, isolatedF550Oct 26, 2023

  Based on observation, clinical record review, policy review, and staff interview the facility failed to uphold resident dignity for 1 of 6 residents sampled (Resident #22). The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Resident required extensive assistance of one staff member for transferring and toilet use and noted Resident #22 as being always incontinent of urine. The MDS listed active diagnoses of diabetes mellitus, morbid obesity, and overactive bladder. […]

• No harm, potential for more than minimal, isolatedF658Oct 26, 2023

  Based on observation, clinical record review, policy review, manufacturer's full prescribing information, and staff interview, the facility failed to administer medicated eye drops per the physician order and per the manufacturer's prescribing information for 1 of 1 residents sampled (Resident #15). The facility identified a census of 27 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive loss. The MDS listed diagnoses of Alzheimer's Dementia and primary open-angle glaucoma, left eye, mild stage. A Order Summary Report signed by the Provider on 10/24/23 detailed the following physician orders: 1. […]