The woman, identified as R385 in federal inspection records, was admitted to the facility on December 11, 2024, from an acute care hospital. Her admission assessment documented pain at level five on a scale of one to ten. The hospital had ordered oxycodone-acetaminophen tablets every six hours as needed for pain.
But medication records show R385 never received the pain medication on December 11 or the following day at 2:22 pm.
Her family member told inspectors during an April 24 phone interview that R385 "had complained of pain all night after her admission to the facility and did not receive any pain medication." The nurse had informed the family that "the order for the pain medication was not sent to the facility from the hospital, and the physician was not notified."
The facility's Director of Nursing later confirmed to inspectors that she could not locate the hard copy prescription in R385's scanned documents. "The hard copy of the prescription was not received upon the resident's admission, and the receiving nurse did not call the physician to obtain an order for overnight pain relief," she said.
River Towne Center's own policy requires staff to contact the prescriber immediately if a resident's pain is not adequately controlled. The policy also mandates that acute pain be assessed every 30 to 60 minutes until relief is obtained.
The pain management failure was one of six violations documented during the April 2025 federal inspection of the 110-bed facility on Warm Springs Road.
Inspectors found an uncapped needle lying on top of a biohazard container attached to a medication cart on the 200 Hall. The three-cubic-centimeter syringe with exposed needle was observed at 9:37 am on April 22.
Registered Nurse MM verified the dangerous placement and told inspectors "the syringe should have been placed completely in the biohazard container." She acknowledged "there was a potential for a resident to pick up the syringe with the attached needle and have an adverse outcome."
The facility's Unit Manager and Director of Nursing both confirmed that syringes and needles should be disposed of by placing them completely inside biohazard containers with the tops closed.
Hazardous cleaning products were found accessible to residents in three different rooms. In R12's room, inspectors observed aerosol disinfecting spray sitting on the bedside table within easy reach. R87's bathroom contained multi-purpose cleanser on top of the toilet tissue dispenser, which staff said the resident's family member had brought in. R36's room had disinfecting cleaner stored under the bathroom sink, also brought by family.
The Director of Nursing was unaware that family members were bringing chemicals into resident rooms and confirmed that such products should not be accessible to residents.
Two residents told inspectors they weren't receiving their scheduled showers. R12, who requires dialysis three times per week, said she hadn't received a bed bath or shower "for about a month." She explained that her scheduled shower days were Monday, Wednesday, and Friday, but she was out of the facility for dialysis on those days.
"I was in and out of the facility for dialysis and was not offered showers," R12 told inspectors on April 22. Bath assessment forms showed she had refused showers on April 1 and April 15, with no documentation of baths or showers on any other April dates.
R43, who is legally blind and has glaucoma, told inspectors on two separate days that she didn't receive showers as scheduled. Her shower days were Monday and Friday. Inspectors noted she was wearing the same pants on consecutive days.
Both residents required substantial assistance with bathing according to their care assessments.
The facility's medication storage room contained multiple expired drugs mixed with unexpired medications on storage shelves. Inspectors found three boxes of bisacodyl suppositories expired in January 2025, Tylenol tablets expired in November 2024, and three containers of Renavite expired in October 2023.
Registered Nurse CC confirmed the findings and said discontinued medications should be placed in a box for monthly pharmacy pickup and destruction.
The kitchen contained numerous expired food items that posed risks to all 110 residents receiving meals. Inspectors documented ground allspice and ginger seasonings, French-style dressing packets, and gelatin that had passed their expiration dates. The walk-in cooler held expired cabbage, cream cheese, cottage cheese, and ricotta cheese.
The Dietary Manager confirmed the findings and acknowledged that inventory checks should result in discarded expired items.
Infection control violations involved respiratory equipment for residents with breathing difficulties. R1's nebulizer mask was observed sitting unbagged and unlabeled on her nightstand during two separate inspections on April 22 and April 23. The facility's policy requires nebulizer circuits to be stored in plastic bags marked with the date and resident's name between uses.
Similarly, R70's BiPAP breathing mask was found lying unbagged on the bedside table during multiple observations. R70 told inspectors that staff often allowed the mask to fall on the floor and didn't place it in protective bags.
A third infection control failure involved R23's feeding tube site. The PEG tube dressing was discolored with dark brown drainage and dated April 16, despite physician orders requiring dressing changes every shift. The dressing was observed on April 22, six days after the date marked on it.
Licensed Practical Nurse AA confirmed the dressing was soiled and overdue for changing.
The Director of Nursing told inspectors her expectation was for feeding tube dressings to be changed daily, with nursing staff responsible for the task.
All violations were classified as having minimal harm or potential for actual harm, affecting few to many residents depending on the specific deficiency. The facility has not yet submitted its plan of correction to address the identified problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Towne Center from 2025-04-24 including all violations, facility responses, and corrective action plans.