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Complaint Investigation

Grand River Health Care

Inspection Date: November 21, 2025
Total Violations 1
Facility ID 265480
Location CHILLICOTHE, MO
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Inspection Findings

F-Tag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

keep him/her occupied and Resident #1 would be monitored for behaviors.During an interview on 11/21/25 at 9:07 A.M., Resident #3 said:- He/She went to the dining room on 10/27/25 to visit and witnessed Resident #1 hit Resident #2 in the arm;- Resident #1 always gets mad and gets a little temper then gets happy.- He/She didn't remember the incident on 11/9/25;- He/She got hit by Resident #1 one time but didn't tell anyone;- Staff watches Resident #1 but here recently the staff leaves Resident #1 alone then the call lights are going off for staff to get him away from them;- He/She stays away from Resident #1 .During an

interview on 11/21/25 at 9:15 A.M., Certified Nursing Assistant (CNA) A said:- He/She had seen Resident #1 yell at other residents and hit staff members;- Resident #1 needed time to cool off and separate from other residents when aggravated;- Resident #1 had threatened to hit him/her. It's important to know how to approach Resident #1;- Resident #1 would sit in the common area with staff and was checked on frequently;- Residents have the right to not get hit by other residents or anyone;- It is abuse for a resident to hit another resident.During an interview on 11/21/25 at 9:21 A.M., Registered Nurse (RN) A said:- He/She was at the facility when the incident on 11/9/25 occurred and had been told Resident #1 hit Resident #2 and both residents had been put on 15-minute checks and Resident #1 was one on one observation with staff;- Resident #1 was not always supervised and had good and bad days. He/She had seen Resident #1 strike out at others but believed it was more so to get attention and not hurt anyone;- Resident #1 had told him/her that he/she did not like Resident #2;- It was reported to him/her that the residents had been close

in the dining room and Resident #1 started hitting Resident #2 in the arm;- Resident #1 had hit him/her once and would hit out at aides, at night, in bed;- A resident has the right not to be hit, and it could be abuse if a resident strikes another resident.During an interview on 11/21/25 at 9:31 A.M., Certified Medication Technician (CMT) A said:- Resident #1 and Resident #2 were having some sort of issue on 11/9/25 and Resident #2 would push Resident #1's chair and instigated it, then Resident #1 popped Resident #2's arm a few times in a row;- Staff separated the residents, let the nurse know, and Resident #1 was on 15 minute checks for awhile;- Staff have now started bringing Resident #1 to the dining room last and was now observed at all times;- A resident has the right to not be hit by anyone and it can be abuse if a resident hits another resident.During an interview on 11/21/25 at 9:40 A.M., Resident #2 said:- Resident #1 had hit him/her on the shoulder and called him/her names;- One other time, Resident #1 had kept coming over to the dining room table, so he/she told Resident #1 to go back to the other table. Then, Resident #1 flipped Resident #2 off, balled up his/her fist and put it in Resident #2's face shaking it and calling Resident #2 a son of a bitch. The only time Resident #1 touched him/her was a couple of weeks ago 0n 11/9/25);The staff don't really watch Resident #1 but he/she just stays away from Resident #1. During an interview

on 11/21/25 at 11:00 A.M., the Administrator said:- He/She believed Resident #2 antagonized Resident #1, Resident #1 didn't understand and to him/her Resident #2 was the bad person;- After the 10/27/25 incident

the facility added managers to the dining room and Resident #1 would be brought in last;- After the 11/9/25 incident the facility added to Resident #1's care plan to redirect the resident and take him/her to a quiet place to lay down;- The facility had been working on improving Resident #2's instigating and better behaviors.Intake 2653050Intake 2664080

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📋 Inspection Summary

GRAND RIVER HEALTH CARE in CHILLICOTHE, MO inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHILLICOTHE, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAND RIVER HEALTH CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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