Inspection Reports for River City Care Center

The complaint investigation was triggered by allegations that CNA A abused Resident #12 by squirting a water gun in her mouth while she slept and dropping a bed remote on her arm. CNA C was also alleged to have been mean and intimidating to Resident #12. The investigation partially substantiated the water gun use pattern but not the specific incident of squirting water in the mouth. CNA A was suspended and terminated. CNA C was suspended pending investigation. Immediate jeopardy was identified and later removed after corrective actions.

The facility was found to have immediate jeopardy related to abuse and neglect of Resident #12 by staff, including use of a water gun and improper treatment. Additional deficiencies included improper medication storage, food safety violations, failure to maintain infection control practices for indwelling catheter care, and failure to provide required room size per resident. The immediate jeopardy was removed but the facility remained out of compliance at a lower severity level.

The complaint involved abuse allegations against CNA A and CNA C reported by Resident #12. CNA A was suspended and terminated after investigation. CNA C was suspended pending investigation. The allegation against CNA A was partially confirmed; the allegation against CNA C was under investigation. Immediate Jeopardy was identified on 07/08/2025 and removed on 07/10/2025.

The facility failed to protect Resident #12 from abuse when CNA A squirted water into the resident's mouth while she slept and dropped a remote on her arm. CNA C was alleged to have been mean and intimidating to Resident #12. Immediate Jeopardy was identified but later removed; the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm. The facility implemented a Plan of Removal including staff training, suspensions, investigations, and ongoing monitoring.

The visit was complaint-related due to Resident #1 eloping on 09/09/2024. The Immediate Jeopardy was identified on 02/27/2025 and removed on 02/28/2025. The facility was out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm after IJ removal. The complaint was substantiated with findings of inadequate supervision and environmental hazards.

The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in an Immediate Jeopardy (IJ) situation. Resident #1, with moderate cognitive impairment and wandering behavior, was able to leave the facility unsupervised. The facility implemented corrective actions including reassessment of all residents for elopement risk, staff in-services on elopement prevention and response, and monitoring to prevent recurrence.

The facility was found deficient in multiple areas including failure to honor resident rights, incomplete advanced directives, inaccurate PASRR screening, incomplete care plans for enhanced barrier precautions, improper catheter care, inadequate respiratory care, medication errors including missed doses and improper administration, failure to maintain infection control practices, unsafe food handling, and insufficient room size for residents.

The facility failed to ensure Resident #1's care plan accurately reflected her mobility status, posing a risk of inadequate care. Additionally, the facility failed to secure the treatment cart, allowing unauthorized access to medications and medical supplies.

The complaint investigation found that Resident #1 did not receive the required plate guard on his meal plate, which was confirmed by observation and interviews. The Food Service Manager confirmed the dietary aide did not provide the assistive device as required by the meal ticket. The deficiency was substantiated with minimal harm and affected a few residents.

The facility failed to provide Resident #1 with a required plate guard to assist with eating, resulting in the resident not eating initially due to inability to scoop food. After intervention, the resident was able to eat with the plate guard. The Food Service Manager acknowledged the failure and planned staff education to prevent recurrence.

The facility was found deficient in multiple areas including failure to maintain proper physician orders for a resident's pacemaker, unsafe storage of gasoline in the laundry room, improper incontinent care technique by staff, medication labeling errors, improper food storage and labeling in the kitchen, inadequate resident room sizes, and unsanitary conditions in the laundry area.