Inspection Reports for River City Living Community

The facility failed to obtain a physician's discharge order and did not provide the resident or representative with a comprehensive discharge summary including all required information such as diagnosis, treatment, lab results, post-discharge care instructions, and medication reconciliation for one resident out of three sampled.

The complaint investigation substantiated that facility staff failed to document medication administration for three residents and that a nursing assistant caused an injury to a resident's finger with an electric nail file, resulting in infection and hospitalization.

The facility failed to document administration of medications as ordered for three residents, and a nursing assistant caused an injury to a resident's finger using an electric nail file, which led to infection, hospitalization, and surgery.

The complaint involved failure to notify the physician timely about an allegation of inappropriate touching between Resident #1 and Resident #2, and failure to document medication administration for Residents #1, #2, and #3. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to notify the physician in a timely manner about an allegation of inappropriate touching between two residents and failed to document medication administration for three residents, including missed documentation of multiple medications and nutritional feedings. The administrator and Director of Nursing acknowledged these issues and concerns about weekend nursing staff.

The complaint investigation found that staff failed to complete neurological checks after unwitnessed falls for three residents and failed to maintain required RN coverage. The Director of Nursing and administrator acknowledged these failures during interviews.

The facility failed to ensure professional standards of care by not completing neurological checks for three residents after unwitnessed falls and failed to provide a registered nurse on duty for at least eight consecutive hours daily on multiple dates.

Facility staff failed to ensure lighters were kept secure for three out of three sampled residents who smoked, despite policies allowing only disposable safety lighters. Observations and interviews confirmed residents kept lighters in their rooms, which posed a safety risk, especially for residents with oxygen in their rooms.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans addressing resident needs, failure to maintain professional standards in obtaining physician ordered blood work, inadequate activity programming and lack of qualified activity director, insufficient staff training and competency documentation, improper food portioning and unsafe food storage, inadequate infection prevention practices including improper oxygen and nebulizer equipment storage and wound care hygiene, failure to implement an effective antibiotic stewardship program, and incomplete documentation of pneumococcal and COVID-19 vaccinations and education.

The complaint involved an alleged sexual assault by CNA A on Resident #1, who has dementia. CNA D witnessed the assault but delayed reporting it for about a month, wanting proof. CNA A worked 18 additional shifts after the assault before the incident was reported to the administrator on 05/13/24. The administrator failed to report the abuse to the Department of Health and Senior Services within the required two-hour timeframe. The investigation was incomplete and did not include interviews with the resident or other residents, nor observation of behaviors.

The facility failed to protect a resident from sexual abuse by CNA A, who sexually assaulted the resident. CNA D witnessed the assault but did not intervene or report it immediately. The facility also failed to timely report the abuse to the state agency and did not ensure proper abuse and neglect training for staff. The investigation was incomplete as it lacked resident interviews and observation of behaviors.

The complaint was substantiated. The investigation revealed LPN A was found asleep and impaired while providing care, had slurred speech, dilated pupils, and was unable to walk properly. A bottle of morphine was missing from the narcotic count, later found in LPN A's car bag. The police were notified, and the LPN was terminated and reported to the State Board of Nursing.

The facility failed to prevent misappropriation when LPN A took a bottle of morphine belonging to a resident without permission. The employee was found impaired at work, the medication was missing from the narcotic lock box, and the facility took corrective actions including termination of the LPN and notification of appropriate authorities.

The facility failed to obtain physician orders for a resident's catheter, failed to document medication administration for one resident, and failed to document wound assessments for another resident. The facility census was 42 at the time of inspection.

The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, inadequate posting of abuse hotline information, failure to maintain a safe and homelike environment, incomplete background checks for staff, failure to notify residents of bed hold policies, incomplete Minimum Data Set (MDS) assessments and care plans, failure to meet professional standards in laboratory and oxygen orders, unsafe wheelchair use, improper storage of hazardous chemicals and sharps, failure to post nurse staffing information, incomplete pharmacist medication regimen reviews, lapses in infection prevention and control practices, and incomplete COVID-19 vaccination documentation for staff.

The facility failed to update care plans for residents with changing needs, maintain proper wound documentation, provide pureed diets and thickened liquids as ordered, store food safely, and properly disinfect glucometers. Additionally, the facility lacked a Legionella water management program.