River City Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 7, 2022

  Based on record review, interviews, and review of a facility investigative summary, the facility failed to ensure the residents' environment remained free of accident hazards by failing to ensure staff's personal medications were stored in a secure location that was not accessible to residents. Specifically, on 11/08/2021, Resident Identifier (RI) #5, who had a diagnosis of Alzheimer's Disease and resided on the facility's Memory Care Unit, accessed and ingested up to twenty [MEDICATION(S)] (an antihistamine medication) tablets from a bottle belonging to Employee Identifier (EI) #19, a Certified Nursing Assistant (CNA). […]

• Immediate jeopardy, isolatedF689Sep 26, 2021

  Based on interviews, medical record review, and review of a facility policy titled, OPS111 Elopement of Patient, this facility failed to ensure Resident Identifier (RI) #6 was supervised in a manner that staff knew of his/her whereabouts and that he/she did not leave the facility without staff knowledge. On 9/14/2021 at approximately 12:05 PM, RI #6, a cognitively impaired resident, was witnessed by a staff member to unlock and open an exit door. As the resident was exiting, two facility staff members went outside to get the resident. As the staff members approached RI #6, he/she began to run, getting approximately 85 feet from the facility near the street. The staff members were able to retrieve RI #6 and bring him/her back into the facility and into his/her room. […]

• No harm, potential for more than minimal, widespreadF803Apr 29, 2021

  Based on observations, interviews, and record review, the facility failed to follow the posted menu for the lunch meal on 04/26/21. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: During the lunch meal observation on the East Short Hallway and the Solona Unit, on 04/26/21 at 12:20 PM, nine residents were served chicken alfredo and green peas. Observation on 04/26/21 at 1:20 PM revealed Resident Identifier (RI) #80 was served a plain hot dog on a bun and mashed potatoes. On 04/26/21 at 1:20 PM, RI #48 was served a plain hot dog on a bun and mashed potatoes. […]

• No harm, potential for more than minimal, widespreadF812Apr 29, 2021

  Based on observation, interview and record review, the facility failed to ensure the proper handling of clean dishes and silverware. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: 1. On 04/26/21 at 9:38 AM an observation of Employee Identifier #18, Dietary Aide (DA) revealed EI #18 was cleaning off dishes, pots, pans, and glasses from breakfast preparing them for the dishwasher wearing gloves. EI #18 was observed spraying/rinsing off dirty dishes and placing them on trays and into the dishwasher and then moving to the clean side of the dishwasher and handling the clean trays of dishes wearing the same gloves. […]

• No harm, potential for more than minimal, widespreadF814Apr 29, 2021

  Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of and contained. This failure has the potential to affect all 134 residents who resided at the facility. Findings include: On 04/26/21 at 9:43 AM an observation of the area behind the building with Employee Identifier #17, a dietary staff member, revealed four dumpsters used for collecting garbage at the facility. One of four dumpsters was left open; multiple bags of garbage and boxes were noted inside. During an interview on 04/26/21 at 9:43 AM an interview with EI #17, EI #17 stated, the door should be closed. […]