River City Living Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 26, 2024

  Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from sexual abuse, when Certified Nurse Assistant (CNA) A sexually assaulted the resident. The facility failed to protect the resident from further abuse when CNA D witnessed the assault, did not intervene, and did not report it immediately. CNA A worked an additional 18 overnight shifts after the sexual abuse was observed. The facility census was 52. The Administrator was notified on [DATE], of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Immediate jeopardy, isolatedF609Jun 26, 2024

  Based on interview and record review, facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) to the administrator on 4/17/24, after witnessing the event. The alleged perpetrator worked 18 additional shifts before the nurse aide reported what was seen to the administrator on 5/13/24. The administrator failed to report the allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two hour timeframe. The facility census was 52. The Administrator was notified on 06/26/24, of an Immediate Jeopardy (IJ) which began on 04/17/24. The IJ was removed on 05/30/24 as confirmed by surveyor onsite verification. 1. […]

• Actual harm, isolatedF689Oct 28, 2025

  Based on interview and record review, facility staff failed to prevent an injury to one resident (Resident #3) when a Nursing Assistant (NA) used an electric nail file to apply acrylic nails to resident's fingernails and cut his/her finger which caused an infection and hospitalization. The facility census was 44.1. Review of facility's Care of Nails - Fingers and Toes policy, undated, showed the purpose of the policy is to provide cleanliness, comfort, and to prevent spread of infection. Nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease. 2. […]

• No harm, potential for more than minimal, widespreadF803Oct 4, 2024

  Based on observation, interview and record review, facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 39 with a capacity of 87. 1. Review of the facility's Food Preparation and Distribution policy, dated May 2015, showed measured utensils are used to serve proportions as described on menu. 2. Review of the facility menus, undated (Week 2, Day 10), showed the menus directed staff to provide the residents on regular diets six ounces of stroganoff, 1/2 cup (four ounces) of noodles and 1/2 cup of vegetable blend at the lunch meal. Observation on 10/01/24 at 12:41 P.M., showed [NAME] I served the residents a #6 scoop (5.3 ounces) of stroganoff, three ounces of noodles, and three ounces of mixed vegetables. […]

• No harm, potential for more than minimal, widespreadF812Oct 4, 2024

  Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use. This failure has the potential to affect all residents. The census was 39 with a capacity of 87. 1. Review of the facility's Safe Food Handling policy, dated May 2015 showed all food, including bulk items, should be tightly sealed with an identifying label and date. 2. Observation on 10/01/24 at 10:01 A.M., showed the reach in refrigerator contained: -A plastic container of pineapple which was not in its original container and was undated; -A plastic container of hot dogs which was undated; -An opened and undated bag of lettuce; -An opened and undated container of tuna salad; -A cardboard flat of eggs which contained five broken eggs; -A… […]