River City Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately documented and complete for each resident, for 1 of 4 residents (Resident #1) reviewed for the accuracy of their medical records. The facility failed to ensure the accuracy and completeness of the resident's clinical record by failing to document controlled substance administration on the MAR after the medication had been signed out on the controlled substance record. This resulted in discrepancies between the residents' MAR and the narcotic accountability records. This failure could place residents at risk of receiving improper care. Record review of Resident #1's face sheet, dated 7/1/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to fill out the night temperatures for 2 freezers and 1 refrigerator on May 2026 temperature log for 05/27/26.2. The facility failed to store sliced cheese in a sealed container on 05/28/26.3. The facility failed to label a bag of onions and bell peppers with a discard date on 05/28/26.4. The facility failed to ensure there was not a personal beverage in the food preparation area on 05/28/26. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 7 residents (Residents #2 and #3) reviewed for care plans. The facility failed to update Resident #2's care plan to reflect what type of assistance the resident needed for eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #3) out of 7 residents reviewed for accidents and supervision. The facility failed to ensure Resident #3 did not have [a cleaning solution] at bedside on 05/28/26 and 05/29/26. These failures could place residents at risk for negative adverse effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food that accommodates residents' food preferences and food allergies for 2 of 7 residents (Resident #1 and Resident #2) reviewed for food preferences and food allergies. The facility failed to ensure Resident #1 received orange juice per her 05/28/26 breakfast meal tray ticket. The facility failed to ensure that Resident #2's 05/28/26 lunch meal tray ticket reflected that he had a lactose allergy. This failure could place residents at risk for a decline in health status or an allergic reaction due to inadequate or inappropriate nutritional intake, respectively.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #12) reviewed for abuse/neglect as evidenced by:The facility failed to ensure Resident #12 was free from abuse when CNA A squirted Resident #12 with a water gun in her mouth while she slept on 5/24/25. The facility failed to ensure Resident #12 was free from abuse when Resident #12 made an allegation of abuse by CNA C. The allegation was reported to the Administrator on 05/31/2025 by CNA C and on 06/19/2025 by HHSC Surveyor L.An Immediate Jeopardy (IJ) was identified on 07/08/2025 at 4:40 p.m. The IJ template was provided to the facility on [DATE] at 5:06 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 3 medication cart (west medication cart and nursing treatment cart) and 1 of 2 medication (west medication storage room) storage rooms reviewed for storage of drugs. 1. The facility failed to ensure the west medication cart did not have loose pills and did not have an insulin vial with no open date. 2. The facility failed to ensure the west hall medication storage room fridge had a permanently affixed narcotic lock box. The box contained vials of liquid lorazepam (controlled benzodiazepine tranquilizer medication used to treat anxiety or seizures). 3. The facility failed to ensure the nurse treatment cart did not store the keys to the cart on the cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food service safety for 1 of 1 facility in that: 1. The facility failed to clean a ceiling vent. 2. The facility failed to clean a side wall panel air vent. 3. The facility failed to date an opened jar on mayonnaise in the refrigerator. 4. The facility failed to date two bags of cookie pieces in the storage room. 5. The facility failed to maintain a dish machine sanitation unit. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 8 residents (Resident #21) reviewed for infection control: The facility failed to ensure Resident #21's indwelling urinary catheter bag was not on the floor. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to provide the required 80 square feet per resident in 45 of 46 resident rooms (Rooms #2-5, #7, #9-30, #32, #34, #36-51) reviewed for bedroom measurement . The facility failed to ensure rooms measured the required 80 square feet per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to leave the front porch of the facility on 09/09/2024 without staff's knowledge and go to a grocery store 1.7 miles away, then became confused when leaving the grocery store as to where he resided. Resident was found at the homeless shelter where he had previously lived. Resident #1 had a cognitive decline and that although staff were concerned about letting the resident sit out on the front porch, they continued to do so prior to his elopement. An IJ was identified on 02/27/2025. The IJ template was provided to the facility on [DATE] at 2:12 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure food was properly labeled. 2. The facility failed to ensure expired food products were discarded. 3. The facility failed to ensure food with freezer burn was discarded. 4. The facility failed to ensure a bag of spaghetti was not spilled on the shelf and a container of sugar was closed. 5. The facility failed to ensure staff did not keep personal drinks on the food prep tables. 6. The facility failed to ensure staff did not lick their fingers while placing dietary cards on resident food trays. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 3 of 6 residents (Resident #22, #40, and #39) reviewed for resident rights, in that: 1. LVN A did not knock on Resident #22's door prior to entering his room. 2. CNA R stood while she fed Resident #40 at dinner time. 3. LVN A stood while she fed two unidentified residents at dinner time. 4. RN E did not knock on Resident #39's door prior to entering her room. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 8 of 13 residents (Resident #14, #19, #21, #23, #31, #34, #35, and #41) reviewed for comprehensive care plans in that: The facility failed to update a plan of care to address Resident #14, #19, #21, #23, #31, #34, #35, and #41 for enhanced barrier precautions. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 5 residents (Resident #11) reviewed for medication administration, in that: The facility failed to ensure Resident #11 was administered Methadone (an opioid prescribed for pain) as ordered by the physician. This deficient practice could place residents at risk of not receiving the intended therapeutic effect of medications and could result in diminished health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 10 of 13 residents (Resident #14, #19, #18, #21, #22, #23, #31, #34, #35, and #41) reviewed for infection control, in that: 1. The facility failed to utilize enhanced barrier precautions for Resident #14, #19, #21, #23, #31, #34, #35, and #41. 2. LVN A failed to utilize appropriate hand hygiene and infection control principles. LVN A did not perform hand hygiene between glove changes and obtained an accu check (a test used to obtain a rapid assessment of blood glucose concentration results; finger stick blood sampling) on Resident #22 without properly sanitizing the site. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #146) reviewed for advanced directives, in that: The facility failed to ensure Resident #146's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by a witness, 2nd physician, and or notary public which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 3 residents reviewed for PASRR (Residents #16). The facility failed to ensure Residents #16 had an accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #21 and Resident #35) reviewed for indwelling urinary catheter care, in that: 1. The facility failed to ensure Resident #21's and Resident #35's indwelling urinary catheter drainage bags were not touching the floor and were in a dignity bag. This failure could place residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #39) reviewed for enteral feeding tubes in that: 1. RN F did not ensure Resident #39's head of bed was elevated to at least 30 degrees. These failures could place residents at risk for complications of enteral feeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #15) reviewed for oxygen therapy in that: Resident #15's oxygen concentrator filter was covered in a thick white substance and the oxygen setting was lower than the physician's orders. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #16) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #16. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 7.14% based on 2 out of 28 opportunities, which involved 2 of 5 Residents (Resident #18 and #28) reviewed for medication administration, in that: Med Aide D failed to ensure Resident #18, and Resident #28 received the correct dosage of Vitamin D. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 4 medication carts (West Wing medication cart) and 1 of 21 resident rooms (Resident #11) reviewed for storage of drugs. 1. The [NAME] Wing medication cart was left unlocked and unattended. 2. The facility failed to ensure medications were not left at the bedside for Resident #11. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #11) reviewed for accuracy of medical records in that: Med Aide Q documented she gave Resident #11's afternoon dose of Methadone (prescribed for pain) on 4/30/24 and 5/1/24 after Resident #11 received his last dose of Methadone on 4/30/24 during the scheduled morning dose. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 1 of 14 employees (DON) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the DON. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 46 of 49 multiple occupancy Resident rooms provided a minimum of 80 square feet per resident room. This deficient practice could affect all residents in need of at least 80 square feet of living space and could pose problems in the Residents' activities of daily living.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the care plan reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for care plan assessments. The facility failed to accurately document Resident #1's care plan dated 2/21/2024 which revealed the resident needed appropriate footwear and was ambulatory and could propel her wheelchair. This deficient practice could place residents at risk of inadequate care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the treatment cart for 1 of 1 treatment cart reviewed for drug storage. The facility failed to ensure staff locked the treatment cart when it was left unattended.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #1) of 5 residents reviewed for special eating equipment and assistance when consuming meals, in that: The dietary staff failed to provide Resident #1 with a plate guard to meet Resident #1's need for assistance with eating related to Resident #1's right side weakness. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 12 residents (Resident #13) reviewed for treatment and services in that: The facility did not maintain physician's orders and medical information needed to monitor Resident #13's cardiac pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm that stimulates the heart with electrical impulses to maintain or restore a normal heartbeat) parameters for proper functioning. This failure could place residents of risk for not receiving proper care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the freezer were dated, labeled, and sealed appropriately. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent accident for 33 of 33 residents living in the facility. There were 2 yellow gas cans containing 5 gallons of gasoline each observed in the laundry room. This deficient practice could affect residents who lived in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bowel/bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #32) reviewed for incontinent care, in that: CNA C did not use proper technique when providing incontinent care and catheter care to Resident #32. This deficient practice could place residents at risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 2 of 9 residents (Resident #4 and Resident #17) reviewed for labeling and storage, in that: 1. The pharmacy label for Resident #4's prescription was missing an expiration date. 2. Resident #17's Carvedilol (medication used to lower blood pressure) was incorrectly labeled to administer the medication through the route of a percutaneous endoscopic gastrostomy (an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall) instead of by mouth. This deficient practice could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications.

Inspectors wroteBased on observation and interview the facility did not provide a safe, functional, sanitary comfortable, environment for residents, staff, and the public for 1 of 1 laundry facilities reviewed for environment, in that: 1. Inside 2 of 2 dryers contained multiple area of unknown dark hard substance and medical tape. 2. 2 of 2 dryers had a thick layer of lint in the lint trap. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is uncomfortable, unsafe, and unsanitary. The Findings Were: During an observation on 03/31/23 at 11:45 a.m. revealed the facility's laundry room contained two dryers. The lint trap under both dryers was covered in a thick layer of lint. Some lint had fallen on the bottom of the dryer. A note was hanging on the side of the dryer reflecting to clean the lint trap every hour. [...]

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure that 47 of 49 multiple occupancy Resident rooms provided a minimum of 80 square feet per resident room. This deficient practice could affect all residents in need of at least 80 square feet of living space and could pose problems in the Residents' activities of daily living.