RIVER CITY CENTER
For profit - Corporation
183 Beds
GENESIS HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#212 of 223 in AL
Last Inspection: April 2021
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
River City Center in Decatur, Alabama has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #212 out of 223 nursing homes in Alabama places it in the bottom half, and it is the least favorable option in Morgan County. The facility is showing some improvement, with a reduction in reported issues from 6 in 2021 to just 1 in 2022. Staffing is average, with a 3/5 rating and a turnover rate of 56%, which is close to the state average. While there are no fines recorded, recent inspections revealed serious incidents, including a resident with Alzheimer's who ingested medication left unsecured by staff, and a prior case of reported physical abuse by a staff member against a resident. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- F
- In Alabama
- #212/223
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Alabama facilities.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Alabama. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 5%
Review needed
6 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2021: 6 issues
2022: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Alabama average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 56%
Near Alabama avg (46%)
Frequent staff changes - ask about care continuity
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Alabama average of 48%
The Ugly 13 deficiencies on record
1 life-threatening 1 actual harm
Nov 2022
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of a facility investigative summary, the facility failed to ensure the residents'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 Atarax (an antihistamine medication) tablets from a bottle belonging to Employee Identifier (EI) #19, a Certified Nursing Assistant (CNA). RI #5 was able to obtain the medication because EI #19 placed her purse, which contained the medication, in a resident closet on the Memory Care Unit and left it unsupervised. RI #5 was transported to the emergency room and received treatment for ingestion of this medication.
This deficient practice placed RI #5, one of one resident reviewed for accidental ingestion of medications, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death.
On 11/07/2022 at 9:07 AM, Employee Identifier (EI) #1, the facility Administrator/Center Executive Director, was provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accidents Hazards/Supervision/Devices. The immediate jeopardy began on 11/08/2021 and continued until 11/11/2021 when the facility implemented corrective actions to address the identified deficient practice, including ongoing monitoring; thus, immediate jeopardy past noncompliance was cited.
Findings include:
On 11/09/2021 at 10:26 AM, the State Survey Agency received an initial report from the facility regarding RI #5 ingesting Employee Identifier (EI) #19's, a Certified Nursing Assistant's (CNA's), personal Atarax prescription, which the staff member had stored on the shelf of a closet in a resident room on the Memory Care Unit.
Review of an admission Record revealed RI #5 was originally admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Cognitive Communication Deficit, Need for Assistance with Personal Care, Major Depressive Disorder, and Dementia with Behavioral Disturbance.
Review of RI #5's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/30/2021, revealed RI #5 scored a 2 on the Brief Interview for Mental Status, indicating severe cognitive impairment.
Review of the facility's investigative file, dated 11/15/2021, revealed RI #5 ingested twenty tablets of Atarax from a bottle belonging to EI #19, a CNA. The investigation indicated the resident was able to obtain the medication because EI #19 placed her purse, which contained the medication, in a resident's closet on the Memory Care Unit and left it unsupervised. EI #10, another CNA, found RI #5 with the purse and medication bottle. There was a green residue on the resident's lips and tongue, matching the color of the pills. The investigation revealed RI #5 was assessed by the nurse, poison control was called, and the resident was transported to the local hospital by Emergency Medical Services (EMS). The investigation report indicated the resident denied eating or taking any medications. EI #19 admitted to placing her purse on the top shelf of another resident's room and covering it with her jacket. EI #19 stated she had the prescription filled prior to coming to work that day.
Review of RI #5's hospital History and Physical, dated 11/08/2021, revealed RI #5 was admitted to the hospital on [DATE] with diagnoses of Toxic Ingestion of Anticholinergic Drugs, Probable Early Onset Toxic Encephalopathy (brain dysfunction caused by exposure to a toxic substance), Dementia, Macrocytic Anemia (a condition in which the blood contains overly large red blood cells and not enough normal red blood cells), and Chronic Kidney Disease. The hospital record indicated the plan was to aggressively rehydrate the resident to enhance the excretion of the Atarax. The Discharge Summary, dictated on 11/22/2021, documented RI #5 initially had .quite a bit of lethargy, and then woke up and was eating and remained hemodynamically stable .
During an interview on 09/16/2022 at 12:45 PM, EI #10, CNA, stated she had given another resident a shower and was returning the resident to his/her room. EI #10 stated she had trouble getting into the room because the door was closed, and when she tried to open it, the door was hitting the open closet door. EI #10 stated when she got the door open, she saw RI #5 lying on the empty bed in the room with a green substance on his/her hands and lips. EI #10 also noted a purse and pharmacy bag on the floor of the closet. EI #10 stated she notified the nurse, who went to the room to take care of RI #5. EI #10 stated she went to the shower room and asked EI #19 if she had any medication in her purse. EI #10 stated EI #19 confirmed she did. EI #10 stated she had never seen staff personal belongings in any resident room before this incident. She stated EI #19 brought belongings to work but EI #10 did not know where she kept them. EI #10 stated the facility had lockers in the breakroom, and that was where staff should keep their belongings.
Review of a witness statement, dated 11/08/2021 and written by EI #11, Licensed Practical Nurse (LPN), revealed she was notified by EI #10 that RI #5 had gotten .into employee personal bag and took a bottle of prescription medications .
During an interview on 09/16/2022 at 12:56 PM, EI #11 stated she was working and was notified by EI #10 that RI #5 got into some medications. EI #11 stated she went down the hall and saw RI #5 walking in the hall. EI #11 stated RI #5 had a green substance around his/her mouth. EI #11 called EI #2, Center Nurse Executive, who was in the building. EI #2 instructed EI #11 to contact poison control. EI #11 stated she stayed with RI #5 until EMS arrived. EI #11 stated she and other staff kept personal belongings locked in the medication room or in the lockers in the break room. EI #11 stated she had never seen any staff belongings in resident rooms before this incident.
Review of a witness statement dated 11/08/2021 and written by EI #19, CNA, revealed EI #19 was giving another resident a shower when another CNA came and told her RI #5 had EI #19's purse with pills in it. EI #19 stated she went to the room and only found nine tablets. EI #19's statement indicated she left her purse high on a shelf with a sweater on top of it, and when she was notified, she went to the room and found the purse on the bed.
During an interview on 09/16/2022 at 1:32 PM, EI #19 stated she had a doctor's appointment on 11/08/2021 and stopped to get the prescription filled before work. EI #19 stated she was running late to work, so she went straight to the unit and put her belongings on the closet's top shelf in a resident's room, which was not RI #5's room. EI #19 stated she could not recall which room it was. During the interview, EI #19 acknowledged that RI #5 would frequently wander into other residents' rooms and open drawers and put on clothing. EI #19 said she did not know why she put her purse in the closet that day, that she had never done that before. EI #19 stated she then went to the shower room to give another resident a shower. EI #19 said while she was in the shower room, EI #10 entered the room and stated RI #5 had gotten into EI #19's purse. EI #19 stated she left the shower room as quickly as she could and went to the room and saw the purse on the bed. EI #19 stated the Atarax prescription was full, with 30 tablets, and had a child-proof cap on the bottle. EI #19 stated she did not know how RI #5 was able to get the lid off. EI #19 stated she did not know how many tablets were missing and did not count the tablets herself. EI #19 stated she did not know why she put her purse on the closet shelf, except that she was in a hurry.
Review of a witness statement, dated 11/08/2021 and written by EI #2, revealed she was notified by EI #11 that there was a problem on the hall. EI #2 went directly to the unit and was told EI #19 left her purse in a resident's closet and that the purse contained medications. EI #2's statement indicated she was told RI #5 had taken the medication and swallowed a good amount. EI #2 saw RI #5 walking in the hallway, accompanied by two staff members and noted a green color to RI #5's lips. EI #2's statement indicated she determined what the medication was and that there were nine tablets remaining. EI #2 stated staff contacted poison control and were advised to take the resident to the emergency room. The statement indicated EI #2 attempted to notify the Administrator without success, then notified the Corporate Administrator. Continued review of EI #2's statement revealed EI #2 was instructed to suspend EI #19, conduct a room sweep for loose pills and staff belongings, and conduct an in-service with staff.
During an interview on 09/16/2022 at 11:21 AM, EI #2 stated she received a call from EI #11 stating that RI #5 had ingested an unknown medication. EI #2 stated she immediately went to the unit and instructed EI #11 to contact poison control. EI #2 stated EMS was contacted, and she waited with RI #5 until EMS arrived. EI #2 stated EI #19 reported she had been to a doctor's appointment earlier in the day and had picked up the prescription prior to coming to work. EI #2 stated EI #19 put the purse on the top shelf of a resident's closet. EI #2 stated she felt RI #5 would have been able to reach it, as the resident was tall.
During an interview on 09/16/2022 at 3:00 PM, EI #1, Center Executive Director, stated he was not working at the facility when this incident occurred but reviewed the investigation. EI #1 stated the facility had investigated the occurrence, provided training to staff, as well as monitored to ensure it did not happen again.
During an interview on 09/16/2022 at 4:36 PM, EI #13, Medical Director, stated he had been notified of RI #5's accidental ingestion of the Atarax. EI #13 stated RI #5 was a little sleepy but had recovered from the ingestion.
Once the facility became aware of the incident involving RI #5 ingesting a staff member's medication, the following corrective action plan was developed and implemented:
ADHOC QAPI (Quality Assurance and Performance Improvement) Plan for Ingestion Event
11/9/21
1. Resident on Memory Support Unit found a staff members purse on the unit and ingested medication that (he/she) found inside the purse. Poison control notified and resident sent to ER for evaluation. Staff member was sent home under administrative leave.
2. All residents have potential to be affected. Full search of Memory Support Unit completed to ensure no other staff personal items or any other potential hazardous items were on the unit. This was completed on 11/8/21. Full center search for potential hazardous items was completed on 11/9/21.
3. Education initiated for Memory Support staff on 11/8/21 regarding safe guarding personal items and potentially hazardous items from residents. Education included keeping personal items off resident care areas. This education was continued for all staff.
4. Nursing Management will inspect resident rooms on Memory Support Unit Daily x (times) 2 weeks, including off shifts and weekends to ensure that there are no staff personal items and/or other potentially hazardous items in resident care areas. Audits will continue 2 x weekly thereafter. Department Heads will audit non Memory Support unit care areas during their Partner Rounds to ensure no staff items and/or other potentially hazardous items are in resident care areas. Any deviations noted will result in further education and/or disciplinary action. Results of these audits will be brought before the Quality Assurance and Performance Improvement Committee monthly with QAPI Committee responsible for ongoing compliance.
5. Date of compliance: 11/11/21.
After review and verification of the information provided in the facility's corrective action plan, in-service/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 11/08/2021 through 11/11/2021, with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.
This deficiency was cited as a result of the investigation of complaint/report number AL00041639.
Apr 2021
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to provide breakfast or a nourishing snack to residents who dialyze on the first/early shift three times a week. This failure aff...
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Based on observation, record review and interview, the facility failed to provide breakfast or a nourishing snack to residents who dialyze on the first/early shift three times a week. This failure affected two of nine residents identified by the facility as receiving dialysis.
Findings include:
During an interview with Resident (RI) #62 on 04/27/21 at 2:00 PM, during a Resident Council Meeting, stated I don't get no breakfast before dialysis and I am a diabetic. RI #62 said that he/she undergoes dialysis three times a week on the first shift (6:30 AM to 10:30 AM).
During an interview with RI #120 on 04/27/21 at 11:05 AM, he/she stated he/she was not provided anything to eat prior to going to dialysis.
During an interview with RI #120 on 04/28/21 at 5:46 AM, in his/her room just prior to his/her being placed on the transport gurney, RI#120 stated he/she had not received anything to eat this morning.
During an interview with EI #25, Registered Nurse (RN), on 04/28/21 at 6:56 AM, at the medication cart in the TCU hallway, when questioned about RI #120 not receiving breakfast this morning, stated the kitchen has a list of residents on dialysis and the kitchen staff is supposed to bring those residents something to eat prior to that resident leaving for dialysis.
During an interview on 04/28/21 at 6:40 AM, with the EI #10, Assistant Director of Nursing (ADON), at the nurses' station of TCU, said he/she thought the kitchen staff brought a snack or breakfast for the residents going to their early (prior to the facility's usual breakfast time) dialysis appointments. EI #10 reviewed RI #120's Electronic Medical Record (EMR) for an order regarding an early breakfast for RI#120 on dialysis days, but was unable to locate that order. EI#10 stated he/she would follow up with the kitchen staff regarding the early breakfast process. EI#10 also reviewed the EMR for RI#290 (an additional Resident that goes to an early dialysis appointment) and was unable to locate any information regarding an early breakfast on dialysis days.
During an interview with the EI #16, Dietary Account Manager (DAM), on 04/29/21 at 10:30 AM, in the dining room, stated there was a list of dialysis residents posted in the kitchen with their dialysis chair times and when they depart the facility to go to dialysis. EI #16 explained the process in the kitchen was if a resident left for dialysis prior to 5:30 AM the night shift cook prepared a snack that was placed in the nursing unit's pantry for the floor nursing staff to give to the Resident prior to leaving for dialysis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's document, and facility policy review, it was determined the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's document, and facility policy review, it was determined the facility failed to ensure a clean and comfortable environment free of the growth of a black substance on three air conditioning units: six overbed tables missing vinyl covering. All located in nine of 39 rooms located on the Solona unit and the East hallway (short hall).
Findings include:
On 04/29/21 at 09:00 AM a tour was performed, with Employee Identifier (EI) #21, the Maintenance Supervisor (MS). Observations of the East Hall and the Solana Unit revealed the following:
1. room [ROOM NUMBER], the overhead air conditioning (AC) unit was found to have dirt, dust, and a black substance covering the air vent.
2. room [ROOM NUMBER], the overhead AC unit was found to have dirt, dust, and a black substance covering the air vent.
3. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
4. room [ROOM NUMBER], the overhead AC unit was found to have dirt, dust, and a black substance covering the air vent.
5. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
6. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
7. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
8. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
9. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing.
In an interview on 04/29/21 at 09:25 AM, EI #21 confirmed the AC units had a black substance, and dirt covering the air vent and need to be cleaned. EI #21 stated, the overbed tables cannot be properly cleaned due to the vinyl tears and missing vinyl.
A review of the facility un-named and undated maintenance monthly check list indicated, HVAC (Heating, Ventilation, Air Conditioning) RTU (Roof Top Unit), Clean / change air filter and verify unit operation.
A review of the undated facility's policy titled, 5-Step Daily Room Cleaning indicated, .2. Horizontal Surfaces - disinfected.Using a solution of properly diluted germicide, sanitize all horizontal surfaces.Table tops, headboards, window sills, chairs - should all be done.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the posted menu for the lunch meal on 04/26/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
On 04/26/21 at 01:20 PM an interview with Employee Identifier (EI) #10, Assistant Director of Nursing (ADON) confirmed RI #80 and RI #48 were served hot dogs for lunch.
On 04/26/21 at 1:40 PM, EI #17, a dietary staff member acknowledged that chicken alfredo was served for lunch today and the change was not updated and posted on the menu.
On 04/26/21 at 2:00 PM, RI #8 stated he/she was served a hotdog with mashed potatoes for lunch today.
A review of the posted lunch menu for 04/26/21 revealed:
Ham and Pinto Beans
Pan Fried Potatoes
Homestyle Cornbread
Alternate:
Sloppy [NAME] on a Roll
Fiesta Corn
Chocolate Ice Cream
A review of the facility's policy titled, Menus, dated 09/2017 revealed, . 6. Menus will be served as written, .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
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 livin...
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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. EI #18 never removed the gloves or performed hand hygiene.
On 04/26/21 at 09:40 AM an interview with EI #18 was conducted. When questioned what actions she had just performed she stated, I went from handling dirty dishes to handling clean dishes and did not change gloves and perform hand hygiene.
A review of the facility's policy titled, Warewashing (sic), dated 09/2017, indicated, Policy Statement All dishware, serviceware (sic), and utensils will be cleaned and sanitized after each use. Procedures 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
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...
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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. She confirmed one of four trash dumpsters had a door open and the dumpster contained a mixture of cardboard boxes and miscellaneous trash.
A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 08/2017, indicated, Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital for three of three residents (Resident Identifier (RI) #27,112 and 72) reviewed who were transferred to the hospital.
Findings include:
Review of RI #27's Electronic Medical Record (EMR) revealed an admission date of 10/26/16 with diagnoses including dementia, Parkinson's Disease and bipolar disorder. The EMR stated RI #27 was transferred and admitted to the hospital on [DATE] and returned on 04/14/21.
Review of RI #73's EMR revealed an admission date of 09/21/16 with diagnoses including diabetes, anxiety and gastroesophageal reflux. RI #73 was transferred and admitted to the hospital on [DATE] and returned on 04/06/21.
Review of RI #112's EMR revealed an admission date of 05/02/13 with diagnoses including multiple sclerosis, diabetes mellitus type II and congestive heart failure. RI #112 was transferred and admitted to the hospital on [DATE] and returned to the facility on [DATE].
Interview with Employee Identifier (EI) #1, Administrator and EI #2, the Director of Nursing on 04/29/21 at 11:27 AM, both confirmed the facility never sent the ombudsman a notice of transfers.
Mar 2019
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, NSG305 Medication Administration: General and [NAME] and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, NSG305 Medication Administration: General and [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Licensed Practical Nurse (LPN) did not leave an insulin pen on top the medication cart, out of her sight, when she entered a resident's room during medication administration on 3/12/19.
This had the potential to affect one of 27 residents who received medications from cart one on the East wing.
Findings Include:
A review of a facility policy titled . Medication Administration: General with a Revised date of 7/24/18, revealed the following:
POLICY . Accepted standards of practice will be followed .
A review of [NAME] and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, with a Copyright of 2017, Chapter 32, page 683, revealed the following: .prepared medications are never left unattended .
On 03/12/19 at 11:15 AM, Employee Identifier (EI) #1, a Registered Nurse (RN), was observed preparing medication. EI #1 removed an insulin flex pen from the medication cart. EI #1 placed the insulin flex pen on top of the medication cart and went into a resident's room to get paper towels. While in the resident's room, a staff member passed the medication cart in the hallway with the insulin flex pen lying on top of the cart. EI #1 returned to the medication cart with paper towels, retrieved the insulin flex pen and continued with medication administration.
After the medication administration, during an interview with EI #1, the surveyor asked EI #1 did she leave an insulin flex pen on the medication cart and go into a resident's room to get paper towels. EI #1 stated, yes. The surveyor asked what if a resident picked up the medicine (Insulin) or even an employee while she was in the resident's room. EI #1 stated, that would be a problem.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and review of a facility policy titled, . Storage and Expiration Dating of Medications ., the facility failed to ensure an opened vial of Influenza Vaccine was marked w...
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Based on observation, interview and review of a facility policy titled, . Storage and Expiration Dating of Medications ., the facility failed to ensure an opened vial of Influenza Vaccine was marked with the date it was opened and the date to be used by.
This deficient practice affected one of two medication rooms observed.
Findings include:
Review of a facility policy titled, . Storage and Expiration Dating of Medications . with a revision date of 10/31/16, revealed the following:
. 5. Once any medication .package is opened .Facility staff should record the date opened on the medication container .5.1 Facility staff may record the calculated expiration date based on date opened on the medication container .
On 03/12/19 at 3:07 PM, during the observation of the medication refrigerator on the Rehabilitation Unit, the surveyor observed an open vial of Influenza Vaccine with no open date or expiration date recorded on the medication.
On 03/12/19 at 3:20 PM, during an interview with Employee Identifier (EI) #2, (Licensed Practical Nurse) LPN, the surveyor asked was there a date on the vial. EI #2 stated, no. The surveyor asked should there be an open date. EI #2 stated, yes. The surveyor asked, without an open date what were the issues. EI #2 stated, we are not sure how long it has been in the refrigerator so we do not know if it is viable or not.
Jul 2018
4 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility's investigat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility's investigation file and a report received by the Alabama State Survey Agency, the facility failed to ensure Resident Identifier (RI) #14 was free from abuse. On 6/22/2018, RI #14 reported a tall girl that worked the previous night grabbed him/her by both arms and threw him/her into the bed. When assessed, it was found RI #14 had bruising to left forearm and swelling and pain was noted to the left hand. The facility's investigation revealed Employee Identifier (EI) #15, a Certified Nursing Assistant (CNA), was responsible for physically abusing the resident. This deficient practice affected RI #14, one of 10 sampled residents reviewed for abuse.
Findings include:
The facility's policy titled, OPS 300 Abuse Prohibition, with a revision date of 11/28/2017, documented POLICY . will prohibit abuse, mistreatment, . for all residents . The Center will implement an abuse prohibition program through the following: . Prevention of occurrences .
Federal Definitions: Abuse is defined as the wilful infliction of injury . with resulting physical harm, injury, or mental anguish .
On 6/22/2018,, the facility notified the Alabama State Survey Agency of an allegation of physical abuse. The report indicated RI #14 reported to staff on 6/22/2018 that a tall girl that worked last night (6/21/2018) grabbed the resident by both of his/her arms and threw him/her in the bed. Bruising was noted to RI #14's left forearm and swelling and pain was noted to the left hand, with x-rays pending. The employee identified as EI #15, a CNA was suspended pending investigation and the local police was notified.
On 7/2/2018, the facility submitted their full investigation file to the Alabama State Survey Agency. The Investigation Summary documented DESCRIPTION OF INVESTIGATIVE PROCESS: Resident (RI #14) reported to nursing staff on 6/22/18 that the night before a very tall black CNA that worked the previous night grabbed (him/her) by both arms of (his/her) arms and threw (him/her) in the bed. By the description of the employee she was identified as (EI #15) who was on shift that night and on that unit. Employee was suspended pending investigation, Event reported to ADHP (ADPH) and (local) Police Dept, Sponsor and Nurse practitioner notified of allegation and investigation initiated . RESULTS/FINDINGS: River City was able to SUBSTANTIATE the allegation of physical abuse based on the evidence of the injury noted to resident. The identification of the employee was not by actual name of employee it was based on the consistant (consistent) description of employee in the initial statements given by (EI #5) and (EI #6) by resident and also to the police officer, CNE (Clinical Nurse Educator) and investigators. This employee was the only one that fit it on the staffing schedule for the facility. Resident was not able to pick out employee due to employee being suspended pending the results of this investigation. RECOMMENDATIONS: . Employee (EI #15) is terminated from employment at River City Center.
RI #14 was readmitted to the facility on [DATE] with a primary diagnosis of Osteoarthritis. RI #14 has a medical history to include a diagnosis of Unspecified dementia without behavioral disturbance.
RI # 14's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/8/2018, indicated RI #14 was moderately impaired in cognitive skills, with a Brief Interview of Mental Status (BIMS) score of 9. The MDS indicated RI #14 is usually understood and usually understands others. During this assessment period, RI #14 had no behaviors.
Contained within the facility's investigation file was a handwritten statement signed by EI #6, a CNA dated 6/22/2018, which read I (EI #6) came in to get (RI #14) a bath an (and) dressed for Breakfast I told (RI #14) excatly (exactly) what I was about to do an (and) I pulled the cover back to (RI #14's) feet (RI #14) yelled at me Don't touch me I ask (RI #14) what was wrong that I needed to get her ready for breakfast (RI #14) then said people like you don't need for me to get up I asked why an (and) (RI #14) repeated it again I told (RI #14) again that I needed to bath (him/her) (RI #14) told me no an (and) don't touch (him/her) I ask could I atlest (at least) change (him/her) an (and) (he/she) yelled no I asked (RI #14) what happen an (and) whats wrong (RI #14) said you know I told her who I was again an (and) (RI #14) said no the tall girl was nasty to me she almost broke my arm an (and) (RI #14) showed me (his/her) arm an (and) I told (RI #14) I would get the nurse an (and) that I would be right back So I let the nurse know an (and) ask (asked) the nurse to encourage (RI #14) to let me get (him/her) bath an (and) dressed.
In an interview on 7/12/2018 at 10:45 AM, EI #6, the CNA assigned to care for RI #14 during the morning of 6/22/2018 was asked about her statement she made regarding RI #14. EI #6 explained she went into RI #14's room on 6/22/2018 around 7:15 AM/7:30 AM to bathe and dress the resident; however, RI #14 was more quiet than usual and said to leave him/her alone. EI #6 said RI #14 made a comment that people like EI #6 didn't need (him/her) to get up. According to EI #6, RI #14 refused to allow her to change or touch him/her. EI #6 stated RI #14 told her a tall girl was mean to him/her and almost broke his/her arm. When asked to describe the bruises she saw on RI #14, EI #6 described a bruise on RI #14's arm as purple, around two inches in length. EI #6 stated she left the resident's room and went and got EI #5, a Registered Nurse (RN). When asked who identified EI #15 as the person responsible for the bruises on RI #14's arm, EI #6 stated EI #15 was taller than anyone else that worked the night of 6/21/2018 to include CNAs and nurses. EI #6 said EI #15 was over six feet tall.
The River City Center Daily Staff Assignment sheet dated 6/21/2018, indicated EI #15, a CNA, was assigned to care for RI #14 on the third shift beginning on 6/21/2018 at 10:00 PM and ending on 6/22/2018 at 6:00 AM.
EI #15's time sheet indicated she clocked in to work on 6/21/2018 at 5:29 PM and clocked out on 6/22/2018 at 7:17 AM.
RI #14's Activities of Daily Living (ADL) Record for June 2018, indicated EI #15 provided ADL care to RI #14 during the third shift (10:00 PM to 6:00 AM) on 6/21/2018.
Contained within the facility's investigation file was a handwritten statement signed by EI #5, a RN dated 6/22/2108, which read CNA (EI #6) reported to nurse (EI #5), RN that resident (RI #14)
staffs (states) that another CNA, (last night) was rough with (him/her) and being mean to (him/her). (RI #14) states to nurse that a tall girl that worked last night picked (him/her) up by both of (his/her) arms and threw (him/her) in (his/her) bed. (RI #14) also states that (he/she) told the CNA that she was an idiot and CNA hit (RI #14) with her fist on (his/her arms). Resident currently complains of pain to (his/her) left forearm. Resident has brusing on the left forearm where (he/she) complaints of pain and swelling in (his/her) right hand. Resident states that (he/she) does not want CNA back in (his/her) room nor does (he/she) want her to work with (him/her) anymore.
During an interview with EI #5, a RN, on 7/12/2018 at 12:30 PM, she explained she noticed a bruise on RI #14's arm on 6/22/2018 when she was called into the room by the CNA, EI #6. EI #5 stated RI #14 told her a tall girl grabbed him/her up and threw him/her in the bed. EI #5 stated she completed an assessment and there was only the bruise on her arm. EI #5 described the bruise as being on the resident's left forearm, it was red and dark purple with red around the outer edges. EI #5 stated she felt this was a new bruise because of the way it looked. EI #5 was asked if RI #14 ever identified who hurt him/her. EI #5 stated the resident only said it was a tall girl from last night. EI #5 was asked how the facility determined EI #15 was responsible. EI #5 replied EI #15 worked the night before and was assigned to RI #14. EI #5 further stated EI #15 was taller than anyone in the building, at around 6' (feet) 2 (inches) or 6'3.
During a follow-up interview with the RN, EI #5, on 7/14/2018 at 10:29 AM, she reported that after identifying the bruise, RI #14 was assessed as having a pain scale of eight. According to EI #5, RI #14 appeared to be in pain, as the resident was grabbing at his/her arm and had facial grimacing.
An interview was conducted with RI #14 on 7/12/2018 at 9:24 AM. RI #14 was asked if someone had hurt him/her. RI #14 stated an employee twisted his/her arm. When RI #14 was asked to recall what happened, the resident said he/she was hurt. RI #14 stated he/she got up to get the wheelchair that was near the door, when the employee entered the room and threw him/her on the bed. RI #14 stated the employee told him/her not to get up. RI #14 stated that during this incident she felt afraid. RI #14 stated he/she had a bruise on his/her arm extending from the elbow to the wrist and it was red and purple. RI #14 was unable to provide a name of the staff member, but described her as tall, very rude and rough talking.
In a statement taken by way of telephone with the CNA, EI #15, on 6/29/2018, EI #15 did acknowledge caring for RI #14 on 6/21/2018; however, she denied the allegations made against her by the resident.
On 7/12/2018 at 9:59 AM, an interview was attempted with EI #15, the CNA accused of allegation of physical abuse against RI #14. EI #15 stated she wished she could talk but she could not talk with the State Surveyor about what happened (on 6/21/2018). EI #15 asked for the telephone number to the State Surveyor and stated she may call back; however, no return telephone call was received.
EI #15's personnel file revealed EI #15 was hired by the facility on 3/14/2018. Prior to hire, on 2/27/2018, EI #15 was checked on the Alabama Certified Nurse Aide Registry and had no adverse findings. On 3/14/2018, EI #15 received inservice education on Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Resident Rights. On 3/16/2018, EI #15 received inservice education of Dementia/Care of Cognitively Impaired resident.
RI #14's Skin Check report dated 6/19/2018 completed by EI #17, a RN revealed on 6/19/2018, no bruises, discoloration, abrasions or skin tears were observed on RI #14.
On 7/13/2018 at 3:28 PM, an interview was conducted with EI #8, a CNA. EI #8 acknowledged she worked with RI #14 during the 7:00 AM to 3:00 PM shift on 6/21/2018. EI #8 said she had not observed any bruising or scratches on RI #14 during her shift, only age discoloration. EI #8 said the following day, on 6/22/2018, she saw discoloration on RI #14's arm that was not there before. When asked if RI #14 told her what happened, EI #8 said a tall girl did it.
RI #14's progress note completed by EI #12, the Nurse Practitioner, dated 6/22/2018, documented HISTORY OR PRESENT ILLNESS: (RI #14) is seen at the request of nursing and admin. (administration). There is an abuse allegation from the resident. (RI #14) has bruising to (his/her) foreman per nursing. Duration: < (less than) 24 hrs (hours) Severity: moderate Assoc (associative) features: no decreased ROM (range of motion). Able to use both hands/arms, moves all extremities. No uncontrolled pain. On exam (RI #14) is alert and in NAD (no acute distress) . Plan: X rays to be obtained and reviewed. Has prn analgesics which are effective. Follow up as need, await xrays . ADDENDUM On 6/24 (2018) I have reviewed the xray reports which reveal no acute findings or obvious fractures.
On 7/12/2018 at 4:39 PM, an interview was conducted with EI #2, the CNE/Director of Nursing (DON). EI #2 stated she completed the abuse investigation for RI #14. EI #2 was asked how she determined EI #15 was responsible for the abuse of RI #14. EI #2 stated by the description of a very tall CNA. EI #2 stated EI #15 was 6'2, taller than anyone assigned to RI #14's unit. EI #2 further stated EI #15 was assigned to care for RI #14 on 6/21/2018 and 6/22/2018. EI #2 was asked to describe the bruise on RI #14's arm. EI #2 stated it was on the resident's left lower arm, with bruising near the elbow. EI #2 further stated it looked like someone wrapped their hand around RI #14's arm. EI #2 stated the bruise looked new, as though it had just happened. EI #2 described the bruise as purple with no yellowing. EI #2 was asked if RI #14 was abused. EI #2 stated there was no doubt in her mind when she saw the bruise that something had happened. EI #2 stated she felt the CNA, EI #15, abused RI #14. EI #2 further stated RI #14 was consistent with the details of what happened and had no history of making false allegations against staff or anyone.
The local police report documented . On June 22, 2018 at 1:45 PM, I (name) was dispatched to an Elder Abuse and Neglect in the 2nd degree call at River City Health Care located at 1350 14th Ave SE Decatur, AL 35601. At 1:49 PM, I arrived on scene and spoke with complainant (EI #2) who was the Director of Nursing. (EI #2) stated at 10:30 AM, a resident (RI #14) informed her of an assault that occurred on June 21, 2018 at about 9:00 PM. (RI #14) reported that a staff member, (EI #15) assaulted (him/her). (RI #14) was in (his/her) room sitting in (his/her) wheelchair when (EI #15) grabbed (RI #14) by (his/her) arm causing swelling to (his/her) right wrist and bruising to (his/her) left forearm. (EI #15) then threw (RI #14) on (his/her) bed. (EI #2) stated (EI #15) had been suspended and was not present at the scene. (EI #2) and I went to (RI #14's) room where I spoke with (RI #14). (RI #14) stated (he/she) was sitting in (his/her) wheelchair near the entrance to (his/her) room when (EI #15) picked (RI #14) up by (his/her) arms and threw (RI #14) on the bed. I saw that (RI #14) right wrist was swollen and (RI #14) had bruising from (his/her) left wrist to (his/her) elbow. I notified (Name) and (Name) with the Violent Crimes Unit about the incident. (Name) and (Name) arrived on scene and it was turned over to them .
This deficiency was cited as a result of the investigation of complaint/report number AL00035773.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed within fourteen days when Resident Identifier (RI) #10 elected to receive Hospice services. This affected one of six residents reviewed for Hospice.
Findings include:
RI #10 was admitted to the facility on [DATE].
RI #10's Physician's Orders dated 7/1/18 documented . admitted to . Hospice on 5/15/17 for heart disease .
RI #10's medical record revealed a Significant Change MDS was completed on 9/28/17.
On 7/12/18 at 6:20 PM, an interview was completed with Employee Identifier (EI) #13, the MDS Coordinator. EI #13 stated RI #10 was admitted to Hospice on 5/15/17. EI #13 stated a Significant Change MDS should have been completed when RI #10 was admitted to Hospice. EI #13 further stated the Significant Change MDS was overlooked when RI #10 was admitted to Hospice and was completed and submitted late on 9/28/17.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interview, review of the facility's online reports to the state agency, and review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility failed to ensure allegations of ver...
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Based on interview, review of the facility's online reports to the state agency, and review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility failed to ensure allegations of verbal and physical abuse were timely reported to the state agency. This deficient practice involved nine residents (Resident Identifier (RI) #9, RI #42, RI #69, RI #70,RI #161, RI #172, RI #178, RI #229 and RI #230) and five of 12 abuse allegations reviewed.
Findings include:
The facility policy titled, OPS 300 Abuse Prohibition, with a revision date of 11/28/2017, revealed the following: . PROCESS . 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following. 6.2 Report allegations involving abuse (physical, verbal, . mental) not later than two hours after the allegation is made .
1) Review of the facility's online report to the state agency revealed an allegation of verbal abuse was reported to EI #11, Social Services, by RI #9's spouse. RI #9's spouse alleged the nurse cursed at RI #9 on 12/28/2017 at 5:02 PM. The allegation was not reported to the state agency until 12/29/2017 at 10:11 AM.
On 7/11/2018 at 3:17 PM, Employee Identifier (EI) #1, the Administrator/Abuse Coordinator,was asked the abuse allegation that occurred on 12/28/2017 at 5:02 PM involving RI #9 that was not reported to the state agency until 12/29/2017 at 10:00 AM. When asked when should it have been reported, EI #1 replied, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred.
2) Review of the facility's online report to the state agency revealed physical abuse was witnessed by Employee Identifier (EI) #16, Licensed Practical Nurse (LPN) on 1/18/2018 at 2:15 AM. EI #16 heard something in the resident's room and entered to observe RI #230 hitting RI #229 with his cap. The abuse was not reported to the state agency until 1/18/2018 at 3:18 PM.
On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked the abuse allegation concerning RI #229 and RI #230 that occurred on 1/18/18 at 2:15 AM and was reported to the state agency until 1/18/18 at 3:18 PM. EI #1 was asked when should it have been reported. EI #1 replied, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred.
3) Review of the facility's online report to the state agency revealed an incident that occurred on 5/7/2018 at 11:45 AM, in which facility staff witnessed RI #69 pushed RI #172 in the chest. This allegation of physical abuse was not reported to the state agency until 5/15/2018 at 4:57 PM.
On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 5/7/2018 involving RI #172 and RI #69 that was not reported to the state agency until 5/15/2018 at 4:57 PM. When asked when it should have been reported, EI #1 said, within two hours from the incident on 5/7/2018. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred.
4) Review of the facility's online report to the state agency revealed an incident witnessed by facility staff on 5/23/2018 at 5:00 PM, in which RI #161 took some napkins from beside RI #42. In response, RI #42 was observed by staff repeatedly slapping RI #161's forearms to get the napkins back. This incident was not reported to the state agency until 5/24/2018 at 1:53 PM.
On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 5/23/2018 at 5:00 PM involving RI #161 and RI #42 that was not reported to the state agency until 5/24/2018 at 1:50 PM. EI #1 was asked when should it have been reported. EI #1 said, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred.
5) Review of the facility's online report to the state agency revealed an allegation of physical abuse that occurred on 6/5/2018 at 3:00 PM. RI #70 reported to facility staff that RI #178 hit him/her and pulled his/her hair. This allegation of abuse was not reported to the state agency until 6/6/2018 at 11:55 AM.
On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 6/5/2018 at 3:00 PM involving RI #70 and RI #178 that was not reported to the State Agency until 6/6/2018 at 11:50 AM. When asked when should it have been reported, EI #1 said, it should have been reported within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred.
This deficiency was cited as a result of the investigation of complaint/report number AL00035777.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews and review of facility policy titled Food and Nutrition Services Use By Dating Guidelines, the facility failed to ensure the following unopened food items in the walk...
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Based on observations, interviews and review of facility policy titled Food and Nutrition Services Use By Dating Guidelines, the facility failed to ensure the following unopened food items in the walk-in refrigerator were discarded after the best before date: thirteen boxes of thickened dairy drink honey consistency with a best before date of 6/2/18; twenty-four boxes of thickened dairy drink honey consistency with a best before date of 12/5/17; thirty-eight boxes of Sysco Imperial thickened dairy drink nectar consistency with a best before date of 12/11/17; and one unopened box of hashbrowns with a best before date of 5/24/18. This deficient had the potential to affect 10 of 10 residents receiving thickened liquids and all residents receiving meals from dietary:
Findings include:
A review of a facility policy titled, Food and Nutrition Services Use By Dating Guidelines, with a revision date of 12/1/15, revealed: The following is a guide to use when establishing a use by date for food items. * The manufacturer's expiration date, when available, is the use by for unopened items.
On 7/10/18 at 1:16 p.m., Employee Identifier (EI) #4, the Dietary Manager accompanied the surveyor during the initial tour of the kitchen. In the walk-in refrigerator, the surveyor observed the following:
(1) thirteen boxes of thickened dairy drink honey consistency with the best before date of 6/2/18;
(2) twenty four boxes of thickened dairy drink honey consistency with the best before date of 12/5/17;
(3) thirty eight boxes of Sysco Imperial thickened dairy drink nectar consistency with the best before date of 12/11/17; and (4) one unopened box of hashbrowns with the best before date of 5/24/18.
An interview was conducted on 7/12/18 at 5:45 p.m. with EI #4, Dietary Manager, regarding the observations on the initial tour. EI #4 was asked, what does the best before date mean. EI #4 said that would be the expiration date we use. EI #4 was asked if the thirteen boxes of thickened dairy drink honey consistency with the best before date of 6/2/18, the twenty four boxes of thickened dairy drink honey consistency with the best before date of 12/5/17, the thirty eight boxes of Sysco Imperial thickened dairy drink nectar consistency with the best before date of 12/11/17 and the box of hashbrowns with the best before date of 5/24/18 should have been discarded. EI #4 , stated yes. EI #4 was then asked what is the harm in not discarding food after the best before date. EI #4 replied it could cause potential illnesses and become bad.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Alabama facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 13 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (23/100). Below average facility with significant concerns.
- • 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is River City Center's CMS Rating?
CMS assigns RIVER CITY CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Alabama, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is River City Center Staffed?
CMS rates RIVER CITY CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Alabama average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at River City Center?
State health inspectors documented 13 deficiencies at RIVER CITY CENTER during 2018 to 2022. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 10 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates River City Center?
RIVER CITY CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 183 certified beds and approximately 153 residents (about 84% occupancy), it is a mid-sized facility located in DECATUR, Alabama.
How Does River City Center Compare to Other Alabama Nursing Homes?
Compared to the 100 nursing homes in Alabama, RIVER CITY CENTER's overall rating (1 stars) is below the state average of 2.9, staff turnover (56%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting River City Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is River City Center Safe?
Based on CMS inspection data, RIVER CITY CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Alabama. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at River City Center Stick Around?
Staff turnover at RIVER CITY CENTER is high. At 56%, the facility is 10 percentage points above the Alabama average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was River City Center Ever Fined?
RIVER CITY CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is River City Center on Any Federal Watch List?
RIVER CITY CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.