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Massive fine for SA nursing home housing COVID patients after state investigation uncovers long list of safety violations

River City Care Center will not appeal findings or attempt to have fine overturned

SAN ANTONIO – An east San Antonio nursing home designated earlier this year to house elderly COVID-19 patients has been hit with a massive fine from the state after investigators this summer said conditions inside the facility put the health and safety of its residents in immediate jeopardy.

River City Care Center, located in the 900 block of Nolan Street, was informed of the violations in August, weeks after officials with the Texas Health and Human Services Commission finished conducting interviews with staff on-site and examining the property.

Texas Health and Human Services Commission (HHSC) records, released to the KSAT 12 Defenders following an open records request, confirm the facility’s HVAC system failed Fourth of July weekend, pushing residents' room temperatures well into the 80s.

The hot environment caused medical issues for multiple residents, including one man who went into heat-induced convulsions and later died at a hospital, records show.

HHSC officials, in an Aug. 7 letter, ordered River City to create a plan to correct its violations and, beginning Aug. 22, froze reimbursements from Medicaid and Medicare programs for new residents until the facility came into compliance.

State officials have not said if the facility has since come into compliance.

An HHSC spokesperson also confirmed the agency hit River City with administrative penalties of at least $120,000 after the facility and staff provided a substandard quality of care.

A spokesperson for River City’s parent company said staff worked with state investigators from the beginning of their probe and that the company does not intend to dispute the state’s findings or appeal the fines.

Resident #2

A lawsuit filed in state district court this month accuses River City personnel of negligence and failing to provide reasonable and adequate care to 91-year-old Richard Isenhour, who stayed at the facility for about two weeks after testing positive for COVID-19 at another care facility in June.

Isenhour, who suffered from dementia, was taken from River City to a hospital July 7 and died in hospice in late July, days after being moved to a care facility closer to his home.

Jacqueline and Richard Isenhour were married 71 years.
Jacqueline and Richard Isenhour were married 71 years. (KSAT)

The lawsuit filed on his behalf states that an order to take an X-ray of Isenhour’s chest was delayed in late June, even though he was suffering from a cough, fever and new delirium.

The X-ray later showed Isenhour was suffering from a collapsed lung or pneumonia, according to the suit.

“I think he was mistreated,” said his widow and wife of 71 years, Jacqueline Isenhour.

Warning: Graphic images below

A photo of Richard Isenhour, taken by a River City employee shortly before he was transferred to a hospital, shows him severely emaciated and with a large skin tear on his arm.

Jacqueline Isenhour called it a stark contrast to the condition just two weeks earlier of her husband, who was walking, eating and talking when he was admitted to the facility.

Photos taken of Richard Isenhour by River City staff show his emaciated state shortly before he was taken to a hospital.
Photos taken of Richard Isenhour by River City staff show his emaciated state shortly before he was taken to a hospital. (KSAT)

Even though Richard Isenhour’s health began to noticeably decline in late June, Jacqueline Isenhour said she was not notified about the change in his condition until shortly before he was taken to the hospital.

“I don’t understand why that place is still open. I want something done so that nobody else will have to go through what we did, what my husband must have gone through. It must have been horrible to him,” Jacqueline Isenhour said.

Richard Isenhour is referred to in the partially redacted HHSC records as Resident #2.

After nurses noticed Richard Isenhour’s decline in health, they failed to notify a physician, a supervisor or his family, despite a state law requiring them to do so, HHSC records show.

The records also indicate nurses failed to properly note changes in Richard Isenhour’s blood pressure and heart rate and that an unauthorized employee, the facility’s activities director, was given access to his confidential medical records.

“It really wasn’t my choice that he went there, but there was no place else to put him,” Jacqueline Isenhour said.

Jacqueline Isenhour said her husband had been in an assisted care facility in Schertz near their home since January, but he had to be moved after testing positive for the virus.

She said his symptoms were not serious enough to require hospitalization, meaning he had to be admitted to River City, the area’s designated isolation facility since April for elderly COVID-19 patients.

Another patient, identified in state records as Resident #1, was left alone in a room for 5-10 minutes after nurses thought they had stabilized him.

When nurses returned, they found the patient “gasping for air,” records show.

The man later died, HHSC records confirm.

Families, staff describe hot conditions for COVID-19 overflow patients at East Side nursing home

River City management confirmed to HHSC investigators that the facility’s HVAC system failed around July 4, records show.

A new outdoor air conditioning compressor-condenser unit was installed July 6, state records show.

However, the hot environment that followed the cooling system’s failure caused one patient, identified as Resident #4, to go into heat induced convulsions, records show. He was taken to a hospital but later died, and state officials wrote that his death was complicated by the “heat in his room.”

Investigators concluded their report by stating that River City failed to provide a safe, functional and comfortable environment for all 50 of its residents.

City officials in late July confirmed that River City reduced the number of residents being housed at the facility in an effort to improve their quality of care.

A spokesperson for River City’s parent company, Forth Worth-based Creative Solutions in Healthcare, released the following statement when asked about HHSC concluding its investigation:

“We have worked closely with Texas Health and Human Services from the outset of their investigation at River City Care Center (RCCC). Issues identified by inspectors were rectified immediately and we are confident in the professionalism and level of care our staff is providing to residents and patients. Since taking over operation of the facility last year, our company has made significant improvements and upgrades and we continue to train and educate staff to ensure they are equipped to manage the challenges brought about by the coronavirus pandemic. We are dedicated to moving forward and will not take action to dispute the administrative violations reported by the agency nor seek a repeal of fines.”

A former River City employee filed a lawsuit against the facility in late July, claiming she was fired after alerting authorities to the Fourth of July cooling problems inside the building.

The employee told supervisors and then called 911 and state health officials and stated the lack of a working air conditioner inside the facility caused residents to become dehydrated and to vomit, according to the suit.

The nurse began to cooperate with an HHSC investigator on July 6, the suit states.

Around July 10, the nurse was contacted by the management of the facility and told she had been terminated.

Percentage of nursing home deaths lower than state and national averages

City officials have defended River City being used to house elderly residents after they test positive at other nursing homes, claiming it’s necessary to isolate them from healthy residents and prevent the further spread of the virus.

As of Oct. 14, only 15.9% of COVID-19 deaths in Bexar County were attributed to nursing homes, according to statistics provided by San Antonio Metropolitan Health officials.

The statewide average for COVID-19 deaths attributable to nursing homes is 24% and the nationwide average is 27.7%, according to Metro Health officials.

Updated figures from Metro Health show the number of COVID-19 deaths in Bexar County attributable to nursing homes is well below the state and national averages.
Updated figures from Metro Health show the number of COVID-19 deaths in Bexar County attributable to nursing homes is well below the state and national averages. (KSAT)

HHSC data as of Oct. 7 shows that 14 residents of River City have died of COVID-19, while more than 120 residents have recovered from the virus.

Six other nursing homes in Bexar County have had more residents die of COVID-19 since the start of the pandemic than River City, HHSC records show.


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