Bria of River Oaks

Inspectors wroteBased on observation and interview the facility failed to ensure appropriate infection control practices in Personal Protective Equipment (PPE) availability. The facility also failed to ensure proper hand hygiene/handwashing is performed after glove usage. This deficiency affects the 1st floor and 2nd floor reviewed for Infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an emergency food supply was in stock and available for dietary services in the facility as documented in the facility assessment. This failure has the potential to affect all 257 residents who receive oral meals from the facility's kitchen during an emergency.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure the resident's right to dignity. This failure affects 4 residents (R5, R9, R15, R113) in a sample of 84 residents reviewed for dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to a safe, comfortable, home-like environment, as evidenced by failing to repair damaged walls, failing to have an adequate door for closets, failing to repair broken beds/room furniture, failing to repair overbed lights, and failing to repair windows. These failures affect 15 residents (R236, R75, R103, R194, R244, R183, R63, R118, R120, R81, R147, R143, R101, R94, and R39) in a sample of 84 residents reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a properly qualified staff completed Level I Pre-admission Screening and Resident Reviews (PASARR). This failure affects 5 (R1, R8, R9, R14, and R188) residents reviewed for pre-admission screening in the sample list of 84 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening assessments were completed as required for residents identified that have a mental illness. This failure affects 4 residents (R1, R9, R188, and R260) reviewed for pre-admission screening in the sample list of 84 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the container of the multi blood glucose test strips were labeled with an open date. These failures have the potential to affect 9 residents (R39, R47, R49, R100, R119, R133, R142, R175, and R184) who receive blood glucose monitoring tests, reviewed for medication storage in storage in the sample of 84 residents.

Inspectors wroteBased on observation, interview and record review, the facility's pest control program failed to ensure the facility was free of pests. This failure affects 7 residents (R90, R257, R183, R63, R60, R203, and R243) in a sample of 84 residents reviewed for pest control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the restorative needs and provide restorative device (hand splints) for a resident with hand contractures to prevent further decline. This failure affected one resident (R235) of three residents, reviewed for restorative care, in a total sample of 84 residents. On 8/25/25 at 10:35 AM, R235 was observed in in the wheelchair with contracted hands and fingers, without any device to prevent further contractures. Again on 8/25/25 at 12:00pm, R235's hands were still in the same position. R235 was asked if staff comes to do exercise for his fingers and hands, but R235 stated that no one has done anything for his hands. At this time, V16 (Restorative Nurse) was notified. V16 stated He(R235) does not have anything ordered for his hand. I will do an assessment and see what he(R235) can get. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and implement sufficient supervision and interventions to prevent fire hazards for residents assessed as requiring supervised smoking for one (R168) resident who was found with a lighter underneath the bed mattress in the room, and one (R179) resident whose bathroom was observed full of smoke and bedroom garbage can with multiple cigarette butts opened with tobacco wrapped in strips of paper. This failure affects two resident (R168, R1790 all reviewed for safety and monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels of 71-81 degrees for residents at the facility. This failure affected 8 residents R1 through R8, who were reviewed for a safe, comfortable environment. Findings Include: On June 23, 2025, between 11:20 a.m. and 11:45 a.m., with V3 (Maintenance Director), several randomly selected rooms were observed to ensure comfortable temperatures. Temperatures in the selected rooms on the second floor where R1, R2, R7, and R8 reside are as follows: room [ROOM NUMBER]-82 degrees; 208-87 degrees; 209-83 degrees; 223-81 degrees; 228-82 degrees. R1 was in bed in the room and stated It's too hot here R1 added that it's been hot for a while. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that air conditioners in the second and third floor hallways and in some residents' rooms are in good repair to provide cool, comfortable and functional environment for residents. This failure affected a total of 127 residents (59 residents on the second and 68 residents on the third floor), that were reviewed for functional and comfortable environment. Findings Include: On 6/23/25 at 10:30am after the entrance conference, V2(Director of Nursing) presented the Facility's Census that shows that 59 residents reside on the second floor while 68 residents reside on the third floor. On 6/23/25 between 10:30am and 11:15am during observation with V3(Maintenance Director), the second-floor hallway temperature was 84 Degrees Fahrenheit. [...]

Inspectors wroteBased on the interview and record review, the facility failed to protect the resident's right to be free from physical assault/abuse for a resident R9 by the V10 (Activity Aide/CNA). V10 grabbed R9 by the arms, took R9 down to the floor, landed on his back, and held R9 down. This failure resulted in R9 subsequently complaining of pain, He was sent to the hospital and diagnosed with acute bilateral lower back pain and elbow and thumb pain; R9 said he was scared this would happen again. This affects one of three residents (R9) reviewed for physical assault/abuse.

Inspectors wroteBased on interview and record review the facility failed to follow their behavior management policy and facility practice and document an incident of performing crisis prevention intervention techniques for one of one residents R9 reviewed for behavior management and documentation.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment for a resident with a new onset of left leg pain. This affected one out of three residents (R1) reviewed for nursing assessments in a total sample of seven. This failure resulted in R1 being delayed treatment and not sent to the hospital for a fractured left hip for four days. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, Todd's paralysis, dementia, and chronic kidney disease. The Hospital Records dated 2/22/25 document R1 was admitted to the hospital for left hip fracture post fall. R1 reported falling while trying to get in the wheelchair two days ago. R1 is unable to move the left lower extremity and reported achy and tenderness. R1 is guarded and rated the pain a ten out of ten. R1 reported taking pain medication with minimal relief. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess and identify the underlying cause of a resident's (R1) new onset of pain in the left leg, and failed to inform the primary care provider of continued pain after being adminstered tramadol 50mg. This affected one out of three (R1) residents reviewed for pain management in a total sample of seven. This failure resulted in R1 having increased pain levels for four days before R1 was sent to the hospital for treatment of a left hip fracture. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, Todd's paralysis, dementia, and chronic kidney disease. The Hospital Records dated 2/22/25 document R1 was admitted to the hospital for left hip fracture post fall. R1 reported falling while trying to get in the wheelchair two days ago. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their discharge and change in condition policies and did not notify a family member of a resident's change in condition and needed to be sent out to the hospital. This affectes one out of three residents (R1) reviewed for change in condition policy and procedures. Findings Include: R1 is a [AGE] year old with the following diagnosis: chronic obstructive pulmonary, disease, type 2 diabetes, and left eye glaucoma. A Nurse Practitioner note dated [DATE] documents the nurse practitioner saw R1 for a concern for hyperglycemia and altered mental status. R1 is positive for confusion and hyperglycemia upon assessment. Plan is to transfer to the hospital for medical evaluation. A Nursing note dated [DATE] at 11:42AM documents R1 was sent to the hospital due to altered mental status and uncontrolled hyperglycemia. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policies and procedures for abuse prevention and behavior management by not calling for assistance or physically intervening during a resident-to-resident verbal and physical altercation; the facility also failed to identify an incident of abuse. This failure applied to two (R2, R3) of two residents reviewed for abuse and resulted in R2 sustaining a compression fracture of the spine, developing anxiety, and feeling unsafe in the facility after an altercation with another resident.

Inspectors wrote-- Based on observations and interviews, the facility failed to follow their policy and procedures for housekeeping and maintenance by not keeping residents' room in clean condition, not replacing heavily soiled mattresses when needed, not removing unclean clothes from the room in a timely manner, and not ensuring residents windows were covered or that windows coverings were replaced when needed. This failure applied to nine (R2, R4, R5, R6, R7, R8, R9, R10, R11) of nine residents reviewed for environment.

Inspectors wrote- Based on interview and record review the facility failed to ensure staff was aware of a high risk falls resident required supervision and monitoring and failed to prevent a resident from falling from the wheelchair while on 1:1 monitoring by staff. This affected two of three residents (R1, R2) reviewed for supervision. This failure resulted in R1 suffering a left arm fracture after falling while walking in the hallway unsupervised or without monitoring, and R2 from falling from the wheelchair and sustaining a laceration to the right ear. Findings Include: 1. R1 is a [AGE] year-old with the following diagnosis: dementia, schizophrenia, unsteadiness on feet, and displaced fracture of the left humerus. A Nursing note dated 9/22/24 at 8:30 PM documents that the nurse was notified by staff that R1 was observed getting off the floor in the annex (hallway on the first floor). [...]

Inspectors wroteBased on the interview and record review, the facility failed to follow the hospital discharge instructions by not scheduling a follow-up appointment to evaluate an ear laceration. This affected one of three residents (R2) reviewed for follow-up appointments. Findings Include: R2 is a [AGE] year-old with the following diagnosis: hemiplegia to the right side following cerebrovascular disease, epilepsy, aphasia, and vascular dementia. A Nursing note dated 9/1/24 documents the CNA made the nurse aware that during meal time, R2 was observed sliding out of the wheelchair. To prevent a fall, the CNA slid R2 from the chair to the floor, where R2 rested on R2's buttocks. A skin tear was noted on the right ear. The physician was made aware, and an order was placed to send R2 to the hospital for evaluation. R2 returned from the emergency department with a treatment order for the laceration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve an portion of food that meets the needs and preferences of the residents. This failure applies to all 238 residents receiving meals from the facility.

Inspectors wroteBased on interview and record review, the facility failed to 1) identify emergency care was needed for two residents who exhibited a change in physical and mental status. These failures applied to two (R1, R2) of four residents reviewed for nursing care and resulted in R1 experiencing a delay in care of two hours before emergency services were called, after being assessed with high blood pressure and mental status change; R1 was admitted to the hospital with a critical change in neurological condition; this failure also resulted in R2 going into cardiac arrest approximately two hours after the nurse assessed R2 with low blood sugar.

Inspectors wroteBased on observation, interview and record review, facility staff failed to 1) identify emergency care was needed for two residents (R1 and R2) who exhibited a change in physical and mental status; 2) failed to monitor blood sugar levels for two residents (R5 and R6) who received diabetic medications daily; 3) failed to accurately demonstrate insulin preparation and 4) failed to ensure availability of resident specific diabetes medications used for emergencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer; failed to timely identify, assess, and treat skin breakdown; failed to provide a plan of care to prevent skin breakdown; failed to provide preventative low air loss mattress; and failed to educate staff on pressure ulcer prevention and treatment. This deficiency applies to 1 resident R77 out of 28 reviewed for pressures in the sample of 28. This failure resulted in R77 sustaining 1 facility-acquired stage 3 sacrum pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse to 1 of 4 residents (R2) reviewed for physical abuse in the sample of 15.

Inspectors wroteBased on observation , interview, and record review, the facility fails to provide a safe, functional, sanitary, and comfortable environment for residents in 10 of 12 resident rooms observed for maintenance of interior surfaces.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse. This applies to 3 of 15 residents (R6, R3 and R1) reviewed for abuse in the sample of 15. This failure resulted in R5 hitting R6 in the face. R6 was sent out to the local hospital and sustained a displaced right maxillary sinus fracture and displaced fracture of the right zygomatic arch.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a stage 4 pressure ulcer was assessed by a Dietician upon admission for 1 of 3 residents (R7) reviewed for Dietician services in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by not reporting an observed incident of abuse to the Abuse Coordinator immediately, and failed to prevent a resident (R5) from being sexually assaulted by another resident (R6), for one out of three residents reviewed for abuse in a total sample of eight. This failure resulted in V11 (CNA) observing R5 facedown in the bed crying with R5's naked buttocks exposed, and R6 directly behind R5 in a bed, while R6's pants were around R6's knees. The Immediate Jeopardy began on 12/12/23 when the sexual assault was witnessed. V1 (Administrator) was notified on 12/21/23 at 11:45 AM of the Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the prescribed treatment order was performed for a resident with a diabatic foot wound. This failure resulted in R1's diabetic foot wound showing signs and symptoms of an infection and requiring hospitalization. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 19.

Inspectors wroteBased on observation, interview, and record revie,w the facility failed to ensure residents were served meals at an appetizing temperature for 4 of 4 residents (R6, R15, R16 and R17) reviewed for cold food in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development and worsening of wound, failed to implement pressure ulcer interventions, and failed to maintain the appropriate amount of linens for incontinence management. These failures affected one (R93), of four residents in the sample of 66, and resulted in R93 re-developing a Stage 4 pressure ulcer to left ischium.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly monitor two cognitively impaired residents (R190, R224) to prevent harm or injury; failed to identify, evaluate, and follow their facility's policy for an injury investigation by not initiating an investigation or assessment of R190's hematoma to her left elbow; and failed to provide adequate supervision for a resident (R224) with gait/and balance impairment. These failures applies to two of five residents (R190, R224) reviewed for falls and/or injury and resulted in R190 sustaining a hematoma to the left elbow, and R224 sustaining bruises to both knees.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensurie ice machine equipment was stored properly, failed to ensure food was stored in a manner to prevent contamination, failed to ensure storage containers were clean and free of contamination, failed to ensure stored foods were free of spillage, failed to ensure storage equipment was clean and free of rust, and failed to promptly discard food showing signs of expiration. These failures have the potential to affect all 232 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and well maintained environment by not ensuring residents residents rooms or the facility were cleaned consistently and thoroughly; and the facility failed to maintain an effective preventative maintenance plan. This failure directly affected 28 residents (R4, R14, R17, R59, R66, R69, R73, R79, R91, R97, R123, R137, R143, R146, R154, R180, R181, R184, R189, R215, R224, R238, R342, R442, and R592 ) and has the potential to affect all 232 residents who currently reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program. This failure affects all 232 residents who currently reside at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain personal hygiene, bathing, and grooming for 4 (R29, R66, R68, R120) of 4 residents reviewed for activities of daily living in the sample of 66 residents.

Inspectors wroteBased on interview and record review, the facility failed to initiate an investigation of an allegation of resident-to-resident abuse, failed to complete a thorough investigation, and failed to maintain documentation that an alleged violation was thoroughly investigated. This failure affected one resident (R180) who was physically assaulted by another resident (R215).