River Oaks Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 67. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting such as a clean, sanitary and orderly environment. Observations on 08/05/25 at 3:03 P.M., and 08/06/25 at 8:00 P.M., of the 300 Hall showed: - A ceiling vent with a buildup of dust and rust in the hallway outside room [ROOM NUMBER]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for one resident (Resident #70) out of three sampled closed resident records that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for two residents (Residents #7 and #17) out of four sampled residents with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 67. Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised August 2022, showed: - To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice; - To address the needs of trauma survivors by minimizing triggers and/or re-traumatization; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than 5 percent (%). There were 26 opportunities with 10 errors made, resulting in an error rate of 38.46% for one resident (Resident #40) in the sample and one resident (Resident #10) outside the sample of six sampled residents. The facility's census was 67. Review of the facility's policy titled, Administering Medications, revised April 2019, showed:- Medications are administered in accordance with prescribers' orders, including any required time frame;- Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document that residents received or declined Influenza (a viral infection of the respiratory system) immunizations and failed to provide and document pertinent education to the resident or resident representative regarding the benefits, side effects, or warnings of those immunizations for five residents (Residents #1, #9, #40, #41, and #49) out of five sampled residents. The facility's census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Residents #1 and #2) were free from physical and verbal abuse by staff. On 11/07/24, Certified Nurse Aide (CNA) A hit Resident #2 on the hand with a mug. The resident reported this to the administrator, in front of a witness. CNA A continued to work and measures were not taken after this incident to protect residents from further abuse. On 11/11/24, CNA A cursed at, shook and roughly threw Resident #1 into bed. This was witnessed by another staff member who reported up the command chain and the administrator was informed. The facility census was 73. The administrator was notified on 11/14/24 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 11/07/24. The IJ was removed on 11/14/24, as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate reports of abuse for two residents (Residents #1 and #2), out of seven sampled residents. While providing care, on 11/07/24, Certified Nurse Aide (CNA) A hit Resident #2 on the hand with a mug. This was reported to the Administrator (ADM) by the resident. The allegation was not investigated and CNA A continued to work. On 11/11/24, Resident #1 was shaken and thrown on the bed by CNA A. The ADM did not investigate the allegations as per the facility policy and procedure. The facility census was 73. The administrator was notified on 11/14/24 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 11/07/24. The IJ was removed on 11/14/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled, Abuse Prevention Program, dated September 2019, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 74. Record review of the facility's Homelike Environment policy, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include clean, sanitary and orderly environment. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe transfer for two residents (Residents #62 and #67) out of 18 sampled residents, when staff did not utilize a gait belt (a thick fabric or vinyl belt that is placed around a patient's waist to help with mobility and prevent falls) as directed by therapy recommendations and the resident's care plan. The facility census was 74. Review of the facility's policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed: - Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure gastric residual volume (the amount of liquid that drains from the stomach after enteral feeding is administered) was measured prior to administering tube feeding for two residents (Residents #62 and #15) out of two sampled residents. The facility also failed to follow standards of practice by using a plunger (used to force liquid into feeding tube catheter) during tube feeding on one resident (Resident #15) out of two sampled residents. The facility census was 74. Record review of the facility's policy, Enteral Nutrition, last revised November 2018, showed: - The provider will consider the need for supplemental orders, including: -Checks for gastric residual volume (GRV) before feeding and medication - The facility did not provide a policy on plunger use during a tube feed. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, disposed of and reconciled for one resident (Resident #100) outside of the 18 sampled residents. The facility census was 74. Review of the facility's policy titled, Pharmacy and Medication Administration, undated, showed: - Narcotics must be counted at the beginning and end of each shift and signed on the narcotic log by the oncoming and off going nurse or medication technician; - Monitoring the log weekly can help identify any missed counts or lax in counting by particular staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use proper infection control techniques for glove use during wound care for two residents (Resident #24 and #56) and during incontinent care for two residents (Resident #62 and #67) out of four sampled residents. The facility census was 74. Review of the facility's policy, Infection Control, revised October 2018, showed: - This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections; - The objectives of our infection control policies and practices are to: - Prevent, detect, investigate, and control infections in the facility; - Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 68. Record review of the facility's Homelike Environment policy, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include a clean, sanitary and orderly environment. 1. Observations on 5/1/23 at 10:35 A.M., 5/2/23 at 9:27 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interventions for one resident (Resident #2) out of two sampled residents. The facility census was 68. Record review of the facility's Care Plans - Baseline policy, revised March 2022, showed: - A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident, but not limited to: initial goals based on admission orders and discussion with the resident/representative, physician goals, dietary orders, therapy services, and social services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe, secure, and orderly manner by allowing medications to sit at the bedside of one resident (Resident #68) out of 17 sampled residents. This had the potential to affect all residents. The facility census was 68. Review of the facility's Storage of Medications policy, undated, showed: - Drugs and biologicals are stored in locked compartments; - Only persons authorized to prepare and administer medication have access. 1. Review of Resident #68's medical record showed: - admission date of 02/23/23; - No order for magnesium (a dietary supplement); - No order for Tums (medication used to treat symptoms caused by too much stomach acid). Observations on 05/01/23 at 11:40 A.M., and 05/03/23 at 03:00 P.M., showed: [...]