River Oaks Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 kitchen (1 kitchen) reviewed for environment. The facility failed to clean puddles of water throughout the kitchen and puddles in the dining area. This failure could place residents at risk of falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from verbal abuse by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to protect residents from verbal abuse, threats, and physical abuse by Resident #1. Resident #2 was threatened by Resident #1 on 4/5/2026, 4-25-2026 by Resident #1 saying [Resident #1] was going to have Resident #2 beat up, was not afraid of Resident #2's phone, was going to slap the dog shit out of [Resident #2], and was going to knock the shit out of [Resident #2]. Resident #3 was verbally abused, physically grabbed, and pushed out of the way by Resident #1 on 4-29-2026. Resident #6 was verbally abused and threatened by Resident #1 when he told her I'm going to kick your ass and physically pushed her out of [Resident #1's] way. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, investigate allegations of abuse, and protected residents from physical and psychosocial harm during and after the investigation when residents were verbally and physically abused by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to identify verbal abuse and intervene when Resident #1 threatened Residents #2 and #3, causing Resident #2 to avoid certain areas of the facility and causing Resident #3 to cry. Resident #1 continued to have access to verbally abuse other residents on multiple occasions. Staff witnessed physical pushing and threats but failed to report the abuse to the administrator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 2 (Residents #2, #3) of 13 reviewed for abuse and neglect. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for one of five residents (Resident #5) reviewed for medication administration. Medication Aide administered (2) Melatonin 5 mg tablets (a supplement used to treat insomnia) to Residents #5 instead of (1) 5 mg tablet as ordered by the physician. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 9 insulin pens with correct open dates. The facility also failed to keep 2 of 5 medication carts locked, in accordance with currently accepted professional principles. Insulin pens in south hall nurse cart and north hall nurse cart were labeled incorrectly. Medication cart on south hall was left unlocked and unattended. Treatment cart on north hall was left unlocked and unattended. These failures could result in adverse reactions to residents, injuries, medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure that food stored in the freezer was labeled and dated. 2. The facility failed to remove the food thermometer prior to food service. These failures had the potential to affect residents by placing them at risk for cross-contamination and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's needs related to indwelling catheter for 1 of 5 residents (Resident #38) reviewed for care plans. Resident #38 was not care planned for indwelling catheter. This failure could result in improper care to residents which could lead to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 (Resident #9) of 5 residents reviewed for bedrails. The facility failed to obtain a bed rail assessment and informed consent prior to the installation of Resident #9's bedrails. These failures could place residents at risk of entrapment or injury.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to help family and visitors understand safe food handling practices reviewed for Resident #8 personal refrigerator. The facility failed to ensure that Resident # 8's in room refrigerator was at a safe cooling/reheating processes meeting food safety temperature standards. These failures had the potential to affect the residents by placing them at risk for cross-contamination and foodborne intoxication. Findings Included:Record review of Resident #8's admission Record revealed an [AGE] year-old female admitted on [DATE] with a primary diagnosis of Parkinson's Disease without Dyskinesia, and secondary Dementia in other diseases classified elsewhere. Record review of Resident #8's Care Plan dated 04/06/2026 revealed; on a Regular diet and chooses to eat all meals in her room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for catheter care for 1 of 6 residents (Resident #38) reviewed for infection control. RN A picked up Resident #38's catheter bag on the floor and hung it back on the resident's bed, failing to replace the catheter bag. This failure could place residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 6 residents records (Resident #1 and Resident #2) reviewed for treatment documentation. 1. The facility failed to document on Resident #1's and Resident #2's Treatment Administration Record, when their catheter bags were emptied and the amount emptied on the night of 10/03/25 and the night of 10/11/25. This failure could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and accessed only by authorized personnel for 1 of 4 residents (Resident #1) reviewed for medication storage. Resident #1 had two unidentified pills on his bedside table on 06/17/25 and did not self-administer his own medications. This failure could place residents at risk of inadequate therapeutic outcomes or decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were reported to the State Survey agency and the administrator of the facility, immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for 1 of 1 resident reviewed for abuse and neglect for one (Resident #1) of 1 resident reviewed for abuse. The facility did not report immediately to the State Survey agency when Resident #1 accused LVN A touched him inappropriately on 03/08/25 and LVN A did not report the allegation immediately to the Administrator. These failures could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 Resident (Resident #2) of 1 resident reviewed for care plans. The facility did not provide interventions as outlined in Resident #2's comprehensive person-centered care plan to address Resident #2's weight loss issues with not interventions including nutritional supplements to improve weight. These failures could place residents identified at risk for weight loss at risk for their medical, physical, and psychosocial needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrated that this was not possible for 1 (Resident #2) of 1 resident reviewed for weight loss. Resident #2 had a 9.37% weight loss in 8 months between 8/6/24 and 4/9/25 with no documentation from the Dietitian on nutritional concerns or recommended interventions to address Resident #2's weight loss. This failure could place residents at risk of not having needs addressed and/or met r/t weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food by methods that conserve nutritive value, flavor, texture and appearance for 3 or of 5 (Residents #4,# 12 and #18) residents reviewed for regular diets. The facility failed to ensure that regular diets served were prepared by methods that conserve nutritive value, flavor, texture, and appearance. This failure could place residents on regular diets at risk for a decrease in quality of life and possible weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #21) during medication administration, and 3 of 16 residents (Residents #27, #32, #40) reviewed for infection control in that: 1. MA A attempted to perform hand hygiene in another resident's room after measuring blood pressure on Resident #21 who was on Enhanced Barrier Precaution (EBP). 2. MA A did not sanitize blood pressure machine after it was used to measure blood pressure for Resident #21. 3. LVN D failed to ensure EBP procedure was followed throughout the wound care treatment and dressing change for Resident #27. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one of six residents (Resident#1) reviewed for environment. 1. The facility failed to properly clean and maintain a sanitary and comfortable environment free of foul odors for Resident#1 room. 2. The facility failed to maintain a safe environment for Resident#1 room. These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 4 resident (Resident # 1) reviewed for activities of daily living. The facility failed to ensure Resident #1 was provided care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #1), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1 took olanzapine 10 mg tablet that was ordered to be taken: 1 tablet by mouth twice a day. DON B found 28 of what appeared to be Olanzapine tablets in 3 drawers of Resident#1 bedside nightstand. This failure could place residents at risk for not receiving medication as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse . The facility failed to protect Resident #1 from physical abuse by Resident #2. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified at PNC. The noncompliance began on 11/25/2024 and ended on 11/25/2024. The facility had corrected the non-compliance by monitoring Resident #1 and Resident #2 every 15 minutes and issuing a discharge notice to Resident #2.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 Residents (Resident #3 and Resident #4) reviewed for pharmacy services. The facility failed to administer Resident #3's PRN pain medication and Resident #4's routine pain medication due to not ordering medications timely. These failures could place residents at risk of not receiving the therapeutic benefit of the prescribed medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food stored in the refrigerator, freezer, and pantry were labeled, dated, and sealed. These failures could place residents who at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area for 1 of 27 (Resident #1) observed for call lights. The facility failed to ensure Resident #1 had a call light installed in his room so Resident #1 could communicate to staff he needed assistance. This failure put residents at risk of not receiving ADL assistance and medical attention when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the oven and stove were maintained in a clean and sanitary manner. 2. The facility failed to ensure hot dog buns that had grown mold were not kept in the panty. These failures could place residents who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Residents #16, #17, #20, and #24) reviewed for infection control. MA B failed to sanitize a re-useable blood pressure cuff between blood pressure checks on Residents #16, #20, and #24. This failure could place residents at risk of contracting or spreading an infection.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to assure full visual privacy for residents in 3 (Resident #4, #5, and #35) of 6 rooms reviewed for visual privacy. The facility failed to provide privacy curtains at the foot of B beds in 6 rooms. This failure could place residents at risk of loss of dignity and decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 8 residents (Residents #5 and #345) reviewed for ADL care. The facility failed to ensure Residents #5 and #345 were bathed and shaved on a regular basis. This failure could place the residents at risk of developing skin issues, and a decreased sense of worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #15) reviewed for dialysis. The facility failed to ensure that Resident #15 had a current order for dialysis after readmission to the facility. This failure could place residents at risk of not receiving the appropriate care as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than 5%. MA B had two medication errors out of 39 opportunities resulting in an error rate of 5.13%. This failure could place residents at risk of not receiving the intended therapeutic effects of medications or receiving the wrong medication.

Inspectors wroteBased on observation, interview, and record reveiw, the facility failed to ensure all drugs were stored in locked compartments with access by authorized personnel only for 1 of 4 carts (South Station Nurse Cart) reviewed for storage of drugs and biologicals. RN C failed to secure her medication cart before she stepped away from it. This failure could place residents at risk of accessing medications not prescribed for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current week's menu in a convenient location so the residents may see it for 1 of 1 facility reviewed for menus, in that: There was no weekly menu posted in any location in the facility on 10/03/2023. This deficient practice could affect the residents who ate food from the kitchen and their right to make choices about their meals beyond the present day.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed, in that: The facility failed to store a seven-day supply of non-perishable food staples. These failures could affect the residents who received their meals from the facility's only kitchen by placing them at serious risk due to a lack of enough food.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide advance food that accommodates resident's preferences for one (Resident #2) of five residents reviewed for food preferences and the accommodation of residents' meal choices. The facility failed to provide Resident #2 with food preferences for breakfast and lunch on 10/17/2023. Resident #1 requested the salad of the day, creole potatoes, coleslaw, and a fruit plate with cottage cheese. Resident #1 received, red beans with pork sausage, rice, collard greens, cornbread, scalloped potatoes and fruit cocktail. This failure could affect residents that are provided daily meals by the facility, by placing them at risk for frustration, decreased meal satisfaction and/or weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for three (Residents #4, #1, and #2) of four residents reviewed for accidents. The facility failed to provide a safe environment for 7 residents at risk of elopement by allowing other residents to have keypad access to exit doors. The failures placed residents with elopement at risk for accidents and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for one of four residents (Resident #3) reviewed for environmental concerns. The facility failed to ensure Resident #3's room was cleaned daily. The facility failed to ensure Resident #3's wheelchair was clean and free of debris. These failures could place residents at risk for decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #4) of one resident reviewed for discharge planning. The facility failed to follow their policy on AMA (against medical advice) protocol for Resident #4.