River Oaks Nursing & Rehabilitation Center LLC

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there was an effective process in place to ensure residents were offered the updated COVID-19 vaccination for 4 (#28, #103, #105, and #113) of 5 residents reviewed for immunizations.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) Assessments were completed timely and accurately for 2 (#10 and #106) of 30 sampled residents. The facility failed to ensure: 1.)Resident #10 Death MDS Assessment was completed in the required timeframe; and2.)Resident #106 was coded correctly for weight loss.

Inspectors wroteBased on observations, interviews and record review the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff followed proper hand hygiene protocols for 2 (#13 and #69) of 3 residents observed during incontinence and perineal care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 2 (#1 and #2) of 3 residents observed for incontinence care. The facility failed to ensure staff performed proper hand hygiene and glove changes during incontinence care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#2) of 6 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by Resident #1. This deficient practice resulted in actual physical harm on 10/28/2025 for Resident #2 when Resident #1 hit Resident #2 in the face with a chair. Resident #2 obtained an Acute right orbital floor and anterior orbital rim fractures with no signs of entrapment, acute fracture of the anterior and posterolateral wall of the right maxillary sinus, and a comminuted fracture of the nasal bone with recommended surgical repair. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#7 and #9) of 4 (#5, #7, #9, and #19) sampled residents reviewed for PASRR Level II.Resident #7 Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Undifferentiated Schizophrenia on 01/09/2023. Review of Resident #7’s Form 142 dated 09/22/2014 revealed he did not meet the criteria for PASRR Level II services. On 07/16/2025 at 10:58 a.m., an interview was conducted with S3SSD. She stated she was responsible for submitting Resident Review Forms to OBH. She reviewed Resident #7’s Form 142 dated 09/22/2014 and confirmed it was the most recent on file. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by failing to:1. Ensure opened foods were sealed properly; and2. Ensured expired food items were disposed. This deficient practice had the potential to affect all 130 residents served from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse by another resident for 2 (#22 and #101) of 3 (#9, #22, and #101) residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure an incident involving abuse was reported to the facility administrator and State Agency in accordance with the mandated reporting guidelines for 2 (#22 and #101) of 3 (#9, #22, and #101) residents sampled for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) resident out of a total of 28 sampled residents by failing to ensure Resident #3 was accurately coded for PASRR (Pre-admission Screening and Resident Review).

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 (#3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 was free from physical abuse by Resident #4; and 2. Resident #6 was free from physical abuse by Resident #5. This deficient practice resulted in an actual physical harm on 02/23/2025 when Resident #4, a severely cognitively impaired resident, pushed Resident #3, a severely cognitively impaired resident, onto the floor in the hallway causing Resident #3 to sustain a left eyebrow laceration. Resident #3 was sent to the local emergency room (ER) where he received 9 sutures to his left eyebrow. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident privacy and confidentiality was maintained for 1 (#1) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #R10) sampled residents. The facility failed to ensure S5A did not take and keep an unauthorized photograph of Resident #1. This deficient practice had the potential to affect all 130 residents on the current census.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles by failing to: 1. Ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents observed during the initial pool; and 2. Ensure Schedule III-IV medications were stored in a permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 Medication Storage Room reviewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#43 and #120) of 28 residents reviewed in the final sample. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over and sitting on Residents #43 and #120's beds while assisting them to eat.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported immediately but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents interviewed during the initial pool and reviewed for abuse.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#130) of 28 residents reviewed in the final sample.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge planning process which focused on the resident's discharge goals for 1 (#71) of 1 residents reviewed for choices. The facility failed to update the discharge plan to accurately reflect the discharge wishes of the resident.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff passed ice and water to 2 (#10 and #112) of 33 residents reviewed in the initial pool.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices. The facility failed to ensure Physician Orders for monitoring of behaviors and side effects for a psychotropic medication were obtained and documented for 1 (#124) of 28 residents reviewed in the final sample.