River Oaks Retirement Manor

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure services provided meet professional standards as evidenced by the nurse failing to follow the facility's policy for verbal orders for 1(#3) of 34 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential to affect the 69 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to ensure staff removed PPE (Personal Protective Equipment) prior to exiting a resident's room that was on enhanced barrier precautions for 1 (Resident #28) out of 34 sampled residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure resident rights were maintained as evidenced by: 1. Failing to ensure the results of the most recent complaint survey dated 08/08/2024 was available for residents, visitors or other individuals to review; and 2. Failing to ensure residents were aware of where to locate state inspection results to review for 4 (#4, #41, #49, and #71) out of 4 (#4, #41, #49, and #71) residents that attended the Resident Council meeting. The facility census was 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (#47 and #74) of 4 (#25, #47, #74 and #78) residents investigated for environment in a final sample of 36 residents as evidenced by: 1. failing to ensure clean bed linen was provided for Resident #47, and 2. failing to ensure the toilet was in good repair for Resident #74.

Inspectors wroteBased on interviews and record review, the facility failed to initiate a grievance for 1 (Resident #21) of 1 sampled residents reviewed for grievances in a final sample of 36 residents.

Inspectors wroteBased on observations, interview, and record review, the facility failed implement the resident's plan of care by not following a physician's order to ensure the resident's indwelling catheter was the correct size for 1 (#25) out of 2 (#19 and #25) residents investigated with Urinary Tract Infection out of a total sample of 36 residents.

Inspectors wroteBased on record review, observations and interview, the facility failed ensure correct use and installation of bed rails to avoid the risk of entrapment. The facility failed to: 1. Identify and use appropriate alternatives prior to using bed rails; 2. Ensure appropriate dimensions of the bed based on the resident's size and weight to ensure the resident's bed frame, mattress, and bed rails were compatible prior to instillation; 3. Ensure correct installation of bed rails including adherence to manufacturer's recommendations and/or specifications for adaptive devices to prevent entrapment; 4. Adequately assess the residents' risk for entrapment and safety prior to applying modified side rails with wooden boards that were not recommended per the manufacturer; 5. Appropriately monitor and supervise residents with bed rails in place. [...]

Inspectors wroteBased on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to provide appropriate oversight to ensure the well-being of residents. The facility failed to have a system in place for residents to ensure the appropriate use, assessment, and monitoring of bed rails according to mattress manufacturer's guidelines to prevent resident entrapment for 5(#1, #R1, #R2, #R3, and #R4) of 5 (#1, #R1, #R2, #R3, and #R4) residents. This lack of administrative oversight resulted in an Immediate Jeopardy on 07/28/2024 at 1:00 p.m. when Resident #1 attempted to climb over the boarded side rail and became entrapped between the air mattress and the modified boarded bed rail attached to the resident's bed. [...]

Inspectors wroteBased on record review interview, and observations, the facility failed to ensure the resident's care plan and physician's order(s), were followed for 4 (#2, #18, #21, #44) out of 33 sampled residents. This was evidenced when the: 1. Facility failed to ensure Resident #21 had a right heel protector. 2. Facility staff failed to ensure Resident #2 did not exceed his 24 hour 1000 ml (Milliliters) fluid restriction. 3. Facility failed to ensure Resident #44 had bilateral hand rolls. 4. Facillity failed to ensure Resident #18 had a bed alarm.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to prevent new ulcers from developing for 1 (#21) of 3 (#21, #43, #60) residents investigated for pressure ulcers, of a total sample of 33 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide the estimated cost for services for which the residents may be responsible for paying for 2 residents (#337 and #338) of 3 sampled residents for Advanced Beneficiary Notice of Non-Coverage (ABN).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1(#64) out of 22 total sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 1 resident ( #9) of 3 (#9,#18, #20) residents investigated for PASARR in a final sample of 33 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had a (PASARR) Pre-admission Screening and Resident Review Level I and/or Level II for 1 (#20) of 3 (#9, #18, #20) residents reviewed for PASAAR screening.

Inspectors wroteBased on observations, records reviews, and interviews the facility failed to ensure respiratory equipment was properly stored when not in use for 1 (#44) of 1 (#44) residents investigated for respiratory care out of a total sample of 33 residents.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with a hospice agency to ensure a resident had a Hospice Plan of Care for 1 (Resident #17) out of 2 (#17, #21) sampled residents for hospice care.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure to facility was free from cockroaches. The deficient practice had the potential to affect 83 residents who resided in the facility.