Riverside Oaks

Inspectors wroteBased on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of six (6) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Discharge Return Not Anticipated MDS assessment, observation end date 12/01/2025, for a physical behavioral symptom directed toward others that was exhibited on Sunday, 11/30/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (1) of six (6) residents (Resident #2) reviewed for clinical records. The facility failed to accurately document the location of Resident #1's 03/07/2026 fall in her care plan report. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, 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 1 narcotic destruction storage area. The facility failed to ensure that all narcotics matched the accompanying logs. Two of Resident #31's Morphine Sulfate oral solution bottles did not match their accompanying logs as medication was being removed from one bottle to be administered and logged on the record for a second Morphine Sulfate oral solution which had not been opened. This failure could place the residents at risk of receiving a medication error or receiving less than therapeutic benefits from medications.

Inspectors wroteBased on observations, interviews, and record reviews, 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 3 of 3 residents (Resident #1, Resident #4, and Resident #5) reviewed for infection control. 1. The facility failed to ensure CNA C performed Resident #1's catheter care according to facility policy and professional standards on 4/27/25. 2. The facility failed to ensure LVN E performed hand hygiene appropriately and donned PPE when providing catheter care to Resident #4 on 4/27/25. 3. The facility failed to ensure RN D performed hand hygiene appropriately when providing wound care to Resident #5 on 4/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 4 of 4 plates with 2 of 3 staff. 1. DA A placed food on the plates-meat, baked potato, and carrots. While DA A fixed the plates, DA A left the work station several times, doffed (removed) his gloves and donned (put on) new gloves without performing hand hygiene. 2. DA B placed condiments, a roll, a carton of milk, and a cup of ice tea on the tray used a plate cover then placed on the cart to serve to the residents in the dining room. DA B left the work station once and doffed his gloves and donned clean gloves without using hand sanitizer or washing his hands. This deficient practice could effect residents that receive food from the kitchen and place them at risk for contamination of food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #30) reviewed for medication storage in that: The facility failed to ensure medications were not left on Resident #30's bedside table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 1 of 24 residents (Resident #4) reviewed for dietary services, in that: The facility failed to provide Resident #4 with milk at every meal which was noted on the resident's meal ticked and preference sheet, dated 10/30/2023 and signed by the NS, on 07/09/2024 at 1:15 PM which was lunchtime. This deficient practice could affect residents who have dietary preferences and result in weight loss or diminished quality of life.

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 service safety for 1 of 1 kitchen, in that: The facility failed to ensure in the kitchen that three (3) ceiling vents in front of the Dietary Manager's office, six (6) ceiling panels in the dishroom, and four (4) ceiling panels in front of the refrigerators were clean and free of dirt and grease. This failure could place residents who received meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program for 2 of 18 rooms on the hall (A) and 1 and 1 kitchen reviewed for pests, in that: The facility failed to ensure the pest control program was thoroughly working in all areas of the facility. 1. Resident #13 had multiple flies on her blankets and one fly on her face. 2. Flying insects were observed in the kitchen. 3. Room A 16 A bed had a 2 inches roach crawling on her wall. This failure could affect residents by increasing their risk of exposure to pests, vector-borne diseases, and infections.

Inspectors wroteBased on observation and record review, the facility failed to provide the required 80 square foot per resident in 3 of 54 resident rooms (Rooms A2, A3, A4) reviewed for bedroom measurements, in that: Based on measured rooms, A2, A3, A4 rooms were approximately between 77.75 and 78.5 sq. ft per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being.