River Oaks Care Center

In the surveyor’s words

From the most serious findings on record at River Oaks Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 20, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF610Nov 20, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF584Aug 8, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF584May 4, 2023

  Based 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,… […]

• No harm, potential for more than minimal, isolatedF655Aug 8, 2025

  Based 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. Review of the facility's policy titled, Care Plans - Baseline, 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 meets professional standards of quality care and must include the minimum healthcare… […]