River Oaks Retirement Manor

In the surveyor’s words

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

• Immediate jeopardy, patternF700Aug 8, 2024

  Based 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. […]

• Immediate jeopardy, patternF835Aug 8, 2024

  Based 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. […]

• Actual harm, isolatedF689Aug 22, 2023

  Based on observation, record review, and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents during provision of care for 1 (#21) of 4 (#18, #21, #55, #60) residents investigated for accidents, of a total sample of 33 residents. This deficient practice resulted in an actual harm for Resident #21 on 07/28/2023 when S7CNA and S8CNA failed to adequately supervise the resident when they lowered the side rails of the bed and walked away from the resident during ADL (Activities of Daily Living) care. S7CNA and S8CNA failed to raise the resident's side rails when they moved away from the bed and Resident #21 fell out of his bed onto the floor. […]

• No harm, potential for more than minimal, widespreadF577Sep 18, 2024

  Based 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. Findings: Review of Resident #4's Quarterly MDS (Minimum Data Set) dated 09/04/2024 revealed the Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. […]

• No harm, potential for more than minimal, patternF658Dec 10, 2025

  Based 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. Findings:Review of the facility's policy titled, Verbal Orders Policy read in part, Policy: Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so .3. Enter the order into the medical record manually or electronically .Review of Resident #3's comprehensive MDS (Minimum Data Set) dated 12/03/2025 revealed she was admitted to the facility on [DATE]. […]