Riveroaks Health Campus

In the surveyor’s words

From the most serious findings on record at Riveroaks Health Campus, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Oct 4, 2024

  Based on interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP had not received specialized training in infection prevention and control when starting as the IP. This had the potential to affect 56 of 56 residents residing in the facility. Finding includes: On 10/4/24 at 9:38 A.M., the Assistant Director of Nursing (ADON) indicated that she was currently responsible for the infection prevention and control program in the facility. She indicated she was able to dedicate approximately 5-10 hours per week on the infection control program. On 10/4/24 at 11:25 A.M., the ADON's employee record was reviewed. The ADON had begun the role as IP on 6/4/24, prior to obtaining her IP certification on 6/17/24. […]

• No harm, potential for more than minimal, patternF880Oct 4, 2024

  Based on observation, record review, and interview, the facility failed to implement infection control practices for 6 of 6 residents reviewed for EBP (Enhanced Barrier Precautions). Signs were not posted, orders were not initiated, and gowns were not worn during high contact activities. (Resident T, Resident S, Resident D, Resident L, Resident W, Resident V) Findings included: 1. On 9/30/24 at 1:48 P.M., during a random observation there was no EBP sign on Resident L's door. On 10/1/24 at 9:00 A.M., during a random observation there was no EBP sign on Resident L's door. On 10/02/24 at 10:28 A.M., during a random observation there was no EBP sign on Resident L's door. On 10/2/24 at 10:11 A.M., Resident L's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF677May 17, 2024

  Based on observation, interview, and record review, the facility failed to provide assistance with bathing and oral hygiene for 4 of 7 residents reviewed for activities of daily living (ADLs). Residents did not receive a complete bed bath, shower, and/or daily oral hygiene according to the plan of care and residents preferences. (Resident F, Resident G, Resident H, Resident J) Findings include: 1. During an observation on 5/16/24 at 10:20 A.M., Resident F was sitting up in his room, dressed, with his hair combed back. His hair appeared to be oily. During record review on 5/16/24 at 11:00 A.M., Resident F's diagnoses included, but were not limited to, heart failure, kidney failure, reduced mobility, and weakness. […]

• No harm, potential for more than minimal, patternF725May 17, 2024

  Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided to maintain residents quality of life and to ensure residents' activities of daily living (ADL's) were completed for 2 of 2 days during the survey. Findings include: On 5/16/24 at 10:00 a.m., the Facility Census Form indicated there were 57 residents residing on the health center. 1. During the survey from 5/16/24 through 5/17/24, the following interviews were conducted. - The staff could use more help. - Call lights take a long time to be answered and it was frustrating. - Waiting 20 minutes for call lights to be answered. - The facility is short staffed. - It was difficult to complete tasks for residents due to staffing. […]

• No harm, potential for more than minimal, isolatedF580Dec 22, 2025

  Based on interview and record review, the facility failed to ensure the physician was notified during a change in condition for 1 of 1 residents reviewed for closed records. (Resident 57)Finding includes: On 12/16/25 at 2:23 P.M., Resident 57's clinical record was reviewed. Resident 57 was admitted on [DATE]. Diagnoses included, but were not limited to, encephalopathy. The most recent admission Minimum Data Set (MDS) Assessment, dated 9/10/25, indicated Resident 57 was cognitively intact. […]