Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Oaks Health And Rehabilitation Center during CMS and state inspections, most recent first.
Incorrect Melatonin Dose Administered After EHR Order Entry Error: A resident with dementia, depression, bipolar disorder, schizophrenia, and insomnia received two 5 mg Melatonin tablets instead of the ordered 5 mg dose because the MAR/EHR reflected the wrong tablet strength after a GDR was entered. The Medication Aide said she followed the MAR and used simple math, while nursing leadership confirmed the order entry error and that the resident was at risk for receiving a higher dose than intended.
Improper insulin pen labeling and unsecured carts were observed in the facility. Two insulin pens had open dates written on the exp date line instead of the proper open-date area, and both south hall and north hall medication carts were found unlocked and unattended. A treatment cart was also left unlocked with wound care supplies and scissors inside, and the DON and ADONs stated carts should remain locked when not in use.
Food was not stored and served in accordance with professional standards in the kitchen. Frozen items in the reach-in freezer were found removed from original packaging without labels or dates, and during lunch service an LPN left a food thermometer in pureed broccoli after the item was reheated and returned to the service line. The Dietary Manager and the LPN stated that food should be labeled and dated and that leaving the thermometer in the food could contaminate it.
Missing Care Plan for Indwelling Catheter: A resident admitted with an indwelling urinary catheter had provider orders for Foley care, urine monitoring, hygiene, infection monitoring, and reassessment of continued use, but the care plan did not include comprehensive catheter care. Staff interviews confirmed that catheter care should be care planned and include monitoring urine output, sediment, color, flow, site condition, and signs of infection.
A resident with intact cognition and multiple serious diagnoses had half bedrails placed on both sides of his bed without a documented side rail assessment, informed consent, or evidence that alternatives were tried first. Staff interviews showed the Maintenance Supervisor was told to install the rails without being shown a signed consent, while RN and ADON staff were unaware the rails were in place or that the required documentation was missing. The resident stated he did not request the bedrails and was never spoken to about them.
Personal Refrigerator Not Maintained at Safe Temperature: A resident with Parkinson's disease and dementia kept meals in her room and had a personal refrigerator that was not cool on observation. Staff found the refrigerator at 48.9 degrees with no thermometer or temperature log, while the DON stated residents monitor their own refrigerators and nursing should help with the contents. The facility policy stated the refrigerator compartment should be maintained at 35-41 degrees.
A resident with an indwelling catheter was observed with the catheter bag and tubing on the floor beside the bed. An RN picked up the bag and hung it back on the bed without replacing it, even though she stated the bag was already contaminated. The ADON stated the bag should have been removed and replaced, and the facility’s catheter care policy stated the tubing and drainage bag should be kept off the floor.
Two residents with complex medical conditions did not have their catheter bag emptying and drainage amounts documented on two night shifts, despite facility policy and professional standards requiring this information. The responsible LPN acknowledged the omission, and both the Administrator and DON confirmed the importance of accurate documentation for proper care.
Two unidentified pills were found on a resident's bedside table, despite the resident not being authorized to self-administer medications and having moderate cognitive impairment. The resident was unaware of the pills, and the nurse responsible for medication administration did not notice them. Facility policy requires direct observation of medication ingestion and secure storage, which was not followed in this instance.
A resident with multiple medical conditions alleged inappropriate touching by an LVN during catheter care. The LVN did not immediately report the allegation to the administrator, resulting in a two-day delay before the administrator became aware and the incident was reported to the State Survey agency, contrary to facility policy requiring immediate reporting.
A resident with a history of cerebrovascular disease, hypertension, and diabetes experienced significant weight loss over several months due to ineffective implementation of a person-centered care plan. Despite documented meal refusal and food preferences, staff did not consistently provide preferred foods or initiate additional interventions such as nutritional supplements, and the dietitian only assessed residents after significant weight loss had occurred.
A resident with a history of cerebrovascular disease, hypertension, and diabetes experienced significant weight loss over several months without documented assessment or intervention by the Dietitian. Despite a care plan outlining specific nutritional interventions, these were not fully implemented, and the facility did not follow its own policy for addressing significant weight changes. Interviews confirmed that the resident's poor appetite and food preferences were not adequately addressed, and no supplements were provided.
The facility failed to prepare meals that conserve nutritive value, flavor, texture, and appearance, affecting three residents on regular diets. Observations revealed that the potato casserole was crunchy and the coleslaw was unpalatable. The dietary manager admitted to not tasting the food before serving, and the cook used a deep pan instead of shallow pans, affecting the cooking process. The DON acknowledged the risk of weight loss due to unappetizing meals, and the Administrator expected adherence to recipes and tasting before serving.
A LTC facility failed to maintain infection control measures, with staff neglecting hand hygiene and proper use of PPE. A medication aide did not sanitize hands or equipment after caring for a resident on Enhanced Barrier Precautions. An LVN did not wear a gown during wound care and mishandled soiled towels. An RN failed to sanitize hands after handling a resident's radio, then assisted another resident. These actions violated the facility's infection control policies.
A resident with mental health conditions refused care, leading to unsanitary conditions in her room, including urine and feces, and a strong odor affecting the hallway. Despite staff attempts to clean and provide care, the resident remained resistant, and the facility determined they could not meet her needs.
A resident with a history of mental health disorders consistently refused hygiene care, leading to a deficiency in maintaining her activities of daily living. Despite being independent in other areas, the resident's refusal to bathe was documented over several months, with staff making multiple attempts to provide care. The facility ultimately determined they could not meet her needs, resulting in her transfer to a hospital for evaluation.
A resident with schizophrenia and bipolar disorder was found to have 28 olanzapine tablets in her nightstand, indicating non-compliance with her prescribed medication regimen. Despite being observed accepting medication, she did not ingest the pills, leading to a failure in pharmaceutical services. Staff reported her aggressive behavior and refusal of care, complicating efforts to ensure proper medication administration.
A resident with severe dementia was physically assaulted by another resident with a history of aggression in the dining room. The assaulted resident sustained bruises, and the incident was witnessed by the Dietary Manager. The facility failed to prevent the altercation due to inadequate monitoring and staff presence.
Two residents experienced deficiencies in medication management due to the facility's failure to reorder medications timely. One resident did not receive Tramadol for pain, while another missed hydrocodone doses due to pharmacy and insurance issues. The facility's policy on timely medication reordering was not followed, leading to unmanaged pain.
The facility failed to ensure that food stored in the refrigerator, freezer, and pantry was labeled, dated, and sealed properly. Observations revealed multiple items in the refrigerator, pantry, and freezer that were not labeled, dated, or sealed, despite the facility's policy requiring these actions. Interviews with dietary staff confirmed the importance of these practices to prevent food contamination and food-borne illnesses.
Incorrect Melatonin Dose Administered After EHR Order Entry Error
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when a Medication Aide administered two 5 mg Melatonin tablets to a resident instead of the ordered 5 mg dose. The resident was a female with diagnoses including non-Alzheimer's dementia, depression, bipolar disorder, schizophrenia, and COPD, and her MDS reflected no cognitive impairment with a BIMS score of 15. Her care plan identified insomnia, and the pharmacist had recommended a gradual dose reduction for Melatonin from 10 mg at bedtime to 5 mg at bedtime, which the Medical Director approved. The resident's April 2026 physician's orders reflected Melatonin 5 mg by mouth daily for insomnia, but the MAR showed that the Medication Aide gave two 5 mg tablets on multiple dates instead of one tablet. During interview, the Medication Aide stated she gave two tablets because the MAR reflected 10 mg and she used simple math to equal the 10 mg order. She also stated she was unaware that a gradual dose reduction had been attempted and that she relied on the MAR for administration. Interviews with nursing leadership showed that the incorrect order entry into the EHR contributed to the error. RN B stated she had not reviewed the night shift medication order and would have called the doctor for clarification if she had seen it. ADON C stated the Regional Compliance Nurse entered the pharmacy recommendation into the EHR but did not change the Melatonin 10 mg tablet to a 5 mg tablet, and the Regional Compliance Nurse confirmed she decreased the order but did not change the tablet strength. The Medical Director stated she agreed with the pharmacist to attempt the gradual dose reduction from 10 mg to 5 mg, and the resident stated she slept well and had not noticed daytime grogginess.
Improper Insulin Pen Labeling and Unlocked Medication and Treatment Carts
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles for 2 of 9 insulin pens with correct open dates. During an observation of the south hall nurses’ medication cart, the cart was left unlocked and unattended, and a Novolin R insulin pen for Resident #30 was labeled with a date written on the line for expiration date. RN A stated that the date was intended to be the open date and that she did not know why it was written on the expiration date line. She also stated an opened insulin pen expires 28 days after opening and that the medication cart should always be kept locked, but she had forgotten to lock it. During an observation of the north hall nurses’ medication cart, five insulin pens were inside the cart, and Resident #44’s insulin pen was labeled with a date on the line marked exp date. ADON C stated nurses should not label insulin pens with the open date on the expiration date line because it could cause confusion about the actual open date, and that insulin pens expire after 28 days of opening. In addition, a treatment cart on north hall was observed unlocked and unattended, containing wound care dressings, wound cleanser, cream, and scissors. ADON D stated all carts should stay locked at all times when not in use and that the treatment cart should not have remained unlocked.
Food Storage and Service Line Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation on 04/14/2026, two bags of frozen pancakes removed from their original boxes and placed in plastic freezer bags, two bags of chicken nuggets removed from their original boxes, and one bag of hushpuppies were found in the reach-in freezer without labels or dates. The record review included the facility policy on food received and storage, which required food removed from its original container to be labeled with the name of the food item and dated with the month, day, and year. During lunch service observation on 04/15/2026, puree broccoli had an initial service line temperature of 137 degrees and was removed from the service line and placed in the facility oven for additional warming. After being returned to the service line and re-temped at 163 degrees, [NAME] C did not remove the food thermometer. At 11:28 A.M., lunch service had started and the thermometer was still laying in the pureed broccoli; [NAME] C removed it at 11:42 A.M. The Dietary Manager stated that not removing the thermometer could cause it to explode in the food, and [NAME] C stated food should be labeled with date received and used by so expired food is not cooked and in case of a recall, and that leaving the thermometer in the food could break and contaminate the food.
Missing Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #38 related to an indwelling urinary catheter. The resident’s face sheet listed the presence of an indwelling catheter as an admitting diagnosis, and the admission note documented that the resident was admitted with a urinary catheter size 16. The provider’s progress note included orders to continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, and reassess the need for continued catheter use. Review of the resident’s care plan showed that, despite these catheter-related needs and orders, there was no comprehensive care plan addressing catheter care. During interviews, RN B, RN A, the ADON, and the DON all stated that residents with indwelling catheters should have a care plan and described catheter monitoring and care elements such as urine output, sediment, urine color, flow, site condition, and signs of infection. The facility’s comprehensive care planning policy stated that care plans should describe services to attain or maintain the resident’s highest practicable well-being and be person-centered, and the catheter care policy stated to review the resident’s plan of care daily for changes.
Bedrails Installed Without Assessment or Informed Consent
Penalty
Summary
The facility failed to attempt alternatives before installing half bedrails on both sides of Resident #9's bed, failed to obtain informed consent before installation, and failed to ensure correct installation and maintenance of the bedrails. Record review showed that Resident #9 was a cognitively intact male with a BIMS score of 15 and diagnoses including type 2 diabetes mellitus, cerebrovascular accident, bilateral below-the-knee leg absence, and dependence on renal dialysis. His MDS did not address bedrail use, and his care plan addressed bed mobility assistance but did not reflect bedrails. The EHR also showed no side rail evaluation. Observation on 04/14/26 showed half bedrails on both sides of Resident #9's bed. The Maintenance Supervisor stated that the previous DON told him to place the bedrails on the resident's bed, but he was not shown a signed consent despite asking for it. He stated he understood consent was needed to show the resident had been evaluated and agreed to the bedrails, and he said he should have notified the Administrator before installing them when consent was not provided. He also stated he checks the rails weekly to ensure they are securely placed. Interviews showed staff were unaware of the bedrails or the required documentation. RN B stated she did not know Resident #9 had half bedrails and said she did not believe they were a restraint, though she acknowledged a resident could get an arm stuck and be hurt and that an assessment should be completed before bedrails are placed. ADON C stated Resident #9 should have had an assessment, care plan, and consent, and the DON stated residents with half bedrails should have a bedrail assessment, consent, care plan intervention, and nurse documentation. Resident #9 stated he did not request the bedrails, no staff spoke with him about them, and he was not given a consent or assessment. The facility policy stated alternatives should be attempted before installing bedrails and that assessment, informed consent, and proper installation and maintenance were required.
Personal Refrigerator Not Maintained at Safe Temperature
Penalty
Summary
The facility failed to help family and visitors understand safe food handling practices for Resident #8's personal refrigerator and failed to ensure the in-room refrigerator met safe cooling and reheating temperature standards. Resident #8 was an [AGE]-year-old female admitted on [DATE] with Parkinson's Disease without Dyskinesia and secondary dementia in other diseases classified elsewhere. Her care plan dated 04/06/2026 stated she was on a regular diet, chose to eat all meals in her room, and required monitoring and documentation of meal intake. Her quarterly MDS assessment dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment, and Section GG indicated she needed setup or clean-up assistance for eating. On 04/14/2026 at 11:00 AM, observation showed Resident #8 had a personal refrigerator in her room that did not feel cool when opened, and there was no inside thermometer or temperature log. Later that day, the Maintenance Supervisor checked the refrigerator and found the temperature was 48.9 degrees, with the control set to 1. The Maintenance Supervisor stated on 04/16/2026 that the family member or responsible party was responsible for maintaining personal refrigerators. The DON stated on 04/16/2026 that residents monitor their own refrigerators, nursing should help with the content, and direct care staff should throw away spoiled food. The Housekeeper Supervisor stated personal refrigerators were cleaned by housekeeping when alerted by the DON, and housekeeping would remove expired items with the resident present. The facility policy for Personal Refrigerator stated housekeeping can assist the resident and/or family member by inspecting refrigerators at least weekly and that the refrigerator compartment should be maintained at 35-41 degrees.
Catheter Bag Contamination During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for catheter care for one resident with an indwelling catheter. The resident’s face sheet showed admission with a diagnosis of presence of an indwelling catheter, and the provider’s progress note included orders to continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, and reassess the need for continued catheter use. The resident’s care plan, dated 3/31/2026, did not include care planning for the urinary catheter. During observation, the resident was sleeping while the catheter bag and tubing were found on the floor next to the bed. The DON saw the bag on the floor and informed RN A. RN A performed hand hygiene, donned PPE, entered the room, picked up the catheter bag, and hung it back on the bed without replacing the bag. RN A later stated the bag was already contaminated because it had been on the floor and that she should have removed it and changed it. The ADON stated that if a catheter bag was on the floor, it should be immediately removed and replaced because it was already contaminated, and that staff were expected to follow the facility’s catheter care policy, which stated the catheter tubing and drainage bag should be kept off the floor.
Failure to Document Catheter Care in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required documentation of catheter care. Specifically, on two separate night shifts, there was no documentation on the Treatment Administration Records regarding the emptying of catheter bags or the amount of drainage for both residents. The nurse assigned to those shifts confirmed that she was responsible for the documentation and acknowledged that the catheter bags were emptied by an aide, but she did not record the procedure or the amounts as required. Both residents had significant medical histories, including conditions such as Parkinson's Disease, dementia, parastomal hernia, benign prostatic hyperplasia, and major depressive disorder. The lack of documentation was confirmed through interviews with the nurse, the Administrator, and the DON, all of whom recognized the importance of accurate record-keeping. The facility's policy required regular assessment and documentation for residents using urinary devices, but this was not followed on the identified dates.
Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when two unidentified pills were found on a resident's bedside table, despite the resident not being authorized to self-administer medications. The resident, who had a BIMS score indicating moderate cognitive impairment and diagnoses including type 2 diabetes, chronic kidney disease, and heart failure, was unaware of the pills' presence. The pills were discovered during an observation and interview, and the resident stated that he may have dropped them when taking his medication. The Wound Care nurse confirmed that medications should not be left at the bedside and removed the pills from the room. Further interviews revealed that the nurse responsible for administering the resident's medication had not noticed the pills on the left side of the bed and stated that she would have removed them if she had seen them. Facility policy requires that medications be administered directly to residents and observed to ensure ingestion, with any refusals documented and reported. The facility's policies also specify that medications must be stored securely and only accessed by authorized personnel. The presence of unsecured medication at the bedside was contrary to these protocols.
Failure to Timely Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey agency and the facility administrator immediately, but not later than two hours after the allegation was made, as required. Specifically, a male resident with a history of cerebral infarction, heart failure, and bipolar disorder, who was cognitively intact and required catheter and incontinent care, alleged that an LVN touched him inappropriately during catheter care. The incident occurred on 03/08/25, but the LVN did not immediately report the allegation to the administrator. Instead, the administrator became aware of the incident two days later, on 03/10/25, after finding a note left by the LVN. An assessment and investigation were initiated only after the administrator learned of the incident, and the report to the State Survey agency was also delayed until 03/10/25. The facility's own policy required immediate reporting and investigation of all abuse allegations, but this protocol was not followed in this case. The delay in reporting was confirmed through interviews, record reviews, and a review of the state database, which showed discrepancies in the reporting timeline.
Failure to Implement Comprehensive Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames to address the medical, nursing, mental, and psychosocial needs of a resident experiencing weight loss. The resident, who had a history of cerebrovascular disease, hypertension, and type 2 diabetes, was admitted with a stable weight but experienced a gradual decline over several months. Despite the care plan identifying the risk for weight loss due to meal refusal and food preferences, interventions such as providing preferred foods, encouraging meal completion, and monitoring weight were not effectively implemented. The resident's weight decreased from 184.2 lbs to 166.4 lbs over approximately eight months, representing a 9.37% loss. Documentation showed the resident often ate less than 51% of meals, preferred snacks brought by family, and expressed dissatisfaction with facility food. The care plan included goals to maintain ideal weight and interventions like determining food preferences and serving snacks, but these were not consistently followed. The facility's policy required intervention only after a 10% weight loss in six months, and staff did not initiate additional measures such as nutritional supplements or further dietary assessment before reaching this threshold. Interviews with staff revealed that the dietitian only assessed residents with significant weight loss and did not document recommendations for further evaluation. Nursing staff noted the resident's poor meal intake but did not implement new interventions. The resident's family was aware of the ongoing weight loss and dissatisfaction with meals, but no documented changes were made to address these concerns prior to the deficiency being identified.
Failure to Address Resident Weight Loss and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding weight loss, as required by regulation. One resident experienced a 9.37% weight loss over eight months, with no documentation from the Dietitian addressing nutritional concerns or recommending interventions to address the weight loss. The resident's care plan included interventions such as determining food preferences, encouraging meal completion, monitoring weight, and regular Dietitian assessments, but these interventions were not fully implemented. The resident had a history of cerebrovascular disease, hypertension, and type 2 diabetes, and was on a regular diet with no supplements. Despite a documented poor appetite and a preference for certain foods, there was no evidence that the Dietitian assessed the resident or made recommendations during the period of weight loss. The resident's weight was recorded monthly, showing a steady decline, but the facility did not initiate additional interventions or document follow-up actions as outlined in their own policy for significant weight changes. Interviews revealed that the Dietitian only assessed residents with significant weight loss and did not document a conversation regarding a possible swallowing evaluation. The nursing staff noted the resident was eating less than 51% of meals, but no supplements were provided, and the resident's family expressed concern about the ongoing weight loss. The facility's policy required action for significant weight changes, but these steps were not taken or documented for this resident.
Deficiency in Food Preparation and Quality
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, flavor, texture, and appearance for residents on regular diets. This deficiency was observed in three residents who were served meals that were not palatable or properly cooked. Specifically, the potato casserole served was crunchy and not fully cooked, and the coleslaw was unpalatable and not set in form. These issues were confirmed through observations and interviews with the residents, who expressed dissatisfaction with the meals, and the dietary manager, who admitted to not tasting the food before serving it. The dietary manager and cook revealed that the potato casserole was prepared in a deep pan instead of two shallow pans, which affected the cooking process, and the coleslaw dressing was improvised due to a lack of ingredients. The dietary manager also admitted to not tasting the food before it was served, which is against the facility's policy. The Director of Nursing acknowledged the risk of weight loss and other health issues due to unappetizing meals, and the Administrator expected the dietary staff to follow recipes and taste the food before serving. The facility's policy requires a test tray evaluation to ensure food quality, which was not adhered to in this instance.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by multiple incidents involving staff and residents. One incident involved a medication aide (MA A) who did not perform hand hygiene after measuring the blood pressure of a resident on Enhanced Barrier Precautions (EBP). Instead of sanitizing his hands immediately, MA A attempted to enter another resident's room to wash his hands, which was stopped by the surveyor. Additionally, MA A did not properly sanitize the blood pressure machine and its components after use, potentially risking cross-contamination. Another incident involved a Licensed Vocational Nurse (LVN D) who did not adhere to EBP procedures during wound care for a resident. LVN D failed to wear a gown upon returning to complete the wound care and improperly handled soiled towels by placing them under his arm instead of in a designated bag. This oversight occurred despite LVN D's awareness of the EBP requirements, as he was one of the infection control preventionists at the facility. A third incident involved a Registered Nurse (RN E) who neglected to sanitize her hands after handling a resident's radio, which had been inside the resident's pants. RN E then proceeded to assist another resident without performing hand hygiene, increasing the risk of infection transmission. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene and proper use of personal protective equipment to prevent the spread of infections.
Failure to Maintain a Safe and Sanitary Environment for a Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident diagnosed with paranoid schizophrenia, bipolar disorder, and dementia, among other conditions. The resident, who had a history of hoarding and refusing care, did not allow staff to clean her room or provide personal hygiene assistance. This resulted in unsanitary conditions, including urine and feces in the room, and a strong odor that permeated the hallway. Despite multiple attempts by housekeeping and nursing staff to clean the room and provide care, the resident remained resistant and aggressive, refusing access to her room. The facility's staff, including the Director of Nursing and Administrator, were aware of the situation and noted a deterioration in the resident's condition since August, with behaviors such as voiding in plastic bags and hoarding items from the facility. Meetings with the interdisciplinary team and external healthcare providers were held, but the facility determined they could not meet the resident's needs. Observations confirmed the unsanitary state of the resident's room, with personal items and facility property scattered throughout, and writing on the walls. Interviews with staff revealed ongoing challenges in managing the resident's behaviors and maintaining a sanitary environment. The facility's admission packet outlined the residents' right to live in safe, clean conditions, which was not upheld in this case.
Failure to Maintain Resident's Hygiene and ADL
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable due to clinical conditions. Specifically, the facility did not ensure that a resident was provided with adequate hygiene care. The resident, who had a history of paranoid schizophrenia, bipolar disorder, and dementia, consistently refused showers and other hygiene-related care. Despite being independent in other functional activities, the resident's refusal to bathe was documented repeatedly over several months, with staff making multiple attempts to provide care each day. The resident's care plan indicated that she required supervision for bathing, yet the facility's records showed a pattern of refusal and lack of intervention to address the underlying issues contributing to the resident's non-compliance. The resident's refusal to bathe led to concerns about her hygiene, skin condition, and overall quality of life. Staff interviews revealed that the resident was aggressive and resistant to care, and the facility struggled to manage her behaviors effectively. The situation escalated to the point where the resident was transferred to a hospital for evaluation, as the facility determined they could not meet her needs. The resident's guardian and psychiatric care providers were involved in discussions about her care, but the facility ultimately decided that they could not provide the necessary support for her psychiatric and mental health needs. The report highlights the facility's inability to manage the resident's care effectively, leading to a deficiency in maintaining her activities of daily living.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the administration of olanzapine as prescribed. The resident, diagnosed with paranoid schizophrenia, bipolar disorder, and other cognitive impairments, was found to have 28 olanzapine tablets in her bedside nightstand drawers. These tablets were supposed to be taken twice daily, but the resident was not compliant with the medication regimen, as evidenced by the accumulation of pills in her room. The resident's medical records indicated a history of non-compliance with medication, including refusal of Risperdal injections and hoarding behavior related to her psychiatric conditions. Despite being observed accepting medication cups, the resident was not ingesting the pills, instead storing them in her drawers. This behavior was reported by a CMA, who noticed the pills in the drawer and informed the charge nurse, leading to further investigation by the DON and Administrator. Interviews with staff revealed that the resident was aggressive and refused care, including medication administration. The DON, upon searching the resident's room, found the olanzapine tablets, which appeared to have been in contact with liquid and were sticking together. The resident denied having the medication and reacted angrily to the search, indicating a lack of cooperation with the facility's efforts to ensure proper medication administration. The facility's policy on medication administration and refusal was not effectively implemented, resulting in the resident not receiving her prescribed medication.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with severe dementia and cognitive impairment, who was physically assaulted by another resident with intact cognition but a history of behavioral issues, including verbal and physical aggression. The assaulted resident had a history of behavioral problems and was at risk for injury due to wandering and impaired cognitive function. The incident occurred in the dining room area, where the resident with dementia was approached by the other resident, who then physically assaulted him by punching him in the face and holding onto his wrist. This altercation was witnessed by the Dietary Manager, who intervened and separated the two residents. The assaulted resident sustained bruises on his right forearm and left eye, which were assessed by an LVN as new injuries. The facility's failure to prevent this incident was further highlighted by the lack of staff presence in the dining room at the time of the altercation, as noted by the resident who committed the assault. Despite previous reports of behavioral issues, the facility did not adequately monitor or separate the residents to prevent such an incident. The facility's policy on abuse and neglect, which includes resident-to-resident abuse, was not effectively implemented to protect the residents involved.
Deficiencies in Medication Management for Pain Relief
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. Resident #3, a male with diagnoses including alcoholic cirrhosis, major depressive disorder, and type 2 diabetes, did not receive his prescribed Tramadol for pain management. Despite having an order for Tramadol to be administered every 8 hours as needed, the medication was not reordered in a timely manner, resulting in the resident experiencing unmanaged pain. Interviews with nursing staff revealed that the medication was not reordered when supplies were low, and the emergency kit did not contain the necessary medication. Resident #4, a male with type 2 diabetes, morbid obesity, and chronic pain, also experienced issues with medication management. The resident's hydrocodone doses were missed due to delays in pharmacy delivery and insurance issues, leading to a period of eight days without the medication. The resident reported that his pain was managed except during this period. The facility's policy required medications to be reordered three to four days in advance, but this was not adhered to, resulting in missed doses and potential pain management issues. The facility's policy on ordering medications was not followed, as medications were not reordered in a timely manner, leading to residents going without necessary pain management. Interviews with staff, including the DON and Administrator, highlighted expectations for timely reordering, but these were not met, resulting in deficiencies in pharmaceutical services. The lack of adherence to the policy and failure to manage medication supplies effectively contributed to the residents' unmet needs for pain management.
Failure to Properly Label, Date, and Seal Food Items
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and pantry was labeled, dated, and sealed properly. During an observation, several items were found in the refrigerator, including cooked bacon and sausage patties, sausage patties in opened plastic packaging, cooked green beans, tuna salad, red sauce, ground meat, sliced meat, and marinara sauce, all of which were not labeled, dated, or sealed properly. Similar issues were found in the pantry and freezer, where items such as cereal, French onion topping, instant milk, frozen breadsticks, and frozen meat were not labeled, dated, or sealed. These deficiencies were confirmed through interviews with the dietary manager, dietary aide, and cook, who acknowledged the importance of proper labeling, dating, and sealing to prevent food contamination and food-borne illnesses. The facility's policy on food receiving and storage, which was last revised in October 2017, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. Despite this policy, the staff failed to adhere to these guidelines, as evidenced by the observations and interviews. The dietary manager admitted that all dietary staff were responsible for ensuring proper labeling, dating, and sealing of food items, and that she was responsible for training the staff. However, the observed deficiencies indicate a lapse in adherence to these professional standards, potentially placing residents at risk for food contamination and food-borne illnesses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 572 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Worth Wellness & Rehabilitation | 1 mi | — | 0 | 0 |
| Marine Creek Nursing And Rehabilitation | 1.6 mi | — | 17 | 0 |
| The Stayton At Museum Way | 3.2 mi | — | 3 | 0 |
| Trinity Terrace | 3.5 mi | — | 0 | 0 |
| James L West Center For Dementia Care | 3.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River Oaks Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.