Inspection Reports for
River Oaks Senior Living

R 325.1932 Resident’s medications: Resident A’s insulin orders were routinely administered outside of the prescribed time parameters.

R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to maintain an organized program to provide protection and supervision as Resident A and Resident B left the facility without staff knowing they were gone.

R 325.1921 Governing bodies, administrators, and supervisors: the facility lacked an organized program pertaining to the documentation and use of controlled substances, with inaccurate medication counts and incomplete record keeping on the second floor medication cart controlled substance count logs.

R 325.1923 Employee's health: the facility was unable to produce evidence that Employees 1 and 2 were screened for TB within 10 days after hire as required.

R 325.1932 Resident’s medications: Resident A, B, and C missed scheduled doses of medications with reasons undocumented or incorrectly documented in medication administration records.

R 325.1972 Solid wastes: multiple garbage cans throughout the facility, including in the memory care kitchen, did not contain lids.

R 325.1976 Kitchen and dietary: perishable food items in the walk-in refrigerator and freezer lacked proper labeling and/or were not sealed to prevent contamination.

R 325.1976 Kitchen and dietary: a reliable thermometer was missing from refrigerators and/or freezers in multiple apartments and the memory care kitchen.

R 325.1976 Kitchen and dietary: a multi-use scoop was located inside a container of sugar with the handle buried in the contents, indicating it was used repeatedly without sanitization after each use.

R 325.1979 General maintenance and storage: two cabinet faces in the memory care kitchen were missing, exposing the front side of the sink.

R 325.1979 General maintenance and storage: unsecured cleaning agents and detergents were observed in unlocked laundry rooms and under Resident D’s kitchen sink, posing an ingestion and poisoning risk to residents lacking safety awareness.

R 325.1980 Soap and towels: the second floor communal bathroom did not contain any soap, and use of the common towel is prohibited.

R 325.1931 Employees; general provisions: facility schedules revealed numerous instances where only one staff was listed in memory care while simultaneously splitting their time on another floor, leaving no staff stationed in memory care.

R 325.1922 Admission and retention of residents: Resident A’s service plan was not updated to accurately reflect her specific care needs including increased agitation and fall prevention methods.

R 325.1944 Employee records and work schedules: staff attested that facility schedules were not entirely accurate to include all staff in the building during the timeframe reviewed.

R 325.1921 Governing bodies, administrators and supervisors: facility staff failed to obtain Resident A’s hospital discharge paperwork and did not follow up timely with the pharmacy, resulting in multiple missed medication doses.

R 325.1932 Resident’s medications: Resident A’s medications were not obtained from the pharmacy timely, resulting in multiple missed doses.

R 325.1931 Employees; general provisions: the facility did not assure the safety of Resident A as written in her service plan when she eloped from the facility without staff supervision.