Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Oaks Nursing & Rehabilitation Center Llc during CMS and state inspections, most recent first.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents with psychiatric and cognitive conditions engaged in a verbal altercation that escalated when one struck the other in the face with a chair, causing multiple facial fractures. Staff were present and intervened, but the incident resulted in significant injury before separation and assessment occurred. There were no prior documented physical altercations or behavioral changes between the residents.
The facility did not ensure that two residents with mental health diagnoses were properly referred for PASRR Level II evaluation. One resident's updated diagnosis of schizophrenia was not reflected in the most recent PASRR documentation, and another resident's delusional disorder was not captured on the Level I screening form, resulting in missed referrals for required services.
Surveyors found that raw chicken was stored above ready-to-eat desserts in the freezer, expired milk was present in the refrigerator, and multiple opened food items were not properly sealed. Staff confirmed these practices did not follow facility food safety policies, potentially affecting all residents served from the kitchen.
Two residents engaged in a physical altercation in the dining room, exchanging blows before being separated by a CNA. Despite staff witnessing or being informed of the incident and recognizing it as physical abuse, there was no documentation in the nurse's notes or care plans, and the event was not reported to administration or the DON as required by facility policy.
Two residents were involved in a physical altercation in the dining room, which was witnessed by a CNA and later mentioned to an LPN. Despite staff recognizing the incident as physical abuse, there was no documentation in the clinical records or care plans, and the event was not reported to the administrator or State Agency as required by policy. Interviews confirmed that the incident was not escalated or documented, resulting in a failure to meet mandated reporting guidelines.
A resident with serious mental health diagnoses and an approved Level II PASRR was not accurately coded in the MDS assessment, as the PASRR section was marked 'No' and the serious mental illness section was left blank, despite documentation supporting a 'Yes' response.
Two incidents of resident-to-resident abuse occurred in an LTC facility. In one case, a severely cognitively impaired resident was pushed by another, resulting in a laceration requiring sutures. In another case, a cognitively intact resident was observed hitting a cognitively impaired resident, though no injuries were reported. The facility failed to protect residents from abuse by others.
A staff member at an LTC facility took and kept an unauthorized photograph of a resident, violating the resident's privacy and confidentiality rights. The resident, who had cognitive impairments, had not consented to any photographs. Facility administrators confirmed the breach after reviewing the photograph and related text messages.
The facility failed to store medications securely, leaving a resident's eye drops at their bedside and not affixing a Controlled Substance Emergency Kit containing Schedule III-IV medications. Staff confirmed the medications should have been secured, and the kit was not stored in compliance with regulations.
The facility failed to maintain dignity during meal assistance for two residents with dementia. CNAs were observed standing over and sitting on the residents' beds while feeding them, contrary to the facility's policy requiring staff to sit in a chair. Interviews confirmed the breach of procedure.
A resident reported being verbally abused by a CNA, an incident witnessed by the resident's roommate. The LPN and Administrator were informed, but the Administrator failed to report the allegation to the state survey agency as required by the facility's policy. The DON confirmed that such behavior is considered abuse.
A facility failed to accurately assess a resident's discharge status. The resident was documented as being discharged to a short-term hospital, but physician orders and nurses' notes indicated a discharge to a group home. Staff confirmed the MDS was incorrectly coded.
A resident with moderate cognitive impairment expressed a desire to transfer to a facility closer to his home, but the facility failed to update the discharge plan to reflect his wishes. Despite the resident being his own responsible party and communicating his desire to staff, no action was taken to facilitate the transfer. The Social Services Director admitted to not initiating transfer documents, resulting in a deficiency in the discharge planning process.
Two residents in the facility did not receive drinks consistent with their preferences and needs. One resident, who is cognitively intact, reported that his water cups were not filled regularly, while another severely cognitively impaired resident had an empty cup out of reach and stated that CNAs did not offer or provide ice and water. Staff interviews confirmed that CNAs failed to adhere to the facility's policy of passing ice and water every shift and as requested.
A resident with depressive disorders and dementia was prescribed Sertraline, but the facility failed to obtain or document physician orders for monitoring behaviors and side effects. Staff interviews confirmed the absence of necessary orders and tasks for monitoring the psychotropic medication, highlighting a deficiency in maintaining accurate medical records.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual physical harm. Two residents, both with psychiatric and cognitive diagnoses, were sharing a room. One resident, who was cognitively intact, became verbally aggressive with his roommate, who had moderate cognitive impairment. This verbal altercation escalated, and the cognitively impaired resident struck the other in the face with a chair, causing significant facial injuries including orbital and nasal fractures. Prior to this incident, there were no documented physical altercations or behavioral changes between the two residents, and both had a history of verbal arguments but no prior physical aggression. On the day of the incident, staff were present in the hallway and initially intervened to de-escalate a verbal argument between the two residents. After the initial intervention, the residents separated briefly, but the argument resumed. As staff approached to intervene again, the cognitively impaired resident picked up a chair and struck the other resident, also hitting the intervening LPN in the arm. Immediate staff intervention followed, and the residents were separated. The injured resident sustained a skin tear, bruising, and later was found to have multiple facial fractures. The resident initially refused emergency care but was eventually sent to the hospital for evaluation and treatment after imaging revealed the extent of the injuries. The injured resident was assessed multiple times following the incident and consistently denied pain, emotional distress, or fear, and continued to participate in daily activities. Staff interviews confirmed that there were no prior indications or behavioral changes that would have predicted the escalation to physical violence. The incident was witnessed by staff, and immediate action was taken to separate and supervise both residents. The facility's failure to prevent this altercation resulted in significant physical harm to the resident.
Failure to Refer Residents for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that residents with identified mental health diagnoses were properly referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. For one resident, the clinical record showed a diagnosis of Undifferentiated Schizophrenia with an onset date after the most recent PASRR Form 142 on file, which did not reflect the updated diagnosis. The staff member responsible for submitting resident review forms confirmed that a new review should have been submitted but was not. For another resident, the clinical record indicated diagnoses of Post-Traumatic Stress Disorder (PTSD) and Delusional Disorder upon admission. The staff member acknowledged that the Level I screening form failed to capture the Delusional Disorder diagnosis, which is considered a Tier 2 diagnosis and should have triggered a Level II review.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed that raw chicken products were stored above ready-to-eat desserts such as Boston cream pies and Philadelphia cheesecakes in the freezer, contrary to the facility's own food storage policy, which requires cooked foods to be stored above raw poultry. Additionally, an expired 1 1/2 gallon container of 2% reduced fat milk was found in the refrigerator, and several opened food items, including cheese slices, ham, and bacon, were not properly sealed. Interviews with facility staff confirmed that these practices did not align with established food safety and sanitation policies. The Dietary Manager acknowledged that desserts should not be stored under raw chicken and that expired milk should be discarded. The Administrator also confirmed that items in the kitchen should be stored in a clean and safe manner. These deficiencies had the potential to affect all 130 residents served from the kitchen.
Failure to Protect Residents from Physical Abuse and Lack of Incident Reporting
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an altercation between two residents in the dining room. One resident, with intact cognition, reported being struck in the face by another resident after grabbing the back of the other resident's wheelchair. The altercation escalated, with both residents exchanging blows, and a CNA intervened to separate them. Both residents confirmed the incident during interviews, and a CNA and LPN also acknowledged witnessing or being informed of the physical altercation. However, there was no documentation of the incident in either resident's nurse's notes or care plans. Staff interviews revealed that the incident was not reported to facility administration or the Director of Nursing, despite staff recognizing the event as physical abuse. The facility's abuse prevention manual defines physical abuse to include hitting and slapping, and both the DON and administrator confirmed that such incidents should be reported immediately. The lack of documentation and failure to report the altercation constituted a deficiency in protecting residents from abuse.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that an incident involving physical abuse between two residents was reported to the facility administrator and the State Agency as required by mandated reporting guidelines. According to the facility's Abuse-Neglect Prevention Manual, any evidence or suspicion of abuse must be reported immediately to the administrator or designee, who is then responsible for notifying the appropriate authorities. However, a review of facility-reported incidents over a one-month period revealed that no such incident involving the two residents was reported. Both residents involved in the altercation described a physical fight in the dining room, with one resident stating he was hit in the face and retaliated, and the other confirming the altercation and that staff were present. Interviews with staff confirmed that the altercation occurred, was witnessed, and was recognized as physical abuse, but there was no documentation in the residents' nurse's notes or care plans regarding the incident. Further interviews revealed that a CNA witnessed the altercation, intervened, and reported it to a nurse, but could not recall the specific date or the nurse's identity. An LPN also recalled being told about the incident by one of the residents but did not document or escalate the report. The Director of Nursing and the Administrator both confirmed that no staff reported the incident to them, despite acknowledging that such an event constitutes physical abuse and should have been reported immediately. The lack of internal reporting and absence of documentation resulted in the failure to notify the appropriate authorities as required by facility policy and state guidelines.
Inaccurate MDS Coding for PASRR Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not properly coding the Preadmission Screening and Resident Review (PASRR) information. Specifically, a resident admitted with diagnoses including Recurrent Depressive Disorders, Bipolar Disorder, and Post-Traumatic Stress Disorder had an approved Level II PASRR for a temporary period, as documented on the state's Form 142. However, review of the resident's Annual MDS assessment showed that Section A1500 (PASRR) was incorrectly coded as 'No' and Section A1510 (Serious Mental Illness) was left blank. Both the MDS coordinator and the Director of Nursing confirmed that the MDS should have indicated a 'Yes' response for PASRR, based on the resident's documentation.
Resident-to-Resident Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in two incidents of resident-to-resident abuse. In the first incident, a severely cognitively impaired resident was pushed by another severely cognitively impaired resident, causing the former to fall and sustain a laceration above the left eyebrow. This incident occurred when the resident wandered into the other resident's room, leading to an altercation. The injured resident was sent to the emergency room where they received nine sutures for the laceration. In the second incident, a cognitively intact resident was observed hitting a cognitively impaired resident. This altercation was witnessed by a CNA who intervened and separated the residents. The cognitively impaired resident did not sustain any injuries from the incident. The aggressive resident was placed on one-to-one supervision and later transferred to a behavioral hospital for evaluation. Both incidents highlight the facility's failure to ensure the safety and protection of residents from abuse by other residents. The facility's policies on abuse and neglect were not effectively implemented, leading to these occurrences of physical harm and distress among residents.
Unauthorized Photograph Breaches Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records. This deficiency was identified when a staff member, S5A, took and kept an unauthorized photograph of a resident in their room. The resident, who was admitted with diagnoses including Alzheimer's Disease, Dementia, and other cognitive impairments, had a consent form on file that explicitly did not authorize photographs for any purpose. Despite this, S5A saved a photograph of the resident on their phone, which was later reviewed and confirmed by facility administrators and nursing staff. The incident was confirmed through interviews and a review of text messages containing the unauthorized photograph. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the action violated the resident's right to privacy and confidentiality, as outlined in the facility's policy on Resident's Rights. The deficiency had the potential to affect all residents in the facility, as it demonstrated a breach in the protection of resident privacy and confidentiality.
Improper Storage of Medications and Controlled Substances
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles. Specifically, medications were not kept in locked compartments accessible only to authorized personnel. During an observation, it was found that a resident had two bottles of eye drops left at their bedside, which were supposed to be securely stored. The resident confirmed that the nurse had left the medications there the previous night. Both the LPN and the Assistant Director of Nursing (ADON) acknowledged that medications should not have been left at the resident's bedside. Additionally, the facility did not properly store Schedule III-IV medications in a permanently affixed compartment or a single unit package drug distribution system. An observation revealed that the Controlled Substance Emergency Kit, containing Schedule III-IV medications, was not permanently affixed and could be easily removed from the medication storage room. Interviews with the Director of Nursing (DON) and ADON confirmed that the kit was not secured as required, and they were unaware of the necessity for it to be stored in a permanently affixed compartment.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were assisted with meals in a dignified manner, which is a violation of their right to a dignified existence and self-determination. Specifically, two residents, identified as #43 and #120, were observed being fed by CNAs who did not adhere to the facility's policy of sitting in a chair while assisting residents with meals. Instead, the CNAs were observed standing over the residents and sitting on their beds during meal assistance. Resident #43, who has diagnoses of Senile Degeneration of Brain and Dementia, was fed by a CNA who initially stood next to the bed and then sat on the bed to continue feeding. Similarly, Resident #120, diagnosed with Dementia, was fed by a CNA who also stood and then sat on the bed. Interviews with the CNAs and the Director of Nursing confirmed that the proper procedure was not followed, as staff should sit in a chair to feed residents, ensuring a respectful and dignified interaction.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, identified as Resident #33, to the State Survey Agency within the required timeframe. According to the facility's policy, any evidence of abuse must be reported immediately to the Administrator or designee, who then notifies the corporate office and appropriate state officials. However, in this case, the allegation was not reported as required. Resident #33, who was cognitively intact with a BIMS score of 15, reported that a CNA yelled and cursed at him. This incident was witnessed by the resident's roommate and reported to an LPN and the Administrator. Despite being informed of the incident, the Administrator confirmed that the allegation was not reported to the state survey agency. The Director of Nursing acknowledged that any staff yelling or cursing at residents would be considered abuse. The failure to report the incident promptly as per the facility's policy and state guidelines constitutes a deficiency in the facility's handling of abuse allegations.
Inaccurate Discharge Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's discharge status. A review of the clinical record for a resident revealed that she was admitted to the facility and later discharged. The Discharge Minimum Data Set (MDS) indicated that the discharge was planned and that the resident was discharged to a short-term general hospital. However, physician orders and nurses' notes indicated that the resident was actually discharged to a group home. Interviews with facility staff confirmed that the MDS was incorrectly coded, as the resident was discharged to a group home, not a hospital.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals. The policy of the facility requires that discharge planning involves the resident, family, interdisciplinary staff, and other resources as needed. However, the facility did not update the discharge plan to reflect the resident's wishes. The resident, who had moderate cognitive impairment with a BIMS score of 12, expressed a desire to transfer to a facility closer to his home. Despite being his own responsible party, the resident's care plan did not reflect his wishes, and the facility's staff did not take action to facilitate his transfer. Interviews with the resident and staff revealed that the resident had communicated his desire to transfer to a facility closer to his family multiple times. The Social Services Director acknowledged that the resident had expressed this wish but had not initiated any transfer documents because the resident was newly admitted. This lack of action and communication among staff members resulted in the resident's discharge wishes not being addressed, leading to a deficiency in the facility's discharge planning process.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to provide drinks consistent with resident preferences and needs, specifically for two residents. Resident #10, who is cognitively intact with a BIMS score of 14, reported that his water cups were not filled regularly, stating he was lucky to get his cup filled once a day. Observations confirmed that his cups were empty on multiple occasions, and he expressed that staff had not filled his cup with water and ice for two weeks. Similarly, Resident #112, who is severely cognitively impaired with a BIMS score of 3, also had an empty cup out of reach and reported that CNAs did not offer or provide ice and water, leading him to stop asking for it. Interviews with staff, including CNAs and the LPN, revealed that the facility's policy required CNAs to pass ice and water to residents every shift and as requested. However, the CNAs admitted to not providing ice and water to the two residents during the week of the survey. The Director of Nursing confirmed that CNAs should pass ice and water once to twice a shift and as requested by residents, indicating a failure in adherence to the facility's hydration management policy.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for a resident diagnosed with Major Depressive Disorder, Other Specified Depressive Episodes, and Severe Vascular Dementia with Other Behavioral Disturbance. The resident was prescribed Sertraline, a psychotropic medication, but the facility did not obtain or document physician orders for monitoring behaviors and side effects associated with this medication. This oversight was identified during a review of the resident's clinical records, which showed no orders or documentation for such monitoring from June 2024 to August 2024. Interviews with facility staff, including two LPNs and the Director of Nursing, confirmed the absence of necessary physician orders and monitoring tasks for the resident's psychotropic medication. The staff acknowledged that there should have been orders and tasks in place to monitor the resident for behaviors and side effects related to the antidepressant medication. This deficiency was noted for one resident out of a sample of 28 reviewed during the survey.
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 149 citations issued within 25 miles in the last 12 months — including the 4 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 Baker
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baton Rouge Health Care Center | 2.6 mi | ★★★★★ | 3 | 0 |
| The Lodge At Lane | 3.9 mi | ★★★★★ | 0 | 0 |
| Zachary Manor Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 9 | 0 |
| Central Guest House Healthcare & Rehabilitation Ce | 7.2 mi | ★★★★★ | 6 | 0 |
| Grace Nursing Home | 9.2 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River Oaks Nursing & Rehabilitation Center Llc.
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 July 2026) and official state health department websites.