Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Care Center during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Environment: Surveyors observed dust and rust buildup on vents in multiple hallways, a deteriorated exit door frame with exposed jagged edges, a damaged mini blind in a resident room, and broken, cracked, and loose flooring in the laundry area. A resident also reported being shocked by a loose electrical outlet cover in the room, and staff said environmental concerns were supposed to be documented on a maintenance requisition form.
A resident’s baseline care plan was not completed within 48 hours of admission, despite facility policy requiring an immediate care plan with minimum healthcare information, initial goals, resident or representative input, and physician orders. RN A said nursing should start the baseline care plan within 2 hours of admission, and the DON and Administrator both confirmed it should be completed within 48 hours.
Failure to Address PTSD Triggers in Care Plans: The facility failed to identify, assess, and include supportive interventions for two residents with PTSD. Trauma-informed care assessments for both residents listed no triggers, and their care plans did not address past trauma or triggers that could lead to behaviors. One resident had PTSD, anxiety, schizoaffective disorder, bipolar disorder, and insomnia and was receiving multiple psychotropic medications; the other had PTSD, bipolar disorder, schizoaffective disorder bipolar type, insomnia, alcohol abuse, major depressive disorder, and unspecified dementia and was receiving Celexa. The DON and Administrator both stated they would expect PTSD triggers and interventions to be addressed.
Medication administration errors exceeded the allowed rate, with an LPN documenting medications as given when they were not actually administered and documenting crushing/mixing of meds that did not occur. One resident’s metoprolol was charted as given despite not being administered, and another resident’s Dialyvite/Zinc was charted as given despite not being administered; the second resident’s meds were also charted as crushed and mixed with pudding or applesauce when they were not.
Failure to document influenza vaccine education, consent, refusal, or administration was identified for five sampled residents. The facility policy required annual vaccine offering, resident or representative education on benefits and side effects, and documentation of vaccination or refusal in the medical record. Records for the residents lacked evidence that education was provided, and several also lacked consent/refusal documentation; for two residents, there was no documentation that the flu vaccine was given or declined. The DON stated consents should be obtained before immunization and refusals signed, and the Administrator said the admitting nurse handles consent and immunizations while the IP and DON should audit new admissions.
Two residents were subjected to physical and verbal abuse by a CNA, who hit one resident with a mug and shook another while cursing. Despite reports to the administrator, no immediate action was taken, and the CNA continued working. The facility failed to document and investigate the incidents, violating its abuse prevention policy.
The facility failed to investigate abuse allegations involving two residents, leading to a deficiency. One resident was allegedly hit by a CNA, and another was reportedly shaken and thrown onto a bed. Despite reports to the ADM and other staff, no thorough investigation was conducted, and the incidents were not documented. The facility's policies on abuse prevention and investigation were not followed, resulting in an immediate and serious jeopardy level deficiency.
The facility failed to provide a safe, clean, and homelike environment, with observations of chipped paint, rotted furniture, dust buildup, stained ceiling tiles, and cracked floor tiles. Staff interviews revealed a lack of documentation and follow-up on maintenance issues, despite existing procedures for reporting and addressing these concerns.
The facility failed to use gait belts for transferring two residents, despite therapy recommendations and care plans requiring their use. One resident with Parkinson's Disease and another with Cerebrovascular disease were transferred without gait belts, contrary to their care plans. Staff lifted the residents by their arms or waistband, and interviews revealed misunderstandings about the residents' transfer needs.
The facility failed to follow proper procedures for tube feeding and checking gastric residual volumes (GRV) for two residents. Staff did not measure GRV before feedings, used a straw to stir feeding mixtures, and used a plunger to force feedings into a G-tube, contrary to expected practices.
A facility failed to properly manage medications for a resident, resulting in a deficiency. The facility did not maintain controlled substance records for the resident's morphine and lorazepam, and staff skipped medication counts after the resident's passing. The DON confirmed the absence of required documentation and was unaware of the medication's status, leading to a lapse in pharmaceutical services.
The facility failed to follow proper infection control techniques during wound and incontinent care for four residents. An LPN did not change gloves or sanitize hands between contaminated and clean tasks for two residents, while two CNAs did not change gloves during incontinent care for another resident. Additionally, a CNA did not change gowns when leaving and re-entering a room. These actions were against the facility's infection control policy.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment. Surveyors observed dust and rust buildup on ceiling vents in multiple hallways on the 300, 400, and 500 halls, an exit door on the 400 hall with deteriorated bottom frame edges and exposed jagged edges near the classroom, and a large window mini blind in a resident room with several broken slats held together with clear tape. In the laundry room, surveyors observed cracked, worn, and loose linoleum in the dirty linen room, broken floor tiles near the laundry sink, broken floor tiles in front of the chemical storage platform and washers, and broken floor tiles near the doorway to the clean linen room. Surveyors also observed a two-plug electrical outlet in a resident room with a protective plate cover that moved with minimal effort over the bed near the window. During interview, the resident stated he/she had been shocked at different times when plugging and unplugging devices from the outlet and had told the last Maintenance Supervisor about it. Staff interviews indicated that repairs or environmental concerns were supposed to be reported to the Maintenance Supervisor or written on a maintenance requisition form, and staff described tripping or almost falling in the laundry area because of the cracked and loose flooring. The Maintenance Supervisor and Administrator stated they expected concerns to be written down on the requisition form for documentation and timely repair, and the Administrator said he was not aware of the outlet issue in the resident room.
Baseline Care Plan Not Completed After Admission
Penalty
Summary
Failure to develop and implement a baseline care plan for Resident #70 occurred after the resident was admitted to the facility and later discharged on 06/02/25. Review of the closed medical record showed no baseline care plan was completed within 48 hours of admission, despite the facility policy requiring a baseline plan of care to meet the resident’s immediate health and safety needs within that timeframe. The facility’s policy titled, Care Plans - Baseline, revised March 2022, stated the baseline care plan must include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders, discussion with the resident or representative, and physician orders, and must be updated as needed until the comprehensive care plan is developed. During interviews on 08/07/25, RN A stated nursing should initiate the baseline care plan within two hours of admission, while the DON and Administrator both stated a baseline care plan should be completed within 48 hours when a new resident is admitted. The record review showed this did not occur for Resident #70.
Failure to Address PTSD Triggers in Care Plans
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two residents with PTSD, based on observation, interview, and record review. The facility policy titled Trauma Informed Care and Culturally Competent Care stated that staff are to minimize triggers and re-traumatization, develop individualized care plans that address past trauma, and identify and decrease exposure to triggers. However, the trauma-informed care assessments for both residents documented no triggers, and their care plans did not address past trauma or any triggers that could cause behaviors. One resident had diagnoses including PTSD, anxiety, schizoaffective disorder, bipolar disorder, and insomnia, and was receiving psychotropic medications including depakote, citalopram, valium PRN, and mirtazapine. The other resident had diagnoses including PTSD, bipolar disorder, schizoaffective disorder bipolar type, insomnia, alcohol abuse, major depressive disorder, and unspecified dementia, and was receiving Celexa for major depressive disorder. During interviews, the DON stated she would expect triggers to be addressed on the care plan for a resident diagnosed with PTSD, and the Administrator stated he would expect a resident with PTSD to have triggers and interventions in place.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with 26 opportunities and 10 errors identified, resulting in an error rate of 38.46% for one resident in the sample and one resident outside the sample. The facility policy required medications to be administered according to prescriber orders, with the right resident, medication, dosage, time, and route verified before administration, and for medications to be documented only after they were given. For one resident with diagnoses including kyphosis, major depressive disorder, anxiety, hyperlipidemia, hemiplegia and hemiparesis following cerebrovascular disease, cerebral infarction, dysphagia, aphasia, dementia, and hypertension, the MAR showed metoprolol 50 mg was documented as administered even though the LPN did not give the medication during observation. The resident’s blood pressure was 148/70, and the LPN later stated he/she did not know the metoprolol had not been given. For another resident with diagnoses including chronic diastolic CHF, vascular dementia, cerebral infarction, neuropathy, hypertension, benign neoplasm of colon, hyperlipidemia, anemia, glaucoma, type 2 diabetes mellitus, respiratory failure, fluid overload, dependence on renal dialysis, and GERD, the MAR showed Dialyvite/Zinc was documented as administered even though it was not given. The MAR also documented that medications were crushed and mixed with pudding or applesauce, but observation showed the LPN did not crush or mix the medications. The LPN stated the resident does not typically require medications to be crushed and said the resident usually takes them whole.
Failure to Document Influenza Vaccine Education, Consent, and Status
Penalty
Summary
The facility failed to provide and document influenza immunization information, consent or refusal, and vaccination status for five sampled residents. Review of the facility policy titled, Influenza Vaccine, showed residents and their legal representatives were to be offered the influenza vaccine annually, provided information about the risks and benefits, and have vaccination or refusal documented in the medical record. However, for Residents #1, #9, #40, #41, and #49, the records contained no documentation that education about the influenza vaccine was provided to the resident and/or resident representative for the current influenza season. The records for these residents also lacked documentation of consent or refusal for the influenza vaccine, and for Residents #1 and #41 there was no documentation that the influenza vaccine was administered or declined for the current season. Resident #1 had an admission date of 03/03/25, Resident #9 of 08/26/20, Resident #40 of 02/21/22, Resident #41 of 02/10/09, and Resident #49 of 01/19/23. During interview, the DON stated consents should be obtained prior to immunization and refusals should be signed by the resident or resident representative. The Administrator stated the admitting nurse obtains consent during admission and is responsible for administering immunizations, while the Infection Preventionist and DON should conduct audits of new admissions.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by a staff member, Certified Nurse Aide (CNA) A. On November 7, 2024, CNA A hit Resident #2 on the hand with a mug and used inappropriate language. Despite the resident reporting the incident to the administrator in front of a witness, no immediate action was taken to protect the residents from further abuse, and CNA A continued to work. Resident #2, who was moderately cognitively impaired and required assistance with activities of daily living, was left feeling afraid of CNA A. The facility did not document the source of the resident's bruising or conduct an investigation into the abuse allegation. On November 11, 2024, CNA A was witnessed by another staff member, CNA B, cursing at and physically abusing Resident #1 by shaking and roughly throwing the resident into bed. Resident #1, who was cognitively impaired and required maximum assistance with daily activities, reported the incident to staff. Despite the report, the administrator was not informed of the physical abuse allegation, and CNA A was not immediately removed from the facility. The facility's failure to document and investigate the abuse allegations contributed to the deficiency. The facility's policy on abuse prevention, which mandates the investigation of all allegations, was not followed. The administrator and Director of Nursing Services were supposed to have an open-door policy for reports of abuse, but the administrator denied being informed of the incidents. The lack of immediate action and failure to follow protocol resulted in the deficiency being classified as an immediate and serious jeopardy to resident safety, although it was later downgraded after corrective actions were implemented.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate reports of abuse involving two residents, leading to a deficiency. On November 7, 2024, a Certified Nurse Aide (CNA) allegedly hit a resident on the hand with a mug, which was reported to the Administrator (ADM) by the resident. However, the ADM did not investigate the allegation, and the CNA continued to work. The resident, who had a history of depression, hemiplegia, chronic kidney disease, stroke, and cognitive communication deficit, was moderately cognitively impaired and required assistance with daily activities. The resident reported the incident to the Social Service Worker (SSW) and the ADM, but no investigation was initiated, and the incident was not documented in the resident's medical record. Another incident occurred on November 11, 2024, involving a different resident who was reportedly shaken and thrown onto a bed by the same CNA. This resident had diagnoses of anxiety, depression, dementia, borderline personality disorder, bipolar disorder, and an amputation above the knee. The resident was cognitively impaired and required maximum assistance with daily activities. A CNA witnessed the incident and reported it to Human Resources (HR) and a Licensed Practical Nurse (LPN), who then informed the Director of Nursing (DON). Despite this, the ADM was only informed of inappropriate language used by the CNA and not the physical abuse. The ADM concluded the investigation without further inquiry, even after finding a written statement alleging physical abuse. The facility's policies on abuse prevention and investigation were not followed, as allegations were not thoroughly investigated or documented. The ADM denied being informed of the incidents, and the facility did not provide an investigation or facility-reported incident for the source of the resident's bruising. The deficiency was determined to be at the immediate and serious jeopardy level, indicating a failure to protect residents from abuse and neglect.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several observations of disrepair and uncleanliness. Observations included chipped and peeled paint on decorative trim near the kitchen door and the nurse's station, a rotted wardrobe cabinet with soiled towels in a resident's room, and a buildup of dust and debris in light fixture covers in the 500 Hall. Additionally, there were several dark stained areas on ceiling tiles throughout the therapy/exercise room and in various resident rooms, as well as cracked and missing floor tiles in the 500-hall shower room. Interviews with staff revealed a lack of documentation and follow-up on maintenance issues. Housekeepers reported using a maintenance log and verbally informing maintenance staff of needed repairs, but the repair requisition log showed no documentation of these concerns. The Maintenance Supervisor expected staff to report issues using a clipboard system, and the Administrator stated that all staff were responsible for reporting maintenance needs. Despite these procedures, the facility failed to address the environmental concerns, as evidenced by the ongoing issues observed during the survey.
Failure to Use Gait Belts for Resident Transfers
Penalty
Summary
The facility failed to provide a safe transfer for two residents, as staff did not utilize a gait belt as directed by therapy recommendations and the residents' care plans. Resident #62, who has diagnoses including Parkinson's Disease and Multiple System Atrophy, requires substantial to maximal assistance for transfers. During an observation, staff members were seen transferring the resident from a wheelchair to a bed without using a gait belt, instead lifting the resident by the waistband of their pants and under their arms. This method was contrary to the care plan, which specified the use of a gait belt and a stand-pivot transfer with maximal assistance from two staff members. Similarly, Resident #67, with diagnoses including Cerebrovascular disease and Dementia, also required substantial to maximal assistance for transfers. During an observation, staff members transferred the resident without using a gait belt, lifting the resident by placing arms under the resident's arms. Despite one staff member wearing a gait belt, it was not used during the transfer. Interviews with staff revealed a misunderstanding of the resident's transfer needs, with one CNA believing the resident could bear weight and assist, while the Director of Nursing expected the use of a gait belt for all transfers.
Improper Tube Feeding Practices and GRV Checks
Penalty
Summary
The facility failed to adhere to proper procedures for administering tube feedings and checking gastric residual volumes (GRV) for two residents. For Resident #62, the nursing staff did not measure the GRV before administering tube feedings, as required by the physician's orders. This oversight occurred multiple times, with both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) failing to check the residuals before feeding. Additionally, the facility's policy on enteral nutrition, which includes checking GRV before feeding, was not followed. For Resident #15, the LPN did not check for tube placement or GRV before administering the feeding. The LPN used a plastic straw to stir the feeding mixture and a plunger to force the feeding and medication into the resident's gastrostomy tube (G-tube), which is not a standard practice. The Director of Nursing (DON) confirmed that these practices were not expected or acceptable, indicating a deviation from the facility's standards and procedures.
Medication Management Deficiency
Penalty
Summary
The facility failed to implement procedures to ensure accurate administration, documentation, disposal, and reconciliation of medications for a resident. Specifically, the facility did not maintain individual controlled substance records for a resident's prescribed morphine and lorazepam, both of which are controlled medications. Observations revealed that the remaining quantities of these medications did not match the expected amounts based on the resident's orders. The facility's policy required narcotics to be counted at the beginning and end of each shift and documented in a narcotic log, but this was not adhered to in this case. Interviews with staff revealed lapses in the medication counting process. A Certified Medication Technician admitted to skipping the count for the resident's medications because the resident had passed away. The Director of Nursing confirmed the absence of controlled substance sheets for the medications and was unaware of why the medications had not been brought for destruction. These actions and inactions led to a deficiency in the facility's pharmaceutical services, as they failed to meet the needs of the resident and comply with their own policies.
Infection Control Deficiencies in Glove Use and Gown Protocol
Penalty
Summary
The facility failed to adhere to proper infection control techniques during wound care and incontinent care for four residents. For Resident #56, an LPN did not sanitize hands or change gloves between removing an old dressing and applying a new one on an unstageable pressure ulcer on the right heel. Similarly, during wound care for Resident #24, the same LPN did not change gloves or sanitize hands between cleansing the buttocks and applying barrier cream for a stage II pressure injury. These actions were contrary to the facility's infection control policy, which mandates changing gloves and performing hand hygiene between contaminated and clean tasks. In addition, during incontinent care for Resident #67, two CNAs did not change gloves between cleaning the resident and applying a clean brief. For Resident #62, a CNA failed to change gowns when leaving and re-entering the room to retrieve supplies. Interviews with the involved staff and the Director of Nursing confirmed that the expected procedures were not followed, as staff should have changed gloves between dirty and clean tasks and removed gowns before leaving a resident's room.
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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 31 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Steele
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pemiscot County Memorial Hospital | 11.1 mi | — | 0 | 0 |
| Southgate Living Center | 11.2 mi | ★★★★★ | 0 | 0 |
| Heritage Square Healthcare Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Gosnell Health And Rehab | 12.5 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare, Kennett | 17 mi | ★★★★★ | 0 | 0 |
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