Above 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 Riverside Oaks during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical diagnoses was involved in an unprovoked physical altercation, documented by an LPN in progress notes and an incident report, and reflected in a short-lived behavior care plan. Despite this, the Discharge Return Not Anticipated MDS assessment, completed after the event, was coded to show no physical behavioral symptoms directed toward others during the look-back period, resulting in an inaccurate assessment of the resident’s behavior.
A resident with parkinsonism, dementia, and impaired coordination experienced a fall that was documented by an LPN in progress notes as occurring in the dining room, while the resident’s care plan inaccurately listed the fall as occurring in the room. Staff interviews showed confusion over who was responsible for entering historical fall information into the care plan, and no new interventions were added because staff believed all fall interventions were already in place. Facility policies required complete and accurate electronic clinical records, including correct incident location and updated care plans after falls, but these standards were not met, resulting in incomplete and inaccurate clinical documentation.
A resident with severe cognitive impairment and a history of cerebral infarction had two Morphine Sulfate oral solution bottles whose counts did not match the accompanying narcotic logs. Surveyors found one bottle in the narcotic destruction storage area with 16 mL remaining while the log showed 29.25 mL, and the DON later stated staff had been charting on the wrong narcotic sheet for the resident’s Morphine bottles from the facility pharmacy and an outside pharmacy.
Staff failed to follow infection prevention protocols during catheter and wound care for three residents, including incomplete cleaning of the genital and perineal area, inadequate hand hygiene by an RN and an LVN, and failure to use required PPE under Enhanced Barrier Precautions. These lapses occurred during care for residents with conditions such as acute kidney failure, obstructive uropathy, and diabetes.
The facility failed to follow hand hygiene protocols during food service, as observed with two dietary aides who changed gloves without washing hands. Despite knowing the importance of hand hygiene, one aide skipped this step due to time constraints, while the other believed gloves negated the need for handwashing. Interviews revealed a lack of awareness and policy enforcement regarding hand hygiene in dietary services.
A resident with cognitive impairment was found with an unauthorized over-the-counter pain-relieving cream on their bedside table, contrary to the facility's policy that only allowed self-administration of a nasal spray. The DON confirmed the oversight, noting the resident might self-administer more medication than prescribed.
A resident with multiple diagnoses, including dementia and intellectual disabilities, did not receive milk with her meals as per her documented preference. Despite being on a regular diet and having her preference noted on her meal ticket, the facility failed to provide milk, which was acknowledged by the NS and RD as an oversight. The facility's policy states that food preferences should be honored.
Inaccurate MDS Coding of Resident Physical Behavioral Symptom
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s behavioral status. The resident, a male with diagnoses including sepsis, epilepsy, and Down syndrome, was admitted in April and discharged in early December. His Discharge Return Not Anticipated MDS assessment, with an observation end date of 12/01/2025 and completed by the MDS Coordinator on 12/09/2026, documented that he did not exhibit any physical behavioral symptoms directed toward others during the look-back period. The assessment also indicated that he was rarely or never understood and had severe cognitive impairment with memory problems. However, review of the resident’s progress notes and incident documentation for the effective date range of 11/25/2025 to 12/07/2025 showed that on 11/30/2025, an LPN documented that the resident, while passing a female resident seated in a wheelchair at the nurses’ station, wheeled himself around her and punched her without provocation. An incident report for a resident-to-resident altercation, prepared by the same LPN, described the same unprovoked physical act. The resident’s care plan also contained a focus indicating that he had a behavior problem related to hitting another resident in the face, initiated on 11/30/2025 and later cancelled on 12/02/2025. Despite these documented behaviors within the MDS look-back period, the MDS behavior section was coded as if no physical behavioral symptoms toward others had occurred.
Inaccurate Fall Location Documentation in Resident Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized clinical records in accordance with accepted professional standards. Record review showed that a resident with parkinsonism, dementia, and lack of coordination, who used a wheelchair and required partial to moderate assistance with transfers, had a documented fall on 03/07/2026. Progress notes entered by an LPN on that date indicated a change in condition related to a fall with no injuries and described the resident as being observed sitting on wheelchair pedals in the dining room. However, the resident’s care plan report documented a fall "in room" associated with her initial admission fall, creating a discrepancy in the recorded location of the 03/07/2026 fall. Interviews with staff revealed uncertainty and inconsistency regarding who was responsible for entering the historical fall information into the care plan and how the incorrect location was documented. The LPN who documented the change in condition and progress notes stated she remembered the fall occurring in the dining room and denied entering "in the room" as the fall location in the care plan, believing that the ADONs or DON entered that information. She also stated she did not add new interventions after the fall because she believed all fall interventions were already in place. The ADON interviewed later stated that ADONs and the DON completed care plans and was unsure why there was a discrepancy in the care plan or who had entered the documentation. The facility’s own policies required complete and accurate electronic clinical records, including nursing documentation and care plans, and specified that incident documentation should include the date, time, nature, and location of the incident, as well as that the resident’s care plan be reviewed and updated after a fall. Despite these requirements, the care plan for this resident contained inaccurate information about the location of the 03/07/2026 fall. Leadership interviews, including with the ED, indicated that charge nurses were responsible for incident reports and that administrative nurses typically completed care planning, but they did not believe the inaccurate fall location would impact care. This combination of inaccurate care plan documentation and unclear responsibility for accurate record entry led to the cited deficiency in maintaining complete and accurate medical records for the resident.
Controlled Medication Records Did Not Match Morphine Supply
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for the narcotic destruction storage area. Surveyors found that two Morphine Sulfate oral solution bottles for one resident did not match their accompanying logs. One bottle in the narcotic destruction storage area had 16 milliliters remaining, while the accompanying record showed 29.25 milliliters documented as the current amount of medication. A small amount of liquid was seen in the bottom of the box, but it did not account for the discrepancy. Record review showed the resident was a [AGE]-year-old female admitted with diagnoses including cerebral infarction, and her quarterly MDS documented a BIMS score of 3, indicating severe cognitive impairment. The narcotic records included a Controlled Substance Count Sheet for Morphine Sulfate Oral Solution with 29.25 milliliters documented and a Controlled Drug Receipt/Record/Disposition Form for Morphine Sulfate Solution with 20.5 milliliters documented. The facility’s medication room narcotic storage was observed behind two locks, with the DON holding the key to the second lock. During interviews, the DON stated the discrepancy was being investigated and later explained that the resident had two Morphine Sulfate oral solution bottles, one from the facility pharmacy and one from an outside pharmacy. The DON said the facility pharmacy bottle was full and unopened at 30 milliliters, but the accompanying log sheet had recorded 20.5 milliliters left, and staff had been charting on the wrong narcotic sheet. The Consultant Pharmacist stated she checked controlled medication quantities against the perpetual inventory form and verified that the form matched the quantity presented for destruction, and the facility policy required controlled medications to be accounted for through receiving, administration, storage, and destruction.
Failure to Adhere to Infection Control Protocols During Catheter and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols during the provision of catheter and wound care for three residents. In one instance, a CNA performed catheter care for a resident with acute pyelonephritis and acute kidney failure but did not clean the resident's genitals, perineum, or meatus, contrary to facility policy and professional standards. The CNA believed that catheter care only involved cleaning the catheter itself and not the surrounding areas, which was confirmed during an interview. Another incident involved an LVN providing suprapubic catheter care to a resident with obstructive and reflux uropathy. The LVN did not don a gown as required under Enhanced Barrier Precautions (EBPs) and performed hand hygiene for less than the recommended 20 seconds on multiple occasions. The LVN acknowledged forgetting to wear a gown and was unsure about the duration of handwashing, despite being aware of the facility's expectations for hand hygiene and EBP compliance. A third deficiency was observed when an RN performed wound care for a resident with type 2 diabetes and hypertension. The RN washed her hands for only 9 seconds after completing the procedure, which did not meet the facility's or CDC's recommended hand hygiene duration. The RN admitted uncertainty about the exact time spent on handwashing but recognized the importance of proper hand hygiene. Interviews with facility leadership confirmed that staff were expected to follow specific protocols for hand hygiene and EBPs, but these were not consistently followed during the observed care activities.
Failure to Follow Hand Hygiene Protocols in Food Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of two dietary aides (DA A and DA B) during meal preparation and service. DA A was observed placing food on plates and leaving the workstation multiple times without performing hand hygiene after doffing and donning gloves. Despite acknowledging the need to wash hands when changing gloves, DA A admitted to skipping this step due to being rushed. Similarly, DA B was seen leaving the workstation and changing gloves without washing hands or using hand sanitizer, under the mistaken belief that glove use negated the need for hand hygiene. Interviews with the Nutrition Supervisor (NS) and the Registered Dietitian (RD) revealed a lack of awareness and policy regarding hand hygiene when using gloves in dietary services. The NS was unaware of the need for hand hygiene before donning new gloves, while the RD confirmed that staff should wash or sanitize hands before putting on clean gloves. A review of the facility's policy on glove use, dated 2004, indicated that hands should be washed before wearing gloves to prevent bacterial transfer, highlighting a gap between policy and practice.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly secured for a resident, leading to a deficiency in medication storage practices. During an observation, it was noted that an over-the-counter pain-relieving cream was left on the bedside table of a resident who was not authorized to self-administer this medication. The resident's care plan only allowed for the self-administration of a saline nasal spray, and there was no order for the resident to self-administer other medications. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the resident should not have had the pain-relieving cream at the bedside. The resident involved was an elderly male with a history of unspecified dementia, chronic kidney disease, and hypertension. The resident's BIMS score indicated an inability to complete an interview, suggesting cognitive impairment. Despite this, the resident reported that his family provided him with over-the-counter medications, as he preferred not to bother the staff. The DON expressed concern that the resident might self-administer more medication than prescribed, highlighting a lapse in the facility's medication monitoring process. The facility's policy required all medications for self-administration to be secured, which was not adhered to in this case.
Failure to Provide Resident with Preferred Beverage
Penalty
Summary
The facility failed to provide a resident with milk at every meal, as noted on the resident's meal ticket and preference sheet. This deficiency was observed during lunchtime when the resident did not receive milk with her meal, despite it being her preferred beverage. The resident, who has diagnoses including dementia, intellectual disabilities, major depressive disorder, and a disorder of bone density and structure, was admitted to the facility with a regular diet and a preference for milk with each meal. The resident's quarterly MDS assessment indicated she was moderately cognitively intact and required assistance with meal setup or cleanup. Interviews with the nursing staff (NS) and the registered dietitian (RD) revealed that the resident's preference for milk was documented and should have been honored. The NS acknowledged that the milk was missed either by the nurse checking the tray or the dietary staff, emphasizing the importance of honoring resident preferences for quality of life. The RD confirmed that the protocol involved assessing resident preferences and ensuring they were noted on meal tickets. However, when questioned, the dietary staff and nurses were unaware of why the resident did not receive milk. The facility's Nutrition Services Policy & Procedure Manual states that food preferences should be honored as reasonable.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Victoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Courtyard Rehabilitation And Healthcare Center | 0.2 mi | ★★★★★ | 14 | 2 |
| Twin Pines Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 20 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 20.6 mi | ★★★★★ | 2 | 0 |
| Lavaca Bay Nursing And Rehabilitation Center | 24.1 mi | ★★★★★ | 17 | 0 |
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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.