River Oaks Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at River Oaks Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 14, 2021

  Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment for three (Residents #10, #17 and #457) of 26 residents and three (South 1 (cold zone), South 3 (cold zone) and Warm Zone halls) of six halls reviewed for infection control. 1.LVN A, DON G and ADON Q failed to completely review Resident #10's Hospital Discharge documents and was unaware the resident had a [CONDITION(S)] diagnoses, until HHSC Surveyors notified the facility. […]

• Immediate jeopardy, isolatedF600May 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal abuse by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to protect residents from verbal abuse, threats, and physical abuse by Resident #1. Resident #2 was threatened by Resident #1 on 4/5/2026, 4-25-2026 by Resident #1 saying [Resident #1] was going to have Resident #2 beat up, was not afraid of Resident #2's phone, was going to slap the dog shit out of [Resident #2], and was going to knock the shit out of [Resident #2]. […]

• Immediate jeopardy, isolatedF607May 1, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, investigate allegations of abuse, and protected residents from physical and psychosocial harm during and after the investigation when residents were verbally and physically abused by Resident #1 for 2 (Residents #2, #3) of 13 reviewed for abuse. The facility failed to identify verbal abuse and intervene when Resident #1 threatened Residents #2 and #3, causing Resident #2 to avoid certain areas of the facility and causing Resident #3 to cry. Resident #1 continued to have access to verbally abuse other residents on multiple occasions.Staff witnessed physical pushing and threats but failed to report the abuse to the administrator. […]

• Actual harm, isolatedF600Dec 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse . The facility failed to protect Resident #1 from physical abuse by Resident #2. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified at PNC. The noncompliance began on 11/25/2024 and ended on 11/25/2024. The facility had corrected the non-compliance by monitoring Resident #1 and Resident #2 every 15 minutes and issuing a discharge notice to Resident #2. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the oven and stove were maintained in a clean and sanitary manner. 2. The facility failed to ensure hot dog buns that had grown mold were not kept in the panty. These failures could place residents who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: Observation on 12/05/23 at 8:47 AM revealed the conventional oven had grease and grime that was the color of dark brown on the window of the oven. […]