River Oaks Health & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Jul 9, 2025

  The findings include:Review of an undated facility policy, Food Safety Sanitation Guidelines revealed dietary staff were to wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food. During observation of the lunch meal preparation in the main kitchen on 07/08/2025 at 11:59 AM, [NAME] 16 had an approximately 3-inch black beard. Continued observation revealed [NAME] 16 did not have the beard covered while he placed covers on residents' food trays and then placed the meal trays in the cart for delivery. During interview on 07/08/2025 at 2:01 PM, [NAME] 16 stated he did not have a beard restraint (cover) in place because he could not find one to put on. […]

• No harm, potential for more than minimal, patternF656Oct 18, 2024

  Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to implement care plan interventions to prevent falls for two of three sampled residents, Resident (R)1 and R2. Both R1 and R2 falls prevention interventions included colored tape on the resident's call light, however the call lights did not have colored tape for multiple days of the survey. The findings include: 1. Review of the facility policy Fall Prevention & Management Program not dated, revealed if a high fall risk was identified, the facility would develop a care plan to address the risk. […]

• No harm, potential for more than minimal, patternF842Oct 18, 2024

  Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure access to complete resident clinical records for two of three sampled residents (Residents (R)2, and R3). The facility transitioned 07/01/2024 to a new computer software system and did not have the residents' prior clinical information available for R1 and R2 for information in their electronic health records from the time of their initial admission to the facility until 07/01/2024. The findings include: 1. Review of the facility policy titled Fall Prevention & Management Program not dated, revealed upon admission the nurse would complete a fall risk assessment with the admission assessment to determine the resident's level of fall risk. […]

• No harm, potential for more than minimal, patternF761Jun 7, 2024

  Based on observation, interview, record review and review of the facility policy, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards, including expiration dates, and with appropriate accessory and cautionary instructions for two of five medication carts. Observation revealed medications for Resident (R) 66 and R42 were not labeled with an opened date, and medications labeled for R12, R26, and R77 contained different medications than what the medications were labeled for. […]

• No harm, potential for more than minimal, patternF812Jun 7, 2024

  Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety related to ensuring all food and drinks were checked for timely use and expiration dates. Observation on [DATE] revealed approximately 45 milk cartons in two milk crates dated [DATE]. The findings include: Review of the facility's Dietetic Solutions Operations Policy dated [DATE], under the Cold Storage Areas, revealed staff were to store cold foods until their used by date or expiration date. Observation during the kitchen tour on [DATE] at 11:55 AM, revealed two milk crates with approximately 45 milk cartons dated [DATE] stored in it. […]