River Oaks Nursing & Rehabilitation Center LLC

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 12, 2025

  Based on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#2) of 6 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by Resident #1. This deficient practice resulted in actual physical harm on 10/28/2025 for Resident #2 when Resident #1 hit Resident #2 in the face with a chair. Resident #2 obtained an Acute right orbital floor and anterior orbital rim fractures with no signs of entrapment, acute fracture of the anterior and posterolateral wall of the right maxillary sinus, and a comminuted fracture of the nasal bone with recommended surgical repair. […]

• Actual harm, isolatedF600Mar 5, 2025

  Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 (#3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 was free from physical abuse by Resident #4; and 2. Resident #6 was free from physical abuse by Resident #5. This deficient practice resulted in an actual physical harm on 02/23/2025 when Resident #4, a severely cognitively impaired resident, pushed Resident #3, a severely cognitively impaired resident, onto the floor in the hallway causing Resident #3 to sustain a left eyebrow laceration. Resident #3 was sent to the local emergency room (ER) where he received 9 sutures to his left eyebrow. […]

• No harm, potential for more than minimal, widespreadF887Jul 8, 2026

  Based on interviews and record reviews, the facility failed to ensure there was an effective process in place to ensure residents were offered the updated COVID-19 vaccination for 4 (#28, #103, #105, and #113) of 5 residents reviewed for immunizations.Findings: Review of the facility's policy titled, COVID-19 Vaccine Policy and Procedures for Residents revised 07/01/2023 revealed the following, in part:Purpose:To establish the COVID-19 vaccination process in order to educate residents, offer the vaccine, and administer the vaccine to any resident who will agree to be vaccinated. […]

• No harm, potential for more than minimal, widespreadF880Feb 1, 2023

  44590 The facility failed to maintain an infection prevention and control program designed to prevent or contain the spread of COVID-19 as evidenced by staff failure to implement the appropriate use of Personal Protective Equipment (PPE) for Resident #1 while on transmission-based precautions for COVID-19. This deficiency had the potential to affect all 108 residents currently residing in the facility. Review of the facility's COVID-19 Policy When Resident Tests Positive indicated, in part, the following: Policy: It is the policy of this Long Term Care Facility to ensure that all measures are properly followed once a resident tests positive for COVID-19. […]

• No harm, potential for more than minimal, patternF644Jul 17, 2025

  Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#7 and #9) of 4 (#5, #7, #9, and #19) sampled residents reviewed for PASRR Level II.Resident #7 Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Undifferentiated Schizophrenia on 01/09/2023. Review of Resident #7’s Form 142 dated 09/22/2014 revealed he did not meet the criteria for PASRR Level II services. On 07/16/2025 at 10:58 a.m., an interview was conducted with S3SSD. She stated she was responsible for submitting Resident Review Forms to OBH. […]