Inspection·February 6, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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. Residents Affected - Some 1. The facility failed to ensure food stored in the refrigerator, freezer, and pantry were labeled, dated, and sealed. These failures could place residents who at risk for food contamination and food-borne illness. Findings included: Observation on 02/06/24 beginning at 9:55 AM revealed the following items: Refrigerator: 1. Cooked bacon and sausage patties in a gallon sized storage bag, not labeled or dated 2. Sausage patties in opened plastic packaging, not labeled or dated, or completely sealed 3. Cooked green beans in a metal bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed 4. Tuna salad in metal bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed 5. Red sauce in white plastic bowl, not labeled or dated, with loose fitting plastic wrap, not completely sealed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675018 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)