Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure all allegations of abuse were reported to the State
Survey agency and the administrator of the facility, immediately but not later than 2 hours after the
allegation is made if the events that cause the allegation involve abuse for 1 of 1 resident reviewed for
abuse and neglect for one (Resident #1) of 1 resident reviewed for abuse.
The facility did not report immediately to the State Survey agency when Resident #1 accused LVN A
touched him inappropriately on 03/08/25 and LVN A did not report the allegation immediately to the
Administrator.
These failures could place residents at risk for abuse, neglect, and exploitation.
Findings included:
Review of Resident #1's Face Sheet dated 04/24/2025 indicated a [AGE] year-old male readmitted on
[DATE], with initial admission on [DATE]. Admitting diagnoses included Cerebral Infarction Unspecified (a
blood vessel supplying blood to the brain has been blocked, leading to brain tissue damage. the cause and
location unknown); Heart Failure, Unspecified (a condition where the heart cannot pump enough blood to
meet the body's needs, and the specific type or cause is not clearly documented); Bipolar Disorder, Current
Episode, Depressed Moderate (periods of intense mood swings, including both manic/hypomanic episodes
and depressive episodes).
Record review of Resident #1's Change of Condition MDS dated [DATE] noted BIMS Score to be 14/15
with memory intact. Functional ability r/t catheter care is Resident #1 has an indwelling catheter which is
managed by the nursing staff in relation to changing the catheter, tubing, and bag as needed. Resident #1
is always incontinent of bowel movements and requires incontinent
care by the CNAs.
Review of the facility's Provider Investigation Report, dated 03/21/25, revealed the incident occurred on
03/08/25 where Resident #1 alleged LVN A touched him inappropriately. Report indicated resident had a
history of making false accusations and calling 911. Findings were unfounded.
In an interview on 04/24/2025 at 12:50 pm, Resident #1 revealed that LVN A needed to change his catheter
bag and the tubing due to leaking. Resident #1 could not remember what day the incident of abuse
occurred. Resident #1 denied ever saying that LVN A touched him inappropriately.
(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 8
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
04/24/2025
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 04/24/2025 at 4:40 pm the ADM revealed an incident occurred between Resident #1 and
LVN A on
03/08/2025 at 12:00 pm where Resident #1 alleged LVN A inappropriately touched Resident #1. ADM first
learned of the alleged incident on 03/10/2025 from a note that had been placed on her office door by LVN
A. An assessment was completed on Resident #1 on 03/10/2025 and an investigation was started.
Reported to HHSC on 03/10/25.
The ADM admitted that the incident was not reported on 03/08/2025, but the staff have been in-serviced to
contact administration immediately with all accidents and incidents to that she can determine the need to
report.
Internet search of [state database] revealed discrepancies in reporting timeline. Incident was reported on
03/10/25, which was two days after the incident first occurred.
Review of facility's In-service, dated 03/11/25, relating to Abuse/Neglect, types of abuse, and timely abuse
of any alleged abuse reviewed LVN A was in-serviced.
Review of LVN A's written statement, dated 03/10/25, revealed the allegation Resident #1 had against her
occurred on 03/08/25.
Record review of the facility's Abuse/Neglect policy revised 03/29/2018 revealed in part: F. Investigation Comprehensive investigations will be the responsibility on the administrator and/or Abuse Preventionist. All
allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property
and injuries of unknown source will be investigated. The Administrator in consultation with the Risk
Management Department will be responsible for investigating and reporting cases to the HHSC.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 2 of 8
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
04/24/2025
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for each resident, consistent with resident rights, that included measurable objectives and time
frames to meet residents' medical, nursing, mental and psychosocial needs, for 1 Resident (Resident #2) of
1 resident reviewed for care plans.
The facility did not provide interventions as outlined in Resident #2's comprehensive person-centered care
plan to address Resident #2's weight loss issues with not interventions including nutritional supplements to
improve weight.
These failures could place residents identified at risk for weight loss at risk for their medical, physical, and
psychosocial needs not being met.
The findings were:
Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the
facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following
Cerebrovascular Disease (long -term consequences and complications that can result from a stroke or
other cerebrovascular issues, including impaired movement, speech difficulties, memory loss, and other
neurological deficits); Essential (Primary) Hypertension (high blood pressure where no specific underlying
cause can be identified); Type 2 Diabetes Mellitus Without Complications (an individual who has been
diagnosed with type 2 diabetes, but has not developed any long-term health problems (complications) that
can arise from high blood sugar levels).
Record review of the facility's Physician's Order List, dated 04/24/2025, listed Resident #2's diet as, regular
texture, regular consistency.
Record review of Resident #2's Assessment, by the facility's Dietitian, dated 09/11/2024, revealed Resident
#2 had an admission weight of 184.2 pounds, with weight history stable. Nutritional Goal: Gradual weight
loss 5% current body weight over the next 60 days 2. No s/s dehydration 3. Maintain adequate nutrition.
Record review of Resident #2's Quarterly MDS assessment, dated 01/29/2025, revealed Resident #2's
BIMS (cognitive assessment) score of 15 indicated intact cognition. Eyesight was severely impaired and
assistance was needed from staff for set up and clean up for eating. Resident #2 had the ability to feed
herself. No swallowing disorder and no significant weight loss/gain were noted.
Record review of Resident #2's comprehensive care plan, dated 03/26/2025 and revised 04/10/2025,
revealed:
Resident has potential for weight loss due to refusal of most meals and prefers to eat a sandwich (grilled
cheese).
Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days.
Interventions include:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 3 of 8
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
04/24/2025
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)
F 0656
Determine food preferences and provide within dietary limitations.
Level of Harm - Minimal harm
or potential for actual harm
Encourage meal completion and document amount consumed.
Monitor weight per facility protocol.
Residents Affected - Few
RD assess per facility protocol.
Serve diet and snacks as ordered.
The facility failed to implement interventions as outlined in the care plan.
Record review of Resident #2's electronic chart listed the following weights recorded on the following dates:
-04/09/2025: 166.4 lbs. (pounds)
-03/10/2025: 171.1 lbs.
-03/06/2025: 170.1 lbs.
-01/08/2025: 175.1 lbs.
-12/09/2024: 179.4 lbs.
-11/08/2024: 175.2 lbs.
-10/07/2024: 178.1 lbs.
-09/06/2024: 184.2 lbs.
-08/08/2024: 183.6 lbs.
The percentage of Resident #2's weight loss is calculated as:
1 month - 03/10/25 - 04/09/25
2.75% weight loss
3 month - 01/08/25 - 04/09/25
4.95% weight loss
8 month - 08/06/24 - 04/09/25
9.37% weight loss (10% in 6 months is considered significant weight loss)
Record review of nursing progress note dated 04/23/2025 at 11:28 am revealed that Resident #2, Resident
has a trend of eating <51%. Res reports she is eating her own food in addition to [facility]
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 4 of 8
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
04/24/2025
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)
F 0656
meals. She denies nausea, vomiting, or difficulty swallowing. Appetite is good.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 04/24/2025 at 12:20 pm Resident #2 said she did not like the food because the food
does not taste good. Resident #2 stated that she likes to eat snacks her family member brings and go out
to eat with her family.
Residents Affected - Few
In an interview on 04/24/2025 at 2:30 pm the ADM said that their company's policy is to address residents
who have a 10% or greater weight loss in six months. Resident #2 has not had that much of a weight loss
according to their company policy, which the facility would be prompted to provide interventions if a resident
experienced significant weight loss. ADM revealed that the facility provides Resident #2 a grilled cheese
sandwich.
In an interview on 04/24/2025 at 2:40 PM the Dietitian said that she visits the facility once a month. She
stated she only sees the residents who had a significant weight loss to provide recommendations for them.
The Dietitian stated that she did make a recommendation to the Speech Therapist to evaluate Resident #2
for swallowing issues for a possible reason resident was not eating, but she did not document the
conversation. The Dietitian said the nursing staff could make the decision for supplements. The Dietitian
stated she will investigate this issue with the resident.
In an interview on 04/24/2025 at 3:00 PM Resident #2's family member said that she has had concerns
with resident not wanting to eat. Family member was aware of Resident #2's weight loss and knows that
she does not care for the food. Family member brings her snacks to eat. Family member stated resident
was much larger when she moved into the facility and has gradually lost weight. She stated that Resident
#2 could lose some weight but has lost so much weight. Family member will speak to Resident #2 about
eating her meals better.
Record Review of facility's Resident Weight policy revised 02/13/2007 revealed in part, An acute care plan
for weight loss will be initiated and the clinical record reviewed for possible need of significant change of
condition MDS assessment. Assess the resident for possible reason for weight loss .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 5 of 8
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
04/24/2025
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident maintained acceptable parameters of
nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical
condition demonstrated that this was not possible for
Residents Affected - Few
1 (Resident #2) of 1 resident reviewed for weight loss.
Resident #2 had a 9.37% weight loss in 8 months between 8/6/24 and 4/9/25 with no documentation from
the Dietitian on nutritional concerns or recommended interventions to address Resident #2's weight loss.
This failure could place residents at risk of not having needs addressed and/or met r/t weight loss.
The findings were:
Record review of Resident #2 Face Sheet, dated 04/24/2025, revealed a [AGE] year-old admitted to the
facility on [DATE] and re-admitted on [DATE]. Resident #2's diagnoses included Other Sequelae Following
Cerebrovascular Disease (long -term consequences and complications that can result from a stroke or
other cerebrovascular issues, including impaired movement, speech difficulties, memory loss, and other
neurological deficits); Essential (Primary) Hypertension (high blood pressure where no specific underlying
cause can be identified); Type 2 Diabetes Mellitus Without Complications (an individual who has been
diagnosed with type 2 diabetes, but has not developed any long-term health problems (complications) that
can arise from high blood sugar levels.
Record review of the facility's Physician's Order List, dated 04/24/2025, listed Resident #2's diet as, regular
texture, regular consistency.
Record review of Resident #2's Assessment, by the facility's Dietitian, dated 09/11/2024, revealed Resident
#2 had an admission weight of 184.2 pounds, with weight history stable. Nutritional Goal: Gradual weight
loss 5% current body weight over the next 60 days 2. No s/s dehydration 3. Maintain adequate nutrition.
Review of Resident #2's electronic medical record revealed no Dietitian notes from 09/11/24 to 04/24/25.
Record review of Dietary Profile dated 04/16/2025 completed by the Director of Food and Nutrition revealed
Resident #2's appetite is poor, favorite meal is lunch, and no chewing or swallowing issues. Resident's
current weight to be 166.4 taken on 04/09/2025. Noted resident has had a weight loss of 8 lbs. in the last 6
month. Resident #2 on a regular diet with no supplements noted.
Record review of Resident #2's Quarterly MDS assessment, dated 01/29/2025, revealed Resident #2's
BIMS (cognitive assessment) score of 15 indicated intact cognition. Eyesight was severely impaired and
assistance was needed from staff for set up and clean up for eating. Resident #2 had the ability to feed
herself. No swallowing disorder and no significant weight loss/gain were noted.
Record review of Resident #2's comprehensive care plan, dated 03/26/2025 and revised 04/10/2025,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 6 of 8
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
04/24/2025
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)
F 0692
revealed:
Level of Harm - Minimal harm
or potential for actual harm
Resident has potential for weight loss due to refusal of most meals and prefers to eat a sandwich (grilled
cheese).
Residents Affected - Few
Goal: Resident will maintain ideal weight and receive proper nutrition daily x 90 days.
Interventions include:
Determine food preferences and provide within dietary limitations.
Encourage meal completion and document amount consumed.
Monitor weight per facility protocol.
RD assess per facility protocol.
Serve diet and snacks as ordered.
The facility failed to implement interventions as outlined in the care plan.
Record review of Resident #2's electronic chart listed the following weights recorded on the following dates:
-04/09/2025: 166.4 lbs. (pounds)
-03/10/2025: 171.1 lbs.
-03/06/2025: 170.1 lbs.
-01/08/2025: 175.1 lbs.
-12/09/2024: 179.4 lbs.
-11/08/2024: 175.2 lbs.
-10/07/2024: 178.1 lbs.
-09/06/2024: 184.2 lbs.
-08/08/2024: 183.6 lbs.
The percentage of Resident #2's weight loss is calculated as:
1 month - 03/10/25 - 04/09/25
2.75% weight loss
3 month - 01/08/25 - 04/09/25
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 7 of 8
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
04/24/2025
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)
F 0692
4.95% weight loss
Level of Harm - Minimal harm
or potential for actual harm
8 month - 08/06/24 - 04/09/25
9.37% weight loss (10% in 6 months is considered significant weight loss)
Residents Affected - Few
Record review of nursing progress note dated 04/23/2025 at 11:28 am revealed that Resident #2,
Resident has a trend of eating <51%. Res reports she is eating her own food in addition to hospital
meals. She denies nausea, vomiting, or difficulty swallowing. Appetite is good.
In an interview on 04/24/2025 at 12:20 pm Resident #2 said she did not like the food because the food
does not taste good. Resident #2 stated that she likes to eat snacks her family member brings and go out
to eat with her family.
In an interview on 04/24/2025 at 2:30 pm the ADM said that their company's policy is to address residents
who have a
10% or greater weight loss in six months. Resident #2 has not had that much of a weight loss according to
their company policy. ADM revealed that the facility provides Resident #2 a grilled cheese sandwich.
In an interview on 04/24/2025 at 2:40 PM the Dietitian said that she visits the facility once a month. She
only sees the residents who are having a significant weight loss to provide recommendations for them. The
Dietitian said that she did make a recommendation to the Speech Therapist to evaluate Resident #2 for
swallowing issues for a possible reason resident is not eating, but she did not document the conversation.
The Dietitian said the nursing staff could make the decision for supplements. The Dietitian stated she will
investigate this issue with the resident.
In an interview on 04/24/2025 at 3:00 PM Resident #2's family member said that she has had concerns
with resident not wanting to eat. Family member is aware of Resident #2's weight loss and knows that she
does not care for the food. Family member brings her snacks to eat. Family member stated resident was
much larger when she moved into the facility and has gradually lost weight. She agrees that Resident #2
could lose some weight but has lost so much weight. Family member will speak to Resident #2 about eating
her meals better.
Record Review of facility's Resident Weight policy revised 02/13/2007 revealed in part, Significant Weight
Loss, The facility review resident weights after monthly weights are obtained, to determine residents with
significant weight changes. A significant weight change will be defined as 5% or greater in one month, 7.5%
or greater in three months, or 10% or greater in six months. The Weight change will be recorded on the
appropriate weight watcher's form along with interventions, and follow-up will also be recorded in the
designated location. The physician and family will be notified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675018
If continuation sheet
Page 8 of 8
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
FAQ · About this visit
Common questions about this visit
What happened during the April 24, 2025 survey of RIVER OAKS HEALTH AND REHABILITATION CENTER?
This was a inspection survey of RIVER OAKS HEALTH AND REHABILITATION CENTER on April 24, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RIVER OAKS HEALTH AND REHABILITATION CENTER on April 24, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.