River Oaks Health & Rehabilitation

Inspectors wroteThe 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. During interview on 07/09/2025 at 11:07 AM, the Dietary Director stated all dietary staff were expected to wear hair and beard coverings as required. [...]

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to notify each resident and/or their representative when their resident trust account balance was within $200 of the social security income (SSI) resource limit for 7 of 12 residents whose current balance was over $1,800.00 (Resident (R) 47, 52, 54, 57, 65, 72, 87).

Inspectors wroteBased on interview, record review, and document review, the facility failed to issue a Notice of Medicare Non-coverage (NOMNC) - Form CMS-10123 to 1 of 3 sampled residents reviewed for beneficiary notification (Resident (R) 60).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure a resident's room had an environment that was safe and homelike environment for 2 of 13 residents sampled for environment (Resident (R) 2 and R57).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts was kept locked when not in the line of sight of the person administering medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 2 sampled residents (Resident (R) 31) reviewed for urinary catheters. In addition, the facility further failed to ensure a resident's urinary catheter drainage bag was not touching the floor for 2 of 2 residents sampled for urinary catheters (R31 and R93).

Inspectors wroteBased on interview, personnel record review, review of website Kentucky Online Offender Lookup (Kentucky Offender Search - Kentucky Department of Corrections - Offender Online Lookup System, review of the Kentucky Statutes (https://apps.legislature.ky.gov/), review of the Kentucky Board of Nursing online licensure validation (kbn.ky.gov), and review of the facility's policy the facility failed have to have an effective system to ensure individuals contracted or hired had pre-employment checks completed for 18 of 18 personnel files. Pre-employment checks were either missing; not fully completed; completed after employment began; or the checks were not dated when completed for: the State nurse aide abuse registry, the Kentucky Adult Caregiver Misconduct Registry (KACMR), and/or criminal background checks.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 06/04/2024 revealed approximately 45 milk cartons in two milk crates dated 05/29/2024.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and the Center for Disease Control and Prevention (CDC) guidance, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent and control the development and transmission of communicable diseases and to implement interventions for protection for three of twelve (12) sampled residents (R), R71, R234, and R238. R71 had an indwelling medical device, a gastrostomy tube (G-tube). Observation revealed however, no Enhanced Barrier Precautions (EBP) signage posted on R71's room door and no Personal Protective Equipment (PPE) supplies available outside the resident's room. R234 had an indwelling medical device, a PEG tube. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the transmission of communicable diseases and infections for four (4) of six (6) sampled residents, Resident #3, #43, #102, and #261. Observations revealed staff failed to wear Personal Protective Equipment (PPE) in isolation rooms and failed to perform hand hygiene during wound care. The isolation rooms did not have designated receptacles to dispose linens and PPE. Continued observation revealed staff failed to perform hand hygiene when administering medication and the facility failed to ensure staff was supplied with the necessary items needed to perform hand hygiene, such as soap and paper towels. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective Antibiotic Stewardship Program (ASP) for tracking antibiotic use using the Antibiotic Tracking Tool (ATT), and failed to ensure supervision of the Infection Preventionist (IP) who was responsible for the ASP. The IP did not complete the ATT for January, February, and March 2019, and was not supervised for ongoing and accurate account of antibiotic use in the facility. In addition, the facility failed to review antibiotic use monthly at the Quality Assurance Performance Improvement (QAPI) meeting, per policy.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to follow their grievance process to make prompt efforts to resolve resident grievances for two (2) of twenty-seven (27) sampled residents, Resident #49 and #308. The residents complained to a supervisor regarding staff behavior; however, the supervisor did not follow the grievance process in order for the complaint to be resolved.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the Certified Nursing Assistant (CNA) Job Description, it was determined the facility failed to ensure only trained nursing staff administered oxygen for one (1) of four (4) sampled residents, Resident #12. Observation revealed a CNA adjusted the resident's supplemental oxygen flow rate.