Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Oaks Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to conduct required pre-employment checks for 18 personnel files, violating their policy on abuse prevention. Criminal background checks were incomplete for 14 employees, and checks for other states were not done for two employees. State Nurse Aide Abuse Registry and Kentucky Adult Caregiver Misconduct Registry checks were also incomplete or late. The HR Manager, new to the role, was unaware of proper procedures, and the facility's transition to a new company may have contributed to these oversights.
The facility failed to implement fall prevention interventions for two residents, as their care plans required colored tape on call lights to enhance visibility and encourage use. Observations revealed the absence of tape on multiple occasions, and interviews with staff and residents confirmed the oversight. The DON and Executive Director acknowledged the lack of procedures to ensure the intervention was consistently applied, compromising its effectiveness.
A facility's transition to a new computer system resulted in incomplete clinical records for two residents, as prior records were not transferred. Staff interviews revealed that the lack of access to previous records hindered the ability to provide accurate and safe care. The transition was managed by a third party, and the facility was not informed that previous records would be inaccessible.
The facility failed to properly label medications following a pharmacy transition, leading to confusion and improper labeling. Medications for several residents were either not labeled with an opened date or contained different medications than what was labeled. Staff interviews revealed that the transition to a new medication administration system was confusing due to the abundance of medications from the previous pharmacy still in use, despite extensive training provided by the new pharmacy.
The facility failed to store food according to professional standards, as approximately 45 milk cartons were found with expired dates. The Dietary Manager initially had no concerns but later acknowledged the issue, attributing it to new staff. The Administrator confirmed the expectation of using the First In - First Out method to ensure freshness and acknowledged the potential for adverse reactions to expired products.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as evidenced by the absence of EBP signage and PPE supplies for three residents. Staff interviews revealed a lack of training and awareness regarding EBP, with some unable to recall receiving training. The Director of Nursing and Administrator expressed concerns about the risk of infection spread due to non-compliance with isolation protocols.
Failure to Conduct Pre-Employment Checks
Penalty
Summary
The facility failed to implement an effective system for conducting pre-employment checks for 18 personnel files, which is a violation of their policy on abuse, neglect, and exploitation prevention. The policy required background checks to be conducted on potential employees and contracted staff, with documentation maintained as proof. However, the review revealed that criminal background checks were not completed for 14 employees, and checks for other states of residence were not conducted for two employees. Additionally, State Nurse Aide Abuse Registry checks were not completed for nine files, and the Kentucky Adult Caregiver Misconduct Registry checks were either not completed or completed late for several employees. The HR Manager, who began employment in January 2024, stated that she was unsure why the dates did not print on the KACMR checks and admitted to not printing the results of background checks for other states. She also acknowledged a lack of awareness on how to complete the NA abuse registry checks, mistakenly believing it was done through the OIG Exclusions List. The HR Manager emphasized the importance of these checks to ensure qualified applicants were hired to serve residents safely, acknowledging that incomplete checks could lead to hiring unqualified applicants. The Administrator confirmed the significance of pre-hire employment checks, stating they provide insight into the applicants' backgrounds and should be completed before orientation. The HR Manager received minimal training upon starting her role, and there was no corporate HR director at the time. The facility's transition to another company in May 2024 may have contributed to the oversight in completing the necessary checks, as the HR Manager and other corporate HR personnel were new to their roles.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for two residents, R1 and R2, as observed during a survey. Both residents had care plans that included the intervention of placing colored tape on their call lights to make them more visible and encourage use, thereby preventing falls. However, during multiple days of the survey, it was noted that the call lights for both residents did not have the colored tape as required by their care plans. For Resident R1, who was admitted with diagnoses including dementia and repeated falls, the care plan intervention for bright orange tape on the call light was added after a fall. Observations on two separate days revealed the absence of the tape. Interviews with R1, nursing staff, and the Unit Manager confirmed that the tape was not present, which increased the risk of falls as the resident might not see the call light. The Director of Nursing acknowledged that the intervention was not in place, which compromised its effectiveness. Similarly, Resident R2, admitted with conditions such as hip pain and weakness, had a care plan intervention for bright tape on the call light following a fall. Observations confirmed the absence of the tape on multiple occasions. Interviews with R2 and staff indicated that the tape had not been seen on the call light for several weeks, and staff were not informed of the intervention. The Director of Nursing and Executive Director admitted there was no procedure to ensure the tape was consistently applied, leading to the intervention's ineffectiveness.
Incomplete Clinical Records Due to System Transition
Penalty
Summary
The facility failed to ensure access to complete resident clinical records for two residents following a transition to a new computer software system on 07/01/2024. The transition resulted in the loss of prior clinical information for these residents, which was not available in their electronic health records. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not have access to the residents' records from their initial admission until the transition date. For Resident 1, who was admitted in 2021 and readmitted in 2024, the facility's records showed interventions for falls were initiated in June 2024, but the earliest documentation in the electronic health record began in late June 2024. Interviews with staff, including the Medical Records Specialist, MDS Coordinator, Unit Manager, and Director of Nursing, confirmed that the transition to the new system did not carry over previous records, leaving the resident's clinical record incomplete. The staff expressed concerns that the lack of access to prior records could impact the resident's ongoing care and safety. Similarly, for Resident 2, admitted in early 2024, the facility's records indicated a fall risk assessment and interventions were documented, but the transition to the new system left the resident's clinical record incomplete. Interviews with staff highlighted that the facility was not informed that previous records would not be accessible, and the absence of these records hindered the ability to provide accurate and safe care. The Executive Director acknowledged that the transition was managed by a third party and that the facility should have had access to the necessary information from the previous system.
Medication Labeling Deficiencies Due to Pharmacy Transition
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with professional standards, including expiration dates and appropriate instructions. During observations, it was found that medications for several residents were either not labeled with an opened date or contained different medications than what was labeled. For instance, a medication box labeled for potassium chloride for one resident contained furosemide pills without a resident label, and another resident's medication box labeled for benzonatate contained carvedilol pills, also without a resident label. The facility had recently switched pharmacy providers, which led to confusion and improper labeling of medications. Staff interviews revealed that the transition to a new medication administration system, which included timed dose packs, was confusing due to the abundance of medications from the previous pharmacy that were still in use. The staff had received training on the new system, but the presence of both old and new systems contributed to the labeling issues. The facility's management acknowledged the challenges posed by the pharmacy switch. The previous pharmacy had sent a 90-day supply of medications, which were still being stored in the facility, awaiting collection. Despite extensive training provided by the new pharmacy, the transition period led to labeling deficiencies, as staff had to manage medications from both the old and new systems. The facility had contacted the previous pharmacy to collect the remaining medications, but they had not yet done so.
Failure to Properly Store and Rotate Milk Cartons
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, specifically regarding the timely use and expiration dates of food and drinks. During an observation, approximately 45 milk cartons were found in two milk crates with expired dates. The Dietary Manager (DM) was interviewed and initially expressed no concerns about the milk stored in the walk-in cooler. However, upon being shown the expired milk cartons by the State Survey Agency (SSA) Surveyor, the DM acknowledged the issue and mentioned that milk deliveries occurred weekly, with the expectation that staff would rotate the milk using the First In - First Out method to maintain freshness. The DM attributed the oversight to having several new employees. Further interviews revealed that any out-of-date products were to be removed immediately, and the DM was to be notified for direction on obtaining credit for damaged goods. The Administrator confirmed that the process to ensure fresh food involved rotating products using the First In - First Out method and acknowledged the potential for adverse reactions to expired food or drink. The Administrator also stated that lower-level staff were expected to report any concerns to their Dietary Manager.
Inadequate Infection Control Measures for Residents with Medical Devices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for three residents with indwelling medical devices. Resident R71, who had a gastrostomy tube, did not have EBP signage posted on the room door, nor were there Personal Protective Equipment (PPE) supplies available outside the room. Similarly, Resident R234, with a PEG tube, was observed being turned by an LPN without the appropriate PPE, and there was no EBP signage or PPE supplies outside the resident's room. Resident R238, also with a PEG tube, lacked EBP signage and PPE supplies at the entrance of the room. The facility's policies on Isolation Precautions and Enhanced Barrier Precautions were not followed, as evidenced by the absence of necessary signage and PPE for residents with indwelling medical devices. The policies required that upon initiation of isolation precautions, signage for specific PPE use should be placed conspicuously outside the resident's room, and PPE should be available immediately near or outside the room. However, these protocols were not adhered to for the residents in question, indicating a failure in implementing the facility's infection control measures. Interviews with staff, including CNAs, LPNs, the Unit Manager, the Infection Preventionist, the Director of Nursing, and the Administrator, revealed a lack of training and awareness regarding EBP. Some staff members could not recall receiving EBP training, and there was confusion about when EBP precautions were necessary. The Director of Nursing and the Administrator expressed concerns about the risk of infection spread due to non-compliance with isolation protocols, highlighting the importance of following signage and using appropriate PPE to protect both staff and residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Louisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Treyton Oak Towers | 0.4 mi | ★★★★★ | 0 | 0 |
| Chestnut Ridge Health & Rehabilitation | 0.7 mi | ★★★★★ | 3 | 2 |
| Kindred Hospital - Louisville | 1.5 mi | ★★★★★ | 3 | 0 |
| Home Of The Innocents | 1.7 mi | ★★★★★ | 37 | 0 |
| Eastway Health & Rehabilitation | 2 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.