Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak River Rehab during CMS and state inspections, most recent first.
A resident with multiple health issues was administered nitroglycerin without a physician's order, leading to a significant drop in blood pressure and transfer to a medical center. The facility's policy requires physician orders for medication administration, which was not followed by an LVN, resulting in a health decline for the resident.
The facility failed to ensure accurate PASARR Level I Screenings for two residents, leading to discrepancies in their documented mental health diagnoses. One resident's screening inaccurately listed bipolar disorder, while another's screening failed to reflect existing anxiety and depression diagnoses. Staff interviews revealed a lack of clarity regarding responsibility for PASARR accuracy.
A resident missed doses of Biktarvy due to the facility's failure to reorder the medication in a timely manner. The facility's transition from a manual to an electronic ordering system led to confusion, resulting in the medication not being reordered in November. The pharmacy confirmed the order was placed on December 1, but the medication was not in stock, causing a delay. The resident, who had intact cognition, confirmed the missed doses, and the physician stated that missing two doses would not have a negative outcome.
A resident with an indwelling catheter was observed receiving inadequate catheter care, leading to potential infection risks. The CNA failed to use a clean portion of the washcloth for each stroke, did not rinse the resident's peri area, and placed soiled washcloths on the bedside table without a barrier. Interviews with facility staff confirmed breaches in infection control practices, contrary to the facility's policies.
A resident with multiple health issues experienced increased confusion and developed new skin wounds. The facility failed to notify the responsible party of these changes at the time they were identified, contrary to its policy. The responsible party was only informed after the resident returned from the hospital, leading to the need for new placement.
Unauthorized Medication Administration Leads to Health Decline
Penalty
Summary
A significant medication error occurred when a resident was administered nitroglycerin without a physician's order. The resident, who had been admitted to the facility with multiple diagnoses including metabolic encephalopathy, morbid obesity, muscle weakness, congestive heart failure, a history of stroke, and hypertension, experienced a decline in health following the administration of the medication. The facility's policy requires that medications be administered only with a physician's order, which was not followed in this instance. The error was identified when the resident complained of chest pain and difficulty breathing, leading to the administration of two doses of nitroglycerin five minutes apart by an LVN. This resulted in a significant drop in the resident's blood pressure from 102/64 to 60/40, necessitating the resident's transfer to a nearby medical center for a higher level of care. The LVN confirmed that the medication was given without a physician's order, which was against the facility's policy. Interviews with the Director of Nursing and other staff confirmed that the facility's policy was not adhered to, as the LVN administered the medication without obtaining a necessary physician's order. The Medical Director also confirmed that no order had been given for the nitroglycerin. This incident highlights a failure to follow established medication administration protocols, which could have contributed to the resident's health decline.
Inaccurate PASARR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Preadmission Screening and Resident Review (PASARR) Level I Screenings for two residents, which is a requirement for identifying mental disorders or intellectual disabilities. For Resident #111, the PASARR Level I Screening inaccurately listed a diagnosis of bipolar disorder, which was not supported by the resident's medical records or hospital history. The resident's actual diagnoses included post-traumatic stress disorder, anxiety disorder, and depression, none of which were accurately reflected in the PASARR. The Admission Director did not review the PASARR for accuracy, and the Medical Records Director acknowledged the inaccuracy but failed to resubmit a corrected PASARR. Similarly, for Resident #76, the PASARR Level I Screening was negative for serious mental illness, despite the resident having diagnoses of anxiety disorder, depression, and post-traumatic stress disorder. The Admission Director ensured the completion of the PASARR but did not verify its accuracy. The Medical Records Director admitted to not having reviewed the PASARR for accuracy and recognized the need to submit a new one with the correct information. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clarity regarding responsibility for ensuring PASARR accuracy. The Administrator stated that both the Admissions Director and the Medical Records Director were responsible for ensuring PASARR accuracy, but this was not effectively executed, leading to discrepancies in the residents' PASARR documentation.
Medication Reordering Failure Leads to Missed Doses
Penalty
Summary
The facility failed to ensure timely ordering and delivery of medication for a resident, leading to missed doses. The facility's policy required medications to be reordered three to four days in advance, or seven days for special processing, to ensure an adequate supply. However, the facility did not reorder the resident's Biktarvy medication in November, resulting in the resident missing doses on November 30 and December 1. The resident, who had intact cognition, confirmed the missed doses, and the facility's records showed the last order was placed on October 29. Interviews with staff revealed confusion during a transition from a manual to an electronic medication ordering system. The LVN responsible for reordering assumed the medication had been reordered due to a missing sticker, which was part of the old system. The DON confirmed the lack of evidence for a November reorder and acknowledged the expectation for staff to monitor and reorder medications timely. The pharmacy confirmed the facility's order on December 1, but the medication was not in stock, leading to a delay until December 2. The physician noted that missing two doses of the long-term medication would not have a negative outcome.
Inadequate Catheter Care and Infection Control Breach
Penalty
Summary
The facility failed to provide catheter care in a manner that prevents cross-contamination and potential infection for a resident observed for urinary catheter care. The facility's policy on indwelling catheters, last reviewed in October 2023, outlined infection control measures such as using standard precautions and maintaining a clean technique when handling the catheter and its components. However, during an observation, a CNA was seen providing catheter care without adhering to these infection control practices. The resident involved had a medical history that included infection and inflammatory reaction due to an indwelling urethral catheter, among other conditions. The resident required moderate to maximum assistance with activities of daily living and had an indwelling catheter. The care plan for the resident included providing catheter care every shift, but during the observed care, the CNA did not use a clean portion of the washcloth for each stroke, did not rinse the resident's peri area, and placed soiled washcloths on the bedside table without a barrier. Interviews with facility staff, including the CNA, the Director of Staff Development, and the Director of Nursing, confirmed breaches in infection control practices. The CNA admitted to not using a barrier for catheter care supplies and using soiled linens for catheter care. The Director of Staff Development and the Director of Nursing acknowledged these breaches and the failure to clean the catheter tubing properly, which were against the facility's infection control policies and procedures.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to update the responsible party (RP) for a resident when a change in the resident's condition was identified. The resident, who had multiple diagnoses including diabetes, heart disease, and kidney disease, was admitted with a urinary catheter. The resident experienced increased confusion and developed new skin wounds, which were documented by a licensed nurse (LN) on a specific date. However, the RP was not informed of these changes at the time they were identified, as confirmed by interviews with the LN and the Director of Nursing (DON). The LN acknowledged that the RP was only informed of the resident's new wounds after the resident returned from the hospital, rather than at the time of the initial change in condition. The facility's policy requires notifying the resident, attending physician, and representative of any significant changes in the resident's medical condition or status. The failure to communicate the resident's change in condition to the RP led to the resident needing new placement after hospitalization, highlighting a lapse in the facility's adherence to its notification policy.
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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 Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Home Of California - Redding | 4.5 mi | — | 6 | 0 |
| Marquis Care At Shasta | 7.8 mi | — | 19 | 0 |
| Crestwood Wellness And Recovery Center | 8.2 mi | — | 2 | 0 |
| Copper Ridge Care Center | 8.9 mi | — | 15 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 9.7 mi | — | 1 | 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 August 2026) and official state health department websites.