Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Walk Care Center during CMS and state inspections, most recent first.
A resident was discharged home without a discharge care plan being developed. The IDT had previously documented that therapy did not consider the resident appropriate for discharge at that time due to decreased activity tolerance and the need for continued strengthening and endurance training, with ongoing therapy services, transfer training, and discharge planning to be reflected in the care plan. Later review found no discharge care plan in the record, and the SSD confirmed none had been developed despite the facility policy requiring one for resident-initiated discharges.
A resident’s written request for a copy of their clinical record was not fulfilled within the timeframe required by the facility’s own “Release of Medical Records” P&P. The MRD received the written request but did not release the record until about 29 days later, despite the policy requiring that a resident or legal representative receive a copy within 2 working days. During an interview and record review, the ADON and MRD confirmed that the policy was not followed, resulting in a violation of the resident’s right to timely access to their medical information.
A resident with bilateral lower leg wounds had wound care documented in the TAR as Kerlix-based treatment even though the LPN changed the dressings to foam because of the resident’s itching and request. The LPN stated no new PO was obtained for the dressing change and acknowledged the documentation was inaccurate. In a separate issue, another resident on hospice had no recorded weights after July 2025, and the DON stated there was no PO to discontinue the weights.
The facility failed to consistently complete required monitoring documentation for several residents with identified safety risks, including falls risk, repeated falls with injury, and elopement/wandering risk. Care plans called for one-to-one monitoring or 15-minute checks, but RBM forms showed repeated missing or incomplete entries across many shifts for multiple residents. The DON stated the forms were used to evaluate whether interventions were effective and to guide future resident safety measures.
A resident with intact cognition reported that meals had been served at incorrect temperatures for about three months, stating hot food was cold and cold food was hot. During meal service observation, the DS confirmed multiple items were below required hot-holding temperatures, while cucumber salad and milk were above the expected cold temperatures. The facility policy required hot foods at or above 140 F and cold items at specified lower temperatures.
Failure to monitor refrigerator and freezer temperatures used to store residents' food. During record review with the DS, the Cold Storage Temperature Log showed missed AM and PM temperature entries on multiple occasions, and the DS stated the temperatures should have been taken but were not. The facility policy required Food and Nutrition staff to record and initial refrigerator and freezer temperatures at the beginning of the AM and PM shifts.
Failure to Use Required PPE and Improper Handling of Soiled Linen: Two staff members provided high-contact care to a resident on EBP without wearing the required gown, despite the resident having a wound and orders for gowns and gloves during high-contact care. In a separate event, a CNA placed bowel movement-soiled bed linens on the floor while changing the linens of a resident who was incontinent of bowel and bladder, contrary to the facility’s linen-handling policy.
A resident with dementia and depression received trazodone 50 mg nightly after a hospital return even though the discharge plan listed 25 mg nightly. The IDT did not review the increase until later, and consent for the higher dose was not obtained until much later. The DON stated the facility did not follow its psychotropic medication policy for IDT review and consent.
A resident with a G-tube had two crushed medications administered without the required stomach residual check after tube placement was verified, and the LVN did not flush with water between the medications as ordered. The resident’s orders required tube placement checks by gastric aspiration and water flushes before and after each medication, and the DON stated flushing between medications is basic nursing and expected of staff.
A resident was admitted with bruising to both forearms, and a subsequent skin assessment documented a right forearm bruise of approximately 6 cm by 5 cm. The bruise was monitored only through the initial ordered period, after which no further re-assessments were documented even though the bruise remained present. During interview and record review, the treatment nurse confirmed that facility practice was to re-assess bruises after the monitoring order ended to ensure they were not new or worsening, and acknowledged that this re-assessment did not occur. Review of the facility’s skin assessment policy showed that head-to-toe skin assessments were required on admission, daily for three days, and weekly thereafter, but this process was not followed for the ongoing bruise.
Surveyors found that expired and unlabeled food items were present in storage areas, including bread, desserts, and dairy products, and that opened frozen foods were left exposed and undated. The steam table used for meal service was observed with food debris and had not been cleaned as required. Dietary staff confirmed these practices did not follow facility policies for food labeling, storage, and sanitation.
A resident with severe cognitive impairment and a history of falls related to toileting needs did not receive scheduled toileting and bowel/bladder retraining as outlined in the care plan. Despite being at high risk for falls and dependent for toilet transfers, the intervention was not consistently implemented or documented, and some CNAs were unaware of the care plan requirements. This failure resulted in the resident attempting to toilet independently, experiencing multiple falls, and ultimately sustaining a hip fracture that required hospitalization and surgery.
A resident developed bluish discoloration and edema in the left foot, which was documented by multiple LVNs over several days without notifying the physician, despite facility policy requiring such notification for significant changes. The physician was only informed after the resident's family requested hospital evaluation, at which point a nondisplaced fracture was discovered.
A resident with multiple wounds was discharged from the hospital with orders for a follow-up at a wound healing clinic to resume grafix and wound vac therapy. Facility staff, including the wound nurse and DON, were unaware of the order and could not find documentation that the appointment was scheduled, despite facility policy requiring implementation of hospital transfer orders.
A resident with a history of spontaneous hip dislocations experienced a dislocated hip, but staff did not complete the required SBAR form or monitor the resident for changes in condition as per facility policy. Although the physician and family were notified and the resident was eventually sent to the ER for further evaluation, documentation and monitoring procedures were not followed, as confirmed by the DON.
A resident with diabetes and osteomyelitis did not have their physician notified when blood sugar readings exceeded 400, as required by physician orders, and missed several doses of prescribed intravenous antibiotics for a bone infection, with no documentation to confirm administration. The DON confirmed the lack of required notifications and documentation.
A resident with diabetes who was prescribed a consistent carbohydrate and no added salt diet was served vanilla mousse pudding with chocolate chips, contrary to physician orders and the facility's dietary guidelines. Staff confirmed the error, and facility policy requires adherence to prescribed therapeutic diets.
A resident with significant medical history was not provided with a recommended restorative nursing program or with ordered PT and OT services. Staff failed to enter physician orders, develop a care plan, or implement the restorative program, and therapy services were not delivered due to insurance issues and communication lapses. This resulted in a documented decline in the resident's bed mobility and functional abilities.
A resident with multiple wounds did not consistently receive wound care treatments and monitoring as ordered by the physician, as evidenced by missing documentation on the TARs over several months. The DON confirmed that without documentation, it could not be determined if the treatments were completed. Facility policy required all wound care to be recorded, but this was not done, potentially impacting the resident's wound healing.
A resident's blood glucose levels were not checked timely as ordered by the physician, leading to potential inaccuracies in readings and insulin administration. Despite the resident's preference and facility protocol requiring checks before meals, logistical issues and delays resulted in late checks, confirmed by the DON and LVN.
A facility failed to complete a medication administration competency assessment for an RN hired three months prior, as required by their policy. The RN confirmed the lack of assessment, and the DON acknowledged the oversight, which could lead to medication errors and unmet care needs.
A resident with dementia and a history of elopement left the facility unsupervised and was found a mile away. Despite being identified as high risk for elopement, the resident was able to exit the facility without staff noticing. Interviews revealed that staff were unaware of the resident's whereabouts until another resident reported the elopement. The facility's policy on supervision was not adequately followed.
A resident with significant cognitive impairment and high fall risk experienced multiple falls over six months, resulting in serious injuries. The facility failed to update the care plan or implement new interventions after each fall, and recommendations from medication reviews were not followed. The lack of adherence to protocols and failure to conduct IDT meetings contributed to the resident's repeated falls.
The facility did not follow its policy on Advance Directives, resulting in 26 out of 30 residents lacking documented directives in their medical records. Interviews revealed that residents and family members were often unaware of or did not recall completing these forms. The Admission Coordinator confirmed the absence of Advance Directives and acknowledged the lack of documentation and process to ensure residents' wishes were recorded.
A resident's bed linen was observed with brown stains, identified as feces, and had not been changed for two days. Housekeeping and CNA staff confirmed the issue, and the Infection Preventionist stated that the linen should have been changed immediately. The facility's policy requires soiled laundry to be handled as potentially contaminated.
A resident with a history of stroke and hemiplegia, dependent on staff for oral hygiene, did not receive adequate oral care as per the facility's policy. Observations showed the resident's lips and teeth were covered with a brown film, and their lips were dry and cracked. Interviews with staff and family confirmed neglect in oral care provision, despite the care plan requiring oral care every shift.
A resident with a G-tube experienced deficiencies in enteral feeding procedures at the facility. The enteral nutrition feeding bottle was not labeled with the necessary information, and the enteral tubing was disconnected with the three-way valve left open, causing stomach contents to leak onto the resident's skin. These issues were acknowledged by the LVN and DON, who confirmed that the facility's policies were not followed.
A facility failed to implement pharmacy recommendations for a resident after multiple falls, as identified in several Interim Medication Regimen Reviews (IMRRs). The IMRRs recommended conducting tests and monitoring vital signs, but the Director of Nursing (DON) could not provide evidence of implementation. The facility's policy requires acting on such recommendations to prevent medication-related issues, but this was not done, potentially leaving staff unaware of adverse consequences.
A resident with hand contractures was not provided with adaptive equipment to drink water independently, despite facility policies and assessments indicating the need. Observations showed the resident's water cup was out of reach, and staff confirmed the resident's difficulty in accessing water. The facility's failure to adhere to its ADL policy resulted in the resident's dependency on staff for hydration.
The facility failed to ensure staff were adequately trained on the elopement binder, leading to a lack of awareness among CNAs about residents at high risk for elopement. Interviews revealed that CNAs were either unaware or relied on informal communication to identify at-risk residents. The Administrator noted that only a small fraction of staff attended the last in-service training on elopement risk, highlighting a significant gap in training and communication.
A CNA in an LTC facility failed to treat a resident with dignity and respect by using foul language and dismissive gestures, leading to the resident's agitation. The resident, diagnosed with Lewy body Dementia and severely impaired cognition, was unable to respond appropriately to questions. The incident was witnessed by two other staff members, and the CNA admitted to the inappropriate behavior, which violated the facility's policy on Resident Rights.
Missing discharge care plan for resident-initiated discharge
Penalty
Summary
The facility failed to follow its policy and procedure for resident-initiated discharge by not developing a discharge care plan for Resident 1. During the interdisciplinary team care conference meeting on 2/27/26, the team documented that therapy did not consider the resident appropriate for discharge at that time because of decreased activity tolerance and the need for continued strengthening and endurance training, and that the care plan would be updated to reflect ongoing therapy services, transfer training, and continued discharge planning. However, the resident was discharged to home on 3/19/26 at 12:30 p.m. During a later review of the resident’s care plans, the Social Service Director was unable to provide a discharge care plan and stated that none had been developed for Resident 1. The Administrator stated there should have been a discharge care plan developed per policy. The facility policy titled Transfer or Discharge, Resident-Initiated, states that for resident-initiated discharges, the medical record contains a discharge care plan and that the comprehensive care plan aligns with the discharge if it is resident-initiated.
Failure to Provide Timely Access to Requested Clinical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for timely release of medical records when a written request for Resident 1’s clinical record was not fulfilled within the required timeframe. On 2/26/26, the Medical Records Director (MRD) received a written request for Resident 1’s clinical record, but the record was not released until 3/27/26, approximately 29 days after the request date. During a concurrent interview and record review on 4/2/26 at 12:57 p.m., the Assistant Director of Nurses (ADON) and MRD confirmed that the facility’s policy titled “Release of Medical Records,” dated 2025, requires that a resident or legal representative receive a copy of the record within 2 working days after the request is made. ADON and MRD acknowledged that this policy was not followed, resulting in a violation of Resident 1’s right to access their clinical records in a timely manner. No additional clinical or medical history details about Resident 1 were provided in the report beyond their status as a resident requesting access to their clinical record.
Inaccurate wound documentation, unauthorized dressing change, and missing weight order
Penalty
Summary
Resident 92 had bilateral lower leg wounds with a physician order dated 2/20/26 for daily treatment using normal saline, silver med gel, Adaptec, ABD pad, and Kerlix wrap. During observations on 2/23/26, 2/24/26, and 2/25/26, the resident’s lower legs were seen wrapped first with Kerlix gauze and then with pink foam dressings. The resident stated the Kerlix gauze caused itching and that the treatment nurse applied a different dressing. During record review and interview with LVN 1, the Treatment Administration Record for February 2026 showed the wound care was documented as normal saline, silver med gel, Adaptec, ABD pad, and Kerlix wrap on 2/23/26 and 2/24/26. LVN 1 stated she had changed the dressing to a foam dressing on those dates, but she had not entered a new treatment order in the chart. She stated she should not have documented the foam dressing care under the current order because it was not the treatment being provided and acknowledged the documentation was inaccurate. The same resident’s wound treatment was changed to a foam dressing because of the resident’s request, but LVN 1 stated there were no physician orders in the chart authorizing that change. The facility’s policy required a physician’s order for the dressing procedure. In a separate finding, Resident 10’s eMAR showed the last recorded weight was 7/14/25, while the OSR indicated hospice admission and a POS stating no weekly weights, only monthly weights, with the daughter’s agreement. The DON stated the weights had not been completed after July 2025 and there was no physician order to discontinue the weights.
Incomplete Monitoring Documentation for Residents with Falls and Elopement Risks
Penalty
Summary
The facility failed to implement care plan interventions for monitoring five sampled residents who had identified safety risks. Resident 27 was documented as at risk for unavoidable falls with major injury, Resident 67 had multiple falls including falls with injury, Resident 36 was identified as high risk for falls, Resident 42 was identified as an elopement risk/wanderer, and Resident 3 was at risk for falls. The care plans for these residents included monitoring interventions such as one-to-one monitoring or checks every 15 minutes. The facility’s FALL PROGRAM and the Resident with Behaviors Monitoring forms required staff to complete narrative documentation at set intervals for these residents. During interview and record review, the Director of Staff Development confirmed that the forms were supposed to be completed every 15 minutes by the assigned shifts and then turned in for record keeping and review. However, the records showed repeated gaps in documentation for Resident 27, Resident 67, Resident 36, Resident 42, and Resident 3 across numerous dates and shifts, including instances where documentation was missing for entire shifts and, in some cases, for all three shifts on multiple days. The Director of Nursing stated that the RBM forms were used to determine whether resident-centered interventions were successful and whether further action was needed to ensure safety. The DON also stated that the forms were used to rationalize or modify interventions and that staff were expected to complete them as required so decisions could be made about future interventions and actions. The facility policy on Safety and Supervision of Residents stated that resident safety and supervision are facility-wide priorities and that interventions must be implemented correctly and consistently, with effectiveness evaluated for new or revised interventions.
Meal Temperatures Not Maintained During Service
Penalty
Summary
Food and drink were not maintained at palatable and safe temperatures during lunch meal service for one sampled resident. During a concurrent observation and interview with the Dietary Supervisor, the last lunch meal tray was served and temperatures were taken. The fish measured 116 F, broccoli 113 F, rice 128 F, cucumber salad 70 F, and milk 52 F. The Dietary Supervisor stated the expected temperatures were 140 F for the hot items, below 68 F for the cucumber salad, and 40 F or lower for the milk. Resident 5 had a BIMS score of 15, indicating intact cognition. During interview, the resident stated he regularly attended resident council meetings and reported that for approximately the last three months the kitchen had been sending out meals that were not heated or chilled correctly, stating, "The hot food is cold, and the cold food is hot." The facility policy titled Meal Service stated meals should be served at the appropriate temperatures, with hot food at or above 140 F and cold items served at specified lower temperatures.
Failure to Monitor Cold Storage Temperatures
Penalty
Summary
The facility failed to monitor refrigerator and freezer temperatures used to store residents' food. During a concurrent interview and record review with the Dietary Supervisor, the Refrigerator and Freezer Temperature Log showed that temperatures were supposed to be taken in the a.m. and p.m., but there was no a.m. temperature recorded on 12/31/25, no p.m. temperature recorded on 11/29/25, and no a.m. temperature recorded on 10/31/25. The Dietary Supervisor stated the temperatures should have been taken but were not. The facility policy titled, Cold Storage Temperature Monitoring and Record Keeping, stated that Food and Nutrition staff shall review and record temperatures of all refrigerators and freezers and record and initial the temperatures at the beginning of the AM and PM shifts.
Failure to Use Required PPE and Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to follow infection control practice when two staff members provided high-contact care to a resident on enhanced barrier precautions without wearing the required gown. During a concurrent observation in the resident’s room, a CNA and a PTA were providing direct care to a resident with a gauze dressing on the right lower leg, and neither was wearing a gown. The CNA stated she should have looked at the sign and used a gown before providing care. The resident’s physician orders indicated enhanced barrier precautions with gowns and gloves for high-contact resident care due to a colonized MDRO, and the facility’s policy stated that gowns and gloves are to be applied prior to high-contact care and that EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO. The facility also failed to follow its policy for handling soiled linen for a resident who was incontinent of bowel and bladder. During observation, a CNA changed the resident’s bed linen and placed bowel movement-soiled sheets on the floor at the bedside leading toward the entry door while providing care. The CNA stated the soiled linens were placed on the floor but should not have been because it could spread infection. The infection preventionist stated soiled bed linen should be rolled off the mattress and placed directly into a designated container and should not be placed on the floor. The facility’s policy stated used or soiled linen should be collected at the bedside, placed in a linen bag or designated receptacle, and not allowed to touch the uniform or floor.
Psychotropic Medication Given Without IDT Approval and Consent
Penalty
Summary
The facility failed to follow its Psychotropic Medication Use policy for one resident when trazodone was administered at 50 mg nightly for 50 days without interdisciplinary team approval and without consent. The resident had been admitted with diagnoses including muscle weakness, history of falling, unspecified dementia, and depression. A BIMS score of 4 was documented, and during interview the resident was alert but confused and could not provide meaningful responses. Record review showed the resident had been started on trazodone 25 mg in 2023 for depression manifested by inability to sleep. In May 2025, a psychiatric follow-up recommended decreasing trazodone from 50 mg nightly to 25 mg nightly, and the resident remained on 25 mg until a hospital transfer in July 2025. The hospital discharge plan indicated trazodone 25 mg nightly, but when the resident returned to the facility, the medication reconciliation form entered trazodone as 50 mg nightly instead of 25 mg. The facility’s IDT did not meet to discuss the increase until 18 days later, and consent for the 50 mg dose was not obtained until 50 days after the medication was increased. The interim medication regimen review noted that consent should be obtained for trazodone 50 mg nightly. The DON stated the error in not obtaining consent was discovered in September 2025 and that the facility did not follow its psychotropic medication policy for obtaining IDT review and consent.
G-Tube Placement and Medication Flush Not Followed
Penalty
Summary
The facility failed to follow the steps for checking G-tube placement before administering two crushed medications to Resident 79. Resident 79’s order summary dated 1/1/25 directed staff to check tube placement every shift by gastric aspiration of contents, report residuals greater than 100 cc, and flush with 15 cc of water before and after each medication. During a concurrent observation and interview on 2/25/26 at 12:35 p.m., LVN 2 administered the medications in Resident 79’s room without checking stomach residual after verifying G-tube placement and did not give 15 ml of water between the two medications. LVN 2 stated she did not check residual after checking placement of the G-tube and did not give the water between the medications. The DON stated that flushing between medications is basic nursing and an expectation for staff.
Failure to Re-Assess and Monitor Ongoing Forearm Bruise
Penalty
Summary
The facility failed to ensure services met professional standards of quality when nursing staff did not re-assess and monitor a resident’s right forearm bruise after the initial monitoring period ended. The resident was admitted with discoloration (bruising) to both forearms, and a skin re-assessment the following day documented a right forearm bruise measuring approximately 6 cm by 5 cm. The treatment record for the month showed that the bruise was monitored only until a monitoring order was completed on 1/23/26, after which no further re-assessments were documented, despite the bruise still being present. During interview and concurrent record review, the treatment nurse confirmed the resident had been admitted with the right forearm bruise, acknowledged that facility practice was to re-assess skin bruises after completion of the monitoring order to ensure they were not new or worsening, and verified that the bruise remained present but was not re-assessed as required. Review of the facility’s undated Skin Assessment policy indicated that a full body, head-to-toe skin assessment was to be conducted on admission/re-admission, daily for three days, and weekly thereafter, which was not followed for this resident’s ongoing bruise.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, labeling, and sanitation practices. In the dry food storage room, a package of hamburger buns was found with a date indicating it was 12 days old, exceeding the facility's guideline of using bread within five to seven days. In the walk-in refrigerator, several food items, including bowls of apple crisp, containers of pudding, mixed fruit, and sliced cheese, were not labeled or dated. Additionally, a large container of orange juice was labeled with an outdated date, and a container of tomato soup and a half-gallon of buttermilk were found past their recommended use or expiration dates. The Dietary Supervisor confirmed that these items should have been labeled, dated, and disposed of according to facility policy. Further observations in the walk-in freezer revealed opened boxes of chopped spinach, beef steaks, and broccoli that were left open to air and lacked open dates. In the kitchen, the steam table used for keeping food hot during meal service was found with food debris on and between the compartments, as well as inside them. The Registered Dietitian acknowledged that the steam table should have been wiped down at least once daily and as needed, and that the covers should be washed daily. Review of facility policies confirmed requirements for labeling, dating, and proper storage of food, as well as maintaining cleanliness of kitchen equipment, which were not followed in these instances.
Failure to Implement Scheduled Toileting and Bowel/Bladder Retraining for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at high risk for falls and had a history of falls related to toileting needs. The resident had severe cognitive impairment, was dependent for toilet transfers, and was frequently incontinent. The care plan included scheduled toileting and bowel and bladder retraining, with specific instructions to offer toileting assistance every two hours and as needed. Despite these interventions being documented in the care plan, there was no evidence that the bowel and bladder retraining was consistently implemented or documented. The resident experienced multiple unwitnessed falls while attempting to use the bathroom independently, as documented in progress notes. Staff interviews revealed that some CNAs were unaware the resident was on a bowel and bladder retraining program, and the required task was not properly triggered in the point of care (POC) system for documentation. The Director of Nursing confirmed that the retraining intervention was not correctly implemented in the POC prior to the resident's final fall. The lack of consistent implementation and documentation of the scheduled toileting intervention contributed to the resident continuing to attempt independent toileting, resulting in repeated falls. On one occasion, the resident fell after going to the bathroom independently and sustained an acute left femoral neck fracture, which required hospitalization and surgical repair. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as monitoring and documentation of interventions. However, the failure to implement and document the bowel and bladder retraining as outlined in the care plan led to the resident's continued risk and eventual serious injury.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician when a resident developed bluish discoloration to the left foot, as documented in multiple progress notes over several days. Despite repeated observations of the discoloration and edema by various LVNs, there was no evidence that the physician was informed until the resident's daughter requested hospital evaluation. The facility's own policy required physician notification for significant changes in a resident's condition, such as clinical complications or deterioration in health, but this was not followed. As a result, the resident's nondisplaced fracture of the left great toe went unrecognized by the facility until after the delayed notification and subsequent hospital evaluation. Interviews with nursing staff confirmed that the discoloration was observed and documented, but the physician was not notified in a timely manner. The Assistant Director of Nursing also acknowledged the lack of timely physician notification, consistent with the facility's policy.
Failure to Schedule Wound Clinic Follow-Up per Physician Order
Penalty
Summary
The facility failed to follow a physician's order for a resident who was discharged from the hospital with multiple wounds, including an unstageable wound to the right buttocks and stage 3 wounds to the left buttock and sacrum. The discharge instructions specified that the resident should have a follow-up appointment at a wound healing clinic to resume grafix (skin graft) and wound vac therapy. However, interviews with the wound nurse, a registered nurse, and the Director of Nursing revealed that there was no documented evidence that this follow-up appointment was scheduled. The review of the resident's clinical record and order summary confirmed the presence of the physician's order for the wound clinic follow-up, but staff were unaware of the order and could not find any documentation that the appointment was made. The facility's policy indicated that written transfer orders from a hospital should be implemented without further validation, yet this order was not carried out. This lapse had the potential for the resident's wound to worsen.
Failure to Complete SBAR and Monitor Resident After Hip Dislocation
Penalty
Summary
The facility failed to follow its policy and procedure for managing a change in condition for one of three sampled residents who experienced a dislocated hip. Specifically, staff did not complete an SBAR (Situation, Background, Appearance, Review and Notify) form to notify the physician of the change in condition, nor did they monitor the resident for changes after the dislocation was identified. Progress notes indicated that the dislocation was discovered via X-ray, and the physician was notified, but there was no documentation of detailed observations or use of the SBAR communication tool as required by facility policy. Additionally, the resident, who had a history of spontaneous hip dislocations, continued to experience pain and was eventually sent to the emergency room for further evaluation and treatment at the request of the family. The Director of Nursing confirmed during interview and record review that there was no completed SBAR or evidence of monitoring for the resident following the dislocation. The facility's policy required nurses to gather and document pertinent information using the SBAR form and to record changes in the resident's condition in the medical record, which was not done in this case.
Failure to Follow Physician Orders for Blood Sugar Notification and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with diabetes and osteomyelitis. Specifically, the resident had multiple blood sugar readings greater than 400, as documented in the Medication Administration Records (MAR) over several months. Despite physician orders to notify the physician if blood sugar exceeded 400, there was no documentation that the physician was notified on any of these occasions. The Director of Nursing (DON) confirmed that there was no evidence of physician notification as required by the orders. Additionally, the same resident was prescribed ceftriaxone to treat a chronic bone infection (osteomyelitis) in the left ankle and foot. The MAR indicated that the resident did not receive the antibiotic on three specific dates, and there was no documentation to confirm administration. The DON acknowledged that if medication administration was not documented, there was no way to verify that the resident received the prescribed treatment. Facility policies reviewed indicated that medications should be administered and documented according to prescriber orders, and that staff should report issues affecting diabetes management.
Therapeutic Diet Not Followed for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a therapeutic menu was followed for one of three sampled residents who was prescribed a consistent carbohydrate (CCHO) and no added salt (NAS) diet for diabetes management. According to the resident's physician orders and the dietary spreadsheet, the resident was to receive vanilla mousse without chocolate chips. However, during observation, the resident was served vanilla mousse pudding with chocolate chips, which was confirmed by a CNA. The Dietary Services Supervisor acknowledged that the resident should not have been served the dessert with chocolate chips. The facility's policy requires that menus for therapeutic diets comply with physician orders and the diet manual, which was not followed in this instance.
Failure to Provide Restorative Nursing and Therapy Services Resulting in Decline
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, type 2 diabetes mellitus, and a history of transient ischemic attack, was not provided with a restorative nursing program as recommended by physical therapy upon discharge from PT services. The physical therapist recommended a bed mobility restorative program to maintain the resident's current level of function and prevent decline, but there was no evidence that physician orders for the program were entered, nor was there documentation that the program was implemented. Interviews with staff confirmed that the restorative nursing program was not provided, and no care plan was developed for it. Additionally, the resident did not receive physical therapy and occupational therapy evaluations and treatments as ordered by the physician on two separate occasions. Although an OT evaluation was completed, no subsequent OT or PT treatments were provided due to insurance coverage issues, and the resident was dropped from therapy services. The lack of therapy interventions and restorative nursing support led to a documented decline in the resident's bed mobility and functional abilities, as evidenced by subsequent MDS assessments showing increased dependence and impairment in range of motion. Facility policy required that staff and physicians assess and respond to changes in resident function, collaborate on care plans, and ensure appropriate rehabilitative or restorative interventions. However, communication failures between nursing and therapy staff resulted in missed opportunities to intervene when the resident's condition declined. The DON and DOR acknowledged that the necessary programs and treatments were not implemented as ordered or recommended, and documentation supporting the provision of these services was absent.
Failure to Follow Physician Orders for Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that physician orders for wound care were followed for a resident with multiple wounds, including diabetic blisters, surgical scars, and areas of skin breakdown. Review of the Treatment Administration Records (TARs) over several months revealed that wound care treatments and monitoring were not consistently documented as completed according to physician orders. Specific dates showed blanks on the TARs, indicating that required treatments and monitoring for wounds, such as cleansing, application of medications, and pressure relief interventions, may not have been performed as ordered. The resident had a complex medical history involving wounds on the abdomen, heels, sacrum, and lower extremities, with orders for daily wound care, use of specialized support surfaces, and regular monitoring for signs of infection or worsening condition. Despite these orders, the TARs for multiple months contained numerous instances where documentation was missing for wound care treatments and monitoring. The Director of Nursing confirmed that if the treatment was not documented, there was no way to verify whether it had been completed. Facility policies required that all wound care provided be recorded in the resident's medical record, including the type of care, date and time, and the name and title of the person performing the care. The lack of documentation and potential omission of ordered treatments had the potential for the resident's wounds to worsen, as there was no assurance that the necessary care was provided as prescribed.
Failure to Timely Check Blood Glucose Levels
Penalty
Summary
The facility failed to ensure professional standards of care for a resident when blood glucose levels were not checked timely as ordered by the physician. The resident, who had intact cognition with a BIMS score of 15, reported that her blood sugar was supposed to be checked four times a day, before each meal and at bedtime. However, the resident stated that the RN often checked her blood sugar either while she was eating or after she had finished, resulting in higher readings and subsequent administration of more insulin. This was confirmed by the Licensed Vocational Nurse, who stated that the facility protocol and physician's order required blood sugar checks prior to each meal to avoid inaccurate readings. A review of the resident's medication administration record from late February to early March revealed multiple instances where blood sugar checks were conducted late, ranging from over an hour to nearly five hours past the scheduled time. The Director of Nursing confirmed these findings and acknowledged that the checks were not performed as ordered. The RN mentioned that the resident preferred to have her blood sugar checked before dinner, but logistical issues, such as the resident being in the dining area far from her room, contributed to the delays. The facility's policy on insulin administration emphasized the importance of checking blood glucose per physician order or facility protocol, which was not adhered to in this case.
Failure to Complete Medication Administration Competency Assessment
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) underwent a medication administration competency assessment, which is a requirement for all nursing staff upon hire according to the facility's policy. The RN was hired on December 30, 2024, and had been working at the facility for approximately three months without this assessment being completed. During an interview, the RN confirmed that he had not been assessed for medication administration competency. The Director of Nurses (DON) also confirmed the absence of this assessment in the RN's employee file, acknowledging that it was the facility's practice to complete such assessments upon hire. This oversight had the potential to lead to medication errors and unmet care needs.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with dementia, who was at high risk for elopement and had a history of elopement. The resident was able to leave the facility without staff awareness, as noted in a progress note dated 11/2/24. The resident was found approximately one mile away from the facility by a staff member who brought him back. The resident's elopement risk was documented in evaluations dated 5/1/24, 7/19/24, and 10/11/24, and the resident had a moderate cognitive impairment as indicated by a BIMS score of 12 on a quarterly MDS dated 9/13/24. Interviews with staff revealed that on 11/2/24, a CNA was unable to locate the resident within the facility, and the resident was eventually found walking on the side of the road. Another resident had observed the elopement, noting that the resident pushed the door open and left the facility. The facility's policy on safety and supervision emphasized the importance of resident supervision based on individual needs and environmental hazards, which was not adequately followed in this case.
Failure to Update Care Plans and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its policy and procedure on comprehensive person-centered care plans for a resident, identified as Resident 341, who was at high risk for falls. Despite being diagnosed with metabolic encephalopathy, difficulty in walking, and muscle weakness, and having significant cognitive impairment, the facility did not update the resident's care plan following multiple fall incidents. The resident experienced several falls over a six-month period, resulting in serious injuries, including fractures to the left hip and shoulder, which required surgical intervention. The facility's Director of Nursing (DON) confirmed that after each fall, the care plan should have been updated, and new interventions should have been implemented. However, the care plan was not revised after several fall incidents, and there was no evidence of interdisciplinary team (IDT) meetings being conducted to address the root causes of the falls. Additionally, recommendations from interim medication regimen reviews (IMRR) were not implemented, and there was a lack of evidence of frequent rounding or monitoring as advised. The facility's policies on care plans and falls were not followed, as the staff failed to gather data, sequence events properly, and consider the relationship between the resident's problems and their causes. The facility did not monitor or document the resident's response to interventions intended to reduce falls, nor did they re-evaluate the situation when the resident continued to fall. This lack of adherence to protocols and failure to implement necessary interventions contributed to the resident's repeated falls and subsequent injuries.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding Advance Directives, as evidenced by the absence of Advance Directives in the medical records of 26 out of 30 sampled residents. This deficiency was identified through interviews and record reviews, revealing that many residents did not have documented Advance Directives, which are crucial for understanding and respecting their healthcare wishes. The Admission Coordinator (AC) acknowledged the importance of Advance Directives and confirmed that several residents, including Resident 341, Resident 292, and others, did not have these documents in their records. Additionally, some residents, like Resident 63, had incomplete or unsigned Advance Directives, further indicating a lapse in the facility's process. Interviews with residents and family members highlighted a lack of awareness and documentation regarding Advance Directives. For instance, Resident 292 and Family Member 1 did not recall being offered or signing an Advance Directive. Resident 63, despite having an Advance Directive with her initials, did not remember completing the form or her wishes. The AC admitted that the form had not been available when she started working at the facility and that there was no documentation of the process to ensure residents or their representatives were asked about Advance Directives. The facility's policy, dated 2022, emphasizes the resident's right to formulate an Advance Directive, but the lack of adherence to this policy was evident in the findings.
Failure to Change Soiled Bed Linen
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Laundry and Bedding, Soiled,' when a resident's bed linen was observed with brown stains. During an observation and interview, a family member noted that the bed linen had been dirty for two days, expressing discomfort with the situation. Housekeeping staff confirmed the presence of dried brown spots on the linen and stated that it was the responsibility of the Certified Nursing Assistant (CNA) to change the bed linen. Further interviews revealed that the CNA identified the brown spots as feces and acknowledged the need for the linen to be changed. The Infection Preventionist also confirmed that the bed linen should have been changed immediately, as dirty linen is unacceptable. The facility's policy indicates that soiled laundry should be handled and processed according to best practices for infection prevention and control, treating all used laundry as potentially contaminated.
Failure to Provide Adequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for supporting activities of daily living, specifically oral care, for a resident who was unable to perform these tasks independently. The resident, who had a history of stroke with hemiplegia and was fed via a gastrostomy tube, was dependent on staff for oral hygiene. Despite the care plan indicating the need for oral care every shift, observations revealed that the resident's lips and teeth were covered with a brown film, and their lips were dry and cracked, indicating neglect in oral care provision. Interviews with staff and family members further highlighted the deficiency. A Licensed Vocational Nurse acknowledged that oral care should have been completed earlier in the day, while a family member reported consistently finding the resident's mouth in a crusted state. The Director of Nursing confirmed that oral care should be performed multiple times daily for residents not taking anything by mouth, with moisturizing required at least every two hours. The facility's policy, dated March 2018, mandates that residents unable to perform activities of daily living independently receive necessary services, including oral hygiene, in accordance with their care plan.
Deficiencies in Enteral Feeding Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure for enteral feedings, resulting in two deficiencies for a resident with a gastrostomy tube (G-tube). The first deficiency involved the failure to label the enteral nutrition feeding bottle with the resident's name, date, or time, as observed during an inspection. This oversight was acknowledged by the Licensed Vocational Nurse (LVN) present, who admitted uncertainty about when the bottle was hung. The Director of Nursing (DON) confirmed that the bottle should have been labeled according to the facility's policy, which mandates documentation of the initials, date, and time the formula was hung. The second deficiency was observed when the enteral tubing was disconnected from the G-tube site, and the three-way valve was left open, causing stomach contents to leak onto the resident's abdomen and clothing. This was noted by the LVN, who recognized the potential harm to the resident's skin integrity. The DON stated that the valve should have been closed whenever the feeding tube was disconnected. The facility's policy emphasizes the importance of preventing misconnection errors and maintaining skin integrity by keeping the exit site clean and dry, and regularly inspecting tubing connections.
Failure to Implement Pharmacy Recommendations After Resident Falls
Penalty
Summary
The facility failed to implement pharmacy recommendations for a resident after multiple falls, as identified during a review of the resident's Interim Medication Regimen Reviews (IMRRs) dated over several months. The IMRRs consistently recommended conducting a basic metabolic panel (BMP), thyroid-stimulating hormone (TSH) test, monitoring blood pressure (BP) and heart rate (HR), and checking orthostatic blood pressures every shift for three days. Additionally, the IMRRs advised notifying a medical doctor if the resident experienced orthostasis. Despite these recommendations, the Director of Nursing (DON) was unable to provide evidence that these actions were implemented. The facility's policy and procedure for Medication Regimen Review and Reporting, dated September 2018, outlines the necessity of acting upon resident-specific medication regimen review recommendations to prevent, identify, report, and resolve medication-related problems. However, the facility did not follow through on these recommendations for the resident, which could have left staff unaware of potential adverse consequences from the resident's medication regimen. This oversight was confirmed during an interview and record review with the DON, who acknowledged that the IMRR recommendations should have been implemented.
Failure to Provide Adaptive Equipment for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident, identified as Resident 52, who required assistance with drinking water due to contractures in both hands. Observations and interviews conducted over several days revealed that Resident 52's water cup was consistently placed out of reach, and the resident expressed difficulty in drinking without spilling. Despite the resident's condition, which was documented in the Minimum Data Set (MDS) and Care Plan, indicating a need for partial assistance and an adaptive device, no such device was provided. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Minimum Data Set Nurse (MDSN), confirmed the resident's inability to independently access water due to hand contractures. The Occupational Therapist (OT) also noted that the resident should have been evaluated for adaptive devices. The facility's policy on Activities of Daily Living (ADL) emphasized the provision of care and services to maintain residents' abilities, yet this was not adhered to in the case of Resident 52, leading to the resident's dependency on staff for hydration.
Inadequate Staff Training on Elopement Risks
Penalty
Summary
The facility failed to ensure that staff were adequately in-serviced on the elopement binder, which is crucial for identifying residents at high risk for elopement. During a review of the Elopement Binder, it was found that several residents were identified as high risk for elopement. However, interviews with various Certified Nursing Assistants (CNAs) revealed a lack of awareness regarding which residents were at risk. CNA 1 was unaware of the residents at risk, while CNA 2 believed all residents were at risk. CNA 3 stated there was no way to know who was at risk without a meeting or in-service, and CNA 4 relied on word of mouth for this information. CNA 5 mentioned needing to ask other staff about the residents at risk. This indicates a significant gap in communication and training regarding elopement risks. The Administrator acknowledged that only 19 out of approximately 100 employees attended the last in-service training on elopement risk, which was deemed unacceptable. The facility's policy and procedure on elopements and wandering residents emphasized the need for a systematic approach to managing residents at risk, including adding interventions to care plans and communicating these to staff. Despite this policy, the lack of consistent training and communication led to staff being unaware of the elopement binder's existence or its contents, potentially compromising resident safety.
Resident Dignity and Respect Violation by CNA
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a Certified Nursing Assistant (CNA 1) used foul language and dismissive gestures towards the resident. This incident was witnessed by two other staff members, CNA 2 and CNA 3, during the night shift. CNA 1 was reported to have used offensive language and shooed the resident away with her hands, which resulted in the resident becoming agitated. The resident, who has a diagnosis of Lewy body Dementia and a severely impaired cognition score, was unable to respond appropriately to questions during an observation. The incident was documented in the Nurses Notes, where it was noted that CNA 1 used inappropriate language towards the resident at around 10:45 p.m. CNA 2 and CNA 3 confirmed the use of foul language and disrespectful behavior by CNA 1. CNA 1 admitted to using foul language and shooing the resident away, acknowledging that it was inappropriate. The facility's policy and procedure on Resident Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Porterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoia Transitional Care | 0.6 mi | ★★★★★ | 12 | 0 |
| Sierra View Medical Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Sierra Valley Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Gateway Post Acute | 1.6 mi | ★★★★★ | 0 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 10.3 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River Walk Care Center.
100% money-back within 48 hours.
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.