Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
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 Riverwood Health Care during CMS and state inspections, most recent first.
The facility failed to prevent resident-on-resident physical abuse when two roommates with a known history of arguments were left together without adequate interventions, resulting in one resident with severe cognitive impairment and multiple neurologic conditions being struck in the back of the head by the other resident. Staff had prior knowledge that one resident became easily agitated and that the pair had repeated disagreements over lights and TV volume, but these behaviors and conflicts were not documented or care planned. On the day of the incident, a CNA heard yelling, temporarily separated the residents and notified an LN that they should be kept apart, but after returning the cognitively impaired resident to the shared room, the other resident got up from bed and hit him from behind, leading to staff intervention and post-incident assessment.
Two residents with a history of disagreements were involved in an incident where one struck the other in the back of the head after staff had earlier observed and reported escalating verbal conflict and suggested the residents be separated. The subsequent abuse investigation was incomplete: only two staff were interviewed with no follow-up questions, prior arguments and behavioral concerns were not documented or reported, and the incident itself was not entered into the medical records. The DON, who had no prior training or experience in conducting abuse investigations, shared limited investigative duties with the ADON, resulting in a failure to uncover prior incidents or fully understand the events leading to the abuse, contrary to the facility’s abuse policy requiring thorough investigation and documentation.
The facility failed to timely notify the State Agency (SA) of a change in the DON position for a census of 85 residents. The DON began the role but the required change-of-DON application and written notice were not completed and mailed until weeks later, as confirmed by the DON’s and acting ADM’s interviews and the dated documents. The ADM reported being unaware of the required timeframe for notification, and SA records showed the DON application was received several days after it was mailed, delaying SA verification of the DON’s qualifications.
A resident with multiple comorbidities was admitted on oxygen and IV antibiotics with hospital discharge orders for oxygen at 2 L/min for SOB or low O2 saturation with immediate MD notification, and weekly CBC and Chem 7 labs. The weekly CBC order was never transcribed into facility orders, and there was no evidence that CBCs were drawn. One morning, the resident complained of SOB and had an O2 saturation of 88%; an LVN administered ordered albuterol and independently increased oxygen from 2 L/min to 4 L/min, despite regulations prohibiting LVNs from adjusting oxygen flow and facility policy requiring prompt MD notification for significant changes in condition. The LVN did not notify an RN or the MD/NP of the change in condition, and there was no oxygen therapy care plan in place. Later that morning, the NP found the resident unresponsive with CPAP still on, initiated a code, and EMS pronounced the resident deceased, with the MD and NP confirming they had not been notified earlier of the resident’s SOB and low O2 saturation.
A resident admitted with multiple complex conditions, including sepsis, sleep apnea, and morbid obesity, arrived with hospital discharge instructions and MD orders for continuous O2 at 2 L/min via nasal cannula and specific parameters for use and physician notification. Although the facility noted and carried out the hospital discharge orders and had a policy requiring a baseline care plan within 48 hours that includes necessary healthcare information, the baseline care plan summary did not include O2-related interventions or instructions. The DON confirmed that no specific O2 care plan was developed for this resident, resulting in a failure to create a person-centered baseline care plan for oxygen therapy.
Unsafe food storage and unsanitary kitchenware were observed in the kitchen. Multiple produce items in the walk-in cooler were spoiled or moldy, onions were found with black spots, soft texture, and small black bugs, and several cutting boards and tray line pans had food residue and dried soil. In addition, 11 of 30 tray line pans were found wet in ready-to-use areas, and the RD stated the items were not acceptable for use.
Broken window blinds were found in 5 of 41 resident rooms, including blinds that were missing, twisted, dented, or had broken slats. An LPN confirmed the damaged blinds were a dignity issue and that gaps in the closed blinds allowed people outside to look into the room, while a CNA stated one set of broken blinds had not been reported to the DES. The DES confirmed the damage in all five rooms and stated staff had not notified him, and an RP reported one room's blinds had been broken for two weeks.
Unsafe handling of hazardous drugs, improper BP device use, and delayed blood sugar monitoring were observed. An LPN administered a hazardous medication without gloves, and several hazardous meds, including a topical product, were stored without clear HD labeling or proper separation. Staff also used a personal BP device when the facility device was not working, despite the DON stating staff-owned devices were not allowed. In another observation, an LPN checked a resident’s blood sugar after the resident had already eaten most of the meal, even though the MAR ordered glucose checks before meals.
Safe pharmaceutical services were not maintained when opened emergency medication kits in the med room did not match the kit logs, including an IV Ekit with undocumented contents and an opened D50% box, while the refrigerator Ekit also lacked documented use. A personal purse was stored on the med room counter near prescription and controlled drugs, and delivery records for controlled and non-controlled meds, including methadone, hydrocodone/APAP, and zolpidem, were not signed by licensed staff upon receipt.
Staff failed to follow infection control practices in several areas. A resident’s kidney basin was stored with clean dishes in the kitchen, a cook handled a phone and clothing with gloved hands during tray line service without hand hygiene, a shared glucometer was not cleaned and disinfected per manufacturer instructions between residents, and a pill cutter with residue was used without being cleaned before and after use.
A CNA failed to treat a resident with dignity during care by referring to him as a "feeder" instead of using his name or respectful language. The resident had dysphagia and an anxiety disorder. The ADON and DON stated staff are expected to speak respectfully and avoid labeling residents, and the facility policy requires care that promotes self-worth and self-esteem.
A resident had multiple OTC medications and supplements found at the bedside, including herbal remedies, foreign-labeled products, and vitamin gummies, without any physician order to keep or administer them. The LPN was unaware of the items, and the EMR showed no orders for bedside storage or use; the DON stated the resident had been in the facility for one week when the unauthorized medications were discovered and that a care conference should have been held for medication reconciliation.
Unattended Computer Screen Exposed Resident Medical Information: An LPN left a computer unattended in the dining room with a resident's medical information visible on the screen to anyone passing by. The LPN stated the screen should have been locked before stepping away, and the DON confirmed staff were expected to lock the screen to protect resident information from unauthorized access.
Medication and treatment supply storage practices were not maintained in multiple carts and the medication room. Surveyors found an undated Humalog insulin pen in a med cart, opened Aplisol vials and an opened Timolol eye drop bottle without open-date markings in the med room, and an open sterile ComfortFoam packet plus DermaSeptin Ointment packets without expiration dates in a treatment cart. Staff acknowledged the findings, and the DON stated nursing staff were expected to date products when first opened when they have a limited beyond-use date.
Staff, including CNAs and LNs, used a group messaging app on personal smartphones to communicate resident names, room numbers, and medical information, despite the app not being HIPAA-compliant. The DON and ADM acknowledged that the app lacked necessary security controls, and staff were not required to report lost or stolen phones, increasing the risk of unauthorized access to PHI. Facility policy required protection of resident information, but the use of this app directly contradicted those requirements.
Two residents at risk for elopement were not adequately protected due to the facility's failure to implement necessary prevention measures. A resident with dementia exhibited exit-seeking behavior, but the facility did not initiate orders for a wander guard or conduct an elopement risk assessment. The resident's wander guard was not functioning, leading to an elopement and injury. Another resident was found with an expired wander guard, highlighting lapses in monitoring and maintenance of safety devices.
The facility failed to follow safe injection practices by storing pre-drawn, unlabeled flu vaccine syringes in a staff food refrigerator. Additionally, pneumonia vaccines for three residents were documented as administered but were found in the refrigerator intended for medication destruction. The facility did not adhere to its policies on vaccine documentation and storage, leading to these deficiencies.
The facility failed to ensure safe medication use and destruction practices, including undated and unsigned medication destruction logs, improper storage of discontinued medications, and discrepancies in vaccine administration records. These issues could lead to drug diversion and unsafe drug use.
The facility failed to ensure safe medication storage, with prescription medications and vaccines improperly stored in a dorm-style refrigerator alongside personal food items, without temperature monitoring or proper labeling. Additionally, discontinued medications were found in an active storage area in the main medication room. The DON and ADON were unaware of these practices, which violated the facility's policies on medication storage and disposal.
A facility failed to provide a written discharge notice to a resident's responsible party, resulting in a deficiency. The RP was verbally informed of the discharge when the resident was sent to the hospital, but no written notice or information on appeal rights was provided. The facility administrator confirmed the lack of documentation in the resident's medical record.
A resident with multiple diagnoses was sent to a hospital on a 5150 hold due to aggressive behavior. The facility failed to reassess the resident's condition or communicate with the hospital about the resident's needs for returning. Interviews and hospital notes revealed a lack of documentation and communication, potentially impacting the resident's psychosocial well-being.
The facility exceeded the acceptable medication error rate, with two residents receiving plain multivitamins instead of the prescribed multivitamins with minerals. The errors were made by an LVN who was unclear about the different types of multivitamins, despite clear physician orders. The DON and Administrator emphasized the need for staff to accurately follow medication orders.
A facility failed to follow physician's orders for a resident's medication administration, leading to carvedilol being given when the resident's SBP was below 130 mmHg and midodrine when SBP was above 120 mmHg. Nursing staff misunderstood the parameters, resulting in multiple instances of incorrect medication administration.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. Despite training and posted signage, a CNA entered the resident's room wearing only gloves and a mask, omitting the required gown. The Director of Nursing and Administrator confirmed that staff had been trained on EBP and expected to follow the PPE guidelines.
A facility failed to carry out a physician's order to reduce a resident's gabapentin dosage, resulting in the resident refusing several doses and leaving the facility against medical advice. The ADON and DON confirmed that the order was communicated but not executed, and the nurse should have checked the physician's note and clarified the order.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. Resident 2, who had epilepsy, depression, muscle weakness, unsteadiness on feet, and a traumatic brain injury, and who was assessed with a BIMS score of 7 indicating severe cognitive impairment, was sharing a room with Resident 1. Staff were aware that Resident 1 could become easily agitated, upset, and rude, and that the two residents had a history of disagreements and arguments about lights and television volume at night. These prior conflicts were not documented or reported in the medical record, and no behavior concerns for Resident 1 were care planned or communicated to leadership. On the day of the incident, CNA 1 was preparing Resident 2 for a shower when Resident 1 began yelling at Resident 2. CNA 1 moved Resident 2 into the hallway to prevent escalation and notified Resident 1’s nurse that Resident 1 was upset and yelling, and that the residents should be separated. CNA 1 then escorted Resident 2 to the shower and returned with him about 15 minutes later. She positioned Resident 2 in his wheelchair in front of his bed toward the back of the room, with his back to the door and to Resident 1’s bed, while she stood along the back wall at Resident 2’s nightstand. While CNA 1 was at the nightstand, she observed Resident 1 get up from his bed, approach Resident 2 from behind, and hit him in the back of the head with a fist. CNA 1 called for help, and staff responded and separated the residents. LN 1 arrived and saw Resident 1 standing between the two beds; both residents were yelling, and Resident 2 reported he had been “sucker punched” in the back of the head and was upset. LN 2, the nurse assigned to both residents that day, later assessed Resident 2 for injuries; Resident 2 stated that Resident 1 came over and hit him in the back of the head and appeared surprised, scared, and startled. The DON and Social Services Director confirmed there was no documentation of prior disagreements or behavior issues in either resident’s record, despite staff knowledge of previous arguments and Resident 1’s tendency to become easily agitated.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident abuse following an incident in which one resident hit another. On the day of the incident, a CNA reported that while preparing one resident for a shower, she heard the roommate yelling and upset, moved the resident into the hallway to prevent escalation, and notified the assigned nurse that the residents should be separated. After completing the shower and returning the resident to the room, the CNA observed the roommate get up from his bed and strike the resident in the back of the head with a closed fist, then called for help and staff separated the residents. The assigned nurse later confirmed he was told the residents were fighting and that the struck resident reported being hit in the back of the head, but he did not document the incident in either resident’s medical record because the ADON and DON were already present taking statements. The facility’s investigation was limited and did not capture key information about prior behaviors and conflicts between the two residents. The ADON confirmed that only two staff members were interviewed and that he asked the CNA only what happened and what she witnessed, without follow-up or clarifying questions, and he could not recall receiving formal training on taking statements or investigating abuse. Another CNA reported she had been told in morning report that the resident who later hit his roommate could become easily agitated, upset, and rude. A nurse reported that the two residents had a history of disagreements and arguments about lights and television volume at night, occurring a few times after they were roomed together, and that the resident who later hit his roommate was known to yell out for staff and be impatient; however, she did not document or report these prior arguments because she felt she had resolved them. The DON stated that when a nurse is notified of residents arguing, she expected the nurse to address it immediately to prevent escalation, and that it was her expectation that staff document and share all incidents between residents that could lead to abuse. Upon review of both residents’ medical records, the DON confirmed there was no documentation of previous disagreements between the two residents and no documented concerns with the aggressor’s behaviors, and she had no knowledge of any prior incidents between them. The DON was assigned by the previous Administrator to complete the abuse investigation and the five-day follow-up report to the State Agency, confirmed it was her first time fully completing an investigation, shared investigative duties with the ADON, and reported she had not been trained in how to complete an abuse investigation. The facility’s abuse policy required that suspected or alleged abuse be immediately reported, thoroughly investigated, and completely documented, with a verification of incident investigation report completed within five working days, but the investigation did not meet these standards and did not reveal several past incidents or provide a full picture of events leading to the abuse.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide timely written notice to the State Agency (SA) of a change in the Director of Nursing (DON) position for a census of 85 residents. The current DON reported in an interview that she began her role on 12/10/25 and that corporate staff requested her licensing information, but she did not know when the leadership change notification was sent to the SA. During a concurrent interview and record review, the acting Administrator (ADM) confirmed that the change-of-DON documents were dated and mailed on 1/7/26, rather than at the time the change occurred, and stated he was not aware of the time requirement for notification. A facility letter to the SA dated 1/7/26, signed by the DON the same day, referenced a “CHANGE OF DIRECTOR OF NURSING Application,” and SA database records showed the DON application was received on 1/13/26. This delay in notification postponed the SA’s verification that the DON was qualified to lead clinical services, which the report states had the potential to compromise resident safety and regulatory compliance for all 85 residents. The deficiency centers on the facility’s inaction in promptly notifying the SA of the DON change at the time it occurred, as required by rules on disclosure of ownership and administrative personnel changes. The DON’s start date, the later date of the application and mailing, and the ADM’s lack of awareness of the time requirement are specifically documented as the factors leading to the late reporting.
Failure to Provide Timely Respiratory Assessment, Physician Notification, and Lab Follow-Through After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate respiratory care, timely clinical assessment, and appropriate physician notification for a resident with complex medical conditions, including sepsis, facial cellulitis, type 2 diabetes, hypertension, morbid obesity, sleep apnea, and blindness. The resident was admitted from the hospital with discharge instructions that included oxygen at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification, and weekly CBC and Chem 7 labs after SNF admission. The facility signed that these hospital discharge orders were noted and would be carried out, but the weekly CBC order was never transcribed into the facility’s physician orders, and there was no evidence that CBC labs were ever drawn. The DON confirmed that the CBC order was not transcribed or completed, despite the resident being on IV antibiotics for infection. On the morning of the incident, the resident was in bed with CPAP and oxygen at 2 L/min via nasal cannula. Around change of shift, a CNA informed LVN 1 that the resident was complaining of shortness of breath and had an oxygen saturation of 88%. LVN 1 assessed the resident, confirmed shortness of breath and low oxygen saturation, administered two puffs of albuterol as ordered, and increased the resident’s oxygen from 2 L/min to 3 L/min and then to 4 L/min via nasal cannula, using her own nursing judgment. LVN 1 documented that the oxygen saturation improved to 94–95% by 8:15 a.m. and stated she remained in the room monitoring the resident until that time. LVN 1 acknowledged that this was a change in condition and that she did not notify the physician, explaining that she was passing medications and did not get the chance to call. The SBAR and progress notes showed that the physician was not notified of the change in condition until after the resident was found unresponsive. The facility’s DON stated that it was not within an LVN’s scope of practice to perform a full clinical assessment for a change in condition or to adjust oxygen flow rates under the updated respiratory care regulations. The DON confirmed that LVN 1 did not escalate the resident’s care to an RN for a full assessment and that LVN 1 should not have titrated the oxygen without a physician’s order. The DON also confirmed that there was no oxygen therapy care plan developed for the resident, despite the resident being on oxygen therapy. Later that morning, at approximately 10:10 a.m., the NP found the resident in bed unresponsive, with no pulse and no respirations, and the CPAP still in place even though the order specified CPAP off at 7 a.m. A code was called, CPR was initiated, and 911 was contacted, but paramedics pronounced the resident deceased at 10:26 a.m. The NP and Medical Director both stated that staff should not have titrated oxygen without an order and that they were not notified of the resident’s earlier change in condition involving shortness of breath and low oxygen saturation. The facility’s written policy on change in resident condition required prompt notification of the attending physician when there is a significant change in the resident’s physical condition, including specific instructions to notify the physician of changes in condition. The facility’s in-service education and regulatory guidance from the Respiratory Care Board and the Board of Vocational Nursing and Psychiatric Technicians specified that LVNs may not initiate or adjust oxygen liter flow or concentration and must work under the supervision of an RCP, RN, or physician. Despite these policies and regulations, LVN 1 independently adjusted the resident’s oxygen flow, did not notify an RN or physician of the change in condition, and the facility did not ensure transcription and implementation of the hospital’s weekly CBC orders. These combined failures resulted in the physician not being aware of the resident’s change in condition, a delay in adequate assessment and potential identification of the need for a higher level of care, and delay in adequate care and treatment, and the resident died within two hours of the documented change in condition.
Failure to Develop Baseline Oxygen Care Plan on Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the interventions and instructions needed to provide effective and person-centered oxygen therapy for a newly admitted resident. The resident was admitted with multiple diagnoses, including acute osteomyelitis, sepsis, cellulitis and abscess of the mouth, type 2 diabetes, essential hypertension, bilateral blindness, depression, sleep apnea, morbid obesity, and anxiety. Hospital inpatient discharge instructions directed that oxygen be started at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification for specified respiratory changes and abnormal findings. The facility signed the hospital discharge orders as noted and carried out, and the physician’s orders dated shortly after admission included continuous oxygen at 2 L/min via nasal cannula every shift. Despite these orders, review of the resident’s care plans showed that no oxygen care plan was developed. The DON confirmed during interview and concurrent record review that the resident was admitted with oxygen therapy and that the baseline care plan summary, which the facility used as the resident’s baseline care plan, did not include specific interventions and instructions for oxygen therapy. The DON acknowledged that a specific oxygen care plan was not developed for this resident. Review of the facility’s “Baseline Care Plan Summary” policy, revised in October 2025, indicated that the facility was required to develop and implement a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but this was not done for the resident’s oxygen needs.
Unsafe Food Storage and Unsanitary Kitchenware
Penalty
Summary
Safe food storage and preparation practices were not maintained in the kitchen for the 87 residents who ate facility-prepared meals. During observation in the walk-in refrigerator, multiple produce items were found in poor condition and confirmed by the Dietary Service Supervisor as not fit to be served, including mushy tomatoes with broken skin and fuzzy black and green substance, brown and soft lettuce with moisture at the base, brown and wilted celery, zucchini with black and white fuzzy spots, strawberries with a white fuzzy substance, and sprouted potatoes with dark brown spots and soft texture. The Registered Dietician stated the produce was expected to be free of mold, discoloration, and signs of breakdown and that compromised produce should be discarded. The onions stored in a white container were observed with black spots, circular discoloration, soft texture, and small black bugs crawling on them and flying within the container. The Dietary Service Supervisor confirmed the condition of the onions and the presence of bugs, and later confirmed more onions had been added to the container after a food delivery. The Registered Dietician stated the onions did not meet expectations, should have been discarded, and that the presence of bugs indicated the food was old and needed to be discarded. Kitchen equipment and food-contact surfaces were also found unclean and wet in ready-to-use areas. In the cook's preparation area, tray line pans had clear liquid and food particles, a green cutting board had multiple layers of dried orange-brown substance with fruit seeds, and a white cutting board had a dried brown substance. In another observation, 11 of 30 tray line pans stored under the kitchen preparation table and tray line table were wet. The Registered Dietician stated food particles on kitchenware were unacceptable and unsanitary, and that dishes and cookware should be washed, sanitized, and air dried.
Broken Window Blinds in Resident Rooms
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for 5 of 41 rooms when window blinds were broken in multiple resident rooms. During observation, broken blinds were seen in room [ROOM NUMBER], and a Licensed Nurse confirmed broken blinds in another room, stating they were a dignity issue and that the gaps in the closed blinds allowed anyone outside to look into the room. The nurse also confirmed that missing blinds created a lack of privacy. Additional observations found broken blinds in several other rooms, including blinds that were twisted, shorter than the window frame, dented, had broken slats, or had a slat broken and missing. A CNA confirmed broken blinds in one room and stated they had been broken since the morning of 9/10/25 and had not been reported to the Director of Maintenance Services. The DES confirmed the blind damage in all five rooms and stated staff had not notified him that the blinds needed repair. The Administrator stated staff were expected to enter missing or broken blinds into the maintenance logbook, and a Responsible Party stated one room's blinds had been broken for two weeks and anyone could see inside the room.
Unsafe handling of hazardous drugs, improper BP device use, and delayed blood sugar monitoring
Penalty
Summary
The facility failed to ensure safe handling of hazardous drugs during medication administration and storage. During an observed medication pass, an LPN administered divalproex sprinkle capsules to a resident without gloves, and the bubble pack did not have a hazardous drug alert label. The label only contained a small-font warning about pregnancy. The LPN stated she was not aware valproic acid was hazardous and required glove use, and said pharmacy labeling and MAR instructions would have helped her know to use gloves. During cart inspections, valproic acid for one resident and oxcarbazepine for another resident were stored on a medication cart without hazardous drug labeling. A treatment cart also contained tacrolimus ointment for another resident, and the ointment was not marked as hazardous to touch and was co-mingled with other topical products in the top drawer without being stored in a Ziplock bag. The DON stated nurses were expected to use gloves when handling hazardous medications and that pharmacy should label hazardous drugs and the MAR should include handling directions. The facility policy reviewed addressed chemotherapy drugs, but did not address other hazardous drugs. The facility also failed to ensure safe use of resident blood pressure devices. During a medication pass, an LPN used the facility BP device, stated it was not working, and then retrieved a personal BP device from the cart to measure a resident’s BP. Another LPN stated she kept her own BP device in the cart and would use it if needed. The DON stated the facility did not allow staff-owned or wrist-type BP devices because accuracy could not be guaranteed. The facility policy stated equipment would be maintained according to manufacturer instructions. The facility further failed to obtain a resident’s blood sugar before the meal as ordered. During an observed medication pass, an LPN checked the resident’s blood sugar when the meal tray was already in front of the resident and almost finished, then administered insulin. The LPN stated she was running behind and was late in measuring the blood sugar prior to dinner, and that the resident had already eaten about 80 percent of the meal when the blood sugar was checked. The MAR directed finger stick blood sugar before meals, and the DON stated staff were expected to check glucose levels before meals as ordered.
Medication Room Storage and Delivery Documentation Deficiencies
Penalty
Summary
Safe pharmaceutical services were not maintained in the main medication room when two opened emergency medication kits were reviewed and their contents did not match the kit records. The IV Ekit had a yellow seal tag showing it had been opened, but the binder did not show any documented use since 2/2025. The IV Ekit contained clindamycin IV that was not listed on the kit content list, and it also contained two zip-lock bags with two opened syringe boxes of D50% carpujet. The refrigerator Ekit was also opened, but the review did not show any items removed or documented use. The facility’s Ekit binder, titled Emergency Kit Pharmacy Log, did not contain nursing documentation of kit use after pharmacy delivery of new red-sealed kits. The DON stated that a yellow seal meant the kit had been opened and that removal of medication should have been documented on the pharmacy-provided Ekit sheet, with the yellow copy returned to the pharmacy and the white copy kept by the facility. The Consultant Pharmacist confirmed that all Ekit access should have been documented and stated the facility should have informed the pharmacy when the refrigerator Ekit seal was broken. The medication room also contained a dark-colored personal purse on the countertop below the discontinued drugs cabinet. The ADON stated staff could temporarily store purses in the medication room, while the DON and Consultant Pharmacist stated personal items such as purses should not be stored there because of diversion concerns. In addition, medication delivery records for prescription and controlled drugs were not signed by licensed staff upon receipt. The delivery sheets included controlled medications such as methadone, hydrocodone/APAP, and zolpidem, but the records had no signatures confirming acceptance, and the DON stated the forms should have been checked and signed when the drugs were delivered.
Infection Prevention Practices Not Followed During Kitchen, Tray Line, Glucometer, and Medication Tasks
Penalty
Summary
The facility failed to maintain proper infection prevention practices in multiple areas of care and service. During the initial kitchen tour, a kidney basin was observed stored with clean dishes in the kitchen. The Registered Dietician confirmed that the basin was a resident’s personal item, did not belong in the kitchen, and should have been thrown away once identified there. The Dietary Service Supervisor also stated the basin should not have been in the kitchen with the dishes. During lunch tray line service, a cook was observed handling her phone with gloved hands and then continuing to serve food without performing hand hygiene. The same cook was also observed repeatedly placing a gloved hand on her clothing while continuing tray line service without changing gloves or washing hands. The cook acknowledged touching her phone and clothing, stated she knew she was not supposed to do that, and said she should have removed her gloves and washed her hands after touching personal items. The RD stated that staff were expected to remove gloves, perform hand hygiene, and put on new gloves after touching clothing or personal items while serving or preparing food. During blood glucose monitoring, a nurse used the same glucometer for two residents and cleaned it with one bleach wipe for less than 5 seconds after each use. The nurse stated she had been trained to use one wipe to clean the glucometer, then wrap it with the same wipe and let it dry. The DON stated the facility’s policy was to follow the manufacturer’s instructions and that a two-step process using two different disinfectant wipes was important. The IP confirmed that the manufacturer’s instructions required a two-step cleaning and disinfecting process, and the facility’s written policy was outdated. In another medication administration observation, a nurse used a pill cutter with white powder residue inside to split an acetaminophen tablet for a resident and then returned the cutter to the medication cart. The nurse stated she should have cleaned the pill cutter before and after use, and the DON stated nurses are expected to clean and wash pill cutters before and after each use.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to ensure that staff treated a resident with dignity and respect when a CNA referred to the resident as a "feeder" during care instead of addressing the resident by name or in a manner that upheld dignity. The resident involved was admitted with multiple diagnoses, including dysphagia and an anxiety disorder. During an observation in the resident's room, CNA 3 was helping CNA 2 provide care and stated, "He [Resident 40] is a feeder now?" During an interview shortly afterward, CNA 3 stated that staff should not have labeled the resident as a feeder because it could have affected the resident's self-esteem. During interviews, the ADON stated that all staff were expected to treat residents with dignity and respect at all times and that staff should have been mindful of their words and actions because demeaning language toward the resident could have caused mistrust and low self-esteem. The DON stated that her expectation was for staff to treat all residents with dignity and respect and that using terms such as feeder in front of residents could have negatively impacted the resident's psychosocial well-being. The facility policy titled Dignity stated that each resident shall be cared for in a manner that promotes feelings of self-worth and self-esteem and that staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling.
Unauthorized OTC Medications and Supplements Found at Bedside
Penalty
Summary
The facility failed to ensure the safe storage and use of a resident's personal medication when over-the-counter medications and supplements were found at Resident 102's bedside without a physician's order. During a concurrent observation and interview with LN 1, two yellow capped bottles of Sualin Natural cough and Cold Remedy, two red capped bottles labeled in a foreign language, one purple bottle of Hajmola, one bottle of Nature Made Multi+ Omega-3 gummies, and one bottle of Nature Made C 250 mg Gummies were observed at the bedside. LN 1 stated she was unaware of these medications and was surprised to see them there. During record review, LN 1 confirmed Resident 102's EMR did not contain any orders for the resident to keep medications or supplements at the bedside and did not contain orders to administer the items found there. LN 1 stated she did not know the purpose of the foreign-labeled medications and explained that the facility only administered medications prescribed by the attending physician. The DON stated Resident 102 had been at the facility for one week when the unauthorized medications were discovered and said a care conference should have been held to address medication reconciliation with the family.
Unattended Computer Screen Exposed Resident Medical Information
Penalty
Summary
The facility failed to ensure the protection of residents' personal information when LN 8 left residents' personal medical information unattended on a computer screen in the facility's dining room. During a concurrent observation and interview on 9/9/25 at 12:15 PM, the computer was observed unattended with a resident's medical information visible to anyone who walked by. When LN 8 returned, they closed the computer and stated that before stepping away from the computer, the lock screen button should have been pressed to protect resident privacy. LN 8 stated that locking the screen was intended to prevent unauthorized access to resident information and that failing to protect residents' health information placed them at risk for identity theft. During an interview on 9/12/25 at 12:42 PM, the DON stated that staff were expected to protect resident information by locking the screen so unauthorized persons would not have access to it, and that not doing so would place residents' personal information at risk for theft. A facility policy titled, Confidentiality of Information and Personal Privacy, stated that the facility would protect and safeguard resident confidentiality and personal privacy and limit access to resident personal and medical records to authorized staff and business associates.
Medication and Treatment Supply Storage Deficiencies
Penalty
Summary
Safe medication storage practices were not maintained in two of four medication carts, one of one treatment cart, and one of one medication room. During observation with LN 4, an undated Humalog insulin pen was found stored in the Hall-2 medication cart. LN 4 stated the insulin pen was safe for use within 28 days after opening and should have been labeled when first used or opened. In the main medication room, two opened Aplisol vials were stored in the refrigerator without open-date markings, and an opened Timolol eye drop bottle was found with a broken seal and no open-date markings. In the Hall-2 treatment cart, an open sterile ComfortFoam packet was stored with other sealed products, and multiple DermaSeptin Ointment packets were stored in a bin without expiration dates. LN 7 stated the ComfortFoam should have been discarded and not returned to the cart, and the DON stated nursing staff were expected to date products when first opened if they had a limited beyond-use date.
Unauthorized Disclosure of PHI via Non-Compliant Messaging App
Penalty
Summary
Facility staff failed to ensure the privacy and confidentiality of residents' personal and medical records by communicating protected health information (PHI) through a group messaging platform (GMP) installed on staff members' personal smartphones. Multiple interviews and observations confirmed that both licensed nurses and certified nursing assistants routinely used this application to share resident names, room numbers, medical updates, and care needs. The GMP was not password-protected once the phone was unlocked, and staff were not required to report if their phones were lost or stolen, increasing the risk of unauthorized access to PHI. The Director of Nursing (DON), Administrator (ADM), and other staff acknowledged that resident identifiers and medical information were shared through the GMP, and that the application was not HIPAA-compliant. The DON admitted that there was no way to control or monitor who could access the information if a staff member's phone was compromised. Staff interviews revealed that the expectation was to use the GMP for communication about resident care, and some staff expressed concerns about the privacy implications, with at least one nurse refusing to install the app due to HIPAA concerns. Facility policies reviewed indicated that PHI should only be disclosed as permitted by law and that employees are responsible for protecting resident information from unauthorized release. However, the use of the GMP, which lacks necessary security features and is not HIPAA-compliant, directly contradicted these policies. The facility's own leadership acknowledged the risks and lack of control over PHI once it was shared via staff personal devices.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement adequate elopement prevention measures for two residents at risk for elopement. Resident 1 exhibited exit-seeking behaviors, but the facility did not initiate orders for a wander guard device or conduct an elopement risk assessment as outlined in the resident's care plan. Additionally, Resident 1's wander guard was not functioning at the time of elopement, and there was inconsistent documentation of the device's placement in the resident's chart. These oversights led to Resident 1's elopement, resulting in a head injury, hospital visit, and stitches. Resident 1, who had a history of dementia and wandering behavior, was not adequately monitored or protected despite having a care plan in place. The care plan included interventions such as frequent monitoring and the use of a wander guard device, but these were not effectively implemented. The facility's staff, including licensed nurses and the Director of Nursing, acknowledged the lack of necessary orders and assessments, which contributed to the resident's ability to leave the facility unsupervised. Furthermore, Resident 3 was found wearing an expired wander guard, indicating a lapse in the facility's monitoring and maintenance of safety devices. The Maintenance Assistant and a licensed nurse confirmed the expiration, and the Director of Nursing acknowledged the risk of elopement due to non-functional devices. The facility's failure to ensure the functionality and timely replacement of wander guards posed a significant risk to residents' safety.
Improper Vaccine Storage and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for safe injection practices, as evidenced by the improper storage and handling of vaccines. The Infection Preventionist (IP) stored pre-drawn, unlabeled, and undated flu vaccine syringes in a staff food refrigerator, which also contained personal food items. The IP admitted to preparing these syringes without labeling them, as she intended them for staff use, and acknowledged that the refrigerator's temperature was not monitored. This practice was deemed unsafe by the Director of Nursing (DON), who was unaware of the situation until it was brought to her attention. Additionally, pneumonia vaccines for three residents were documented as administered, yet the actual vaccines were found in the same refrigerator, intended for medication destruction. The Assistant Director of Nursing (ADON) could not explain how these vaccines, documented as given nearly a year prior, were still present in the refrigerator. The facility's policy required documentation of vaccine lot numbers and expiration dates in residents' medical records, which was not adhered to in these cases. The facility's policies on administering medications and vaccinations were not followed, as evidenced by the improper storage and lack of documentation. The DON and Administrator could not provide a reason for storing discontinued medications in a refrigerator instead of a designated medication cabinet. The facility's failure to comply with its policies and CDC guidelines for vaccine administration and storage contributed to the deficiencies identified during the survey.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure safe medication use and destruction practices, as evidenced by several deficiencies. Firstly, the prescription medication destruction and disposition logs were not properly dated, witnessed, or co-signed by licensed staff. During an inspection of the main medication room, it was found that the binder for medication destruction was overfilled with pages lacking dates and co-signatures. The Director of Nursing (DON) was unsure about the need for a witness co-signature and when the last medication destruction occurred. The facility's Consultant Pharmacist confirmed that all prescription destructions should be documented and witnessed by two licensed nurses. Additionally, a discontinued medication, semaglutide, prescribed to a resident who had been discharged, was improperly stored in an active storage area. The medication was never used, as the resident's treatment was changed to insulin. Despite the facility's policy requiring discontinued medications to be stored in a locked cabinet until destruction, the semaglutide was found in the medication refrigerator. The Assistant Director of Nursing (ADON) acknowledged that the resident's discontinued medications should have been stored securely until destruction. Furthermore, three pneumonia vaccines belonging to different residents were found in a staff food refrigerator, despite being documented as administered in the Medication Administration Record (MAR). The ADON could not explain how these vaccines were found in the refrigerator or why they were documented as administered. The facility's policy requires proper documentation of vaccine administration, including lot numbers and expiration dates, but this was not adhered to. These failures could contribute to the risk of drug diversion and unsafe drug use.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed in a dorm-style refrigerator located in an office shared by the Director of Staff Development (DSD), Infection Preventionist (IP), and the staffing coordinator. This refrigerator contained personal food items alongside a drawer full of prescription injectable medications, including vaccines and unlabeled pre-drawn syringes of a flu vaccine. There was no temperature monitoring performed for this refrigerator, and the DSD was unaware of how long the medications had been stored there. The DSD acknowledged the improper storage of medications with personal food and indicated that the medications might belong to facility staff. The IP admitted to preparing the pre-drawn syringes for staff administration and acknowledged the lack of labeling and temperature monitoring. In the main medication room, the refrigerator stored opened vials of flu vaccine and Tuberculosis testing agent without any marking for a beyond-use date. Additionally, discontinued medications belonging to a discharged resident were found in an active storage area in the refrigerator. The Director of Nursing (DON) was unaware of these storage issues and expressed concern over the unsafe practices, including the presence of pre-drawn flu vaccine syringes without labels. The Assistant Director of Nursing (ADON) confirmed that discontinued medications should not have been stored in the unsecured office refrigerator and should have been kept in a locked cabinet in the medication room. The facility's policies on medication labeling and storage, as well as discarding and destroying medications, were not adhered to. The policies require that all medications and biologicals be stored in locked compartments under proper conditions and that discontinued medications be stored in a locked cabinet until destruction. The failure to follow these policies resulted in unsafe medication storage practices, posing a risk to the safety of the residents and the potential for drug diversion.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated discharge for a resident, resulting in a deficiency. The resident's responsible party (RP) was verbally informed of the discharge when the resident was sent to the hospital, but no written notice was provided. This omission meant that the RP was not informed of the appeal rights or the process to contest the discharge decision, nor was contact information for the appeal unit and the ombudsman provided. The RP only became aware of these rights through a hospital social worker. The facility administrator acknowledged that a written 30-day notice of discharge was not sent to the RP and confirmed the absence of documentation in the resident's electronic medical record. The discharge was due to the resident's psychotic episodes, and the verbal notice was given to the RP because the resident was developmentally delayed. The facility's policy requires documentation of appropriate notice in the medical record, which was not adhered to in this case.
Failure to Reassess Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to determine if a resident could return to the facility after being transferred to an acute care hospital. The resident, who had been admitted with diagnoses including heart failure, bipolar disorder, schizophrenia, depression, and anxiety disorder, was sent to the hospital on a 5150 hold due to aggressive behavior. There was no documented evidence that the facility communicated with the hospital to assess the resident's condition or to determine if the facility could meet the resident's needs upon discharge from the hospital. Interviews with the resident's responsible party and facility staff revealed that the facility did not attempt to reassess the resident's readiness to return. The facility's Social Services Director and Case Manager were unsure if anyone from the facility had visited the hospital to evaluate the resident. The resident's primary physician confirmed that neither he nor anyone from the facility had assessed the resident at the hospital. Hospital notes indicated that the facility had communicated with the hospital, stating that the resident was discharged and would not be accepted back. The facility's policy requires documentation and communication of the resident's needs and the facility's inability to meet those needs, but there was no evidence of such documentation. This lack of communication and documentation had the potential to negatively impact the resident's psychosocial well-being.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. Two errors were identified out of 26 opportunities, involving two residents. Resident #23, who has a medical history of multiple sclerosis and intact cognition, was prescribed a multivitamin with minerals but was administered a plain multivitamin instead. Similarly, Resident #82, with severe cognitive impairment and a history of anemia and moderate protein-calorie malnutrition, was also prescribed a multivitamin with minerals but received a plain multivitamin. The errors were attributed to Licensed Vocational Nurse (LVN) #5, who admitted to administering the incorrect medication due to confusion over the different types of multivitamins. Interviews with the Nurse Practitioner and Director of Nursing (DON) confirmed that the physician's orders were not followed, as the residents were supposed to receive multivitamins with minerals. The DON and Administrator both expressed expectations that staff should review and follow medication orders accurately, highlighting the importance of adhering to the specific details of physician prescriptions.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of medications for a resident with a history of end-stage renal disease, hypertensive heart, and chronic kidney disease with heart failure. Specifically, the facility did not follow the order to hold carvedilol when the resident's systolic blood pressure (SBP) was below 130 mmHg and to refrain from administering midodrine when the SBP was above 120 mmHg. This oversight was identified for one resident among five sampled for unnecessary medications. The Medication Administration Record (MAR) showed that carvedilol was administered on multiple occasions when the resident's SBP was below the specified threshold, and midodrine was given when the SBP exceeded the prescribed limit. Interviews with nursing staff revealed a misunderstanding of the parameters, with one nurse mistakenly believing the hold parameter for carvedilol was an SBP below 100 mmHg instead of 130 mmHg. The Director of Nursing and the Administrator both expressed that they expected nurses to follow medication orders and parameters as prescribed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. The policy, dated April 5, 2024, mandates that staff perform hand hygiene and don a gown and gloves before engaging in high-contact resident care activities, such as dressing. Resident #196, admitted on July 17, 2024, had a medical history that included a gastrostomy tube and was at risk for aspiration. An order for enhanced standard precautions related to the gastrostomy tube was in place for every shift. On July 22, 2024, a Certified Nursing Assistant (CNA) entered the resident's room wearing only gloves and a mask, despite signage indicating the need for a gown, gloves, and mask. The CNA acknowledged that she had been trained on EBP and was aware of the requirement to wear a gown when providing care to residents with a gastrostomy tube. The Director of Nursing confirmed that staff had been in-serviced on EBP and that signage was posted to guide staff on the necessary personal protective equipment (PPE). The Administrator also expected staff to adhere to the training and signage instructions.
Failure to Carry Out Physician's Order for Medication Adjustment
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality when a physician's order to reduce gabapentin for a resident was not carried out. The resident, who had multiple diagnoses including surgical aftercare following surgery on the nervous system and diabetes mellitus, had an active order for gabapentin 400 mg every eight hours. On 4/6/24, the physician ordered to taper the gabapentin to 300 mg daily, but this order was not executed. The resident subsequently refused several doses of the medication, citing that the current dosage was too high and caused trouble for her legs. The resident left the facility against medical advice on 4/8/24. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the physician's order to reduce the gabapentin dosage was communicated but not carried out. The ADON and DON both stated that the nurse should have checked the physician's note for new orders and clarified the order when the resident refused the medication. The facility's policies on medication orders and administering medications were reviewed, indicating that medications should be administered as prescribed and that a current list of orders must be maintained in the clinical record of each resident.
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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 Stockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Post Acute | 1 mi | ★★★★★ | 67 | 0 |
| Clearwater Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Fulton Gardens Post Acute, Llc | 1.4 mi | ★★★★★ | 3 | 0 |
| Delta Oaks Post Acute | 1.7 mi | ★★★★★ | 36 | 0 |
| Noble Care Center | 1.9 mi | ★★★★★ | 8 | 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 June 2026) and official state health department websites.