Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Riverwood Center during CMS and state inspections, most recent first.
The facility failed to provide adequate restorative nursing therapy for two residents in the dining restorative program, leading to a decline in their abilities to perform activities of daily living. One resident experienced significant weight loss due to inaccurate meal consumption documentation and lack of participation in the Restorative Nursing Program (RNP). Another resident, who required social interaction during meals, was not consistently included in the RNP. The facility's staff did not effectively manage or document the residents' participation, contributing to the deficiency.
A resident with hemiplegia and moderate cognitive impairment was observed multiple times with his call light out of reach while seated in his wheelchair. Despite understanding how to use the call light, the cord was too short to reach him, and staff did not ensure it was accessible. The resident's care plan included reminders to use the call bell, but it did not address ensuring its accessibility.
A resident with Alzheimer's and other conditions was observed without a privacy curtain in her semi-private room, compromising her privacy. Facility staff interviews revealed confusion over responsibility for curtain installation and monitoring, and the facility lacked a specific privacy curtain policy, relying on a general Resident Rights Policy.
A resident with scabies did not have isolation precautions implemented as per the care plan, with no signage or PPE on the door despite active orders. Staff interviews revealed a lack of awareness and communication regarding the resident's isolation status. The facility's policies require adherence to physician orders, but the failure to follow isolation precautions indicates a deficiency in infection control practices.
A resident with multiple chronic conditions, including diabetes, was found with elongated and jagged fingernails, indicating a failure in providing adequate fingernail care. Despite the resident's preference for short nails and her need for substantial assistance with personal hygiene, staff interviews revealed inconsistencies in the responsibility and scheduling of nail care, particularly for diabetic residents.
A resident did not receive their prescribed Fluoxetine due to a delay in delivery from the pharmacy, resulting in missed doses. The LPN discovered the medication was unavailable during administration and attempted to reorder it. Facility policies require timely reordering and physician notification if medications are missed, which were not adequately followed.
The facility reported a medication error rate of 11.54% due to three errors. Two residents were affected: one did not receive Fluoxetine and was given crushed Potassium Chloride ER against orders, while another received Humalog insulin without proper aseptic technique. The facility's medication administration policies were not followed.
A resident with cognitive impairments and foul-smelling breath did not receive necessary dental consultations or care, despite the facility's policy to facilitate dental services through external providers. The DON was unaware of the resident's oral condition, and no dental records were found in the resident's medical record. A CNA reported the resident's breath odor to nursing staff, but no further action was documented.
Failure in Restorative Nursing Program Management
Penalty
Summary
The facility failed to provide adequate restorative nursing therapy to prevent the decline in residents' abilities to perform activities of daily living, specifically in the dining restorative program. Two residents, among a total of 11 in the program, were observed to have not received the necessary support. Resident #193, who had a history of traumatic subarachnoid hemorrhage, depression, anxiety, and other conditions, was observed consuming only 25% of her meals and transferring the rest to other residents. Despite this, her records inaccurately documented 100% meal consumption, and she experienced significant weight loss. The resident was not listed in the Restorative Nursing Program (RNP), and there was no documentation of her participation, despite active orders for the program. Resident #56, diagnosed with atrial fibrillation, dementia, and depression, was observed eating alone and consuming only 25% of her meal, leaving the carrots uneaten. Her care plan indicated a need for social interaction during meals, yet she was not consistently included in the RNP. The restorative aide responsible for her care admitted to not regularly including her in the program, despite the resident's willingness to participate and enjoy conversations. The facility's policy on restorative nursing services emphasizes the importance of individualized care plans and regular documentation of residents' progress. However, the lack of adherence to these guidelines resulted in the failure to provide necessary restorative care, leading to the decline in residents' abilities and significant weight loss in Resident #193. The facility's staff, including the LPN and restorative aides, did not effectively manage or document the residents' participation in the RNP, contributing to the deficiency.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident had access to his call light, which is a critical tool for requesting assistance. Observations over several days revealed that the resident, who was seated in his wheelchair at the foot of his bed, consistently had his call light placed out of reach on top of the bed near the pillow. Despite being able to use the call light when it was within reach, the resident was unable to access it independently due to its placement and the limitations of the call light cord. The resident in question had a history of hemiplegia and hemiparesis following a stroke, affecting his right side, along with other medical conditions such as anxiety disorder, dysphagia, and moderate cognitive impairment. His care plan included interventions for fall risk and reminders to use the call bell for assistance, but it did not specifically address ensuring the call light was within reach. The resident required substantial assistance for various activities of daily living and was receiving occupational therapy to improve his upper extremity strength. Interviews with staff, including a CNA and an occupational therapist, confirmed that the resident understood how to use the call light and when to use it. However, the call light cord was not long enough to reach the resident when he was seated in his wheelchair at the foot of the bed, and staff did not consistently ensure it was within his reach. This oversight was observed multiple times, indicating a failure to accommodate the resident's needs and preferences adequately.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to honor the personal privacy of a resident, identified as Resident #81, who was observed multiple times without a privacy curtain in her semi-private room. Observations on different occasions revealed the absence of a privacy curtain, which compromised the resident's privacy. The resident, who has a medical history including Alzheimer's disease, neurological disorder, mood disorder, and major depressive disorder, was admitted to the facility with specific care plan focus areas addressing her cognitive and self-care deficits. Interviews with facility staff, including an LPN and the Administrator, revealed a lack of clarity and responsibility regarding the installation and monitoring of privacy curtains. The LPN indicated that housekeeping was responsible for hanging and checking the curtains, while the Administrator mentioned a Guardian Angel Program for monitoring room conditions. However, a review of the Guardian Angel Rounds worksheets showed that the absence of a privacy curtain was noted but not addressed. Additionally, the facility lacked a specific policy on privacy curtains, relying instead on a general Resident Rights Policy that emphasizes respect, dignity, and privacy for residents.
Failure to Implement Isolation Precautions for Resident with Scabies
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident diagnosed with scabies, as isolation precautions were not followed according to the care plan. The resident expressed a desire to be out of isolation, stating she was not being treated, and there was no precautions sign or PPE on her door during multiple observations. The resident's medical record indicated orders for contact precautions and treatment with Permethrin cream, but these were not adhered to, as evidenced by the lack of signage and PPE. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's isolation status. A CNA was unaware of any recent scabies cases, and an LPN was not informed of the contact precautions for the resident, believing they had ended earlier. The Unit Manager confirmed the resident should have been on isolation until a specified date, but the necessary precautions were not in place. The Infection Preventionist and DON acknowledged the oversight, with the Infection Preventionist confirming the active order for contact isolation was not followed. The facility's policies and procedures require physician orders to be followed as prescribed, with any deviations recorded in the resident's medical record. However, the failure to implement the isolation precautions as ordered indicates a breakdown in adherence to these procedures. The lack of proper signage and PPE on the resident's door, despite active orders, highlights a deficiency in the facility's infection control practices.
Failure to Provide Adequate Fingernail Care for a Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for Resident #47, who was observed with elongated and jagged fingernails. The resident, who has a history of multiple chronic conditions including congestive heart failure, COPD, and diabetes, expressed a preference for short nails and reported that her nails often broke off painfully. Despite requiring substantial assistance with personal hygiene, the resident's care plan did not ensure regular fingernail maintenance, leading to discomfort and potential risk of injury. Interviews with facility staff revealed a lack of clarity and consistency in the responsibility for providing fingernail care, particularly for diabetic residents. A CNA admitted to not providing fingernail care on the day of observation and was uncertain about the specific procedures for diabetic residents. An LPN confirmed that CNAs were responsible for nail care but indicated that it was done on an as-needed basis without a specific schedule. The facility's policy emphasized the provision of necessary ADL support, including nail care, but this was not effectively implemented for Resident #47.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of medications. During a medication administration observation, an LPN was preparing medication for a resident and discovered that the prescribed Fluoxetine was not available. The medication had been ordered from the pharmacy but had not yet arrived, resulting in the resident missing doses on two consecutive days. The LPN attempted to reorder the medication to ensure its delivery. The facility's policies and procedures require that physician orders be followed as prescribed, and any deviations should be documented in the resident's medical record. Additionally, the nurse is expected to reorder medications 3-4 days before they run out and to notify the physician if a medication will be missed. The Director of Nursing confirmed these expectations during an interview. However, the failure to have the medication available and administered as ordered led to a deficiency in pharmaceutical services for the resident.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an error rate of 11.54% due to three errors out of 26 opportunities. Two residents were affected by these errors. One incident involved a Licensed Practical Nurse (LPN) who did not administer Fluoxetine to a resident as it was not available, despite being ordered from the pharmacy. Additionally, the LPN crushed Potassium Chloride ER, which was labeled 'Do Not Crush,' and administered it to the resident mixed with applesauce, without a physician's order to crush medications. The resident's medical record indicated that the medication should be swallowed whole. Another incident involved a different LPN who prepared Humalog insulin for a resident without following proper aseptic technique. The LPN did not cleanse the rubber top of the insulin vial with an alcohol swab before drawing the medication, which is a standard procedure to prevent contamination. The LPN admitted to being unaware of this requirement. The facility's policies and procedures for medication administration and physician orders were not adhered to, as evidenced by these observations and staff interviews.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident #84, in obtaining routine and emergency dental care. Observations noted that the resident had noticeably foul-smelling breath on multiple occasions. Despite the resident's cognitive impairments and need for assistance with oral hygiene, there were no dental consultations or hygienist visit notes in the resident's medical record from January 2024 through January 2025. The resident's care plan indicated a potential or actual oral health concern, yet no dental services were coordinated or documented. Interviews with the Director of Nursing (DON) revealed that the facility contracts with external dental providers, but the DON was unable to locate any dental consultation reports for the resident. The DON stated that dental services are typically requested by the resident, their representative, or nursing staff when issues are identified. However, the DON was not aware of the resident's specific oral condition or the process in place to improve the resident's oral health. A Certified Nursing Assistant (CNA) reported that the resident was not cooperative with oral care and had a terrible odor to her breath, which had been communicated to the nursing staff. The facility's policy on dental consults indicated that dental services should be facilitated through external providers as needed, but there was no evidence that this was done for the resident. The lack of dental care coordination and documentation led to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 263 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jacksonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Jacksonville | 1.1 mi | ★★★★★ | 12 | 0 |
| Aviata At Jacksonville | 1.2 mi | ★★★★★ | 10 | 0 |
| Vivo Healthcare University | 1.2 mi | ★★★★★ | 0 | 0 |
| University Crossing | 1.3 mi | ★★★★★ | 0 | 0 |
| Woodland Grove Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.