Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riviera Palms Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple health conditions experienced an unwitnessed fall resulting in a hip fracture. Staff failed to report, assess, or document the incident according to policy, and did not notify the physician or DON. The resident's pain was not addressed until family involvement led to further assessment, resulting in delayed intervention and ongoing suffering until death.
Nursing staff failed to recognize and report an unwitnessed fall for a resident with severe cognitive impairment, resulting in delayed treatment of a hip fracture. Staff also did not follow physician orders for lab monitoring of a resident on Depakote, did not maintain a hazard-free environment by allowing a disposable razor in a cognitively impaired resident's bathroom, and failed to verify resident identification before medication administration. These actions and inactions were confirmed through observations, interviews, and record reviews.
Two rooms were found with environmental deficiencies: one had a leaking toilet with a towel placed around its base due to delayed maintenance, and another had missing shower tiles exposing a discolored pipe, which went unreported by staff. Communication lapses and lack of a homelike environment policy contributed to these unresolved issues.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was prescribed antidepressant and antipsychotic medications, but there were no orders or documentation for monitoring side effects as required. Despite the care plan and facility policy mandating such monitoring, nursing staff and the DON confirmed that it was not implemented or recorded on the TAR.
A resident with severe cognitive impairment and a history of falls was found on the floor by a CNA, but the incident was not reported as a fall or injury of unknown origin by the nurse, nor was it documented or communicated to the DON or physician as required. The resident later exhibited pain, and an X-ray revealed a hip fracture. The deficiency resulted from staff failing to follow facility policy for reporting and documenting unwitnessed falls and changes in condition.
A resident with severe cognitive impairment and nonverbal status, who communicated only by gestures and head movements, did not have a person-centered care plan addressing communication needs. Staff confirmed reliance on the Kardex for communication information, but acknowledged the lack of a formal care plan, despite facility policy requiring comprehensive care plans for all identified needs.
Two dependent residents with neurological and mobility impairments were not provided with individualized, resident-centered activities as outlined in their care plans and preferences. Despite documented interests in music, crafts, and social events, these residents received minimal engagement, with staff primarily distributing written materials and not offering in-room or tailored activities. Staff interviews confirmed that activity staff did not routinely provide individualized activities for residents unable to attend group sessions.
A disposable razor was found accessible in the bathroom of a resident with severe cognitive impairment and multiple physical limitations. Staff interviews confirmed that razors are to be kept by staff and only used under supervision, with all residents requiring assistance. The facility could not provide a policy on accident hazards, and staff acknowledged that personal items brought in by families are not always properly inventoried or monitored.
Failure to Report and Respond to Unwitnessed Fall Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not properly reporting, assessing, documenting, or intervening in a timely manner after an unwitnessed fall that resulted in a major injury. The resident, who had severe cognitive impairment and multiple comorbidities including dementia, coronary artery disease, and was under hospice care, was found on the floor by a CNA. The CNA notified a nurse, who assessed the resident and, along with two other staff, assisted the resident into a wheelchair. The nurse did not report the incident as a fall, did not notify the physician or the DON, and did not document the event as required by facility policy. The nurse assumed the resident's behavior was typical and did not consider the possibility of injury, despite the resident being combative and having a skin tear. Following the incident, the resident was observed by staff and family, with the family later reporting the resident was in pain during a transfer. The pain was communicated to the nurse, but no immediate action was taken to further assess or report the change in condition. It was only after the family informed the hospice nurse of the fall and the resident's pain that a stat X-ray was ordered, which revealed an acute right hip fracture. The resident subsequently received pain management and comfort care, but the delay in assessment and intervention resulted in ongoing pain and suffering until the resident's death. Interviews with facility staff, including the DON, RN, CNA, hospice nurse, and family members, confirmed that the incident was not reported or investigated in accordance with facility policy. The nurse involved did not recognize the event as a reportable fall and failed to notify appropriate parties or document the occurrence. The facility's policies required immediate reporting, assessment, and documentation of any accident or change in condition, which were not followed in this case. This failure led to a determination of Immediate Jeopardy due to the worsened condition and likelihood of serious injury or death for the resident.
Failure to Ensure Nursing Staff Competency and Adherence to Care Protocols
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in providing care and services to several residents, resulting in multiple deficiencies. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia and being under hospice care, experienced an unwitnessed fall. The fall was not immediately reported or documented by the nurse, and the physician was not notified. The resident was found on the floor by a CNA, who notified the nurse, but the nurse assumed it was a behavioral issue and did not follow facility policy for unwitnessed falls. The resident subsequently developed pain, and an X-ray two days later revealed an acute right hip fracture. Pain medication was not administered until after the fracture was confirmed, despite a standing order for PRN morphine. The incident was only brought to the attention of the DON and hospice nurse after a family member reported the resident's pain. In another instance, staff failed to follow physician orders for laboratory testing. A resident with a history of depression and dementia was prescribed Depakote, with an order for periodic Depakote level monitoring. The required lab work was not completed as ordered, and there was no documentation of the lab being performed or of the provider being notified about the missed lab. Staff interviews revealed confusion about the process for lab orders, with discrepancies between what was documented and what was actually completed. The DON confirmed there was no facility policy related to following physician orders for lab work. Additional deficiencies included failure to provide a safe, hazard-free environment and failure to verify resident identification prior to medication administration. A disposable razor was found in the bathroom of a resident with severe cognitive impairment, contrary to staff statements that razors should be kept by staff and only used under supervision. During a medication pass, a nurse administered medications to a resident without verifying their identification, in violation of facility policy. These failures were confirmed through staff interviews and record reviews.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms. In one room, a towel was observed wrapped around the bottom of the toilet due to a leak that caused water to pool on the floor whenever the toilet was flushed. A CNA reported that she had notified maintenance about the issue, and the Maintenance Assistant confirmed he was aware of the problem and had ordered a part for the repair. However, despite the part arriving, the repair was not completed promptly. The Regional Director of Maintenance stated that leaking toilets should be fixed immediately and that staff are expected to purchase necessary parts without delay. In another room, two tiles were missing from the shower, exposing a pipe with brown discoloration. The Maintenance Technician was unaware of the missing tiles, as previous residents used the shower for storage, and the issue was not reported in the maintenance log. The housekeeper assigned to the room noticed the missing tiles but did not report it, believing it was outside her responsibilities. The CNA assigned to the room had not noticed the missing tiles, as she did not use the shower area. The facility did not have a policy related to maintaining a homelike environment, and staff communication regarding environmental issues was inconsistent.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with diagnoses including major depressive disorder, dementia, and anxiety was observed repeatedly sleeping in a wheelchair, both in her room and in a dining area. The resident had a history of severe cognitive impairment and was prescribed multiple psychotropic medications, including antidepressants and antipsychotics. Review of the resident's medical records revealed that there were no physician orders for monitoring the side effects of these medications, nor was there documentation of such monitoring on the Treatment Administration Record (TAR). The resident's care plan included interventions to monitor for side effects and adverse reactions to psychotropic medications, as well as ongoing assessment of symptoms related to depression and medication use. However, these interventions were not implemented, as evidenced by the absence of side effect monitoring orders and documentation. Interviews with nursing staff and the DON confirmed that side effect monitoring should have been in place and documented on the TAR, but this was not done for the resident in question. The facility's policy required that the interdisciplinary team assess and monitor the appropriateness, effectiveness, and side effects of psychotropic medications, with licensed nurses responsible for completing this monitoring. Despite this policy, the required monitoring was not performed or documented for the resident receiving antipsychotic and antidepressant medications, resulting in a failure to comply with established standards and the facility's own procedures.
Failure to Report Injury of Unknown Origin Following Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and multiple comorbidities, including dementia, coronary artery disease, and a history of falls. The resident was found on the floor by a CNA, who notified a nurse. The nurse assessed the resident, noted a scratch on the arm, and, with assistance, transferred the resident to a wheelchair. The resident was combative during the transfer and did not verbalize pain, but no further assessment or documentation of the incident as a fall was completed at that time. The nurse did not notify the physician, DON, or complete an incident report as required by facility policy. The resident continued with daily activities, and later that day, a family member transferred the resident to bed and noted the resident was in pain. The family member informed staff, but the incident was still not reported as a fall or injury of unknown origin. Two days later, the family member reported the resident's pain to the hospice nurse, who then ordered a STAT X-ray, revealing an acute right hip fracture. The DON was only made aware of the incident at this point and initiated an investigation, confirming that the nurse had not followed policy for reporting unwitnessed falls or changes in condition. Interviews with staff revealed a lack of understanding and adherence to facility policy regarding the reporting of accidents and changes in condition. The nurse involved assumed the resident's behavior was typical and did not consider the possibility of injury, while the CNA followed protocol by notifying the nurse but did not escalate the incident further. The facility's policies required immediate reporting and documentation of unusual occurrences, as well as physician and family notification for significant changes in condition, which were not followed in this case.
Failure to Develop and Implement Communication Care Plan for Nonverbal Resident
Penalty
Summary
The facility failed to implement a person-centered care plan addressing communication needs for a resident with severe cognitive impairment and nonverbal status. The resident, admitted with diagnoses including hemiplegia, aphasia, and severe cognitive impairment (BIMS score 0/15), was observed to only respond to yes or no questions by shaking his head. Despite these significant communication barriers, review of the resident's care plan revealed no individualized plan for communication, even though the facility's policy requires comprehensive care plans to address all identified needs. Interviews with staff, including a CNA, speech therapist, MDS coordinator, and DON, confirmed that the resident was nonverbal and communicated through gestures or head movements. Staff relied on the Kardex for information about the resident's communication methods, but acknowledged the absence of a formal communication care plan. The speech therapist specifically stated that the resident should have a care plan for communication, and the DON expected one to be in place, in accordance with facility policy.
Failure to Provide Resident-Centered Activities for Dependent Residents
Penalty
Summary
The facility failed to provide resident-centered activities for two dependent residents, resulting in a deficiency related to meeting their physical, mental, and psychosocial needs. Observations and interviews revealed that one resident, who had significant neurological and mobility impairments, was not offered activities aligned with her interests, such as music, crafts, and social events, despite these being documented in her care plan and activity assessments. Documentation showed minimal participation in activities of interest over a 29-day period, and no such activities were offered during a specific five-day window. Family and staff interviews confirmed that the resident was not capable of initiating activities independently and relied on staff for engagement, which was not provided. Another resident, diagnosed with Parkinson's Disease and dementia, also experienced a lack of individualized activity offerings. This resident preferred small group and in-room activities, such as listening to music, reading magazines, and pet visits, and required reminders and assistance to participate. However, documentation indicated that the resident only participated in reading or similar activities on three out of 31 days. Staff interviews further revealed that activity staff did not routinely provide in-room activities or individualized engagement for residents who did not attend group activities in common areas. The facility's activity calendar and policy indicated that room visits were only offered twice weekly, and staff practices did not align with the documented needs and preferences of the residents. Activity staff primarily distributed written materials and did not consistently interact with or offer tailored activities to residents in their rooms. The deficiency was further substantiated by staff and administrative interviews acknowledging the lack of person-centered activity offerings and documentation for these dependent residents.
Failure to Prevent Accident Hazard: Razor Left Accessible to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a pink disposable razor was found on top of the toilet bowl in the bathroom of a resident with severe cognitive impairment. The resident, who has diagnoses including hemiplegia, hemiparesis, diabetes with neuropathy, lack of coordination, and significant cognitive deficits, was unable to identify the razor's owner and stated she thought it might belong to her roommate. The resident's family confirmed that they would not provide her with a razor due to safety concerns. Staff interviews revealed that razors are typically kept by staff and only used under supervision, with all residents requiring assistance for shaving. Staff also indicated that razors should not be left in resident rooms and are disposed of after use. Further review of the resident's care plan confirmed interventions for impaired cognitive function, including supervision and cueing as needed. Staff and the Director of Nursing stated that only alert and oriented residents may keep razors, and these are stored in lock boxes. However, the razor found did not match facility-issued razors, and the roommate did not have family to bring in personal items. The facility was unable to provide a policy related to accident hazards, and staff acknowledged that sometimes families bring in items that are not always inventoried or monitored.
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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 Palmetto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Bradenton | 1.5 mi | ★★★★★ | 25 | 0 |
| Braden River Rehabilitation Center Llc | 1.8 mi | ★★★★★ | 0 | 0 |
| Westminster Point Pleasant | 2.2 mi | ★★★★★ | 6 | 0 |
| Greenbriar Healthcare Rehabilitation And Nursing C | 2.8 mi | ★★★★★ | 0 | 0 |
| Surrey Place Healthcare And Rehabilitation | 4.8 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.