Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Riverwalk Village during CMS and state inspections, most recent first.
Two residents received ongoing antipsychotic medications without adequate documented GDRs or contraindication support. One resident with dementia, anxiety, and bipolar disorder remained on Risperdal despite no hallucinations, delusions, or maladaptive behaviors documented during the review period, and the provider declined a pharmacy-recommended GDR without a risk-benefit analysis or guardian education documentation. Another resident with dementia and schizoaffective disorder remained on Zyprexa twice daily despite no documented hallucinations, delusions, or psychotic behaviors during the review period, and the provider also declined a pharmacy-recommended GDR without a contraindication statement.
Failure to Follow Fall Interventions for a High-Risk Resident: A severely cognitively impaired resident with a history of falls, unsteadiness, and wheelchair use had repeated falls from the wheelchair in the dining room, including falls with head injury and a witnessed slip from the chair. Although the care plan directed that the resident be transferred to a standard chair for all meals, staff observed the resident remaining in the wheelchair at the dining room table while being assisted with meals, and staff confirmed the intervention was not being followed and was not reflected on the CNA care sheets.
Medications Left at Bedside Without Order: An LPN left a resident's morning meds at the bedside without a physician order, and the resident said there were too many pills to take at one time. The resident was cognitively intact, and the chart lacked orders allowing bedside medication storage or self-administration. The DON stated meds were not supposed to be left at the bedside.
A resident with dementia and a history of falls was admitted to the facility and experienced two unwitnessed falls on the day of admission. The facility failed to accurately assess the resident's fall risk and implement specific interventions. Documentation of the falls was incomplete and delayed, and the facility's fall management policy was not followed.
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for six medication carts, as observed during a survey. Narcotic Count Sheets lacked signatures and reconciliation for various dates in October 2024. Nursing staff acknowledged the lapses, and the DON noted the use of incorrect forms, which were later changed.
The facility failed to implement enhanced barrier precautions (EBP) for three residents, leading to deficiencies in infection control. A resident with a Stage III pressure ulcer did not have EBP signs, and staff did not wear gowns during wound care. Another resident with a gastrostomy tube was not provided EBP during medication administration. A third resident with a chronic wound also lacked proper EBP during care. These oversights indicate a systemic issue in the facility's infection prevention program.
The facility failed to manage medication storage and labeling properly. In the D hall, an unlabeled ondansetron pill and an expired insulin pen were found. In Cottage 2, an unlabeled morphine bottle was discovered. Staff acknowledged these issues, which violated the facility's policies on medication management.
A resident with type 2 diabetes was given the wrong type of insulin due to a nurse's failure to verify the medication before administration. The resident was supposed to receive Levemir but was given Novolog instead, leading to fluctuating blood sugar levels and a trip to the ER. The nurse did not follow the facility's policy on medication verification.
The facility failed to date insulin vials and pens after opening, as required by policy. During observations, multiple in-use insulins for several residents were found without open dates on two medication carts. Both an RN and an LPN indicated that they would normally date the insulins, but this was not done in these instances.
Unnecessary Antipsychotic Use Without Documented GDRs
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medication use and from antipsychotic use without documented gradual dose reductions or adequate contraindication support. Resident 19 had diagnoses including severe dementia with agitation, anxiety, and bipolar disorder and was receiving Risperdal 1 mg twice daily, an order that had been in place for more than a year. Her quarterly MDS showed moderate cognitive impairment, no hallucinations or delusions during the assessment period, no maladaptive behaviors, and use of antipsychotic and antidepressant medications. The record contained only three behavioral events over the prior three-and-a-half months, involving yelling, name calling, exit seeking, and refusing or resisting care, but no documentation of hallucinations, delusions, or psychotic behaviors. A pharmacy recommendation called for a gradual dose reduction of Risperdal, but the provider declined and noted the resident was doing well and that the guardian had refused medication changes. The decline form did not include a statement of contraindication with a risk-benefit analysis, and the record lacked documentation that the guardian had been educated about the restrictions associated with declining treatment or the need for the medication to remain medically necessary at the current dose. A psychiatry note stated the medication was started for dementia, that the resident displayed no hallucinations or delusions, and that agitation was intermittent exit seeking. Observations during the survey found Resident 19 resting in bed, conversing with a visitor, and later seated on her bed after lunch. Resident 13 had diagnoses including dementia with behavioral disturbances, schizoaffective disorder, depression, and anxiety and was receiving Zyprexa 2.5 mg each morning and 7.5 mg at bedtime, both ordered for about 11 months. Her quarterly MDS showed moderate cognitive impairment, no hallucinations or delusions during the assessment period, no maladaptive behaviors, and use of antipsychotic, antianxiety, antidepressant, and hypnotic medications. The record documented only two behavioral events during the prior three-and-a-half months, involving refusing medication, yelling out, and cursing, without documentation of hallucinations, delusions, or psychotic behaviors. A pharmacy recommendation suggested a gradual dose reduction, but the provider declined without a contraindication statement or risk-benefit analysis; the record also lacked documentation of delusions during the review period, and staff interviews stated the resident did not display hallucinations, delusions, or maladaptive behaviors.
Failure to Follow Fall Interventions for a High-Risk Resident
Penalty
Summary
The facility failed to implement and follow fall interventions for a dependent resident who was at high risk for falls. The resident had diagnoses including Alzheimer's disease, atrial fibrillation, abnormal posture, unsteadiness on feet, and other abnormalities of gait and mobility. The resident was severely cognitively impaired, used a wheelchair for mobility, and was dependent on staff for eating, toileting, bathing, dressing, footwear, and personal hygiene. The care plan identified the resident as a fall risk and included interventions such as transferring the resident to a standard chair for all meals. The resident experienced multiple falls from the wheelchair in the dining room. On one occasion, the resident had an unwitnessed fall with a head abrasion and pain; on another, the resident had an unwitnessed fall with no injuries; on another day, the resident had two unwitnessed falls in the same morning; and later the resident had a witnessed fall when she leaned forward and slipped out of the wheelchair. Documentation showed that immediate interventions varied, including placing the resident in bed, returning the resident to the wheelchair, or sending the resident to the emergency room. One fall was associated with the wheelchair pad being placed upside down by a night shift aide. During observation, the resident was seated in her wheelchair at the dining room table and was not placed in a standard chair as directed by the fall intervention. Staff assisted her with her meal while she remained in the wheelchair, and no staff were present in the dining room for a period of time after she was positioned there. Interviews with nursing and management staff confirmed that the standard-chair intervention was not being followed and that the CNA care sheets did not reflect the intervention at the time of observation. Staff also stated that each fall required a separate fall event, assessment, and resident-specific intervention, and they could not provide separate events for two falls that occurred on the same day.
Medications Left at Bedside Without Order
Penalty
Summary
The facility failed to ensure a resident was assessed for and deemed appropriate to self-administer medications when medications were left at the bedside without a physician's order. During observation and interview, the resident stated morning medications had been given between 9:00 a.m. and 9:30 a.m., and a medication cup containing several pills was seen on the over-the-bed table. The resident said she had too many pills to take in the morning at one time. An LPN later identified the medications in the cup as amlodipine 2.5 mg, ascorbic acid 500 mg, cyanocobalamin 1,000 mcg, fluoxetine 40 mg, furosemide 40 mg, losartan 25 mg, magnesium gluconate 27 mg, metoprolol succinate 12.5 mg, and pramipexole 0.5 mg, and confirmed these matched the physician's orders. The resident's clinical record showed diagnoses including COPD, acute and chronic respiratory failure with hypoxia, pulmonary edema, CHF, multiple sclerosis, chronic pain, iron deficiency anemia, depression, GERD, osteoarthritis, spinal stenosis, gait and mobility abnormalities, history of sudden cardiac arrest, cardiac pacemaker, pulmonary hypertension, hypertension, and nonrheumatic tricuspid valve insufficiency. The record lacked a physician's order to leave medications at bedside and lacked a physician's order for the resident to self-administer medications left at bedside. The quarterly MDS indicated the resident was cognitively intact. The DON stated the facility expectation was that medications were not left at the bedside and that the LPN should not have left the resident's medications there.
Failure to Implement and Document Fall Interventions
Penalty
Summary
The facility failed to accurately assess and document fall risks and interventions for Resident F, who was admitted with a history of falls, unspecified dementia, and difficulty walking. Upon admission, the resident's fall risk was assessed as moderate, but the assessment inaccurately noted no falls in the previous six months, despite documentation of a fall one week prior. The care plan included general fall prevention interventions, but specific interventions tailored to the resident's needs were not implemented. On the day of admission, Resident F experienced two unwitnessed falls. The first fall occurred when the resident was found seated on the floor, and the second fall resulted in a head laceration and a brain bleed, requiring hospitalization. The staff did not immediately assess the resident or the environment after the falls, and the fall event documentation was incomplete and delayed. The facility's policy required immediate assessment and documentation of falls, which was not followed. Interviews with staff revealed that the facility's fall management policy was not adhered to, as the staff member on duty did not follow procedures for reporting and documenting falls. The Director of Nursing indicated that fall interventions should be specific to each resident, but this was not the case for Resident F. The facility's policy also required that all new admissions be considered fall risks, but the interventions were not adequately tailored to address Resident F's specific risk factors.
Failure in Shift-to-Shift Narcotic Reconciliation
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for six out of seven medication carts reviewed. During observations, it was found that the Narcotic Count Sheets for these carts lacked signatures and reconciliation for various dates in October 2024. This deficiency was noted across multiple medication carts, including those labeled HI, [NAME], C, D, and Cottage 2. The absence of required signatures and reconciliation was confirmed through interviews with the nursing staff, who acknowledged the lapses in procedure. For the HI medication cart, the Narcotic Count Sheet lacked shift-to-shift count and reconciliation signatures for several dates, including the 1st through the 12th of October. LPN 7 admitted that the narcotic count was not signed for the day shift on the 25th of October, as she was late, and the count was completed by another LPN without proper reconciliation. Similar issues were observed with the [NAME] medication cart, where the Narcotic Count Sheet was missing signatures for multiple shifts, and LPN 8 confirmed the oversight during the interview. The D hall and C hall medication carts also exhibited similar deficiencies, with missing narcotic card counts and reconciliation signatures for numerous dates. RN 3, responsible for these carts, acknowledged the requirement for completing the sign-in/sign-out sheet at the beginning and end of each shift. The Cottage 2 medication cart had similar issues, with LPN 4 confirming the lack of proper documentation. The Director of Nursing (DON) later indicated that the facility had been using incorrect forms, which were changed on October 10th, but the expectation for complete documentation remained unfulfilled.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during high-contact care for three residents, leading to deficiencies in infection control. Resident 41, who had a Stage III pressure ulcer, did not have EBP signs outside or inside her room, and her clinical record lacked a care plan for EBP. During wound care, staff did not wear gowns, exposing their clothing to potential contamination. Interviews revealed that staff were unaware of the need for EBP for residents with open wounds, indicating a lack of proper implementation and communication of infection control protocols. Resident 2, diagnosed with spastic quadriplegic cerebral palsy and other conditions, was at risk of transferring multidrug-resistant organisms (MDROs) due to an indwelling medical device. Although an EBP sign was present, a nurse failed to don a gown while administering medication through the resident's gastrostomy tube, contrary to the facility's isolation care plan. This oversight highlights a gap in adherence to EBP protocols, which are crucial for preventing the spread of infections in residents with medical devices. Resident 79, with a diagnosis including a malignant neoplasm of the prostate and a Stage 3 pressure ulcer, was also subject to EBP due to his chronic wound. Despite the presence of an EBP sign, staff members did not wear gowns during wound care, failing to comply with the required precautions. Interviews with staff and the Infection Preventionist confirmed that EBP protocols were not consistently followed, underscoring a systemic issue in the facility's infection prevention and control program.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and labeling, as observed during a survey. In the D hall medication cart, an unlabeled 8 mg ondansetron pill was found, and a glargine insulin pen with an open date was identified as expired. During the observation, RN 3 acknowledged that the ondansetron pill had fallen out of its bag and confirmed that the insulin pen was expired and should not be administered to the resident. In Cottage 2, a medication storage observation revealed an unlabeled bottle of morphine with approximately 14 units remaining. LPN 4 indicated that the bottle had been removed from the facility's medication management system and should have been labeled with resident information. The facility's policy on medication storage and expiration, as well as a document on dating medications and supplies, emphasized the importance of discarding expired or undated medications and ensuring proper labeling, which was not adhered to in these instances.
Failure to Verify Correct Insulin Type Before Administration
Penalty
Summary
The facility failed to verify the correct type of insulin prior to administration for a resident, resulting in the wrong type of insulin being given. The resident, who had type 2 diabetes mellitus without complications, was supposed to receive 55 units of Levemir (long-acting insulin) but was instead given 55 units of Novolog (short-acting insulin). This error was discovered immediately after administration when the nurse noticed the insulin pen was orange (Novolog) instead of green (Levemir). The resident's blood sugar was monitored, and he was sent to the emergency room for further evaluation and treatment. His blood sugar levels fluctuated, requiring treatment with dextrose and supplemental potassium for hypokalemia. He was eventually stabilized and returned to the facility with an IV in place for continued monitoring. The nurse involved in the incident indicated it was her first time working on that medication cart and did not verify the insulin pen before administration. She later realized that someone else's insulin pen was in the resident's storage bag. The facility's policy on medication administration requires staff to verify the medication name and dose against the medication order each time a medication is administered. This policy was not followed, leading to the medication error. The resident was cognitively intact and aware of the error, and the facility provided education to the nurse involved after the incident.
Failure to Date Insulin Vials and Pens
Penalty
Summary
The facility failed to date residents' insulin vials and insulin flex pens after opening, which is a violation of the facility's policy. During a medication administration observation, an RN administered 22 units of Lispro insulin to a resident, and neither the insulin vial nor the container had an open date on it. Further inspection of the H hall medication cart revealed that other in-use insulins for multiple residents also lacked open dates. Specifically, the Lispro insulin vials for two residents, a glargine-yfgn insulin pen, and insulin aspart and glargine-fygn insulin pens for other residents were found without open dates. The RN indicated that they would normally date the insulin vials and pens after opening, but this was not done in these instances. Additionally, an observation of the K/I hall medication cart showed that another resident's in-use insulin glargine pen also had no open date, despite 160 units of insulin being used from the 300-unit pen. The LPN indicated that she would normally date the insulin as soon as she pulled it from the refrigerator. The facility's policy, revised on 1/1/22, clearly states that staff should enter the date opened on the label of medications with shortened expiration dates, such as insulins. This deficiency was related to a specific complaint investigation.
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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 Noblesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbour Manor Health & Living Community | 0.7 mi | ★★★★★ | 11 | 0 |
| Prairie Lakes Health Campus | 3.7 mi | ★★★★★ | 3 | 0 |
| Bridgewater Healthcare Center | 5.6 mi | ★★★★★ | 8 | 0 |
| Maple Park Village | 5.6 mi | ★★★★★ | 8 | 0 |
| Mcgivney Health Care Center | 5.8 mi | ★★★★★ | 17 | 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.