Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Riverwalk Post Acute during CMS and state inspections, most recent first.
A resident with Wernicke’s encephalopathy, who was generally alert and ambulatory with a cane, was last seen in common areas before being discovered missing from his room, triggering the facility’s missing resident code and a search of the building and grounds. Although the charge nurse notified law enforcement and the MD when the resident could not be found, the resident’s designated family contact was not notified at that time, contrary to facility policy requiring family notification when a resident is not located on-site. Interviews with the LVN, RN, and DON confirmed that nursing staff were responsible for notifying the family and documenting it, and that this did not occur until the next day, many hours after the initial discovery that the resident was missing.
A resident with Wernicke’s encephalopathy, described as sometimes confused and unhappy with placement, was observed moving between his room and common areas and was last seen in the lobby before staff later discovered he was missing. Staff reported that they did not check on him further because he was considered independent, and surveillance footage later showed him exiting the unsecured, unalarmed front door in regular clothes. After the receptionist left, no specific staff member was assigned to monitor the front entrance; instead, nurses and CNAs at the nearby station were expected to watch it, though they acknowledged this was not consistently possible during busy evening hours. The resident was subsequently found wandering offsite and transported to a GACH, demonstrating a failure to maintain an accident-hazard-free environment and provide adequate supervision to prevent elopement.
A resident with a history of repeated falls and high fall risk was admitted without fall prevention interventions included in the baseline care plan. Despite assessments indicating high risk, the BCP did not address falls, and the resident subsequently fell and was hospitalized. Staff interviews confirmed the omission of fall-related interventions in the care plan.
A resident's legal representative did not receive requested medical records within the required timeframe after submitting a written request with proper authorization. The DMR forwarded the request to the legal department, but the records were not released within the facility's policy timeframe, resulting in a deficiency.
A resident with multiple medical conditions receiving palliative care had several personal belongings go missing after passing away. The facility did not update the inventory of the resident's belongings when new items were brought in, and a search for the missing items was unsuccessful. Staff interviews confirmed that facility policy required updating the belongings list, but this was not followed, resulting in the loss of items with potential sentimental value for the family.
A nurse held an antihypertensive medication for a resident despite the physician's order specifying it should only be held if systolic blood pressure was below 110, while the resident's reading was 119. The nurse did not notify the physician or document the deviation, and the DON confirmed the order was not followed.
A resident with a gluten allergy and physician orders for a gluten-free diet was served cornbread containing gluten. The resident identified the issue and declined to eat the cornbread, while staff interviews confirmed awareness of the allergy and the use of a cornbread mix with wheat gluten. Facility policies required avoidance of gluten for such residents.
A resident with muscle wasting and atrophy experienced severe weight loss over two consecutive months, but staff did not document weekly weight monitoring as required by facility policy. The DON confirmed that weekly weights should have been taken after the initial loss, but records showed this was not done.
Surveyors found that some resident rooms had adhesive residue, chipped paint, black marks on the walls, chipped baseboards, and stained floors. The MTD confirmed these issues were due to contact from beds or wheelchairs and previous electrical work, and stated that the floors could not be adequately cleaned. Renovations had not been completed in these rooms because residents and families did not want to move, and staff acknowledged the rooms were not in acceptable condition.
A facility failed to notify a resident's POA when a physician ordered lorazepam for anxiety, leaving the POA unaware of the resident's condition. Despite facility policy requiring notification of changes in medical condition, there was no documentation that the POA was informed, as confirmed by staff interviews and record reviews.
The facility failed to address significant weight loss in two residents, one with obstructive uropathy and another with diabetes mellitus. Despite notable weight loss, there was no evidence of physician or RD notification, nor were interventions initiated. The RD struck out an initial weight entry without informing the DON, causing confusion. The facility's policy for notifying the dietitian for weight changes was not followed, leading to unaddressed nutritional needs.
A resident with cerebral palsy and moderate risk for pressure injuries developed an unstageable pressure injury on the right hip due to the facility's failure to follow its prevention policy. The resident's wound was not properly assessed or documented, and the Treatment Nurse was unaware of the wound until it was observed by a CNA. The facility's policy required daily skin inspections and documentation, which were not adhered to, resulting in the oversight.
A facility failed to document a care conference for a resident with a fracture, mild intellectual disability, and cerebral palsy. Despite the care conference being conducted, it was not recorded in the electronic health record, PointClickCare (PCC). Interviews revealed that the Social Service Director (SSD) was unable to open the care conference note, and the interdisciplinary team (IDT) did not document their notes. The facility lacked a policy for mandatory documentation of care conferences, potentially impacting the resident's care plan.
A resident with moderate cognitive impairment was unable to reach their call light, which was found on the floor behind their bed. This deficiency was confirmed by a CNA, an LVN, and the DON, who all stated that the call light should be within reach to prevent delays in care. The facility's policy supports this practice, but it was not followed in this instance.
A facility failed to monitor a dialysis catheter for a resident with ESRD, leading to improper care. Another resident with CHF and CKD did not receive physician-ordered fluid restrictions, with records showing excess fluid intake. Additionally, a resident's skin condition was not assessed or treated, resulting in dry and scaly skin. Staff interviews confirmed these deficiencies.
The facility failed to implement infection control practices for two residents. A resident's oxygen nasal cannula was left exposed on the bed, contrary to the facility's policy of storing it in a plastic bag to prevent infection. Another resident's wound vacuum device and tubing were left on the bedside table after a dressing change, with the Treatment Nurse admitting to not discarding the used tubing or disinfecting the equipment, risking cross-contamination. Both incidents were acknowledged by the facility's staff as breaches of infection control protocols.
A resident with a history of behavioral issues was discharged from a facility without proper documentation after being cleared from a psychiatric hold. Despite being initially given a 30-day discharge notice, the facility failed to issue a new notice or re-evaluate the resident's condition after hospital clearance. Interviews with staff indicated ongoing behavioral challenges, but the facility did not follow its procedures for re-evaluation, leading to a deficiency in the discharge process.
A facility failed to provide an updated discharge notice for a resident who was not readmitted after a hospital stay. The resident was initially transferred for psychiatric evaluation, and a 30-day discharge notice was issued. However, after the psychiatric hold was lifted, no new notice was sent to the resident or the Ombudsman, despite the decision not to readmit the resident. Interviews revealed that staff did not complete or send an updated notice, contrary to facility policy.
A resident with major depressive disorder and generalized anxiety disorder was transferred to a hospital due to aggressive behavior without being provided a notice of bed-hold. The facility's staff, including the Social Services Director and DON, were unaware of the requirement to issue such a notice, despite the facility's policy mandating it for all residents during periods of absence.
A resident with a history of violent behavior was not re-evaluated for re-admission after being cleared from a psychiatric hold at a hospital. Despite being cleared, the facility refused re-admission, citing ongoing behavioral issues. The facility did not provide a new discharge notice or document a re-evaluation of the resident's condition, failing to adhere to its policies on transfer and discharge.
The facility failed to ensure timely response to call lights, with residents reporting waits of up to an hour, leading to unmet care needs and potential risks. Staff confirmed the importance of prompt responses, and facility policies were reviewed, highlighting the deficiency.
Failure to Notify Family of Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member when the resident eloped from the facility. The resident was admitted with diagnoses including Wernicke’s encephalopathy and had a family member listed as emergency contact number one. An elopement and wandering risk assessment indicated the resident was alert and oriented to person, place, and time and able to follow instructions. Nursing notes documented that on the evening in question, the resident was alert, oriented to two spheres, able to follow commands, and ambulatory with a cane. The resident was last seen at the nurses’ station around 6:30 p.m. and later in the lobby doing word search puzzles, and then was noted to be missing from his room at approximately 8:50 p.m., prompting a facility-wide search and activation of the facility’s missing resident code. When the resident could not be located within the building or on the grounds, staff initiated external search efforts, and the charge nurse notified law enforcement and the physician. However, the charge nurse did not notify the resident’s family member at that time, despite the facility’s policy requiring family/responsible party notification when a resident is not found in the facility or on the grounds. Interviews later confirmed that the LVN did not contact the family because staff were still looking for the resident, and the LVN acknowledged the family should have been notified. The RN stated she had asked the LVN to call the family, and the DON stated that the RN or LVN is responsible for notifying the family and documenting it in the record. Documentation showed that social services did not attempt to contact the family until the following day, nearly 15 hours after the resident was first noted missing, at which time the family reported the resident was at a general acute care hospital. This sequence of events demonstrates that the facility did not follow its own emergency procedure for missing residents regarding timely family notification.
Failure to Prevent Resident Elopement Through Unmonitored Front Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent a resident from exiting the facility without staff knowledge. The resident was admitted with Wernicke’s encephalopathy and was described in various assessments as alert and oriented to name and place, sometimes to time, but also forgetful, confused at times, and unhappy or not accepting of placement. An elopement and wandering risk assessment documented that the resident was alert and oriented x3 and able to follow instructions, while also expressing dissatisfaction with being in the facility. Nursing notes indicated the resident was ambulatory with a cane and moved between his room, the lobby, activity room, and patio. On the day of the incident, staff documented that the resident was in his room at approximately 3:15 p.m., later seen in the lobby doing word search puzzles, and received medications in the lobby around 4:00 p.m. The resident ate dinner in his room between about 4:30 and 5:00 p.m., and was again seen at the front nurse station asking for a pen and sitting in the lobby. The charge nurse reported noticing during rounds between 6:00 and 6:30 p.m. that the resident was not in his room, and staff initiated the facility’s missing resident code and searched the building and surrounding area without locating him. A CNA reported last seeing the resident around 5:50 p.m. when picking up the dinner tray and stated he did not check further on the resident because he considered the resident independent. Review of surveillance footage with maintenance staff showed the resident, dressed in regular clothes, exiting through the front door at 6:59 p.m. It was noted that the front door did not have an alarm at that time and was routinely locked at 8:00 p.m. Interviews with nursing staff and the DON revealed that after the receptionist leaves, there is no specific person assigned to monitor the front door; instead, LVNs, the desk nurse, charge nurse, RN, or a CNA at Station 1 are expected to keep an eye on it. Staff acknowledged that although there should always be someone at Station 1, this was not guaranteed, especially during busy hours between 6:00 and 9:00 p.m. The resident was later reported by a GACH RN to have been found by law enforcement wandering on a college campus and transported to the hospital. The facility’s policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
Failure to Include Fall Prevention in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan (BCP) was developed within 48 hours of admission to address a resident's high risk for falls. Upon admission, the resident had a documented history of repeated falls, left-sided weakness, was non-ambulatory, and required assistance with transfers and dressing. The admission and fall risk assessments both indicated the resident was at high risk for falls, yet the BCP did not include any mention of the resident's fall history or interventions to prevent falls. Subsequently, the resident experienced a fall while attempting to reach for clothes independently, resulting in injury to the shoulder and head, and required transfer to an acute hospital. Interviews with facility staff, including an LVN, DON, and ADON, confirmed that the BCP lacked necessary fall prevention interventions and did not communicate the resident's fall risk to staff. The facility's policy required a baseline care plan to address immediate health and safety needs, but this was not followed in the resident's case.
Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide copies of a resident's medical records upon request and within the required two business days after receiving a request from the resident's legal representative. The resident, who had diagnoses including respiratory failure and type 2 diabetes mellitus, had been transferred to an acute care hospital and did not return. The legal representative, through an attorney, submitted a written request for the resident's complete medical records, including a signed authorization form. The Director of Medical Records (DMR) received the request and forwarded it to the facility's legal department, following the facility's usual process for requests from law firms or subpoenas. Despite the DMR uploading the resident's entire medical record to a secure link provided by the legal department, the records were not released to the legal representative within the required timeframe. Interviews with the DMR, Director of Nursing (DON), and Nurse Consultant revealed confusion regarding responsibility for fulfilling such requests, with the DMR and DON deferring to the legal department. The facility's policy indicated that non-personnel representatives, such as legal firms, should have access to records within 30 days of a written request, but the records were not provided within this period, resulting in the deficiency.
Failure to Safeguard Resident Belongings After Death
Penalty
Summary
The facility failed to safeguard the personal belongings of a resident after the resident passed away. The resident, who had diagnoses including cerebrovascular disease, cerebral infarction, anemia, and was receiving palliative care, had an inventory of personal effects completed upon admission. After the resident's death, the family reported several missing items, including a radio/CD player, a jazz CD, a pair of pajama pants, and a pair of reading glasses. The facility's Social Worker confirmed that these items were not found despite a search and acknowledged that the belongings list was not updated when new items were brought in by the family. Interviews with facility staff, including the Social Worker and the DON, revealed that the facility's policy required updating the inventory of resident belongings as necessary, but this was not done in this case. The facility's own policy also stated that resident belongings should be treated with respect and that residents have the right to be free from theft or misappropriation of property. The failure to update the belongings list and secure the resident's property resulted in the loss of items that could have had sentimental value for the family.
Antihypertensive Medication Held Outside Physician Order Without Notification
Penalty
Summary
A deficiency occurred when a nurse failed to administer an antihypertensive medication, losartan-hctz, to a resident in accordance with the physician's order. The physician's order specified that the medication should be held only if the resident's systolic blood pressure (SBP) was less than 110 or pulse was less than 60. On the date in question, the resident's SBP was 119, which was above the hold threshold, but the nurse held the medication based on her own judgment, citing concern that the blood pressure was 'low.' There was no documentation that the resident's physician was notified about the medication being held outside of the ordered parameters. The Director of Nursing confirmed that the nurse did not follow the physician's order and that there was no progress note or physician notification regarding the held dose. The facility did not have a specific policy on holding blood pressure medications, but the expectation was that nurses would follow physician orders and document any deviations.
Failure to Provide Gluten-Free Diet as Ordered
Penalty
Summary
A resident with a documented gluten allergy and the capacity to make decisions was admitted with physician orders specifying a gluten-free diet. Despite these orders, the resident reported being repeatedly served food containing gluten, specifically cornbread, which she identified as containing gluten and therefore could not eat. During meal service, her tray was observed to include cornbread, and her meal ticket indicated her gluten allergy. The resident stated she would only eat the vegetables provided, as the cornbread would upset her stomach. Interviews with facility staff revealed that the dietary supervisor was aware of the resident's gluten allergy and that the facility used a standard cornbread mix containing wheat flour and wheat gluten. The dietary supervisor could not explain why the resident was served cornbread, and the director of nursing confirmed that dietary staff should ensure residents with gluten allergies do not receive gluten-containing foods. Facility policies reviewed indicated the importance of avoiding wheat products, including cornbread, for residents with gluten intolerance or allergies.
Failure to Monitor Weight Weekly After Significant Weight Loss
Penalty
Summary
The facility failed to follow its weight management policy for one resident who experienced significant weight loss. According to the resident's records, there was a loss of 17 lbs. between December 2024 and January 8, 2025, and a further loss of 13 lbs. by February 4, 2025. Despite this severe weight loss, there was no documentation of weekly weight monitoring after the initial loss was identified, as required by the facility's policy. The policy states that any weight change of 5% or more should prompt a retake the next day for confirmation and weekly monitoring thereafter. The deficiency was confirmed through record review and interview with the DON, who acknowledged that the resident should have been weighed at least weekly following the observed weight loss. The resident had diagnoses including muscle wasting and atrophy, making weight monitoring particularly important. The lack of weekly weight documentation after the significant weight loss was a direct violation of the facility's established procedures for weight assessment and intervention.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
Surveyors observed that certain resident rooms were not maintained in a clean and comfortable condition. Specifically, one room had adhesive residue, chipped paint, black horizontal lines across the wall in front of the residents' beds, chipped baseboards, and yellow and black stains on the floor. Another room had adhesive residue, chipped paint, and black horizontal lines on the wall in front of the residents' beds. These conditions were directly observed during the survey, and the Maintenance Director confirmed the presence of these issues, attributing the black lines and chipped baseboards to contact with beds or wheelchairs, and the adhesive residue and chipped paint to recent electrical work. The Maintenance Director also acknowledged that the floor was old, stained, and could not be adequately cleaned. Interviews with facility staff revealed that renovations had begun three years prior, but some rooms, including those observed, had not yet been renovated because residents and their families were reluctant to move out. The Maintenance Director stated that repairs and renovations could not be performed while rooms were occupied. The Director of Nursing confirmed that room changes were necessary for renovations but were sometimes resisted by residents and families. The Administrator stated that maintaining resident rooms was a team effort, primarily overseen by the Maintenance Director, and acknowledged that the observed room conditions were not acceptable and could be off-putting to residents. Facility policy requires that all areas be maintained in a safe and operable manner, in compliance with regulations, and free from hazards.
Failure to Notify POA of Medication Change
Penalty
Summary
The facility failed to notify the power of attorney (POA) for Resident 1 when a physician ordered lorazepam, an anti-anxiety medication, for the resident. This oversight resulted in the POA being unaware of the resident's overall condition. The resident was admitted with diagnoses including obstructive uropathy and had a designated POA. On November 22, 2024, a Licensed Vocational Nurse (LVN) documented receiving a new order for lorazepam for the resident's anxiety and restlessness, but there was no evidence that the POA was informed of this new medication order. Interviews with facility staff, including LVN 2, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the POA should have been notified of the new orders. The facility's policy requires prompt notification of the resident's representative for changes in medical or mental condition. However, the medical record review and staff interviews revealed a lack of documentation indicating that the POA was informed, highlighting a failure to adhere to the facility's policy and procedure.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address significant weight loss in two residents, leading to potential nutritional deficiencies. Resident 1 was admitted with obstructive uropathy and was at risk for malnutrition. Despite a documented weight loss of 15 lbs. or 8.9% within two weeks, there was no evidence that the physician or registered dietician (RD) was notified, nor were any interventions initiated. The RD later struck out the initial weight entry, citing it as an outlier, but this action was not communicated to the Director of Nursing (DON), leading to confusion about the resident's weight status. Resident 2, diagnosed with diabetes mellitus, experienced a weight loss of 25 lbs. or 11% over two weeks. Although the Licensed Vocational Nurse (LVN) verbally notified the Physician's Assistant, this was not documented, and no change of condition report or care plan was initiated. The resident was aware of the weight loss but had not been consulted about his nutrition plan. The RD was informed of the weight loss but was not updated on any re-weighing results, and there was no documentation of physician notification or intervention initiation. The facility's policy required immediate notification of the dietitian for weight changes of 5% or more, but this protocol was not followed. The lack of documentation and communication among staff members contributed to the oversight in addressing the residents' nutritional needs, as evidenced by the unaddressed weight loss and absence of documented interventions.
Failure to Prevent and Address Pressure Injury
Penalty
Summary
The facility failed to adhere to its policy and procedure for the prevention of pressure injuries for a resident, resulting in an unstageable pressure injury on the resident's right hip. The resident, who was admitted with cerebral palsy and an unspecified local infection of the skin, was at moderate risk for developing pressure injuries according to the Braden Scale. Despite this, the facility did not conduct a proper assessment or follow-up after a dressing was placed on the resident's right hip. The deficiency was identified when a Certified Nurse Assistant (CNA) observed a wound on the resident's right hip and lower back, both covered with dressings. The Treatment Nurse (TN) confirmed that the resident was being treated for an abscess on the lower back but was unaware of any other wounds. Upon further examination, a yellow wound with slough was found on the resident's right hip, which was classified as an unstageable pressure injury. The wound had not been documented or addressed in the resident's medical records prior to this discovery. The facility's policy required daily skin inspections and documentation of any changes, which were not followed in this case. The Director of Nursing (DON) stated that the TN should have assessed the resident's skin, notified the medical doctor, and documented a treatment order when skin redness was reported. However, these steps were not taken, leading to the oversight and subsequent development of the unstageable pressure injury.
Failure to Document Care Conference in Resident's Medical Record
Penalty
Summary
The facility failed to ensure the completeness of a medical record for a resident when a care conference meeting was not documented. This deficiency was identified during an unannounced visit to investigate a complaint. The resident in question had been admitted with diagnoses including a fracture of the right tibia, mild intellectual disability, and cerebral palsy. Despite the care conference being conducted, it was not documented in the electronic health record system, PointClickCare (PCC), as confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Interviews with facility staff revealed that care conferences are typically documented in PCC, with the Social Service Director (SSD) responsible for opening the care conference note. However, in this instance, the SSD was unable to open the note, and the interdisciplinary team (IDT) members did not document their notes. The facility lacked a policy mandating the documentation of care conferences, although the DON expected such documentation to occur. This oversight had the potential to impact the resident's plan of care by creating miscommunication among the care team and the resident's caregiver.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 126, by not ensuring the call light button was within reach. During an observation and interview, it was noted that the call light was on the floor behind the resident's bed, making it inaccessible. Resident 126, who has moderate cognitive impairment and the capacity to make his own decisions, was unaware of the call light's location and unable to reach it for assistance. This oversight was confirmed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), both of whom acknowledged that the call light should be within the resident's reach to prevent delays in care and potential emergencies. The Director of Nursing (DON) also confirmed that the facility's practice is to keep call lights within easy reach of residents, as outlined in the facility's policy and procedure. The failure to adhere to this policy was observed during the survey, highlighting a deficiency in the facility's ability to meet the needs and preferences of Resident 126. The report does not mention any corrective actions taken to address this issue.
Failure to Monitor Dialysis Catheter, Fluid Restrictions, and Skin Condition
Penalty
Summary
The facility failed to properly identify, assess, and monitor a central dialysis catheter for a resident with End Stage Renal Disease. Despite the resident having a left chest tunneled catheter for dialysis, the facility's records and staff observations did not document or monitor this catheter upon admission or during subsequent shifts. The facility's staff were incorrectly monitoring an AV shunt on the resident's left upper arm, which was not in use, leading to a lack of proper care for the actual dialysis access site. Another resident with congestive heart failure and chronic kidney disease was not provided with the physician-ordered fluid restrictions. The resident's fluid intake records showed multiple instances where the daily fluid intake exceeded the prescribed 1500 ml limit. Interviews with facility staff confirmed that the fluid restrictions were not adhered to, which could potentially impact the resident's health condition. Additionally, the facility did not assess or monitor a skin condition for a resident, leading to dry and scaly skin on the resident's lower legs. The resident reported that no one had checked their legs, and the treatment nurse was unaware of the condition. The facility's policy required daily skin inspections and reporting of abnormalities, but this was not followed, resulting in a lack of necessary treatment for the resident's skin condition.
Infection Control Lapses with Oxygen and Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents. For Resident 48, the oxygen nasal cannula tubing was left exposed on top of the resident's bed while the resident was not in the room. This was observed on multiple occasions, and both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the tubing should have been stored in a plastic bag when not in use to prevent contamination and infection. Resident 48 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was prescribed oxygen therapy as needed. For Resident 39, a wound vacuum device and tubing with brown sediment were left on the bedside table after a wound dressing change. The Treatment Nurse (TN) admitted to forgetting to discard the used tubing and failing to disinfect the wound vacuum machine, which could lead to cross-contamination and infection. The Infection Preventionist (IP) and the DON confirmed that the used supplies should have been discarded immediately, and the equipment should have been disinfected. Resident 39 had a history of pressure ulcers and urinary tract infections, with specific physician orders for wound care.
Inadequate Discharge Documentation for Resident Post-Hospitalization
Penalty
Summary
The facility failed to adequately document the necessity for discharging a resident, identified as Resident 4, after the resident was cleared from a psychiatric hold during hospitalization. Resident 4, who had been admitted with diagnoses including spinal tumor resection, hemiplegia, major depressive disorder, and generalized anxiety disorder, was initially given a 30-day discharge notice due to behavioral issues. However, the facility did not issue a new discharge notice after the resident was cleared to return from the hospital, nor did they provide documentation justifying the discharge decision. The facility's records indicated that Resident 4 was transferred to a general acute care hospital for a psychiatric evaluation following violent and aggressive behaviors. Despite the hospital's clearance for the resident to return, the facility did not re-evaluate the resident's current behavior or condition to determine if they could meet the resident's needs. The facility's policy required such an evaluation, but it was not conducted, and no updated notice was provided to the resident or the Ombudsman. Interviews with facility staff, including the Director of Nursing, Administrator, Social Services Director, and Psychiatrist, revealed that Resident 4 had been abusive and refused treatment for behavioral issues. Despite these challenges, the facility did not follow its own procedures for re-evaluating the resident's condition post-hospitalization, leading to a deficiency in the discharge process. The lack of documentation and failure to issue a new discharge notice after the psychiatric hold was discontinued contributed to the deficiency identified in the report.
Failure to Provide Updated Discharge Notice
Penalty
Summary
The facility failed to provide a notice of discharge for a resident when it decided not to accept the resident back after a stay at a general acute care hospital (GACH). The resident, who had been living at the facility since 2015, was initially transferred to the hospital for a psychiatric evaluation. The facility issued a 30-day discharge notice on the same day as the transfer, indicating the resident would be moved to a board and care or preferred setting. However, after the psychiatric hold was discontinued, the facility did not issue a new notice of discharge to the resident or the Ombudsman, despite the decision not to readmit the resident. Interviews with facility staff revealed that the Discharge Planner was responsible for sending out discharge notices and notifying the Ombudsman, but a second notice was not completed after the resident's hospital treatment. The Director of Nursing and the Social Service Director confirmed that no updated notice was sent to the Ombudsman after the resident's psychiatric hold was lifted. The facility's policy required that any changes in the discharge notice be communicated to the resident and the Ombudsman as soon as practicable, but this was not done, leading to a deficiency in the facility's discharge notification process.
Failure to Provide Bed-Hold Notice for Transferred Resident
Penalty
Summary
The facility failed to provide a notice of bed-hold to a resident upon their transfer to an acute care hospital. The resident, who had been admitted to the facility with diagnoses including major depressive disorder and generalized anxiety disorder, was transferred due to aggressive behavior and threats to the safety of others. The transfer was initiated on the basis of a 5150 hold for danger to others, and the facility had issued a 30-day Notice of Discharge due to behavioral concerns. However, there was no documented evidence that the resident was informed of the bed-hold policy, which is a right of the resident. Interviews with the Social Services Director and the Director of Nursing revealed a lack of awareness and misunderstanding regarding the requirement to issue a notice of bed-hold. The Social Services Director acknowledged that the resident should have had a bed-hold on file, while the Director of Nursing stated that the resident was not offered a bed-hold due to the nature of the transfer and the existing discharge notice. The facility's policy, dated October 2022, clearly indicates that all residents should be provided with written information regarding bed-hold policies during periods of absence, such as hospitalization or therapeutic leave.
Failure to Re-evaluate Resident for Re-admission After Hospitalization
Penalty
Summary
The facility failed to re-evaluate a resident's clinical behavior or condition for re-admission after a therapeutic hospitalization. The resident, who had been living in the facility since 2015, was initially transferred to a general acute care hospital (GACH) for a psychiatric evaluation and placed on a 5150 hold due to violent and aggressive behaviors. Despite being cleared by the hospital and the psychiatric hold being discontinued, the facility refused to readmit the resident, citing ongoing behavioral issues. The resident's medical history included diagnoses such as spinal tumor resection, hemiplegia, major depressive disorder, and generalized anxiety disorder. The facility had issued a 30-day discharge notice, which was effective immediately, indicating the resident would be discharged to a board and care or preferred setting. However, this discharge did not occur as planned due to the resident's transfer to the GACH for psychiatric evaluation. The facility did not provide a new discharge notice after the resident was cleared to return. Interviews with facility staff, including the Administrator, Social Services Director, and Psychiatrist, revealed that the decision not to readmit the resident was based on the resident's history of violent and aggressive behavior. The facility did not document a re-evaluation of the resident's condition after the hospital clearance, nor did it provide written justification for the refusal to readmit. The facility's policies on transfer, discharge, and bed-holds require that residents be evaluated based on their current condition, not their condition at the time of transfer, which was not adhered to in this case.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, as evidenced by interviews and record reviews of four residents who required assistance with activities of daily living (ADLs). Residents reported waiting up to an hour or longer for their call lights to be answered, resulting in them sitting in soiled briefs and experiencing delays in receiving necessary care. This issue was observed during an unannounced visit, where residents expressed their concerns about the inconsistent response times, particularly during certain shifts or depending on the staff on duty. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) confirmed that call lights should be answered promptly to prevent falls, skin breakdown, and other adverse outcomes. They acknowledged that it was unacceptable for residents to wait an hour for assistance and emphasized that all staff members were responsible for responding to call lights. The Director of Nursing (DON) also stated that call lights should be answered timely to prevent accidents. The facility's policies on answering call lights and supporting ADLs were reviewed, indicating that residents' requests should be responded to as soon as possible and that residents unable to carry out ADLs independently should receive the necessary services to maintain good hygiene and nutrition. Despite these policies, the facility's failure to answer call lights promptly led to unmet care needs and potential risks for the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 786 citations issued within 25 miles in the last 12 months — including the 4 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Health Care Center | 0.7 mi | — | 1 | 0 |
| Alta Vista Healthcare & Wellness Centre | 0.8 mi | — | 0 | 0 |
| Citrus Grove Post Acute | 1.2 mi | — | 18 | 0 |
| Mission Care Center | 1.3 mi | — | 1 | 0 |
| Arlington Gardens Care Center | 1.5 mi | — | 17 | 1 |
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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 August 2026) and official state health department websites.