Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Riverwood Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Staff did not consistently use PPE or perform hand hygiene as required, particularly when caring for residents on enhanced barrier precautions and during medication administration. Multiple staff members were observed entering rooms, providing care, and handling equipment without donning gowns or sanitizing hands, even for residents with indwelling devices or respiratory equipment. Facility policies required these precautions, but staff interviews revealed lapses and uncertainty about procedures.
Three residents prescribed opioid pain medications did not consistently receive their scheduled doses due to pharmacy delays, lack of access to the automated medication dispensing machine, and insufficient staff training or orientation. Residents reported increased pain and withdrawal symptoms, while staff interviews revealed confusion about medication refill processes and emergency access. Documentation of missed doses and communication with physicians was often incomplete or missing, resulting in inadequate pain management.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' health and quality of life.
Nurse staffing data was not posted daily as required, with an outdated staffing form observed and staff confirming that the correct report was not displayed on the designated day. The DON and Staffing Coordinator described a process for posting reports, but a lapse occurred, resulting in noncompliance with daily posting requirements.
Surveyors found that food items, including expired milk, undated sandwiches, and unlabeled liquids, were improperly stored in two nourishment rooms. Staff interviews revealed confusion over responsibility for labeling and dating food, and facility policy requires proper labeling for stored food items.
A resident with multiple chronic conditions experienced a code event and was pronounced dead by EMS after resuscitation efforts by staff. There was no documentation in the medical record regarding the code, resuscitation efforts, or the resident's death, despite facility policy requiring such documentation. Staff and the DON confirmed the absence of required documentation.
A resident with cognitive impairment and ADL/self-care deficits was repeatedly observed in bed without the call device within reach, as required by facility policy and the resident's care plan. The call device was found either hanging on the wall by the resident's feet or on the floor, and staff confirmed it should have been accessible at all times.
A facility failed to ensure accurate discharge assessments for a resident with multiple diagnoses, including diabetes and hypertension. The resident was discharged to an assisted living facility, but the MDS assessment incorrectly documented a discharge to a hospital. The MDS Coordinator confirmed the error and stated that the facility lacked a specific policy for MDS discharge assessments, relying on the RAI instead.
The facility failed to secure medications properly, with residents found with medications at their bedside without physician orders for self-administration. An RN left medications unattended, and the DON stated that medications should not be left at the bedside. These actions indicate non-compliance with the facility's medication storage policy.
The facility failed to properly store, label, and discard food items in the dietary department, as observed during a survey. Unlabeled and outdated food items were found in the walk-in cooler and storage room, contrary to facility policies. The Dietary Manager confirmed these deficiencies.
A resident with schizophrenia and other conditions experienced a health decline, necessitating a hospital transfer. The facility failed to document the transfer properly, missing key records like the transfer form and physician order. Staff interviews revealed confusion over the documentation process, and despite efforts to locate the paperwork, it remained incomplete.
A facility failed to ensure proper hand hygiene during medication administration and did not properly store reusable medical equipment. An LPN was observed not performing hand hygiene before or after administering medications to residents, contrary to facility policy. Additionally, a nebulizer in a resident's room was not stored correctly, with tubing undated and the face mask uncovered, violating infection control protocols.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
Staff failed to consistently use appropriate personal protective equipment (PPE) and perform hand hygiene as required by facility policy and procedure, particularly when providing care to residents on enhanced barrier precautions (EBP) and during medication administration. Multiple observations documented staff entering resident rooms, including those with EBP signage and available PPE, without donning gowns or performing hand hygiene. Staff were seen donning gloves without prior hand hygiene, providing direct care such as flushing midline catheters, administering medications, and performing incontinence care, then removing gloves and exiting rooms without hand hygiene. In several cases, staff proceeded to handle medication carts, computers, and other residents without sanitizing their hands between tasks. Residents involved included those with significant infection risks, such as individuals with indwelling medical devices (e.g., midline catheters, artificial joints, feeding tubes) and those requiring respiratory care equipment. For example, one resident with a right upper arm midline catheter and a history of joint replacement and surgical wound complications was cared for by staff who did not follow EBP protocols or hand hygiene requirements. Another resident's oxygen concentrator humidification bottle was observed sitting on the floor, contrary to infection prevention standards. Staff interviews revealed a lack of understanding or recall of EBP requirements and hand hygiene protocols, with several staff acknowledging lapses or uncertainty about the correct procedures. The facility's policies on EBP and hand hygiene, last revised in August 2025, require the use of gowns and gloves for high-contact care activities and mandate hand hygiene before and after resident contact, after glove removal, and before handling medications or invasive devices. Despite these policies, repeated failures were observed across multiple staff members and shifts, including LPNs and CNAs, during medication administration, vital sign collection, respiratory care, and meal assistance. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Provide Consistent Pain Management Due to Medication Access and Documentation Issues
Penalty
Summary
The facility failed to provide adequate pain management for three residents who were prescribed opioid pain medications. Multiple instances were documented where residents did not receive their scheduled opioid medications due to issues such as pharmacy delays, lack of access to the automated medication dispensing machine, and insufficient staff knowledge or training regarding medication refills and emergency access procedures. In several cases, the medication administration record (MAR) indicated missed doses coded as 'other/see nurses note,' but corresponding nursing notes were often missing or incomplete. Residents reported experiencing increased pain, withdrawal symptoms, and anxiety as a result of missed doses, and staff interviews revealed confusion about protocols for obtaining and administering controlled substances when regular supplies were depleted or inaccessible. For one resident with a history of spinal stenosis, diabetic neuropathy, and chronic pain, there were repeated missed doses of oxycodone due to pharmacy delivery delays and inability to access the emergency drug kit, especially when only agency nurses were present who lacked the necessary access. The resident described experiencing withdrawal symptoms and increased anxiety during these periods. Staff interviews confirmed that agency nurses often did not know the refill process or lacked access to the emergency supply, and documentation of physician notification or alternative pain management was inconsistent or absent. The facility's own protocols required timely preparation of prescriptions and notification of supervisors or the DON when medications were unavailable, but these steps were not reliably followed. Two other residents with chronic pain conditions also experienced missed or held doses of opioid pain medications, with documentation gaps and lack of clear communication with physicians or pharmacy. In some cases, medications were held due to resident refusal or drowsiness, but required documentation was not completed. Staff interviews indicated a lack of orientation and education for agency nurses, and some staff were unaware of emergency access procedures or on-call contacts. The facility's failure to ensure consistent access to pain medications, proper documentation, and adherence to pain management protocols resulted in residents not receiving necessary pain relief as ordered.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not fully support the residents' overall health and quality of life. The report specifically notes that the staff's competencies were insufficient to ensure that every resident received care tailored to their needs, impacting their well-being.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily as required. During an observation, the Daily Nursing Staffing Form displayed was found to be dated several days prior, rather than reflecting the current date. Interviews with the DON and Staffing Coordinator revealed that the Staffing Coordinator was responsible for posting the report on weekdays, while the Weekend Receptionist handled this task on weekends. The Staffing Coordinator reported that she prepared the weekend reports in advance for the Receptionist to post each day. However, it was confirmed that the correct staffing report was not posted on the observed morning, indicating a lapse in the daily posting process.
Failure to Store and Label Food Items Properly in Nourishment Rooms
Penalty
Summary
Surveyors observed that food products in two nourishment rooms were not stored and maintained in a safe and sanitary manner. Specifically, five chocolate milks with expiration dates that had already passed were found in the refrigerator, along with a Tupperware container and a bag of sandwiches that were both undated and unlabeled. Additionally, a 20-ounce cup half full of liquid was found without a label or date, and two fortified nutritional shakes were also undated. These observations were made during routine checks of the nourishment rooms. Interviews with facility staff revealed a lack of clarity regarding responsibility for labeling and dating food items. The Certified Dietary Manager in training was unaware of who was responsible for ensuring all food was properly dated and labeled. The Administrator stated that nursing staff should be responsible for dating and labeling food items in the nourishment rooms, while the kitchen is responsible for dating the shakes. The Regional Food Service Manager indicated that dietary staff are responsible for cleaning the refrigerators and freezers daily, but the facility is responsible for dating and labeling food items. Review of the facility's policy confirmed that staff are required to label foods with the resident's name and current date when food is intended for later consumption.
Failure to Document Code Event and Resident Death in Medical Record
Penalty
Summary
The facility failed to accurately and completely document the medical record of a resident who experienced a code event and subsequently died in the facility. The resident had multiple diagnoses, including hypertension, anemia, heart failure, dementia, schizoaffective disorder, and a history of COVID-19. On the day of the incident, staff responded to a code in the resident's room, performed CPR, and continued resuscitation efforts until EMS arrived and pronounced the resident deceased. Despite these events, there was no documentation in the resident's nursing progress notes regarding the resuscitation efforts, the code event, or the resident's death. Interviews with nursing staff and the Director of Nursing confirmed that there was no code sheet documentation or detailed note in the resident's chart about the incident. The facility's policy required that all services provided, changes in condition, and incidents be documented in the clinical record. However, a review of the medical record and interviews revealed that these requirements were not met, as there was no record of the code or the resident's death in the clinical documentation.
Failure to Ensure Call Device Accessibility for Resident with ADL Deficit
Penalty
Summary
A deficiency was identified when a resident with an ADL/self-care performance deficit and cognitive impairment was repeatedly observed without access to a call device while in bed. Multiple observations over several days documented that the call device was either hanging on the wall by the resident's feet, not within reach, or on the floor at the foot of the bed. The resident was observed in various states of dress, sometimes wearing only a brief, and at times with no blankets on the bed. The overbed table and breakfast tray were also noted to be positioned in ways that did not facilitate access to the call device. Interviews and record reviews confirmed that facility policy requires call lights to be within easy reach of residents when in bed or confined to a chair. The resident's care plan specifically included an intervention to encourage use of the call bell for ADL assistance. The DON confirmed that the call device should have been within reach at all times, but this was not consistently ensured for the resident in question.
Inaccurate Discharge Assessment Documentation
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for a resident reviewed for discharge. The resident was admitted with diagnoses including type II diabetes mellitus, hypertension, osteoarthritis, depression, and anxiety disorder. The discharge summary indicated that the resident was discharged to an assisted living facility, and progress notes confirmed the resident left without distress or concerns. However, the Minimum Data Set (MDS) Discharge Return Not Anticipated assessment inaccurately documented the resident as being discharged to a short-term general hospital. During an interview, the MDS Coordinator confirmed the error and noted that the facility did not have a specific policy for completing MDS discharge assessments, instead following the Resident Assessment Instrument (RAI).
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured in three of five hallways, as observed during a survey. In one instance, a resident had Dorzolamide HCl Solution at his bedside without a physician's order to self-administer, despite the resident's claim of using the medication himself. The RN confirmed the absence of an order for self-administration, and the Director of Nursing expressed that medications should not be left at the bedside. The facility's policy requires nursing staff to maintain medication storage in a safe manner, which was not adhered to in this case. In another instance, a resident had a medication cup with seven pills on his overbed table, stating he had not taken them due to personal preferences. The RN admitted to leaving the medications unattended while addressing other tasks. Similarly, another resident was found with a cup containing four pills on his bedside table, intended to be taken later, without a self-administration order. These observations indicate a failure to secure medications properly and ensure compliance with physician orders for self-administration.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage, labeling, and discarding of food items in the dietary department's walk-in cooler and stock/storage room. During an initial tour of the kitchen, surveyors observed 93 bowls of lemon gelatin with a use-by date that had already passed, as well as a tray of 70 glasses of iced tea and containers of vegetables and soup, all without identifying labels or dates. The Dietary Manager (DM) confirmed these observations and acknowledged that outdated foods should have been discarded and that all containers should be labeled and dated. In a follow-up tour, additional issues were noted, including packages of hotdog buns, hamburger buns, and sliced bread with no open dates, as well as partial containers of oil and instant mashed potatoes without open or use-by dates. The DM stated that all opened bread items should have an open or use-by date and that all products should be labeled and dated for storage. The facility's policies on receiving and food storage require that all food items be appropriately labeled and dated, and that food and drink items be discarded prior to expiration or within acceptable time frames for opened items.
Incomplete Medical Records for Resident Transfer
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was reviewed for discharge. The resident, who had a history of schizophrenia and other medical conditions, experienced a decline in health, prompting a recommendation for hospital evaluation. However, the medical record lacked documentation related to the discharge to the hospital, including the transfer form, physician order, change in condition, and notification to the responsible party. Interviews with staff revealed that there was confusion and uncertainty regarding the completion and documentation of the transfer process. A nurse stated that they did not see any documentation regarding the transfer in the electronic medical record. The Director of Nursing acknowledged the issue and mentioned efforts to locate the missing paperwork. A progress note was later entered as a late entry, detailing the steps taken during the transfer, but the original documentation was still missing. Further investigation showed that the nurse responsible for the transfer was confident that they completed the necessary paperwork, including the EMS and AHCA packets. However, the transfer form was not found in the system, and the Regional DON confirmed that while the form was started, it was unclear what happened to it. The facility's policy on transfer and discharge documentation was not adhered to, resulting in incomplete medical records for the resident.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration, as observed with a Licensed Practical Nurse (LPN) who did not perform hand hygiene before or after administering medications to residents. The LPN was observed preparing and administering medications to two residents without using hand sanitizer or washing hands, both before entering and after exiting the residents' rooms. The LPN admitted to forgetting the hand hygiene protocol and was unaware of the necessity to perform hand hygiene at each step of the medication administration process. The Director of Nursing (DON) confirmed that the facility's policy requires hand hygiene before entering and after exiting a resident's room, as well as the use of gloves when handling medications. Additionally, the facility did not ensure the proper storage of reusable medical equipment, specifically a nebulizer, in a resident's room. The nebulizer was repeatedly observed on the bedside table with attached tubing and a face mask that was not covered or dated. The resident mentioned that the nebulizer was provided for a cough, which had since improved, but was instructed to keep it for use as needed. The DON stated that the tubing should be changed weekly, dated, and the face mask should be stored in a bag when not in use. These observations indicate a failure to adhere to infection prevention and control protocols, potentially increasing the risk of infection spread within the facility.
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 6 citations issued within 25 miles in the last 12 months — 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 Starke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Health And Rehabilitation Center | 0.4 mi | — | 1 | 0 |
| Pavilion For Health Care, The | 17.5 mi | — | 0 | 0 |
| Middleburg Rehabilitation And Nursing Center | 20.7 mi | — | 5 | 0 |
| Macclenny Nursing And Rehab Center | 23.5 mi | — | 0 | 0 |
| W Frank Wells Nursing Home | 24.2 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverwood Healthcare & Rehabilitation Center.
100% money-back within 48 hours.
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.