River Walk Care Center

In the surveyor’s words

From the most serious findings on record at River Walk Care Center, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 5, 2025

  Based on interview and record review, the facility failed to implement the care plan (specific healthcare goals, interventions, and monitoring strategies) for one of two sampled residents (Resident 1) when the bowel and bladder retraining (scheduled toileting) was not implemented for Resident 1 who was at high risk for falls and had a history of falls related to toileting needs. This failure resulted in Resident 1 going to the bathroom on 8/20/25, independently, falling and sustaining an acute (new) left femoral neck fracture (break in the bone that connects the head of the femur (ball of the hip joint) to the shaft of the femur) extending to the lesser trochanter (attachment point for hip flexor muscles) and requiring hospitalization and surgical repair.Findings:During a review of… […]

• Actual harm, isolatedF688Mar 13, 2025

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided: 1. A restorative nursing program (program where restorative nursing assistants [RNA]-assist residents with performing exercises to maintain their ability to perform daily activities and tasks, impacting their quality of life and overall well-being and independence) from February 2024-December 2024. 2. Physical therapy (PT-exercises, massages and various treatments used to relieve pain, help you move better or strengthen weakened muscles) and Occupational therapy (OT-focuses on everyday tasks and activities that people value and need to do, such as self-care, work, play, and social participation) as ordered by the physician in August 2024 and December 2024. […]

• Actual harm, isolatedF689Oct 17, 2024

  Based on interview and record review, the facility failed to follow its policy and procedure on Care Plans, Comprehensive Person-Centered for one of three sampled residents (Resident 341) to reduce the risk of falls and minimize injuries. This failure resulted in Resident 341 falling multiple times in six months and sustaining a fracture (broken bone) to his left hip and left shoulder requiring surgical repair. Findings: During a review of Resident 341 Admission Record (AR) dated 4/2/24, the AR indicated, Resident 341 was admitted on [DATE]. […]

• Actual harm, isolatedF689Jun 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 1) was safely moved in bed by one Certified Nursing Assistant (CNA) while providing care. This failure resulted in Resident 1 rolling out of the bed, falling to the floor, and sustaining a fracture (broken bone) to the collar bone. Findings: During a review of Resident 1's Care Plan titled Activity of Daily Living (ADL), dated 9/26/21, the CP indicated, Bed mobility; extensive (resident involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) assistance. […]

• Actual harm, isolatedF602Apr 19, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant (CNA 1) physically hit Resident 1 resulting in injuries to the resident's face, back of head, right hand and both arms. Findings: During a review of Resident 1's Face Sheet (FS), dated 12/27/2022, the FS indicated, Resident 1 was a [AGE] year-old male with a history of hypo-osmolality (low nutrients in the blood) and hyponatremia (low sodium), hypertension (high blood pressure), Schizophrenia (effects one ability to think), and a history of COVID - 19 (contagious respiratory infection), depression (mood disorder). […]