Riverwood Health Care

In the surveyor’s words

From the most serious findings on record at Riverwood Health Care, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 19, 2026

  Based on interviews, and record reviews, the facility failed to provide adequate respiratory care services, immediate ongoing clinical assessment, treatment, and identified changes in condition as per professional standards of practice for one out of two sampled residents (Resident 1) when,1. LVN (Licensed Vocational Nurse) 1 did not notify the Physician of Resident 1's change in condition when he had shortness of breath and low oxygen saturation level on [DATE],2. LVN 1 increased Resident 1's oxygen therapy from 2 liters to 4 liters without a Physician's order, 3. LVN 1 adjusted Resident 1's oxygen liter flow and did not escalate Resident 1's care to a qualified healthcare professional, not following their scope of practice, and,4. […]

• Actual harm, isolatedF689Jan 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) who were at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), had implemented elopement prevention measures in place when: 1. Resident 1 had exit seeking behaviors on [DATE] but orders for a wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) and monitoring for wandering behavior were not initiated according to Resident 1's care plan , and an elopement risk assessment was not completed; and, 2. Resident 1 ' s wander guard was not working when the elopement happened on [DATE]; and, 3. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2025

  Based on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 87 residents who ate facility prepared meals when:1. Over ripe and spoiled produce was available for use in the walk-in refrigerator; 2. Black small bugs were found crawling on the onions and flying within the container that encompassed the onions; 3. Cutting boards and tray line pans were found with food particles, black, and brown colored substances on them; and,4. […]

• No harm, potential for more than minimal, widespreadF583May 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe and secure communication among staff when resident personal health information (PHI) was communicated via a facility approved group messaging platform (GMP, a smart phone (a mobile phone that performs many of the functions of a computer) free messaging application that lets users call and exchange texts, photos audio, and video messages with others across) on facility staff's personal smart phones based on regulatory requirements (HIPAA-Health Insurance Portability and Accountability Act, a set of federal rules requiring appropriate safeguards to protect the privacy of protected health information from disclosure without patient's consent) for a census of 88 residents. […]

• No harm, potential for more than minimal, patternF584Sep 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 5 out of 41 facility rooms when window blinds were broken in Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]).These failures removed residents' rights to a dignified homelike environment, with the potential to result in psychosocial harm.Findings:During an observation on 9/09/25, at 10:58 AM, in room [ROOM NUMBER], the window blinds were observed to be broken.During a concurrent observation and interview on 9/09/25, at 12:59 PM, in room [ROOM NUMBER], Licensed Nurse (LN) 3 confirmed the window blinds were broken. LN 3 stated broken blinds were a dignity issue for the residents. […]