Inspection Report Summary
The most recent inspection on June 26, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a mixed record with deficiencies primarily involving fall risk management, medication administration errors, infection control, abuse reporting, and Life Safety Code violations such as obstructed exits and sprinkler maintenance. Some complaint investigations were substantiated with deficiencies, including issues with abuse prevention, medication errors, and environmental cleanliness, while many complaints were unsubstantiated or found to have no related deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent inspections indicate improvement, with no deficiencies cited in the latest visits following prior findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
300% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 127
Capacity: 127
Deficiencies: 0
Jun 26, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00458236 and IN00461193 at Riverwalk Village.
Findings
No deficiencies related to the allegations in complaints IN00458236 and IN00461193 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Investigation of Complaints IN00458236 and IN00461193 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 127
Total Capacity: 127
Medicare Residents: 1
Medicaid Residents: 79
Other Payor Residents: 47
Inspection Report
Complaint Investigation
Census: 127
Capacity: 127
Deficiencies: 0
Apr 23, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456788.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00456788; no deficiencies related to the allegations were cited.
Report Facts
Medicare residents: 2
Medicaid residents: 80
Other residents: 45
Inspection Report
Complaint Investigation
Census: 121
Capacity: 121
Deficiencies: 0
Mar 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454645, IN00453666, and IN00452222.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00454645, IN00453666, and IN00452222 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 121
Total Census: 121
Medicare Census: 4
Medicaid Census: 77
Other Payor Census: 40
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Jan 15, 2025
Visit Reason
This visit was conducted for the Investigation of Complaint IN00449966.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint.
Complaint Details
Complaint IN00449966 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 119
Total Capacity: 119
Medicare Census: 3
Medicaid Census: 74
Other Payor Census: 42
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 14, 2025
Visit Reason
Paper compliance review was conducted for the Investigation of Complaints IN00447395 and IN00448034.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigations.
Report Facts
Complaint Investigation IDs: Investigation of Complaints IN00447395 and IN00448034
Inspection Report
Re-Inspection
Census: 125
Capacity: 169
Deficiencies: 0
Jan 8, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/21/24 was performed to verify compliance with applicable regulations.
Findings
Riverwalk Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for two detached storage buildings.
Report Facts
Facility capacity: 169
Census: 125
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey completed on October 30, 2024.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 1
Nov 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446386, IN00447395, and IN00448034. Complaints IN00446386 and IN00447395 had no deficiencies cited, while complaint IN00448034 resulted in federal deficiencies.
Findings
The facility failed to accurately assess fall risks, implement fall interventions, and thoroughly document falls for one of three residents reviewed (Resident F). Resident F experienced multiple falls, including one with injury resulting in a hospital admission for a brain bleed. The facility's fall management policies and interventions were found deficient, particularly related to new admissions and staff adherence to protocols.
Complaint Details
Complaint IN00448034 was substantiated with federal deficiencies cited. Complaints IN00446386 and IN00447395 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to accurately assess fall risks, implement fall interventions, and thoroughly document falls for Resident F. | SS=D |
Report Facts
Census: 118
Total Capacity: 118
Medicare Census: 5
Medicaid Census: 72
Other Payor Census: 41
Fall Assessment Score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Notified of Resident F's fall and involved in reviewing fall interventions | |
| Assistant Director of Nursing (ADON) | Provided information about intake referral and hospital paperwork process for new admissions | |
| RN 7 | Registered Nurse | Interviewed regarding fall assessment and documentation procedures |
Inspection Report
Life Safety
Census: 120
Capacity: 169
Deficiencies: 4
Nov 21, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included issues with egress door accessibility, hazardous area door self-closing devices, cooking facility appliance placement, and sprinkler system maintenance.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 1 of 8 exits were readily accessible; a courtyard door was magnetically locked and required a code not posted at the exit. | SS=E |
| Failed to ensure the corridor door to 1 of over 8 hazardous areas was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. | SS=E |
| Failed to provide an approved method to ensure cooking appliances were returned to approved design location after maintenance and cleaning, specifically a six burner flat grill lacked such a method. | SS=E |
| Failed to ensure 9 of over 100 sprinklers were replaced or cleaned in accordance with NFPA 25; sprinklers were dirty, over 50 years old, and needed replacement. | SS=E |
Report Facts
Certified beds: 169
Census: 120
Exits inspected: 8
Hazardous areas inspected: 8
Residents potentially affected: 25
Residents potentially affected: 14
Residents potentially affected: 12
Sprinklers inspected: 100
Sprinklers deficient: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Roe | Executive Director | Signed the report and participated in exit conference |
| Maintenance Director | Interviewed and involved in observations and corrective actions | |
| Maintenance Assistant | Participated in observations and exit conference | |
| Administrator | Participated in exit conference |
Inspection Report
Annual Inspection
Census: 119
Capacity: 119
Deficiencies: 3
Oct 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00444592.
Findings
The facility was found deficient in multiple areas including failure to ensure shift-to-shift narcotic count and reconciliation for medication carts, failure to appropriately discard expired insulin pens and label medications, and failure to implement enhanced barrier precautions during high contact care for certain residents.
Complaint Details
Complaint IN00444592 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure shift-to-shift narcotic count and reconciliation was completed for 6 of 7 medication carts reviewed. | SS=E |
| Failed to appropriately discard expired insulin pens and label medications with resident information in 2 of 6 medication carts observed. | SS=D |
| Failed to implement enhanced barrier precautions during high contact care for 3 of 6 residents reviewed for infection control. | SS=E |
Report Facts
Census: 119
Total Capacity: 119
Survey Dates: October 23-30, 2024
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Roe | Executive Director | Signed the report and referenced in plan of correction |
| LPN 7 | Interviewed regarding narcotic count sheet issues on HI medication cart | |
| LPN 6 | Interviewed regarding narcotic count sheet issues and enhanced barrier precautions | |
| RN 3 | Observed medication storage and administration, interviewed about narcotic count and enhanced barrier precautions | |
| LPN 4 | Observed medication storage and interviewed about narcotic count and medication labeling | |
| CNA 11 | Interviewed about enhanced barrier precautions adherence | |
| ADON | Assistant Director of Nursing | Interviewed about enhanced barrier precautions and wound care |
| Unit Manager | Observed wound care and interviewed about enhanced barrier precautions | |
| DON | Director of Nursing | Interviewed about enhanced barrier precautions and narcotic count policies |
| Infection Preventionist | Interviewed about enhanced barrier precautions protocols and signage |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Sep 30, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00441286, IN00442875, IN00440385, and IN00440605.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00441286, IN00442875, IN00440385, and IN00440605 were investigated and no deficiencies related to the allegations were found.
Report Facts
Census SNF/NF: 119
Total Capacity: 119
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 78
Census Payor Type - Other: 28
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Jun 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00436644.
Findings
No deficiencies related to the allegations in Complaint IN00436644 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00436644 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 119
Total Capacity: 119
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 52
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 26, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00430621 completed on April 4, 2024.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00430621 completed on April 4, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00429561 completed on March 8, 2024.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was complaint-related, specifically a paper compliance review of Complaint IN00429561. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 2
Apr 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430621, which involved federal and state deficiencies related to medication administration and storage.
Findings
The facility failed to verify the correct type of insulin prior to administration for one resident, resulting in a medication error that required hospital transfer. Additionally, the facility failed to date insulin vials and pens after opening on two medication carts, violating facility policy and regulatory requirements.
Complaint Details
Complaint IN00430621 was substantiated with federal/state deficiencies cited at F760 and F761 related to medication errors and improper labeling/storage of insulin.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to complete verification of the correct type of insulin prior to administration for 1 of 3 residents reviewed, resulting in a medication error and hospital transfer. | SS=D |
| Failed to date resident's insulin vials and insulin flex pens after opening in accordance with facility policy for multiple residents on 2 of 3 medication carts observed. | SS=D |
Report Facts
Census: 117
Total Capacity: 117
Residents receiving insulin: 6
Units of insulin administered: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed the inspection report |
| RN 14 | Nurse involved in insulin medication error and interviewed regarding the incident | |
| RN 12 | Nurse who indicated normal practice of dating insulin vials and pens | |
| LPN 23 | Nurse who observed with medication cart and indicated normal dating practice |
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 2
Mar 6, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00429561, IN00429518, IN00429316, and IN00429373) regarding alleged abuse and other concerns at the facility.
Findings
The facility was found to have failed to prevent verbal and mental abuse of a severely cognitively impaired resident by a staff member, and failed to ensure timely reporting of suspected physical abuse of another resident. Several staff interviews and record reviews confirmed inappropriate and intimidating behavior by staff member QMA 1 towards Resident D, and failure to report an incident involving Resident J. Corrective actions including suspension of involved staff and staff education on abuse policies were planned.
Complaint Details
Complaint IN00429561 was substantiated with federal/state deficiencies cited at F600 and F609 related to abuse and failure to report abuse. Complaints IN00429316, IN00429518, and IN00429373 had no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to prevent verbal and mental abuse of a severely cognitively impaired resident by a staff member. | SS=D |
| Failed to ensure staff reported suspicions of physical abuse of a severely cognitively impaired resident to the Administrator immediately per facility policy. | SS=D |
Report Facts
Census: 122
Total Capacity: 122
Medicare Census: 9
Medicaid Census: 66
Other Payor Census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| QMA 1 | Qualified Medication Aide | Named in findings related to verbal and mental abuse of Resident D and failure to report suspected physical abuse of Resident J |
| Lab Tech 2 | Witnessed verbal abuse incident involving QMA 1 and Resident D | |
| CNA 3 | Certified Nursing Assistant | Witnessed and reported verbal abuse by QMA 1 towards Resident D |
| LPN 4 | Licensed Practical Nurse | Heard raised voice of QMA 1 and reported incident |
| LPN 6 | Licensed Practical Nurse | Involved in sending QMA 1 home after incident |
| CNA 5 | Certified Nursing Assistant | Reported QMA 1's rude and inappropriate verbal interactions with Resident D |
| CNA 7 | Certified Nursing Assistant | Reported hearing QMA 1 yell at Resident D |
| DON | Director of Nursing | Provided facility policy and confirmed lack of timely reporting of abuse |
| keith davis | Senior executive director | Signed the report |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 2
Feb 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427076, IN00427114, IN00426593, and IN00425435 at Riverwalk Village.
Findings
The facility was found deficient related to unresolved resident grievances regarding laundry services and failure to assess a resident after an unwitnessed fall, resulting in delayed treatment for a hip fracture. Some complaints had no deficiencies cited, while others resulted in federal/state deficiencies.
Complaint Details
Complaints IN00427076 and IN00425435 had no deficiencies related to the allegations. Complaints IN00427114 and IN00426593 had federal/state deficiencies cited at F585 related to grievances and laundry services.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to resolve resident grievances by providing adequate laundry services related to the accurate and timely return of personal resident clothing. | SS=D |
| Failure to assess a resident after an unwitnessed fall, resulting in delayed identification and treatment for a fracture of the left hip. | SS=D |
Report Facts
Census: 117
Total Capacity: 117
Medicare Census: 8
Medicaid Census: 70
Other Payor Census: 39
Missing dentures cost: 5000
Missing comforter cost: 400
Date of fall: Jan 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ken Pflumm | RVPO | Provider/supplier representative who signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 5, 2024
Visit Reason
Paper compliance review was conducted related to the Investigation of Complaints IN00427114 and IN00426593.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00427114 and IN00426593, with paper compliance completed on February 5, 2024. The facility was found in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 30, 2024
Visit Reason
Paper compliance review to the unrelated deficiencies cited during the Investigation of Complaints IN00423551 and IN00423956 completed on January 3, 2024.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaints IN00423551 and IN00423956; paper compliance review completed.
Inspection Report
Complaint Investigation
Census: 114
Capacity: 114
Deficiencies: 2
Jan 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423551 and IN00423956 at Riverwalk Village.
Findings
No deficiencies related to the complaints were cited; however, unrelated deficiencies were found including failures in sanitary food handling practices and infection control measures such as improper use of personal protective equipment (PPE).
Complaint Details
Complaint IN00423551 and IN00423956 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure meal service was completed in a sanitary manner for 3 of 3 residents reviewed, with staff handling food with ungloved hands. | SS=D |
| Facility failed to ensure personal protective equipment (PPE) was worn during patient care for 1 of 3 residents with COVID-19 infection reviewed. | SS=D |
Report Facts
Census: 114
Total Capacity: 114
Medicare Residents: 4
Medicaid Residents: 68
Other Residents: 42
Survey Dates: 2
Corrective Action Completion Date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Adam McGraw | Executive Director | Signed the report and involved in corrective action education |
| Director of Nursing (DON) | Interviewed regarding expectations for food handling and PPE use; no full name provided |
Inspection Report
Life Safety
Census: 115
Capacity: 169
Deficiencies: 0
Dec 18, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/30/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Riverwalk Village was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 169
Census: 115
Inspection Report
Re-Inspection
Census: 120
Capacity: 120
Deficiencies: 0
Nov 21, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 10, 2023.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 120
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 73
Census Payor Type Other: 46
Inspection Report
Life Safety
Census: 123
Capacity: 169
Deficiencies: 12
Oct 30, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 10/30/2023.
Findings
The Emergency Preparedness survey found the facility in compliance with requirements. The Life Safety Code survey identified multiple deficiencies including obstructed means of egress, improperly secured fire extinguisher, missing drip tray in kitchen hood, incomplete maintenance documentation for smoke alarms, improper storage of propane tanks, use of portable space heaters, extension cords used as fixed wiring substitutes, corridor doors not latching properly, and soiled linen carts stored improperly in corridors.
Severity Breakdown
SS=E: 9
SS=F: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Means of egress corridor near resident room #214 was obstructed with 24 boxes. | SS=E |
| J-Hall exit door was magnetically locked with code not posted by keypad. | SS=E |
| Exit discharge near resident room 201 was obstructed with 3 large wooden pallets. | SS=E |
| Documentation for preventative maintenance of battery-operated smoke alarms in resident rooms was incomplete. | SS=F |
| LP propane tank was stored connected to a gas grill in the staff smoking area. | SS=F |
| Kitchen range hood system lacked a drip tray to collect grease. | SS=E |
| Automatic sprinkler system deficiencies from prior inspections were not corrected. | SS=F |
| Portable fire extinguisher in Data Room was unsecured, sitting on A/C ledge. | SS=E |
| Corridor double doors failed to latch positively into door frames. | SS=E |
| Two soiled linen carts exceeding 32 gallons capacity were stored in corridor near resident room 110. | SS=E |
| Portable space heater was in use in the Data Room, contrary to facility policy. | SS=E |
| Extension cord was used as a substitute for fixed wiring powering a ceiling light in maintenance office. | SS=E |
Report Facts
Certified beds: 169
Census: 123
Boxes obstructing egress corridor: 24
Wooden pallets obstructing exit discharge: 3
Soiled linen carts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Named in relation to findings and corrective actions |
Inspection Report
Annual Inspection
Census: 111
Capacity: 111
Deficiencies: 7
Oct 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from October 2 to October 10, 2023.
Findings
The facility was found deficient in multiple areas including resident dignity in wound care, unresolved resident council concerns about call light response times and missing clothing, failure to notify Ombudsman of resident transfers, inaccurate MDS assessments for oxygen therapy, improper catheter care, respiratory equipment management, and lack of staff competency in caring for a resident with Huntington's disease.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure prompt wound care was provided in a manner to promote resident dignity for 1 of 1 residents reviewed for dignity (Resident 5). | SS=D |
| Failed to resolve resident council concerns related to long call light wait times and missing clothing items (Residents 5, 47, 4, 87, 59). | SS=E |
| Failed to provide notice of transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman for 4 of 4 residents reviewed for hospitalization (Residents 92, 22, 77, and 27). | SS=E |
| Failed to ensure the Minimum Data Set (MDS) assessments were complete and accurate for 1 of 3 residents reviewed for oxygen therapy (Resident 41). | SS=D |
| Failed to ensure proper management of a supra-pubic urinary catheter and infection prevention strategies for 1 of 5 residents reviewed for catheters (Resident 85). | SS=D |
| Failed to manage respiratory equipment and oxygen therapy as ordered for 2 of 3 residents reviewed for oxygen therapy (Residents 41 and 9). | SS=D |
| Failed to ensure nursing staff were competent to demonstrate skills and techniques necessary to provide care for a resident with Huntington's disease for 1 of 30 residents reviewed (Resident 38). | SS=D |
Report Facts
Survey dates: 6
Census: 111
Total capacity: 111
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 30
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Davis | Senior Executive Director | Signed the report and involved in corrective action plans |
| QMA 6 | Named in catheter care deficiency and observation | |
| LPN 7 | Interviewed regarding oxygen therapy and catheter care | |
| LPN 8 | Interviewed regarding oxygen therapy tubing and humidification | |
| CNA 9 | Interviewed regarding care for resident with Huntington's disease | |
| CNA 13 | Interviewed regarding care for resident with Huntington's disease | |
| CNA 14 | Interviewed regarding care for resident with Huntington's disease | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including catheter care, oxygen therapy, and staff education |
| ADON | Assistant Director of Nursing | Interviewed regarding wound care and resident behavior |
| Administrator | Interviewed regarding resident council concerns and staff education |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Sep 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417656.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint.
Complaint Details
Complaint IN00417656 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 110
Total Capacity: 110
Medicare Census: 2
Medicaid Census: 69
Other Payor Census: 39
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00413895 completed on August 3, 2023.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00413895 completed on August 3, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 1
Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414027, IN00413426, and IN00413895, including a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies were cited related to complaints IN00414027 and IN00413426. Deficiencies related to complaint IN00413895 were cited at F584 for failure to ensure shower rooms were properly cleaned, affecting 19 residents with issues including malodorous smell, dried brown material, broken tiles, and dark substances in grout.
Complaint Details
Complaint IN00414027 and IN00413426 had no deficiencies related to allegations. Complaint IN00413895 was substantiated with federal/state deficiencies cited at F584.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure shower rooms were properly cleaned, with malodorous smell, dried brown material on floor and around drain, missing and broken tiles, and dark black substance in grout between tiles. | SS=D |
Report Facts
Residents potentially affected: 19
Census: 126
Total licensed capacity: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David E. Pruett | Executive Director | Signed the report and completed education of housekeeping staff. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 0
Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00410725 and IN00410282.
Findings
No deficiencies related to the allegations in Complaints IN00410725 and IN00410282 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00410725 and IN00410282 found no deficiencies related to the allegations.
Report Facts
Medicare residents: 11
Medicaid residents: 63
Other residents: 44
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
May 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408824.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint.
Complaint Details
Investigation of Complaint IN00408824 found no deficiencies related to the allegations.
Report Facts
Census: 117
Total Capacity: 117
Medicare Census: 16
Medicaid Census: 62
Other Payor Census: 39
Inspection Report
Complaint Investigation
Census: 121
Capacity: 121
Deficiencies: 0
Apr 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404603, IN00403866, and IN00402617.
Findings
No deficiencies related to the allegations in complaints IN00404603, IN00403866, and IN00402617 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00404603, IN00403866, and IN00402617 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 121
Total Capacity: 121
Census Payor Type - Medicare: 21
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 38
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 0
Feb 23, 2023
Visit Reason
This visit was conducted for the investigation of four complaints: IN00399686, IN00401342, IN00401356, and IN00401924.
Findings
Complaint IN00399686 was unsubstantiated due to lack of evidence. Complaints IN00401342, IN00401356, and IN00401924 were substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00399686 was unsubstantiated due to lack of evidence. Complaints IN00401342, IN00401356, and IN00401924 were substantiated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 125
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 46
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 8, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00398173 and IN00397850 completed on December 30, 2022.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaints IN00398173 and IN00397850; paper compliance review completed.
Inspection Report
Complaint Investigation
Census: 119
Capacity: 119
Deficiencies: 0
Jan 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398920.
Findings
The complaint IN00398920 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398920 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census: 119
Total Capacity: 119
Medicare Census: 9
Medicaid Census: 74
Other Payor Census: 36
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 3
Dec 30, 2022
Visit Reason
This visit was conducted for the investigation of two substantiated complaints, IN00398173 and IN00397850, involving allegations of abuse and failure to meet professional standards in medication administration.
Findings
The facility failed to report an allegation of abuse in a timely manner and failed to ensure direct observation of medication administration for a resident. Additionally, infection control protocols were not followed during medication administration, and medications were left unattended. Deficiencies were cited related to reporting alleged violations, services meeting professional standards, and medication storage and handling.
Complaint Details
Complaint IN00398173 was substantiated with deficiencies cited at F609 related to failure to timely report abuse allegations. Complaint IN00397850 was substantiated with deficiencies cited at F658 related to failure to ensure professional standards in medication administration.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure allegations of abuse were reported to the appropriate State agency in a timely manner for 1 of 3 residents reviewed for abuse (Resident B). | SS=D |
| Failure to ensure direct observation of a resident who did not self-administer during medication administration (Resident E). | SS=D |
| Failure to ensure infection control protocols were followed during medication administration, including leaving oxycodone unattended on medication cart. | SS=D |
Report Facts
Census: 115
Total Capacity: 115
Medicare Residents: 10
Medicaid Residents: 69
Other Payor Residents: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David E. Pruett | Executive Director | Interviewed regarding abuse reporting and facility investigation |
| RN 15 | Interviewed about medication administration to Resident E | |
| LPN 13 | Interviewed about medication administration to Resident E | |
| Unit Manager | Interviewed about medication left unattended and assisted in destruction of oxycodone | |
| QMA 1 | Qualified Medication Assistant | Observed preparing medications and leaving oxycodone unattended |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 28, 2022
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited related to Life Safety Code (NFPA 101) provisions were corrected as of 10/21/2022, with no uncorrected deficiencies noted at the time of this revisit.
Report Facts
Deficiency correction dates: 10
Inspection Report
Complaint Investigation
Census: 117
Capacity: 117
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00389779.
Findings
Complaint IN00389779 was unsubstantiated due to lack of evidence. Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation.
Complaint Details
Complaint IN00389779 was unsubstantiated due to lack of evidence.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 44
Inspection Report
Life Safety
Census: 118
Capacity: 169
Deficiencies: 14
Sep 28, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code. Multiple deficiencies were identified including emergency power system testing, exit door locking codes, corridor obstructions, exit discharge conditions, exit signage, hazardous area door self-closing devices, sprinkler system maintenance, corridor door latching, electrical safety, fire drill scheduling, soiled linen storage, generator testing documentation, power strip usage, and oxygen cylinder storage.
Severity Breakdown
SS=C: 4
SS=E: 10
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; no documentation of load percentage during monthly generator load tests. | SS=C |
| Failed to ensure means of egress doors had correct exit codes posted; incorrect codes posted on 5 exit doors. | SS=E |
| Corridor near resident room 207 contained furniture and equipment obstructing clear width requirements. | SS=E |
| Exit discharge from J-Hall exit door had large cracks and uneven concrete surface. | SS=E |
| One courtyard door not posted with 'NO EXIT' sign, likely to be mistaken as an exit. | SS=E |
| Failed to ensure 6 hazardous area doors had self-closing devices; hot oil popcorn popper used in open corridor area. | SS=E |
| Sprinkler heads in laundry were covered with dust or showed signs of loading; electrical wires supported by sprinkler pipe. | SS=E |
| Corridor door to Resident Room 218 failed to close and latch properly, not resisting passage of smoke. | SS=E |
| Electrical outlet box behind ice machine was not attached to wall and wires were exposed; electrical panel near Resident Room 116 was unlocked. | SS=E |
| Failed to conduct quarterly fire drills at unexpected times and days under varying conditions. | SS=C |
| Two soiled linen receptacles in corridor exceeded 32 gallons capacity within 64 square feet area. | SS=E |
| Failed to exercise generator for 12 of 12 months and no documentation of load percentage during monthly load tests. | SS=C |
| Power strips used as substitute for fixed wiring to power high current draw equipment in resident rooms; power strips not secured or labeled properly. | SS=E |
| Three of four oxygen cylinders in resident room were not properly secured from falling. | SS=E |
Report Facts
Certified beds: 169
Census: 118
Exit doors with incorrect codes: 5
Soiled linen receptacles: 2
Generator monthly load tests missing documentation: 12
Power strips without proper UL label: 5
Oxygen cylinders unsecured: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Acknowledged multiple deficiencies including generator testing, exit door codes, corridor obstructions, sprinkler maintenance, electrical safety, and oxygen cylinder storage | |
| Executive Director | Present at exit conference acknowledging findings |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 131
Deficiencies: 3
Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388582, in conjunction with a Recertification and State Licensure Survey and the investigation of Complaints IN00382938, IN00388110, and IN00388161.
Findings
Complaint IN00388582 was substantiated with no deficiencies cited. Complaints IN00382938, IN00388110, and IN00388161 were substantiated with federal/state deficiencies cited at various tags including F550, F558, F588, F677, and F725. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding Complaint IN00388582.
Complaint Details
Complaint IN00388582 - Substantiated with no deficiencies cited. Complaints IN00382938, IN00388110, and IN00388161 - Substantiated with federal/state deficiencies cited.
Deficiencies (3)
| Description |
|---|
| Deficiencies related to Complaint IN00382938 cited at F550 and F677 |
| Deficiencies related to Complaint IN00388110 cited at F550, F588, F677, and F725 |
| Deficiencies related to Complaint IN00388161 cited at F550, F558, F677, and F725 |
Report Facts
Survey dates: August 22, 23, 24, 25, 26, and 29, 2022
Census SNF/NF: 131
Total census: 131
Medicare census: 8
Medicaid census: 68
Other census: 55
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 29, 2022
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure, including investigation of complaints IN00382938, IN00388110, and IN00388161.
Findings
Riverwalk Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the recertification, state licensure survey, and complaint investigations.
Complaint Details
Investigation of complaints IN00382938, IN00388110, and IN00388161 was included in the review; no deficiencies were found.
Inspection Report
Annual Inspection
Census: 131
Capacity: 131
Deficiencies: 11
Aug 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00382938, IN00388110, IN00388161, and IN00388582.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and privacy, improper use of security bracelets, inadequate assistance with dining, failure to provide showers per resident preferences, improper catheter care, inaccurate code status documentation, insufficient staffing, unsecured medication storage, incomplete facility assessment, and improper infection control practices.
Complaint Details
Complaints IN00382938, IN00388110, IN00388161 were substantiated with related federal/state deficiencies cited. Complaint IN00388582 was substantiated with no deficiencies cited.
Severity Breakdown
SS=E: 3
SS=D: 7
SS=C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure privacy and dignity for terminal and dependent residents, including exposed breasts and improper dining assistance. | SS=E |
| Failure to provide reasonable accommodations including access to call lights for residents. | SS=D |
| Failure to ensure residents' rights to request, refuse, or discontinue treatment and to have accurate code status documentation. | SS=D |
| Failure to provide showers or complete bed-baths per care planned preferences for multiple residents. | SS=E |
| Failure to identify and assess skin impairment for a resident with wounds. | SS=D |
| Failure to ensure care of a contracture was completed for a resident. | SS=D |
| Failure to ensure urinary catheters were handled in accordance with professional standards. | SS=D |
| Failure to maintain sufficient nursing staff to meet resident care needs. | SS=E |
| Failure to post nursing staffing information daily as required. | SS=C |
| Failure to securely store medications, including unlocked medication carts and narcotic storage. | SS=D |
| Failure to use appropriate personal protective equipment (PPE) in resident rooms requiring transmission-based precautions. | SS=D |
Report Facts
Survey dates: 6
Current census: 131
Total capacity: 131
Medicare census: 8
Medicaid census: 68
Medication count variance: 1
Staffing levels: 35
Residents requiring two-person assist: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 71 | Notified and provided care to Resident 106 regarding privacy issues. | |
| RN 40 | Provided information about security bracelet use and code status. | |
| Interim Administrator | Provided information about security bracelet discontinuation and staffing. | |
| Unit Manager 39 | Assisted with wound care observation and shower scheduling. | |
| QMA 36 | Indicated proper catheter drainage bag placement. | |
| LPN 47 | Indicated medication cart should be locked and confirmed medication count. | |
| CNA 34 | Observed catheter tubing touching floor and assisted resident with incontinent care. | |
| CNA 46 | Observed not using full PPE when entering TBP room. | |
| Housekeeper 49 | Observed not using PPE when cleaning TBP room. | |
| Floating Director of Nursing Services | Provided information on security bracelet policy and infection control. |
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