Inspection Reports for Riverwood Assisted Living Facility
711 W Atkins St Dobson, NC 27017, Dobson, NC, 27017
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
Report of a Construction Section Biennial Follow Up Survey conducted on June 18, 2025.
Findings
Deficiencies have been corrected. No further action is needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tod Hancock | Conducted the Construction Section Biennial Follow Up Survey |
Inspection Report
Capacity: 65
Deficiencies: 4
Date: Nov 19, 2024
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1967 Edition of the North Carolina Building Code, Institutional Occupancy during a Biennial Construction Section Survey.
Findings
Deficiencies were cited related to the lack of current sanitation and fire safety inspection reports, failure to maintain fire safety equipment in safe operating condition including fire doors and magnetic hold open devices, lack of documented evidence of compliance with fire, sanitation, and building codes, and failure to maintain exhaust ventilation in specified spaces such as bathrooms.
Deficiencies (4)
Facility failed to maintain current sanitation and fire and building safety inspection reports available for review; no record of a Fire Alarm system inspection.
Failure to maintain fire safety equipment in safe operating condition; fire doors do not latch properly and magnetic hold open devices are broken or not engaging.
Facility did not maintain documented evidence of compliance with applicable fire, sanitation, and building codes; kitchen hood suppression system inspection outdated.
Facility did not maintain exhaust ventilation in specified spaces; exhaust fans in bathroom near Room 16 and employee bathroom not working.
Report Facts
Licensed capacity: 65
Date of last kitchen hood inspection: Jan 13, 2023
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
The Adult Care Licensure Section conducted a follow-up survey on 12/06/23 through 12/07/23 to verify correction of previous deficiencies related to medication administration and controlled substances management.
Findings
The facility failed to ensure physician notification for medication refusals by Resident #1 and failed to maintain accurate accounting for receipt, administration, and disposition of controlled substances for Resident #3. Multiple medication refusals were not properly communicated to the Mental Health Provider, and discrepancies were found in the inventory and medication administration records for lorazepam.
Deficiencies (2)
Failed to ensure physician notification for medication refusals of antipsychotic and psychotropic medications for Resident #1.
Failed to maintain accurate accounting for receipt, administration, and disposition of controlled medications (lorazepam) for Resident #3.
Report Facts
Medication refusal occurrences: 11
Medication refusal occurrences: 8
Medication refusal occurrences: 11
Medication refusal occurrences: 8
Lorazepam administration opportunities: 32
Lorazepam administered doses: 22
Lorazepam tablets released: 7
Lorazepam tablets returned: 3
Lorazepam administration opportunities: 60
Lorazepam administered doses: 47
Lorazepam tablets released: 7
Lorazepam tablets returned: 3
Lorazepam tablets released: 7
Lorazepam tablets returned: 3
Lorazepam tablets remaining: 5
Lorazepam tablets remaining: 31
Lorazepam administered doses: 3
Lorazepam administered doses: 5
Lorazepam administered doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Administered medications and failed to notify Mental Health Provider of refusals for Resident #1 | |
| Resident Care Coordinator | Responsible for auditing eMARs and notifying providers; missed notifying Mental Health Provider of refusals for Resident #1 | |
| Administrator | Responsible for auditing eMARs and notification; acknowledged staffing issues and lack of documentation for notifications | |
| Pharmacist | Provided information on medication dispensing and refill schedules |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 7, 2023
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted a follow-up survey on 09/06/23 through 09/07/23 to verify correction of previous deficiencies.
Findings
The facility failed to ensure physician notification for medication refusals for 2 of 5 sampled residents, failed to implement a dermatologist referral for one resident, failed to provide at least 14 hours of group activities weekly, failed to administer medications as ordered for 2 residents, and failed to maintain accurate accounting of controlled substances for 2 residents.
Deficiencies (5)
Failed to ensure physician notification for medication refusals for 2 of 5 sampled residents related to multiple medications including inhalers, insulin, antidepressants, antipsychotics, and laxatives.
Failed to ensure implementation of orders for a referral to a dermatologist for 1 of 5 sampled residents.
Failed to ensure a minimum of 14 hours of a variety of group activities provided each week for residents.
Failed to ensure medications were administered as ordered by a licensed prescribing practitioner for 2 of 5 sampled residents with orders for antibiotics, expectorants, steroidal medication, and antibiotic ointment.
Failed to ensure accurate accounting for receipt, administration, and disposition of controlled medications for 2 of 3 sampled residents related to an anti-anxiety medication.
Report Facts
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 10
Medication refusals: 12
Medication refusals: 1
Medication refusals: 5
Medication refusals: 19
Medication refusals: 4
Medication refusals: 21
Medication refusals: 19
Medication refusals: 89
Medication refusals: 90
Medication refusals: 19
Inspection Report
Follow-Up
Deficiencies: 8
Date: May 18, 2023
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted a follow-up survey on May 17-18, 2023.
Findings
The facility failed to ensure staff training on care of diabetic residents, failed to provide adequate supervision for a resident with wandering and aggressive behaviors, failed to ensure referrals for health care needs, failed to document and implement monthly weights and vital signs, failed to provide the required minimum hours of group activities, failed to maintain resident privacy related to wandering resident incidents, failed to administer medications as ordered including insulin and antifungal cream, and failed to ensure mandatory annual infection control training for staff.
Deficiencies (8)
Failed to ensure 1 of 2 sampled medication aides had completed training on care of diabetic residents prior to obtaining fingerstick blood sugars and administering insulin.
Failed to provide supervision according to the needs of 1 of 6 sampled residents (#6) with wandering and aggressive behaviors, resulting in resident conflicts and safety risks.
Failed to ensure referrals were completed for 1 of 5 sampled residents (#4) related to refusal of multiple medications and supplements.
Failed to ensure implementation and documentation of monthly weights and vital signs for 3 of 5 sampled residents (#2, #3, and #4).
Failed to ensure a minimum of 14 hours of a variety of group activities were provided each week for the residents.
Failed to maintain privacy for 3 of 8 sampled residents related to a resident wandering into rooms, taking belongings, causing mental anguish and altercations.
Failed to ensure medications were administered as ordered for 2 of 5 sampled residents (#2 and #4) related to insulin administration based on fingerstick blood sugars and antifungal cream application.
Failed to ensure mandatory annual state approved infection control training was completed for 1 of 1 sampled staff (Staff A) within 30 days of hire and for 1 of 1 sampled staff (Staff B) annually.
Report Facts
FSBS checks missed: 23
FSBS checks missed: 20
FSBS checks missed: 9
Nystatin cream not applied: 35
Nystatin cream not applied: 33
Nystatin cream not applied: 11
Nystatin cream not applied: 12
Nystatin cream not applied: 30
Nystatin cream not applied: 4
Bingo activity duration: 90
Activity hours scheduled: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Medication Aide | Failed to complete mandatory annual State approved infection control training and diabetic care training |
| Staff B | Medication Aide | No documentation of completing mandatory annual State approved infection control training since 12/29/20 |
| Administrator | Responsible for ensuring staff qualifications including training; interviewed multiple times regarding deficiencies | |
| Resident Care Coordinator | Involved in medication pass and documentation removal related to weights and vital signs | |
| Mental Health Provider | Interviewed regarding resident wandering and mental health concerns | |
| Personal Care Aide | Interviewed regarding resident supervision and complaints about wandering resident | |
| Medication Aide | Interviewed regarding medication administration and refusal documentation |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Feb 22, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual and follow-up survey from 02/22/23 to 02/24/23 and exit via telephone on 02/27/23.
Findings
The facility had multiple deficiencies including failure to complete competency evaluations for licensed health professional support tasks, lack of current CPR trained staff for many shifts, incomplete tuberculosis testing for residents, inadequate supervision of residents with behavioral issues, failure to ensure follow-up with primary care providers for health care needs, failure to document and implement monthly weights and vital signs, failure to complete licensed health professional support evaluations, insufficient group activities, failure to administer medications as ordered, and failure to treat a resident with respect and dignity.
Deficiencies (10)
Failed to ensure a licensed health professional support (LHPS) competency validation checklist had been completed with a return demonstration for tasks including checking fingerstick blood sugar, oxygen administration, and medication injection for 1 of 3 sampled staff.
Failed to ensure at least one staff person was on the premises at all times who had completed an accredited course on cardiopulmonary resuscitation (CPR) within the last 24 months for 22 of 28 sampled shifts.
Failed to ensure 2 of 5 sampled residents had completed two-step tuberculosis skin testing upon admission.
Failed to provide supervision according to the needs of 1 of 5 sampled residents who had a history of wandering into other residents' rooms, resulting in a physical altercation without increased supervision or documentation.
Failed to ensure follow-up with the primary care provider to meet the health care needs for 4 of 5 sampled residents, including missed laboratory work, physical assault incidents, and medication refusals.
Failed to ensure implementation of orders for 5 of 5 sampled residents who had orders for monthly weights and vital signs.
Failed to ensure an updated licensed health professional support (LHPS) evaluation had been completed by an appropriate licensed health professional for 3 of 5 sampled residents with LHPS tasks.
Failed to ensure a minimum of 14 hours of a variety of group activities were provided each week for the residents.
Failed to ensure medications were administered as ordered for 3 of 5 sampled residents regarding multiple medications including antipsychotics, anti-inflammatory, anti-hypertensive, laxative, anti-anxiety, anti-depressant, anti-convulsant, insomnia, pain/fever, and cholesterol medications.
Failed to ensure that 1 of 5 sampled residents was treated with respect and dignity related to being told he would lose privileges if he did not do what staff asked him to do.
Report Facts
CPR training missing shifts: 22
Residents missing two-step TB skin test: 2
Residents with missed monthly weights and vital signs: 5
Residents with incomplete LHPS evaluations: 3
Residents with medication administration issues: 3
Residents refusing medications: 2
Missed medication doses: 8
Missed medication doses: 11
Missed medication doses: 7
Missed medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #3 | Named in finding related to being told he would lose privileges if he did not comply with staff requests. | |
| Executive Director | Executive Director | Named in multiple findings including supervision, medication administration, and resident interaction. |
| Staff A | Medication Aide | Named in finding related to LHPS competency validation checklist. |
| Resident Care Coordinator | Resident Care Coordinator | Named in multiple interviews regarding medication administration, LHPS evaluations, and resident care. |
| Activity Director | Activity Director | Named in findings related to activities program and resident store. |
| Medication Aide | Medication Aide | Named in findings related to medication administration and activities. |
| Personal Care Aide | Personal Care Aide | Named in findings related to resident supervision and altercation. |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 2
Date: Aug 25, 2021
Visit Reason
The Adult Care Licensure Section and the Surry County Department of Social Services conducted an annual and follow-up survey on August 24 - 25, 2021.
Findings
The facility failed to ensure that furniture in the day room and outdoor smoking area was clean and in good repair, and failed to maintain outdoor areas including patio, walkways, and entrance areas in an uncluttered, clean, and hazard-free manner.
Deficiencies (2)
Facility failed to ensure that 2 chairs in the day room and 1 sofa and 2 chairs in the outdoor smoking area were clean and in good repair.
Facility failed to ensure outdoor areas including patio, walkways, laundry room entrance, and main entrance were maintained in an uncluttered, clean and orderly manner, free of obstructions and hazards.
Report Facts
Census: 35
Building sanitation score: 94.5
Demerits: 1
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 13, 2019
Visit Reason
The visit was a Biennial Follow Up Construction Survey to verify correction of previously identified deficiencies.
Findings
The facility has not maintained plumbing fixtures in a safe and operating condition, specifically toilets not secured to floors in Room 14/North Hall and Shower Room/Central Hall. Staff reported attempts to tighten the fixtures but residents are rough on them.
Deficiencies (1)
Toilet fixtures are not secured to the floors in Room 14/North Hall and Shower Room/Central Hall.
Inspection Report
Capacity: 65
Deficiencies: 6
Date: Jul 25, 2019
Visit Reason
The facility was surveyed for conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the 1967 Edition of the North Carolina Building Code, Institutional Occupancy.
Findings
Multiple deficiencies were cited related to the physical plant, including exterior maintenance issues such as rotten fascia and soffit, unsecured electrical conduits, missing PTAC cover, damaged window blinds affecting resident privacy, fire safety equipment malfunction, and unsecured plumbing fixtures.
Deficiencies (6)
The exterior back porch fascia and soffit are rotten with openings into the flat roof construction.
PVC electrical conduits mounted on the exterior brick veneer between Rooms 11 to 21 and 23 to 31 are not secured.
PTAC cover was not in place on the exterior for Room 35.
Window blinds in Room 19 are damaged and not operational, affecting resident privacy.
Cross-corridor fire door adjacent to Room 24 did not release from the magnetic hold open device during fire alarm test.
Toilet fixtures are not secured to the floors in Room 14/North Hall and Shower Room/Central Hall.
Report Facts
Licensed capacity: 65
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 19, 2017
Visit Reason
The Adult Care Licensure Section and Surry County Department of Social Services conducted an Annual survey and complaint investigation on October 18 and 19, 2017. The complaint investigation was initiated by the Surry County Department of Social Services on September 5, 2017.
Complaint Details
The complaint investigation was initiated by the Surry County Department of Social Services on September 5, 2017. Resident #2 was not interviewable. Attempts to interview Resident #2's physician and responsible party were unsuccessful.
Findings
The facility failed to assure therapeutic diets were served as ordered for 1 of 1 sampled residents (Resident #2) with physician orders for a pureed diet. Observations revealed Resident #2 did not receive a pureed diet as ordered during breakfast on 10/19/17, although lunch on 10/18/17 was served correctly. Interviews indicated staff were not properly trained or instructed on preparing pureed diets according to recipe books provided.
Deficiencies (1)
Failed to assure therapeutic diets were served as ordered for Resident #2 with physician orders for a pureed diet.
Report Facts
Dates of survey: 2
Resident sample size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| 1st shift cook | Interviewed regarding preparation of pureed diets; had about 1 year experience; not instructed to follow therapeutic menu recipes | |
| facility contracted Dietician | Reviewed diet spreadsheets and provided recommendations; did not oversee dietary staff | |
| another 1st shift cook | Had about 4 years experience; aware of how to prepare pureed meals; trained by local health department | |
| facility Administrator | Reported Dietary Manager responsible for ordering food and menus; staff training on pureed diets was informal and incomplete | |
| Dietary Manager (DM) | Responsible for ordering menus, food, updating diets, and training staff; unaware staff were not using recipe books; expected diets to be served as ordered | |
| Executive Director | Reported dietary staff trained by prior staff; recipe books provided but no instruction on use |
Inspection Report
Capacity: 65
Deficiencies: 13
Date: Jun 22, 2017
Visit Reason
The inspection was a Construction Section Biennial Survey conducted to assess conformance with the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds and applicable portions of the North Carolina Building Code and licensing rules in effect at the time of initial licensure.
Findings
The facility was found to have multiple deficiencies related to physical plant maintenance including unsafe exterior grounds, broken furniture, doors and floors not in good repair, presence of mildew, and fire safety equipment failures such as doors not closing and latching properly, missing components on fire alarm pull stations, and penetrations in fire resistant ceilings.
Deficiencies (13)
Exterior grounds were not maintained in a safe condition; a rocking chair on the front porch was broken and unsafe for use.
Facility did not maintain doors in good repair; exit doors did not close or latch properly and were difficult to open.
Floors were not kept in good repair; rubber base pulling away and carpet heavily stained.
Walls were not maintained clean and in good repair; holes in walls and black mildew spots observed.
Fixtures were not maintained in good condition; sink faucet not secure and toilet seat too large for fixture.
Ceilings were not maintained in good repair; stained, cracked, and puckered areas around air supply vent.
Failure to maintain fire safety equipment in safe operating condition; doors with automatic self-closing hardware did not operate correctly.
Multiple corridor doors did not close and latch upon activation of the fire alarm.
Fire safety equipment not maintained; missing glass bar on pull station and exit light did not illuminate on battery backup.
Penetrations and gaps in fire resistant rated ceilings allowing potential spread of fire and smoke.
Doors that open to corridors did not close completely and latch, including dining room, living room, and shower doors.
Unapproved devices used to keep doors open, such as furniture propping living room doors open.
Resident room doors had holes around door hardware compromising smoke resistance.
Report Facts
Licensed capacity: 65
Inspection Report
Capacity: 65
Deficiencies: 7
Date: Jul 9, 2015
Visit Reason
The facility was surveyed for conformance with the applicable portions of the 2005 Rules for Licensing of Adult Care Homes of Seven or More Beds, and applicable portions of the 1958 Edition of the North Carolina Building Code(s), Institutional Occupancy, as part of a Biennial Construction Survey.
Findings
The survey found multiple deficiencies including lack of required fire detecting devices in certain bathrooms, absence of combustion air inlets for a new gas dryer, missing current annual fire alarm inspection reports, compromised one-hour fire rated walls and ceilings with multiple holes and penetrations, a non-functioning battery powered emergency light, presence of latching hardware that could trap individuals, and an open drain allowing entry of noxious gases.
Deficiencies (7)
No fire detecting devices (heat or smoke detectors connected to fire alarm system) in full bathroom off corridor and several half baths off corridor.
New 165,000 BTU gas dryer installed without combustion air or make up air inlets.
Required annual fire alarm system inspection report could not be located; last Fire and Building Safety report dated 5-19-2014.
Required one-hour fire rated walls and/or ceilings compromised in several locations with holes and penetrations not sealed with approved materials.
Battery powered emergency light in corridor near room 23 would not work when tested.
Hasp and padlock on water heater closet that can only be operated from one side, presenting risk of entrapment.
Open drain in corridor near dining room where water cooler had been removed, allowing noxious and combustible gases to enter facility.
Report Facts
Licensed capacity: 65
BTU rating: 165000
Date of last Fire and Building Safety report: May 19, 2014
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