Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
87 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 87
Deficiencies: 9
Date: Sep 12, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory standards related to resident dignity, medication management, infection control, environment safety, and food safety at Riverwood Health Care.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, unsafe medication storage and administration practices, breaches in resident privacy, environmental maintenance issues such as broken window blinds, unsafe pharmaceutical services, poor food safety and sanitation practices, and lapses in infection prevention and control protocols.
Deficiencies (9)
Staff referred to Resident 40 as a feeder during care, failing to treat the resident with dignity and respect.
Unsafe storage and use of Resident 102's personal medications and supplements at bedside without physician's order.
Licensed nurse left residents' personal medical information unattended on computer screen visible to others.
Broken window blinds in 5 resident rooms compromising privacy and homelike environment.
Hazardous drugs not consistently labeled; staff used personal blood pressure devices; blood sugar measured late.
Emergency medication kits not properly accounted for; personal purse stored in medication room; medication delivery records unsigned.
Unsafe medication storage: undated insulin pen, opened undated vials and eye drops, and expired wound care supplies.
Spoiled produce, presence of bugs on onions, unclean cutting boards and pans, and wet stacked kitchenware in food preparation areas.
Infection control lapses including storage of resident kidney basin with clean dishes, improper glove use by dietary staff, inadequate cleaning of shared glucometers, and unclean pill cutter.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 81
Residents affected: 5
Resident census: 87
Medications administered: 12
Residents affected: 87
Residents affected: 87
Residents affected: 87
Residents affected: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in dignity and respect deficiency related to Resident 40 |
| Assistant Director of Nursing | ADON | Interviewed regarding dignity, medication, and pharmaceutical service deficiencies |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including dignity, medication, privacy, pharmaceutical services, and infection control |
| Licensed Nurse 1 | LN 1 | Interviewed regarding medication storage and administration deficiencies |
| Licensed Nurse 3 | LN 3 | Observed and interviewed during hazardous drug administration and medication cart inspection |
| Licensed Nurse 4 | LN 4 | Observed using pill cutter without cleaning and using personal blood pressure device |
| Licensed Nurse 5 | LN 5 | Observed improper cleaning of glucometer between residents |
| Licensed Nurse 6 | LN 6 | Interviewed regarding medication delivery record signing |
| Licensed Nurse 7 | LN 7 | Observed medication cart and treatment cart storage issues |
| Licensed Nurse 8 | LN 8 | Observed leaving medical information unattended on computer screen |
| Dietary Service Supervisor | DSS | Interviewed regarding food safety and infection control deficiencies |
| Registered Dietician | RD | Interviewed regarding food safety and infection control deficiencies |
| Consultant Pharmacist | CP | Interviewed regarding pharmaceutical service deficiencies |
| Infection Prevention Nurse | IP | Interviewed regarding infection prevention and control deficiencies |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: May 14, 2025
Visit Reason
The inspection was conducted due to a complaint regarding unsafe and insecure communication of resident personal health information (PHI) among staff via a facility-approved group messaging platform on personal smartphones.
Complaint Details
The complaint involved staff communicating resident information through a group messaging platform on personal phones, potentially violating HIPAA privacy rules. The complaint was substantiated by interviews and review of messaging content showing resident names and room numbers shared in unsecured messages.
Findings
The facility failed to ensure safe and secure communication of resident PHI, as staff used a non-HIPAA compliant messaging app on personal phones to share resident names, room numbers, and medical information, posing a risk of privacy violations. The Director of Nursing and Administrator acknowledged the risks and lack of control over access to this information.
Deficiencies (1)
Failure to ensure safe and secure communication of resident personal health information via a non-HIPAA compliant group messaging platform on staff personal smartphones.
Report Facts
Census: 88
Date of survey completion: May 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding communication practices and incident reports |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed and provided evidence of group messaging use |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed about staff communication via messaging app |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Interviewed about use of messaging app for resident care communication |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Interviewed about messaging app use and security perceptions |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Interviewed about messaging app use and communication content |
| Licensed Nurse 3 | Licensed Nurse | Interviewed about refusal to use messaging app due to HIPAA concerns |
| Director of Nursing | Director of Nursing | Acknowledged risks and described messaging app use and limitations |
| Administrator | Administrator | Discussed facility policy and concerns about messaging app security |
| Social Services Assistant | Social Services Assistant | Interviewed about staff communication practices using messaging app |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to implement adequate elopement prevention measures for residents at risk of leaving the facility unsupervised, specifically focusing on two residents with exit-seeking behaviors and the functionality and monitoring of wander guard devices.
Complaint Details
The visit was complaint-related focusing on elopement prevention failures. The complaint was substantiated as the facility failed to implement required safety measures, resulting in actual harm to Resident 1 and potential harm to Resident 3.
Findings
The facility failed to ensure that two sampled residents at risk for elopement had proper elopement prevention measures in place, including obtaining orders for wander guard devices, consistent monitoring and documentation of device placement, and ensuring devices were functional and not expired. These failures resulted in Resident 1's elopement causing a head injury requiring hospital treatment and posed a risk of harm to Resident 3 due to an expired wander guard.
Deficiencies (4)
Failure to obtain orders for wander guard placement and monitoring when wandering behavior started for Resident 1.
Resident 1's wander guard was not working at the time of elopement.
Inconsistent documentation of wander guard placement monitoring for Resident 1 over multiple shifts and months.
Resident 3 was found wearing an expired wander guard device.
Report Facts
Stitches received: 8
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 2 | Licensed Nurse | Interviewed regarding Resident 1's care plan and lack of wander guard order. |
| LN 3 | Licensed Nurse | Interviewed about Resident 1's exit seeking care plan and wander guard monitoring. |
| Director of Nursing | Director of Nursing | Interviewed about expectations for elopement risk assessment and wander guard orders. |
| MD | Resident 1's Doctor | Interviewed regarding expectations for wander guard orders and monitoring. |
| CNA 2 | Certified Nursing Assistant | Interviewed about wander guard placement and Resident 1's fall incident. |
| LN 4 | Licensed Nurse | Nurse assigned during Resident 1's elopement incident and reported expired wander guard. |
| LN 1 | Licensed Nurse | Responsible for checking wander guard placement and expiration every shift. |
| Administrator | Administrator | Interviewed about missing logs for wander guard device functionality checks. |
| Maintenance Assistant | Maintenance Assistant | Observed Resident 3's expired wander guard device. |
Inspection Report
Routine
Census: 86
Deficiencies: 6
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards for medication administration, storage, and destruction practices, including safe injection practices and vaccine handling.
Findings
The facility failed to ensure safe injection practices by storing pre-drawn, unlabeled, and undated flu vaccine syringes in a staff food refrigerator and documented pneumonia vaccines as given when the actual products were found stored for destruction. Additionally, medication destruction logs were incomplete, discontinued medications were improperly stored, and medication storage practices were unsafe, including storing medications with personal food and lack of temperature monitoring.
Deficiencies (6)
Stored pre-drawn, unlabeled, and undated flu vaccine syringes in staff food refrigerator.
Pneumonia vaccines documented as given were found stored for destruction in staff food refrigerator.
Prescription medication destruction logs were not dated, witnessed, or co-signed by licensed staff.
Discontinued medication semaglutide prescribed to discharged Resident 4 was stored in active medication storage area.
Medications and biologicals stored improperly with personal food items and without temperature monitoring.
Opened multi-dose vials of flu vaccine and TB testing agent stored without marking beyond use date.
Report Facts
Census: 86
Number of unlabeled pre-drawn syringes: 14
Number of pneumonia vaccines found in staff refrigerator: 3
Number of semaglutide boxes stored improperly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Director of Staff Development (DSD) | Interviewed regarding medication storage and destruction practices; found medications stored improperly in office refrigerator |
| Infection Preventionist | Infection Preventionist (IP) | Prepared pre-drawn flu vaccine syringes stored unlabeled in staff food refrigerator |
| Director of Nursing | Director of Nursing (DON) | Interviewed and expressed shock at unsafe medication storage and practices |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication administration records and improper medication storage |
| Licensed Nurse 1 | Licensed Nurse (LN 1) | Interviewed about medication administration and documentation practices |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Interviewed about medication destruction documentation and procedures |
| Administrator | Administrator (ADMIN) | Interviewed regarding medication destruction storage and facility policies |
| Resident 4 | Resident | Discharged resident whose discontinued medication was improperly stored |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 23, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide written notice of a facility-initiated discharge to Resident 2's Responsible Party and failure to permit Resident 2 to return to the facility after hospitalization.
Complaint Details
The complaint involved the facility's failure to provide written discharge notice and appeal rights to Resident 2's Responsible Party and failure to allow Resident 2 to return to the facility after hospitalization. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide written discharge notice and appeal rights to Resident 2's Responsible Party, only providing verbal notification. Additionally, the facility did not communicate with the hospital to assess Resident 2's readiness to return or attempt to meet Resident 2's needs upon discharge from the hospital, resulting in Resident 2 not being allowed to return to the facility.
Deficiencies (2)
Failure to provide written notice of a facility-initiated discharge and appeal rights to Resident 2's Responsible Party.
Failure to determine if Resident 2 could return to the facility after hospitalization and failure to communicate with the hospital regarding Resident 2's condition and needs.
Report Facts
Date of discharge: Sep 5, 2024
Date of survey: Sep 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 2's Responsible Party | Interviewed regarding verbal notification of discharge and lack of written notice. | |
| Facility Administrator | Administrator | Acknowledged failure to provide written discharge notice and lack of documentation. |
| Social Service Director | SSD | Interviewed regarding communication with hospital and resident assessment. |
| Case Manager | CM | Interviewed regarding resident assessment and communication with hospital. |
| Primary Care Provider | Medical Doctor | Interviewed regarding assessment of Resident 2's readiness to return to facility. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, medication error rates, medication order adherence, and infection prevention and control practices at Riverwood Health Care.
Findings
The facility was found to have medication errors including administering incorrect multivitamins to residents, failure to follow physician orders regarding blood pressure medication administration parameters, and failure to implement enhanced barrier precautions for infection control for a resident with a gastrostomy tube. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting few residents.
Deficiencies (3)
Failed to ensure medication error rate less than 5%, with two errors out of 26 opportunities involving incorrect multivitamin administration to Residents #23 and #82.
Failed to follow physician's order to hold carvedilol when systolic blood pressure was below 130 mmHg and not administer midodrine when systolic blood pressure was above 120 mmHg for Resident #21.
Failed to ensure enhanced barrier precautions were implemented for Resident #196 with a gastrostomy tube, including failure of staff to wear gown during care.
Report Facts
Medication error rate: 7.69
Medication errors: 2
Residents observed for medication administration: 5
Residents sampled for unnecessary medications: 5
Residents sampled for infection control: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN #5 | Licensed Vocational Nurse | Prepared and administered incorrect multivitamin to Residents #23 and #82 |
| LVN #6 | Licensed Vocational Nurse | Interviewed regarding difference between multivitamin and multivitamin with minerals |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding expectations for medication administration per physician orders |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for medication order review and administration |
| Administrator | Administrator | Interviewed regarding expectations for staff to follow physician medication orders |
| LVN #3 | Licensed Vocational Nurse | Interviewed regarding medication administration and parameters for Resident #21 |
| LVN #4 | Licensed Vocational Nurse | Interviewed regarding medication administration and parameters for Resident #21 |
| CNA #2 | Certified Nursing Assistant | Observed and interviewed regarding failure to wear gown during care for Resident #196 on enhanced barrier precautions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to carry out a physician's order to reduce a resident's gabapentin medication dosage.
Complaint Details
The complaint investigation found that Resident 1's physician order to taper gabapentin was communicated to the RN but not carried out. The resident refused medication doses and left the facility against medical advice. The Assistant Director of Nursing and Director of Nursing confirmed the order was not implemented and staff failed to clarify the order when the resident refused medication.
Findings
The facility failed to ensure services met professional standards when Resident 1's physician order to taper gabapentin from 400mg every eight hours to 300mg daily was not implemented. This failure resulted in the resident not receiving medication as ordered, potentially causing ineffective treatment and unwanted side effects.
Deficiencies (1)
Failure to carry out physician's order to reduce gabapentin dosage for Resident 1.
Report Facts
Medication dosage: 400
Medication dosage: 300
Dates of medication refusal: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed and confirmed failure to carry out physician's order | |
| Director of Nursing | Interviewed and confirmed failure to carry out physician's order |
Inspection Report
Routine
Deficiencies: 11
Date: Jun 18, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, infection control, medication management, discharge procedures, foot care, pain management, pharmaceutical services, food safety, and infection prevention practices.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination regarding COVID-19 quarantine cohorting, failure to honor residents' visitation rights regardless of vaccination status, incomplete discharge documentation, inadequate foot care, insufficient pain management, medication administration errors, improper medication storage and labeling, expired food storage, and lapses in infection prevention practices including improper cohorting and PPE use.
Deficiencies (11)
Failure to promote and facilitate resident self-determination by unnecessarily extending quarantine beyond 14 days for several residents and placing fully vaccinated residents in quarantine.
Failure to honor residents' right to visitation by denying indoor visits to unvaccinated or partially vaccinated residents or families.
Failure to issue Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) when Resident 46's payment status changed from Medicare to Medicaid.
Incomplete discharge instructions for Resident 33 with multiple blank sections.
Failure to provide appropriate foot care for Residents 20 and 42, including long, discolored toenails and lack of podiatry services.
Failure to provide comprehensive pain management for Resident 380, including lack of pain assessment documentation for 12 days.
Pharmacy services failed to recognize discrepancies between medication dosage forms and orders for Residents 45 and 16; controlled drugs were not destroyed properly.
Medication administration error rate was 11%, exceeding the 5% threshold, including errors with chewable medications and medication form discrepancies.
Medications were improperly stored and labeled, including discontinued medications remaining on carts, medications stored at incorrect temperatures, and unlabeled eye drops.
Food safety violations including unlabeled meat packages in the freezer and expired food and drink thickener available for use.
Infection prevention failures including inadequate cohorting of residents in quarantine and failure of laundry supervisor to wear proper PPE entering a yellow zone room.
Report Facts
Medication administration error rate: 11
Quarantine duration: 21
Quarantine duration: 20
Quarantine duration: 18
Expired food date: Jun 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 331 | Named in findings related to quarantine cohorting and visitation rights. | |
| Resident 332 | Named in findings related to quarantine cohorting. | |
| Licensed Nurse 7 | Licensed Nurse | Interviewed regarding yellow zone quarantine procedures. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding quarantine, visitation, medication, and infection control findings. |
| Admission Coordinator | Admission Coordinator (AC) | Interviewed regarding quarantine cohorting and visitation scheduling. |
| Activities Director | Activities Director (AD) | Interviewed regarding visitation scheduling and policies. |
| Business Officer Manager | Business Officer Manager (BOM) | Interviewed regarding SNFABN issuance. |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding SNFABN issuance. |
| Licensed Nurse 6 | Licensed Nurse | Interviewed regarding foot care for Resident 20. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant (CNA) | Interviewed regarding podiatry services. |
| Licensed Nurse 3 | Licensed Nurse | Interviewed regarding pain management for Resident 380. |
| Licensed Nurse 4 | Licensed Nurse | Interviewed regarding pain management documentation. |
| Licensed Nurse 5 | Licensed Nurse | Observed medication administration and interviewed regarding medication errors. |
| Licensed Nurse 1 | Licensed Nurse | Observed medication administration and interviewed regarding medication errors. |
| Laundry Supervisor | Laundry Supervisor (LS) | Observed entering yellow zone without proper PPE. |
| Dietary Services Supervisor | Dietary Services Supervisor (DSS) | Interviewed regarding food labeling and expired food. |
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