Riverwalk Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean, and sanitary environment for resident use for three of four communal shower rooms (shower rooms [ROOM NUMBER]). This failure had the potential to result in cross-contamination, increasing the spread of infection to vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of seven residents reviewed (Resident 1) when Resident 1 did not receive her showers or bed baths on June 22, July 6, 9, and 20, 2026. This failure had the potential for Resident 1 to have unpleasant odors, develop skin irritations, and bacterial growth that could lead to infection.

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment for one of three residents reviewed (Resident 1) according to the physician's orders and the resident care plan when the Licensed Vocational Nurse (LVN) did not administer insulin as ordered when the resident experienced hyperglycemia (elevated blood sugar). This failure had the potential to cause fluctuations in Resident 1's blood sugar (BS) levels that could lead to serious illness and life threatening conditions.

Inspectors wroteBased on interview and record review, the facility failed to maintain and complete accurate clinical records in accordance with accepted professional standards and practices for one of three residents reviewed (Resident 1) when the Licensed Vocational Nurse (LVN):- did not document Resident 1's blood sugar (BS) readings of 486 and 71 on May 25, 2025; and- did not document Resident 1's blood sugar while monitoring for the effectiveness of the interventions. These failures had the potential to compromise Resident 1's diabetic management and overall health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the family member was notified, for one of three residents (Resident 1), when Resident 1 eloped (when a resident leaves the facility without the knowledge of the staff) from the facility. This failure had the potential to result in Resident 1's family member to not being aware of Resident 1's condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment was provided for one of two residents, Resident 1, when Resident 1 exited the facility through the front door without the staff knowledge. Resident 1 was found wandering on the grounds of a college campus and was transported to a general acute care hospital (GACH) by emergency medical services. This failure had the potential to result in Resident 1 to sustain serious injury such as being struck by a vehicle or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of one resident, Resident 1, the baseline care plan (BCP- initial, person-centered care guide developed within 48 hours of a resident's admission) included interventions to prevent and/or minimize falls. This failure had the potential to result in Resident 1 to have repeated falls and fall related injury.

Inspectors wroteBased on interview and record review, the facility failed to review and update its facility assessment to accurately reflect the current resident census (official count or survey of a population) and the sufficient staffing levels required to meet residents' needs. This failure resulted in an inaccurate evaluation of the staffing necessary to provide appropriate care and support for the residents.

Inspectors wroteBased on observation, interview, and record review, on four of four residents reviewed for quality of care (Residents 130, 33, 78, and 178), the facility failed to ensure:1. For Resident 130, the ophthalmologist (eye doctor) consult visits were addressed, care-planned and recorded in the resident's record. In addition, the facility did not address Resident 130's right eye cataract surgery performed on December 5, 2025. This failure had the potential for Resident 130 to experience complications and worsened vision due to a possible delay in treatment to address her vision needs;2. For Resident 33, the physician's order to restrict 1500 milliliters (ml - unit of measurement) fluid restriction per day, was followed correctly. In addition, the fluid intake and output monitoring due to fluid restriction was not performed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician conducted the initial visit for four of six residents reviewed, for physician services (Residents 5, 12, 57, and 160). These failures had the potential to result in unidentified medical conditions and/or insufficient provision of medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for four out of five residents reviewed for infection control practices (Residents 66, 2, 94, and 57) when: 1. For Resident 66, nursing staff did not clean and disinfect a shared blood pressure (BP) machine with an attached BP Cuff, after use, in accordance with the facility's infection control policy; 2. For Resident 2, a disconnected foley catheter insertion tubing was observed at bedside on the floor readily and available to use;3. For Resident 94, the respiratory tubing was not changed in accordance with the facility's prevention of infection respiratory equipment policy; and4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light button was functioning properly for one of eight residents reviewed for resident's rights (Resident 188). This failure had the potential for delayed assistance to meet resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a written copy of the baseline care plan (documented information indicating the resident's initial goals for stay, summary of current medication, dietary instructions and the services and treatments to be provided or arranged by the facility) was provided to one of eight residents reviewed for Care Planning (Resident 188). This failure resulted in Resident 188 to not fully understand, due to the lack of information, the treatments and services being provided by the facility to meet her needs during her stay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was initiated and/or developed to address the need and use of indwelling foley catheter ((flexible tube inserted into the bladder to drain urine) for one of two residents reviewed for foley catheter use (Resident 57). This failure has the potential to place Resident 57 at high risk for infection and complications related to foley catheter use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one out of five residents (Resident 159) observed during medication administration. The failure to clarify incomplete physician orders, including a Vitamin D3 (supplement) order without a specified dose and a Toprol XL (metoprolol succinate extended release - medication for high blood pressure) order with an inappropriate holding parameter of hold if HR (heart rate) <110, resulted in unsafe medication orders for Resident 159.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for one resident reviewed (Resident 2) when smoking materials were observed at Resident 2's bedside. This failure had the potential for environmental risk, hazards and accidents including fire and/or burn injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate care to prevent complications of enteral feeding (feeding received directly through a tube in the stomach) when one of five residents (Resident 7) reviewed for tube feeding (TF - nutrition provided through a tube inserted into the stomach) was positioned with the head of the bed (HOB) not elevated 30-45 degrees while receiving tube feeding. This failure had the potential for Resident 7 to experience complications from tube feeding, such as aspiration (food or liquid accidentally enter the lungs), nausea, vomiting, or abdominal pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services were provided to meet the needs of the residents when: 1. For Resident 66, medications were left unattended during medication administration. This failure had the potential for medication misuse, contamination, or access by unauthorized individuals, including residents, staff, or visitors. 2. For Resident 142, as-needed controlled substance (CS - medication with high potential for abuse and addiction) pain medication was not administered according to the physician's order. This failure had the potential to result in inadequate pain management, prolonged pain, and unnecessary discomfort for the residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration, for two out of five residents observed (Resident 142 and 159). These failures included administration of an incorrect dosage form (aspirin chewable tablet administered for a delayed-release order) and administration of as-needed pain medication without required pain assessment prior to administering medication, resulting in medications not being administered in accordance with physician orders and the facility's policies and procedures, which had the potential to compromise residents' medication therapy and safety.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of medical records upon request and within two business days after receiving the request from an attorney on behalf of the resident, for one of two residents reviewed, Resident 1. This failure resulted in Resident 1's legal representative not receiving the requested records within the two working day timeframe.

Inspectors wroteBased on interview and record review, the facility failed to keep one of five residents reviewed (Resident 1) belongings safe from theft or loss after the resident passed away in the facility. This failure resulted in Resident 1's belongings being lost and not available to the family.

Inspectors wroteBased on interview and record review, the facility failed to ensure an antihypertensive medication was held in accordance with the physician order for one of two sampled residents (Resident 1). In addition, the facility facility failed to ensure the physician was notified that Resident 1's antihypertensive medication was not administered in accordance with the physician order. These failures had the potential to negatively affect the resident's medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's order for one of two sampled residents (Resident 1). This failure has the potential to result in poor intake, leading to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow their weight management policy for one of five residents (Resident 2), when Resident 2 was not weighed weekly after severe weight loss was noted on January 8, 2025. This failure had the potential to lead to continued unmonitored weight loss which could negatively impact Resident 2's health condition.

Inspectors wroteBased on observation and interview and record review, the facility failed to ensure residents' rooms were maintained clean and comfortable when: 1. room [ROOM NUMBER] had adhesive residue, chipped paint and black horizontal lines across the wall in front of the residents' bed, chipped baseboards and the floor had yellow and black stains; and 2. room [ROOM NUMBER] had adhesive residue, chipped paint and black horizontal lines across the wall in front of the residents' bed. This failure had the potential to negatively impact the psychosocial well-being of Residents 1, 2, 3, 4, 5 and 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of two residents, Resident 1, the power of attorney (POA-someone who is legally authorized to act on the resident's behalf) was notified when Resident 1 ' s physician ordered lorazepam (an anti-anxiety medication). This failure resulted in Resident 1 ' s POA to be unaware of his overall condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, weight loss for two of three residents reviewed was evaluated (Residents 1 and 2). This failure had the potential for Residents 2 and 3 to experience further weight loss and not have their nutritional needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavior of anxiety (feelings of worry, unease, and tension) was evaluated and monitored prior to obtaining a PRN (as necessary) lorazepam (an anti-anxiety medication), for one of two sampled residents, Resident 1. This failure had the potential for unnecessary medication use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure for prevention of pressure injuries, for one of two residents, Resident 1, when a dressing (a covering put on a wound to protect it while it heals) was placed on Resident 1's right hip and no further assessment or follow up was conducted. After removal of the dressing, Resident 1 was found to have an unstageable pressure injury (a sore that is covered by slough [tan, yellow or green debris] or eschar [thick black or brown scab or crust]) to his right hip. This failure resulted in Resident 1's wound to not be properly assessed and treated.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete, for one of one resident, Resident 1, when a care conference meeting was not documented in the medical record. This failure had the potential to impact Resident 1 ' s plan of care by not having a clear understanding of the resident ' s needs, preferences, and any changes in the care plan. In addition, this failure had the potential to create miscommunication among the care team, Resident 1, and Resident 1 ' s caregiver.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one of 27 sampled residents (Resident 126), when the call light button was observed not within reach. This failure had the potential for Resident 126 not to be able to call staff for assistance which could result in needs of the resident not being met as well as the delay in the provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed for three of eight residents reviewed (Resident 183, 101, and 32) to ensure: 1. For Resident 183, the central dialysis catheter was identified, assessed and monitored; This failure had the potential to delay the necessary care and services Resident 183 may need if complications developed with the central dialysis catheter; 2. For Resident 101, the physician order for fluid restriction was followed; This failure had the potential to result in fluid overload and a decline in Resident 101's health condition; and 3. For Resident 32, a skin condition was identified, assessed, monitored, and necessary treatment was implemented. This failure had the potential to result in Resident 32's development of skin breakdown and other skin complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control program practices were implemented for two of seven residents reviewed (Residents 48 and 39) when: 1. For Resident 48, the oxygen nasal cannula (a plastic tube with two prongs that deliver oxygen through the nose) was left exposed on top of the resident's bed; and 2. For Resident 39, the wound vacuum, also known as vacuum-assisted closure (VAC - a machine that uses suction to help the wound heal more quickly) was left at the bedside table. These failures had the potential to increase the spread and the development of infection and would have placed Resident 39 and 48 at risk for illnesses and other complications.

Inspectors wroteBased on interview and record review, the facility failed to document that the discharge from the facility was necessary for one of three sampled residents (Resident 4), even after Resident 4 was cleared and the psychiatric hold was discontinued during hospitalization. This failure has the potential to negatively affect the resident's psychosocial well-being, who considered the facility as her home.

Inspectors wroteBased on interview and record review the facility failed to provide a notice of discharge for one of three sampled residents (Resident 4), when the facility made the determination not to accept the resident back to the facility while the resident was still at the general acute care hospital (GACH). In addition, the facility failed to provide a copy of Resident 4's updated notice of discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman. These failures had the potential for the resident and the resident's representative not to fully understand the reason for not being able to return to the facility which was her home since 2015; and could delay the Ombudsman in advocating for the resident.

Inspectors wroteBased on interview, and record review, the facility failed to provide a notice of bed-hold for one of three residents (Resident 4) reviewed, upon transfer to the acute care hospital. Resident 4 was transferred to the acute care hospital on June 18, 2024. This failure resulted in Resident 4 not being aware of the bed-hold policy of the facility. In addition, this failure resulted in the resident not to be aware of her rights to be allowed to go back to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 4) clinical behavior or condition was re-evaluated for re-admission to the facility after a therapeutic hospitalization. Resident 4 was cleared and the psychiatric hold was discontinued on [DATE], but was refused re-admission at the facility. This failure had the potential for Resident 4 not to be provided the opportunity to return to the facility she considered home since 2015, which could negatively affect the psycho social well-being of Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure the notice of transfer or discharge was sent to the Office of the Long-Term Care (LTC) Ombudsman prior to the transfer or discharge of three sampled residents (Residents 1, 2, and 3). In addition, the facility failed to maintain consistent documentation that the notice was sent to the Ombudsman. This failure has the potential for the Ombudsman not to be able to advocate for the residents in protecting their rights form inappropriate transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from abuse, for three of four residents reviewed (Residents 1, 2, and 3), when Certified Nursing Assistant (CNA) 1 used a cellular telephone to record a video of CNAs 2, 3, 4, and 7, providing resident care. In addition, CNA 1 distributed the video via group text (a text communication between several individuals) to persons not employed at the facility. This failure had the potential to negatively impact the residents psychosocial and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for fluid restrictions for one resident (Resident 1). This failure had the potential to result in fluid overload and decline in the resident's health condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the call lights (devices that emit a tone and light up indicating the location of the call, used by the residents to signal a need for assistance from facility staff), were answered timely, when four out of four residents (Residents 1, 2, 3, and 4), who required assistance from staff with activities of daily living (ADLs), verbalized their concerns of facility staff not answering their call lights and/or attending to their needs in a timely manner. This failure had the potential for delayed medical management and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge order was transcribed into the resident's electronic medical record (EMR) for one of three residents (Resident 1). This failure had the potential to affect Resident 1's overall health and well well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents, (Resident 3), had the call light within reach. This failure had the potential for Resident 3 to have unmet needs and assistance.

Inspectors wroteBased on interview and record review, for one (Resident 1) of five residents, the facility failed to accommodate Resident 1's reasonable request for assistance to arrange to visit his significant other on May 28, 2023, at 7:00 p.m. The facility failure to extend assistance had resulted to Resident 1 to miss his opportunity to spend the remaining time left to be with his significant other and pay his last respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety, when: 1. Unlabeled/undated food item was observed stored in the refrigerator, readily available for use; and 2. Frozen meat was not properly labeled and thawed. These failures had the potential to result in foodborne illness to an already vulnerable facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was conducted, for one of thirty-five residents reviewed (Resident 55), to safely self-administer medication. This failure had the potential for unsafe medication administration practices which could result in resident injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide vision consult, for one of two residents reviewed for vision (Resident 61). This failure had the potential for Resident 61 to not receive the necessary treatment timely to maintain effective vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was provided according to the facility's policy and procedure, for one of one resident reviewed for smoking (Resident 117), when a pack of cigarettes and lighter were observed in Resident 117's possession. This failure had the potential to increase Resident 117's risk for smoking related injuries and accidental fires.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of straight catheter (a soft, thin tube inserted into the bladder to pass urine) during self-catheterization (procedure of inserting the catheter into the bladder) was monitored, for one of two residents reviewed for urinary tract infection (Resident 77). This failure placed the resident at risk for complications of catheter use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment according to the physician's order, for two of two residents reviewed for oxygen (Residents 49 and 321). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition for Residents 49 and 321.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain assessment was conducted before pain medication was administered, for two of two residents reviewed for pain (Residents 34 and Resident 221). This failure had the potential for the residents to have ineffective pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored, disposed and/or discarded when: 1) Multiple medications for two discharged residents were not disposed timely and were still stored in the medication cart readily available for use. This failure had the potential for the medications to be administered to other residents; and 2) One opened insulin quick pen (medication to treat diabetes mellitus [DM - abnormal blood sugar]) without a proper label was stored in the medication cart readily available for use. This failure increased the possibility for residents to receive medications unsafely.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's order for HgbA1C (a laboratory test to check blood sugar level) was completed as ordered by the physician, for one of 35 residents reviewed (Resident 67). This failure had the potential to result in a delay in the care and treatment of abnormal blood sugar levels for Resident 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control and prevention practices were observed when: 1. For Resident 77, a used straight catheter (a soft, thin tube used to pass urine from the body, used one time and then thrown away) was observed on top of the resident's over bed table, together with grooming materials and eating utensils. In addition, the straight catheter was being reused multiple times by Resident 77 to self-catheterize (inserting a catheter into the bladder). This failure had the potential to cause urinary tract infection (UTI - a bladder infection) for Resident 77; and 2. A yellow stained urinal (a bottle used for urination) was observed uncovered and unlabeled at Resident 76's bedside. This failure had the potential to increase the risk for bacterial growth, cross-contamination and spread of infection.