Riverwood Healthcare & Rehabilitation Center
808 S Colley Rd, Starke, FL 32091 · For profit - Limited Liability company · 120 certified beds · (904) 964-6220 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (72%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.0% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.7% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 7.2% | 4.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.7% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.4% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.9% | 14.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.5% | 10.5% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.4% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.3% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 34.1% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.5% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.59 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.60 | 1.15 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 49.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 75 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.5%CMS range 40.9–59.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.2–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 49.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 40.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 95.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 91.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.5%CMS range 3.4–11.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 112.3 residents a day — about 94% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.73 hrs/resident/day on weekends vs 3.29 on weekdays — 17% thinner on weekends. RN hours go from 0.27 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · E2025-08-29 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide midline catheter dressings changes according to professional standards of practice when the facility failed to change midline dressings according to physician orders and standards for 3 (Resident #104, #28 and #114) of 3 resident reviewed with midline catheters. Findings include:1. During an observation on 8/25/25 at 1:38 PM, Resident #104 was observed sitting in a wheelchair at their bedside with a left single lumen PICC (peripherally inserted central catheter) line. The semipermeable transparent dressing was pulling up at all the edges, there was old, dried blood at the insertion site and dressing date of 8/16/25.During an observation on 8/26/25 at 7:09 AM, Resident #104 was observed in bed with a left single lumen PICC line. The semipermeable transparent dressing was pulling up at all the edges, there was old, dried blood at the insertion site and dressing date of 8/16/25.Review of Resident #104's admission record documented diagnosis that includes chronic systolic (congestive) heart failure, chronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-29 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that adequate pain management was provided for 3 (Resident #43, Resident #86 and Resident #85) of 5 residents reviewed that were prescribed opioid pain medications. Findings include: 1. During an interview on 08/27/2025 at 11:10 AM, Resident #43 stated, I don't remember the exact date, but when I was waiting on my pain medicine last month, pharmacy didn't bring it for a long time, and I started going through withdrawals. I was sweating and nauseous. I had a lot of anxiety. I did go to the hospital the next day for chest pains, but I don't think it was related. I was told the chest pain was due to my muscle. Review of Resident #43’s admission record documented a admission date of 4/22/2025 with medical diagnoses that included spinal stenosis, cervical region, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified fracture of right lower leg, central pain syndrome, and muscle spasm of back. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-29 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure that sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, including those employed through nurse staffing agencies, as identified through resident assessments and described in the plan of care. Findings include:1. During an interview on 8/28/2025 at 12:10 PM, Resident #85 stated that he had been told something about the facility being out of his pain medication, and that was why he had missed several doses. He has pain all the time and it had been worse over the past couple of days.Review of Resident #85's admission record documented an admission date of 12/06/2021 with medical diagnoses including nontraumatic compartment syndrome of abdomen (a painful condition that causes an increase in pressure inside a muscle which restricts blood flow), quadriplegia, C5-C7 (cervical spine 5 through cervical spine 7)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on enhanced barrier precautions, failed to perform hand hygiene when administering medications in 7 of 11 observations of medication administration, when obtaining vital signs and when caring for respiratory care equipment to prevent the possible spread of infection and communicable diseases.Findings include: 1.During an observation on 8/25/2025 at 1:40 PM, Resident #28 was observed sitting in bed with a right upper arm midline catheter with gauze under transparent dressing dated 8/18/2025. There was a completed Intravenous (IV) bag of antibiotics attached to the midline. There was enhanced barrier precaution signage on the doorway and available PPE (personal protective equipment) in the hallway. Staff O, Licensed Practical Nurse (LPN) entered the residents room to flush the midline catheter. Staff O did not don…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-29 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure the nurse staffing data was posted on a daily basis. Findings include:During an observation on 8/25/2025 at approximately 9:00 AM, the Daily Nursing Staffing Form, was dated August 22, 2025. (photographic evidence)During an interview on 8/28/2025 at approximately 8:45 AM, the DON (Director of Nursing) stated that the Staffing Coordinator was responsible for posting the daily staffing report. On the weekend, it was the Weekend Receptionist's responsibility to post the staffing report. Her expectation was that the staffing report would be posted 1st thing in the morning.During an interview on 8/28/2025 at 8:50 AM, the Staffing Coordinator stated that on Fridays she put the staffing reports up for Friday, and places the Saturday and Sunday reports behind it. The Weekend Receptionist switches them out each day. She puts the staffing report up daily before day shift starts at 6:45 [AM]. She confirmed that the correct staffing report was not posted at 9:00 AM on Monday.
- Potential for harm · Dcited before2025-08-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure food products were stored and maintained in a safe and sanitary manner in 2 of 2 nourishment rooms. Findings include:During an observation of nourishment room [ROOM NUMBER] on 8/25/2025 at 9:32 AM, there were 5 chocolate milks with an expiration date of 8/21/2025 in the bottom drawer of the refrigerator. There was a Tupperware container and a bag of sandwiches that were undated and unlabeled.During an interview on 8/25/2025 at 9:32 am, the Certified Dietary Manager in training stated that she was unaware of who is responsible to ensure all food is dated and labeled in the nourishment rooms.During an observation of nourishment room [ROOM NUMBER] on 8/25/2025 at 9:40 AM, there was a 20 ounce cup half full of liquid that was unlabeled and undated and there were two fortified nutritional shakes that were undated.During an interview on 8/28/2025 at 2:42 PM, the Administrator stated, Nursing staff should be responsible for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-29 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately and completely document resident information in the medical record for 1 (Resident #122) of 3 closed records reviewed.Findings include:Review of the admission record for Resident #122 documented an admission date of [DATE] with diagnosis that included essential (primary) hypertension, iron deficiency anemia unspecified, pain unspecified, other specified depressive episodes, heart failure unspecified, constipation unspecified, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, schizoaffective disorder bipolar type, anemia in other chronic diseases classified elsewhere, deficiency of other specified b group vitamins, other specified disorders of bone density and structure unspecified site, personal history of covid-19, tachycardia unspecified, tremor unspecified, and anxiety disorder unspecified. Review of Resident #122's nursing progress notes on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-29 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the call device was within reach for 1 (Resident #6) out of 8 residents evaluated for call device accessibility. During an observation on 08/25/2025 at 10:14 am Resident #6 was observed laying on his back, on a pad in bed, wearing nothing except a brief.The call device was hanging on the wall on the side of the resident's feet, not in reach.During an observation on 08/25/2025 at 10:26 AM Resident #6 was observed laying in the same position, on his back in bed, wearing nothing but a brief, with no call device in reach. No blankets on the bed. The overbed table containing the breakfast tray was in the same position, over the bed in the area of the resident's lap.During an observation on 08/25/2025 at 11:00 AM Resident #6 was laying in bed on his back, wearing only a brief. There was a fitted sheet and a pad on the bed, with no blankets. The breakfast tray was removed, and the over bed tablet was on the side of the bed. The call device was hanging on the wall on the left side of the resident's feet, not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents reviewed for discharge, Resident #102. Findings include: Review of Resident #102's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, hypertension, osteoarthritis, depression, and anxiety disorder. Review of Resident #102's Discharge summary dated [DATE] showed the discharge date of 5/9/2024 and discharge to assisted living facility. Review of Resident #102's progress note dated 5/9/2024 at 11:00 AM, showed it read, Resident discharged with transport. Resident discharged to [Name of an assisted living facility]. Resident left with no signs of distress. Resident left with all belongings. Resident left with no question comments or concerns per resident. Attempted to call [Name of an assisted living facility] to give report twice. Review of Resident #102's Minimum Data Set (MDS) Discharge Return…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure medications were secured in 3 of 5 hallways. Findings include: 1. During an observation on 6/10/2024 at 10:45 AM, Resident #72 had Dorzolamide HCl Solution at his bed side (Photographic evidence obtained). During an interview on 10/6/2024 at 10:45 AM, Resident #72 stated, Those are my eye medications and I use them. During an interview on 6/10/2024 at approximately 11:05 AM, Staff A, Registered Nurse (RN), stated, He [Resident #72] has a doctor's order to keep his medication in his room. I know that he can self-administer his eye drops. Staff A was not able to find an order for Resident #72 to self-administer his eye drops. Staff A stated, There is no order, then he should not have the medication at bedside. During an observation on 6/10/2024 at 12:30 PM, Resident #72 had Dorzolamide HCl Solution at his bedside. During an interview on 6/13/2024 at 7:35 AM, the Director of Nursing (DON) stated, My expectation is for nurses not to leave medications at bedside. My preference is for nurses not to leave…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · Dcited before2024-06-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, or discarded in the areas of the dietary department's walk-in cooler and the stock/storage room. Findings include: During an observation while conducting an initial tour of the kitchen on 6/10/2024 at 9:10 AM with the Dietary Manager (DM), there were one sheet pan with a total of 93 bowls labeled Lemon Gelatin with a use by date of 6/8 in the walk-in cooler, one tray with 70 glasses of iced tea with no type of identifying label or date, one clear container of vegetables with no identifying label, and one large clear container of soup with no identifying label. During an interview on 6/10/2024 at 9:30 AM, the DM confirmed the presence of the outdated gelatin and iced tea and stated that outdated foods should have been discarded. The DM identified the unlabeled containers as one containing peas and carrots and the other containing vegetable soup. The DM stated that the containers should be labeled and dated. During an observation while conducted the follow-up tour of the kitchen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure accurate and complete medical records were maintained for 1 (Resident #43) of 5 residents reviewed for discharge. Findings include: Review of Resident #43's admission record documented the resident was readmitted on [DATE] with diagnoses including Schizophrenia. Review of Resident #43's progress note authored by the attending physician dated 5/6/2024, documented, History of Present Illness: Patient is a [AGE] year old female with hx [history] of schizophrenia, hyperlipidemia, hypothyroid, chronic back pain, COPD [chronic obstructive pulmonary disease], and colostomy. She was admitted [DATE] for long term care. She is being evaluated due to decline. She was found eating her own feces and unable to sit in her wheelchair. She is responsive to tactile stimuli, would not tolerate IV [intravenous] rehydration. Recommending her to go to hospital for eval [evaluation]. Review of Resident #43's medical record on 6/11/2024 at 2:00 PM revealed there was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration and failed to ensure the residents' reusable medical equipment was properly stored to prevent the possible spread of infection. Findings include: 1. During an observation on 6/12/2024 at 8:00 AM, Staff D, Licensed Practical Nurse (LPN), began preparing Resident #60's medications without performing hand hygiene. Staff D entered the resident's room, did not perform hand hygiene and administered the medications. Staff D, LPN, exited the room, did not perform hand hygiene, returned to the medication cart and began preparing medications for another resident. During an observation on 6/12/2024 at 8:10 AM, Staff D, LPN, did not perform hand hygiene and began preparing Resident #20's medications for administration. Staff D entered Resident #20's room, did not perform hand hygiene, and administered the medications. Staff D exited the resident's room and did not perform hand hygiene. During an interview on 6/12/2024 at 8:20 AM Staff D, LPN, stated, I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-02-02 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts. Findings include: During an observation of 400 Hall Medication Cart on 1/30/2023 at 9:39 AM with Staff A, License Practical Nurse (LPN), there were one opened Refresh Liquigel Lubricant Eye Gel with no opened date, one opened bottle of Dorzolamide HCl Solution 2% not in the original packing with no opened date, one opened bottle of Brimonidine Tartrate Ophthalmic Solution 0.2% with no opened date, and one opened bottle 0of Artificial Tears eye drops with no opened date and no resident identifier. During an interview on 1/30/2022 at 9:41 AM, Staff A, LPN, stated, Medication should be labeled with opened date and expiration date. Over the counter mediation should also be labeled with resident name. During an observation of 500 Hall Medication Cart on 1/30/2023 at 9:45 AM with Staff B, Registered Nurse (RN), there were one opened Novolog insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-02-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff followed the accepted infection control practice standards during administration of intravenous (IV) medication to prevent the possible development and transmission of communicable diseases and infections. Findings include: During an observation on 1/31/2023 at 9:01 AM, Staff C, Licensed Practical Nurse (LPN), proceeded to administer Vancomycin HCl (Hydrochloride) in NaCl (Sodium Chloride) Intravenous Solution 1-0.9% gram/250 milliliter to Resident #46. Staff C cleaned the needleless connector and flushed the PICC (Peripherally Inserted Central Catheter) line with normal saline and placed the needleless connector back down on the resident's arm. Staff C removed the medication tubing and spiked the medication bag. Staff C primed the tubing and connected the tubing to the needleless connector without cleaning the needleless connector. The line had air occlusion. Staff C removed the tubing from the PICC line allowing needleless connector to come in contact with the resident and bed. Staff C primed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE SHERMAN FAMILY — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 1 of 5 | 2.1 | -1.1 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 6 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RIVERWOOD NURSING SNF HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2024 |
| 5H1 LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| GOLDEN EAGLE HEALTHCARE LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| RIVERWOOD NURSING SNF HOLDCO II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| RIVERWOOD NURSING SNF JV LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| STARS FL LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| STARS RE PROPERTIES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| WEINSTOCK FAMILY 2021 TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| GOLDSTEIN, JEFFERY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 06/27/2024 |
| PRESSER, AARON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 06/27/2024 |
| SHERMAN, SAMUEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| STERN, ISAAC | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/27/2024 |
| TESSLER, CHAIM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 06/27/2024 |
| TESSLER, ELIA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| WEINSTOCK, YECHIEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| WEINSTOCK, YOSEF | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2024 |
| COPPOLA, AARON | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 07/01/2024 |
| INNOCENT SIMON, JOELLE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 07/01/2024 |
CMS files one row per role, so the 34 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105488. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.