Riverwood Healthcare: Agency Nurse Orientation Failures - FL
A federal inspection completed August 29, 2025, found that Riverwood had been routinely deploying agency nurses and aides without any verified proof those workers understood the facility's basic procedures, knew who to call in an emergency, or had ever confirmed in writing that they'd read a single policy handed to them.
There were nights, the night shift supervisor told inspectors, when only one regular staff nurse was on duty. Everyone else was agency.
The inspection was triggered by a complaint. What investigators found when they arrived was a paper trail that stopped well short of any real accountability, and a binder at the nurses' station whose emergency contact list carried the names and phone numbers of people who no longer worked there.
The facility used at least three separate staffing agencies. For one of them, Riverwood had set up a five-question online quiz that agency workers were required to pass before booking their first shift. The questions asked where to report a fall, where the time clock was located, what employees should review on their first shift, who to contact for a change in condition or medication access issues, and where to park.
The other two agencies had no equivalent quiz. No similar system. Nothing.
The education packet that agency staff, both nurses and aides, were supposed to receive ran 45 pages and covered topics including resident rights, abuse prevention, dementia care, hand hygiene, blood and body fluid exposure, and antimicrobial resistance protocols. The cover page listed all of it. Page 1 ended mid-sentence. There was no page 2. The policies themselves were present, running together as one continuous document with no breaks, no section markers, nothing to indicate where one ended and the next began.
There was no attestation page. No signature line. No mechanism for a worker to confirm they had received the packet, let alone read it.
The Director of Nursing told inspectors she could not produce attestation statements from any agency nurses demonstrating that they had received or understood the education packet. Not one.
When inspectors examined the binder sitting at the nurses' station serving the 100, 200, and 300 halls, the one labeled "Agency Education," they found the education packet inside. What they did not find: any telephone numbers for reaching the facility's current management team, any instructions for how to access the automated medication dispensing system, any guidance on how to contact the pharmacy if access became an issue, or any way to reach an on-call manager or the Director of Nursing.
There was a sheet listing phone numbers for some support services and vendors. Radiology was on it. There was a section with administrative staff contacts. The names and numbers belonged to people who had already left the facility. The current Administrator and the current Director of Nursing were not listed.
An agency nurse arriving for a night shift at Riverwood, working a floor where they might be one of several agency nurses and the only non-regular staff member with any clinical authority, would have had a binder telling them to call people who no longer answered those phones.
The night shift supervisor, a licensed practical nurse identified in the report as Staff R, put it plainly when inspectors interviewed her on the morning of August 29. She said that to the best of her knowledge, agency nurses were not oriented or educated to the facility's processes. She had been operating under the assumption that they couldn't access the medication dispensing machine at all.
That assumption, if correct, would mean agency nurses working medication-related tasks had no reliable path to the drugs their patients needed. The inspection report does not document a specific patient harmed on the night of June 17 or any other night. The level of harm cited is minimal harm or potential for actual harm. But the gap between what agency staff needed to know and what Riverwood gave them to work with was not theoretical. It was structural, and it had been in place long enough that the contact list in the binder had gone stale through at least one full turnover of facility leadership.
The five-question quiz used for one agency's workers is worth sitting with for a moment. The questions were not clinical. They did not ask about fall protocols in any procedural sense, or about what to do when a resident's condition changed, or how to escalate a concern. They asked where to park. They asked where the time clock was. One question asked what employees should review on their first shift, which, in context, appears to be a question about the education packet itself, the same packet with no page 2 and no attestation page and no way to confirm anyone had read it.
Passing that quiz was the bar for booking a shift. For the other two agencies, there was no bar.
The Director of Nursing's acknowledgment that she could not produce attestation statements was not a record-keeping failure in the narrow sense. It reflected the absence of any process designed to produce such documentation. The packet existed. The binder existed. The quiz existed, for one agency. None of it was connected to any mechanism that would tell a supervisor, on any given night, which of the agency nurses on the floor had read what, understood what, or knew how to reach anyone when something went wrong.
Staff R was the night shift supervisor on June 17. She was working under beliefs, not verified facts. She believed the agency nurses weren't oriented. She believed they couldn't get into the medication machine. She wasn't sure who had told her that, or whether it was true, or what the procedure was supposed to be if it wasn't.
The binder at the nurses' station had the answers to some of those questions, in theory. The phone numbers in it rang to people who were gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverwood Healthcare & Rehabilitation Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL was cited for violations during a health inspection on August 29, 2025.
There were nights, the night shift supervisor told inspectors, when only one regular staff nurse was on duty.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.