Riverside Postacute Care changed the transportation method for Resident 1 without updating her care plan or discussing it with her family, federal inspectors found during an October complaint investigation.
The resident had undergone an operation on her feet and was not supposed to put pressure on them. She needed a wheelchair-accessible van for safe transport to her three-times-weekly dialysis appointments.
Instead, facility staff arranged Uber rides starting the week of September 22, 2025.
The Social Services Director told inspectors the facility had been using a private wheelchair van service for the resident's dialysis appointments. But the facility stopped paying the transportation company, and the van owner informed staff he could no longer provide rides without payment.
"The corporate office determined to use Uber because they did not want to pay for wheelchair van transportation," the Social Services Director said during an October 3 interview.
The decision was made without consulting the resident or her family member.
The resident's family member told inspectors during a telephone interview that his relative "had an operation on her feet and was not supposed to put pressure on her feet and that she needed a lifted van for a wheelchair transfer."
He said he met with facility staff on October 1, 2025, after learning about the Uber transportation. Staff promised they would "take care of the transportation," but he heard nothing back.
The inappropriate transport method caused the resident to miss dialysis treatments. She was subsequently hospitalized and suffered physical injury, according to the inspection report.
Federal inspectors reviewed the resident's care plan and found no interventions addressing transportation to dialysis, transfer assistance, or mobility safety. The facility failed to revise the care plan after changing the transportation method or after the injury occurred.
There was no documentation that the resident or family participated in developing or revising any care plan regarding transportation methods.
The Social Services Director explained that dialysis residents are typically admitted to the facility with transportation and appointments already arranged. She said the resident's insurance was accepted by very few transportation companies, creating challenges in finding appropriate transport.
According to facility policy described by the Social Services Director, if a resident's insurance doesn't cover transportation, the resident can pay privately. If the resident cannot pay, the facility will cover the cost.
But in this case, the corporate office chose Uber over continuing to pay for wheelchair-accessible transport that the resident medically required.
The violation represents a failure to develop and implement a complete care plan that meets all resident needs, with measurable actions and timetables. Federal regulations require nursing homes to conduct interdisciplinary assessments and update care plans when residents' conditions or needs change.
The facility's decision to substitute standard vehicle transport for wheelchair-accessible transport without medical evaluation or family consultation violated these requirements.
The inspection found the facility affected few residents but created minimal harm or potential for actual harm through its care planning failures.
The case illustrates how corporate cost-cutting decisions can override medical necessity in nursing home care. The resident required specialized transportation due to her post-surgical condition and mobility limitations, but received rides in regular passenger vehicles that could not safely accommodate her wheelchair or medical restrictions.
The missed dialysis treatments that resulted from inappropriate transportation posed serious health risks. Dialysis patients require consistent treatment schedules to prevent dangerous fluid buildup and toxin accumulation that can lead to hospitalization or death.
The resident's family member had specifically explained her medical needs and transportation requirements to facility staff. Despite this clear communication and a promised resolution, the facility continued using inappropriate transport that led to treatment disruptions and injury.
Federal inspectors completed their investigation on October 14, 2025, documenting the care planning violations and cross-referencing related deficiencies in the facility's overall resident care management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Postacute Care from 2025-10-14 including all violations, facility responses, and corrective action plans.