Riverwood Healthcare: Opioid Doses Missed, Undocumented - FL
The pattern surfaced during a complaint inspection completed August 29, 2025. Inspectors interviewed five nurses about the care of Resident 85, a patient with a standing prescription for Oxycodone 10mg. What they found was a rotating cast of staff, several of them agency or one-time workers, each making individual decisions about whether to give a scheduled opioid and then leaving almost no record of what they did or why.
On August 21, Staff D, a licensed practical nurse, held Resident 85's 6:00 PM dose because he appeared drowsy or lethargic. She marked a "7" on his medication administration record. She told inspectors she must have forgotten to write a note. She did not contact the physician.
On the night of July 26, Staff Q held his midnight dose of Oxycodone because he was sleeping. She checked a "7" on his MAR. She had not written a note or taken any other action. She told inspectors there had been times when medications for her residents simply weren't available.
Staff R remembered Resident 85 by name but could not recall the details of his care from June 17. If she had charted a "7" for his midnight Oxycodone, she said, she believed it was because he was sleeping, and she assumed that was sufficient documentation. She did not contact the doctor.
Staff O, who had worked at the facility for a couple of months, told inspectors he wasn't sure whether he gave Resident 85 his 6:00 AM Oxycodone on August 26. He wasn't sure why he would have documented a "9" in the electronic medical record. He said he had not been provided any orientation or education by the facility and didn't believe the automated medication dispensing machine existed at the location. If it did, he had no access to it.
Staff P had worked at Riverwood one time. She did not recall Resident 85 or whether she had given him a noon dose of Oxycodone on June 27. She had never had access to the dispensing machine and received no orientation from the facility. Nobody had given her a phone number for the Director of Nursing or told her there was an on-call nurse she could reach.
The prescribing physician told inspectors she did not recall being contacted about Resident 85's Oxycodone at any point during the relevant period. If the facility had run out of the medication, she said, the standard approach would have been to pull from an emergency supply until the pharmacy refilled the prescription. Holding a medication because the facility ran out of it was not her practice.
The Director of Nursing told inspectors her expectation was clear: nurses administer medications as ordered, and if they cannot, they contact the physician and notify her or a supervisor. The inspection record does not indicate that any of the nurses who withheld Resident 85's Oxycodone reached her.
The facility's Regulatory Compliance Consultant, interviewed on the final day of the inspection, said the facility needed to ensure residents received the care they needed, especially when it came to pain management.
What the inspection does not contain is any account of who was responsible for orienting agency staff, why multiple nurses across multiple shifts encoded unexplained numbers into a resident's opioid record without a clinical note, or what Resident 85 experienced during the periods he went without his prescribed pain medication.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL was cited for violations during a health inspection on August 29, 2025.
The pattern surfaced during a complaint inspection completed August 29, 2025.
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.