River Walk Care Center
RIVER WALK CARE CENTER in PORTERVILLE, CA — inspection on February 26, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
recommends continuing current medication as a GDR may hinder his [Resident 45] quality of life and
and recommended a consent be obtained for Resident 45's Trazadone 50 mg every night.During a
PMEC indicated, on 9/15/25 the facility obtained a consent for Resident 45's Trazadone 50 mg every night (50 days after the medication was started).
During an interview on 2/26/26 at 3:33 p.m. with Director of Nursing (DON), DON stated the error in not obtaining consent for Resident 45's Trazadone was discovered in September 2025. DON stated the facility did not follow their policy and procedure for psychotropic medication on obtaining IDT and consent.During a review of the facility's P&P titled, Psychotropic Medication Use, dated 2/2025, the P&P indicated, Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.
Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications.
Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes . determining adequate indications for use . establishing appropriate dose . and duration .Psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff.When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident.
The evaluation includes the resident's . physical, behavioral, mental, and psychosocial status .Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include . admission or readmission . an irregularity identified during drug regimen review .
Diagnosis alone does not necessarily warrant the use of psychotropic medication.
Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal . the indications and rationale for the recommendation . the potential risk and benefits . the resident's/representative right to accept or decline the treatment.
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257
During a concurrent observation and
dressing/wrap that was designed to absorb moderate to heavy wound drainage) dated 2/22/26.
92's room, Resident 92 was sitting in a chair, his bilateral lower legs were covered with pink foam dressings (highly absorbent bandage) dated 2/23/26. Resident 92 stated he had a reaction to the Kerlix gauze dressing that made his skin itch. Resident 92 stated the treatment nurse applied a different dressing.
During an observation on 2/25/26 at 10:40 a.m. in Resident 92's room, Resident 92 was sitting on his bed, his bilateral lower legs were covered with pink foam dressings, dated 2/24/26.
During a concurrent interview and record review on 2/25/26 at 11:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 92's Physician Orders (PO) dated 2/20/26 was reviewed.
The PO indicated, Resident 92 was to have daily wound treatment to his bilateral lower legs that consisted of cleaning wounds with normal saline [NS, a sterile solution of salt dissolved in water that is gentle and non-irritating for wound care], pat dry, apply silver med gel [brand name, a water based gel mixed with silver ions (active ingredient) used to manage infections and keep a moist wound bed] to wound bed, cover with Adaptec [mesh dressing designed to protect the wound bed and prevent bandages from sticking to healthy tissue], layer with ABD pad [abdominal pad, highly absorbent cotton filled dressing], wrap with Kerlix every day shift. LVN 1 stated Resident 92's current wound treatment order was NS, Silver med gel, Adaptec, ABD pad and kerlix wrap.
During an interview on 2/25/26 at 11:09 a.m. with LVN 1, LVN 1 stated she had changed Resident 92's wound treatment to a foam dressing on 2/23/26 and 2/24/26 due to Resident 92's request. LVN 1 stated there were no POs in Resident 92's chart to change Resident 92's wound treatment to a foam dressing. LVN 1 stated she should have obtained a PO for the foam dressings.
During a review of the facility's policy and procedure (P&P) titled, Dressings, Dry/Clean, dated September 2013, the P&P indicated, The purpose of this procedure is to provide guidelines for the application of dry clean dressings.1.
Verify that there is a physician's order for this procedure.2.
Review the resident's care plan, current orders, and diagnosis. 3.
During review of Resident 10's Electronic Medical Record (eMAR) on 2/26/26, the eMAR indicated, Resident 10's last recorded weekly/monthly weight was 7/14/25, with a recorded weight of 104 pounds (unit of weight).
During a review of Resident 10's Order Summary Report (OSR), dated 2/26/26, the OSR indicated, Resident 10 was admitted to hospice (compassionate care for near end of life within a facility) on 1/8/26 with a diagnosis of Parkinson's disease (incurable, disorder, tremors, stiffness, and slow movement).
During a review of Resident 10's Physician Order Sheet (POS), dated 12/30/26, the POS indicated, No weekly weights only monthly - daughter has agreed to monthly weights.
During a concurrent interview and record review on 2/26/26 at 3:34 p.m., with Director of Nursing (DON), Resident 10's eMAR was reviewed.
The eMAR indicated Resident 10's last daily weight 7/14/25. DON stated, The weights were not completed after July, 2025 there's no Physician order to discontinue the weights.
During a review of the facility's policy and procedure (P&P) titled, Physician Services, dated 2001, the P&P indicated, The medical care of each resident is supervised by a licensed physician . 1. A physician must recommend in writing that an individual be admitted to the facility . 2.
Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) . 3.
Supervising the medical care of residents includes (but not limited to): b. monitoring changes in resident's medical status.
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 2001, the P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain .
Weight Assessment 1.
Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2.
Weights are recorded in each unit's weight record chart and in the individual's medical record. 3.
Any changes of 5% or more since the last weight assessment is retaken the next day for confirmation.
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257
systems approach to safety.
The type and frequency of resident supervision is determined by the
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257
During an interview on 2/25/26 at 3:36 p.m. with Director of Nursing (DON), DON stated it is basic nursing to flush between medications, and it is an expectation for her staff.During a review of the facility policy and procedure (P &P) titled, Enteral Tube Feeding via Syringe (Bolus), dated November 2018, the P & P indicated, When correct tube placement has been verified, flush tubing with at least 30 ml warm water (or prescribe amount).
temperature.
This failure had the potential for food borne illnesses to affect all residents eating from
loss.Findings:During a concurrent observation and interview on 2/25/26 at 12:55 p.m. with Dietary Supervisor (DS), the last lunch meal tray was served, and food temperatures were taken. DS observed and confirmed the following food temperatures: Fish temperature was at 116 degrees Fahrenheit ( F- a unit of measurement). DS stated the temperature was supposed to be at 140 FBroccoli temperature was at 113 F. DS stated the temperature was supposed to be at 140 FRice temperature was at 128 F. DS stated the temperature was supposed to be at 140 FCucumber salad was at 70 F. DS stated the temperature was supposed to be below 68 FMilk was at 52 F. DS stated the milk was supposed to be 40 F or lowerDuring a review of Resident 5's Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition is. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests the cognition is intact. A score of 99 suggest the resident was unable to complete the interview and therefore unable to determine the resident's cognition), dated 2/21/26 the BIMS indicated Resident 5's score was 15
During an interview on 2/26/26 at 8:44 a.m. with Resident 5, Resident 5 stated he attended resident council (group of residents who meet to discuss facility/resident concerns) meetings on a regular basis. Resident 5 stated the facility kitchen had been sending out meals that were not heated or chilled correctly for approximately the last three months. Resident 5 stated, The hot food is cold, and the cold food is hot.During a review of the facility's policy and procedure (P&P) titled, MEAL SERVICE, UNDATED, the P&P indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appointment temperatures.
Hot food serving temperature must be at or above minimum holding temperature of 140 F.
The temperatures of the food should be periodically monitored throughout the meal service to ensure proper hot and cold temperature.
Temperature of the food when the resident receives it is based on palatability.
The goal is to serve cold food cold and hot food hot.
Recommended Temp (temperature) at Delivery to Resident .
Cold entree . (at or lower than) 50 F .
Salads . (at or lower than) 45 F .
Milk/cold beverage . (at or lower than) 45 F .
Hot entree . (at or higher than) 120 F .
Vegetables . (at or higher than) 120 F.
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257
During a review of the facility's policy and procedure (P&P) titled, COLD STORAGE TEMPERATURE MONITORING AND RECORD KEEPING, undated, the P&P indicated, Food and Nutrition staff shall review and record temperature of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling.
Food (and) Nutrition Services staff will check the inside temperature of refrigerators and freezers.
Food (and) Nutrition Services staff will record and initial the temperatures on the Healthcare Menu Direct, LLC.'s Cold Storage Temperature Log . at the beginning of the AM and PM shifts.
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257
During a review of the facility's policy and procedure (P&P) titled, Handling Soiled Linen, undated, the P&P indicated, It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection.
Linen can become contaminated with pathogens (tiny organisms that can cause sickness and disease) from contact with intact skin, body substances, or from environmental contaminants.
Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen.
All used linen should be handled using standard precautions (basic methods to control infection such as washing hands, wearing gloves and other appropriate protective equipment) . and treated as potentially contaminated .
Linen should not be allowed to touch the uniform or floor and should be handled as little as possible .
Used or soiled linen shall be collected at the bedside . and placed in a linen bag or designated linen receptacle.
When task is complete, the bag shall be closed securely and placed in the soiled linen utility room.
555658 02/26/2026
River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257