Riverwalk Post Acute
Inspection Findings
F-Tag F0655
F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview and record review, the facility failed to ensure, for one of one resident, Resident 1, the baseline care plan (BCP- initial, person-centered care guide developed within 48 hours of a resident's admission) included interventions to prevent and/or minimize falls.This failure had the potential to result in Resident 1 to have repeated falls and fall related injury. Findings:A review of Resident 1's admission Record dated January 2, 2026, indicated he was admitted the facility on April 30, 2025, with diagnoses which included repeated falls.A review of Resident 1's Admission/readmission Evaluation Assessment dated April 30, 2025, indicated the reason for Resident 1's admission to the facility included status post fall (experienced a fall previously), the resident had left sided weakness, was non-ambulatory and required assistance with transfer and dressing.A review of Resident 1's Fall Risk Observation/Assessment dated April 30, 2025, indicated the resident was a high risk for falls.A review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated April 30, 2025, did not indicate that the resident had a history of falls and did not include any intervention for falls.A review of Resident 1's Nurse's Note dated May 3, 2025, indicated the resident was found on the floor at 10:00 p.m., and the resident reported he was trying to reach for his clothes by himself, he hit his shoulder and his head. Resident 1 was transferred to the general acute hospital at 10:45 p.m.Further review of Resident 1's medical record indicated the resident did not return to the facility.On January 2, 2026, at 2:17 p.m., during a concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review of Resident 1's medical record, LVN 1 stated a BCP is initiated as soon as a resident is admitted to the facility so the staff will know what they have to do to care for the resident. If a resident had a history of falls, she would include interventions such as placing call right within reach and bed in low position. LVN 1 stated Resident 1's BCP did not indicate any interventions to address falls.On January 2, 2026, at 3:14 pm., during an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON stated a BCP is initiated so that the staff would know how to care for
a resident. The ADON reviewed Resident 1's BCP and stated the BCP did not indicate that the resident had
a history of falls and did not indicate any interventions to prevent the resident from falling, and it should have been added to make the staff aware that the resident is at risk for falling.A review of the facility's policy and procedure titled, Care Plans - Baseline dated March 2022, indicated, A baseline plan of care to meet
the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include
the minimum healthcare information necessary to properly care for the resident .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
RIVERWALK POST ACUTE in RIVERSIDE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RIVERSIDE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from RIVERWALK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.