Riverwood Healthcare & Rehabilitation Center
Inspection Findings
F-Tag F0684
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-29.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
expectation was that nurses administered medications as ordered, and if they were unable to administer
the medication, they were to contact the physician and their supervisor or her.
During an interview on 8/28/2025 at 10:42 AM, Staff D, LPN (Licensed Practical Nurse), stated that she held Resident #85's Oxycodone and marked 7 on the MAR on 8/21/25 at 6:00 PM because he appeared drowsy or lethargic, but she must have forgotten to document a note.
During an interview on 8/28/2025 at 12:38 PM, Physician #1 stated that she did not recall being contacted earlier in the week regarding Resident #85's Oxycodone medication. If the facility had run out of the resident's prescribed Oxycodone, she thought they would obtain the necessary doses from their emergency supply until the pharmacy could refill the prescription. It was not her practice to hold a medication if the facility had run out of it.
During an interview on 8/28/2025 at 1:37 PM, Staff O, LPN, stated that he was not sure whether he gave Resident #85's Oxycodone 10mg at 6:00 AM on 8/26/25. He wasn't sure why he would have documented a 9 in the EMR (electronic medical record). He had worked in the facility for a couple of months. He had not been provided any orientation or education to the facility… He didn't believe the facility had a (name of
the automated medication dispensing machine), and if they did, he did not have access to it.
During an interview on 8/28/2025 at 3:25 PM, Staff P, LPN, stated that she had worked in the facility one time. She did not recall Resident #85, or whether she had administered a dose of Oxycodone at 12:00 PM
on 6/27/25. She had never had access to the (name of the automated medication dispensing machine) and did not receive any education or orientation from the facility. She was not provided with any information regarding an on-call nurse or a phone number for the DON (Director of Nursing).
During an interview on 8/28/2025 at 3:42 PM, Staff Q, LPN, stated that she remembered Resident #85 and
she believed that when she checked a 7 on 7/26/25 at midnight on his MAR, it was because he was sleeping, and she did not administer his scheduled dose of Oxycodone 10mg. She had not written a note or taken any other actions. There had been times when medications for her residents were not available.
During an interview on 8/29/2025 at 12:46 PM, Staff R, LPN, stated that she remembered Resident #85 by name but did not recall taking care of him or any details regarding medication administration from 6/17/25.
If she charted a 7 for his scheduled Oxycodone at midnight, she believed it would have been because he was sleeping, and she assumed that was sufficient documentation. She did not contact the doctor or take any other action steps.
During an interview on 08/29/2025 at 2:10 PM, the Regulatory Compliance Consultant stated that they needed to ensure their residents received the care they needed, especially when it came to pain management.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverwood Healthcare & Rehabilitation Center
808 S Colley Rd Starke, FL 32091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0726
F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
confirmation that the agency staff members had received any orientation or education regarding the facility.During an interview on 8/29/2025 at 12:46 PM, Staff R, LPN, stated that she believed she was in the position of the Night Shift Supervisor on 6/17/25. To the best of her knowledge, the agency nurses really were not oriented or educated to the processes in the facility. She had been under the impression that the agency nurses were not provided with access to the [automated medication dispensing machine]. There were times when there was only 1 regular staff nurse on, and the others were all agency nurses.Review of
the packet titled, Education Packet, provided to agency staff, both nurses and CNAs, included a cover page that read, I, acknowledge and understand that I am required to read and refer to the following handouts: Preventing/Minimizing injury during resident transfers; Gait/Transfer belts; Accident prevention and body mechanics; Resident's Rights; The club policy prohibiting abuse, neglect, and misappropriation; Alzheimer's disease and related dementias; 12 Steps to prevent antimicrobial resistance among LTC residents; Blood and body fluids exposure policy; Work practices policy; Hand washing/hand hygiene policy; Exposure reporting and investigating policy; Standard precautions policy; Employee's notice of reportable conditions; Time and attendance policy; Risk Management; HIV/AIDS - Page 1 of 45 There was no page 2. Each of the above listed policies were in the packet, all running together as one continuous document. There was no attestation page included in the packet. During an interview on 8/29/25 at 9:08 AM, the DON stated that
she was not able to provide any attestation statements from the agency nurses working in the facility to demonstrate receipt and understanding of the education packet provided to them by the facility. The documents provided by the DON representing the process for booking staff from the [Nurse Staffing Agency's name] agency were reviewed. Included were a document titled, Workplace Rules Quiz (Pre-booking Quizzes) FAQs [frequently asked questions] that read, This feature is available to all Long Term Care facilities and Schools, as well as select other facilities. What is this? When professionals book a shift at your workplace for the first time they'll be required to read the rules and expectations that your workplace has shared in the Workplace Rules Quiz section. The rules you enter will be used to automatically generate a customized quiz for your workplace. Professionals must then pass the quiz before
they are eligible to book a shift at your workplace. A document titled, Workplace Quiz, contained 5 questions, with multiple choice options for responses. It read, 1. Where should you report a fall incident? 2.
Where is the timeclock located? 3. What must employees review on their first shift? 4. Who should be contacted for a change of condition or medication access issues? 5. Where is parking located for the building?There were no similar quizzes provided for the other 2 agencies utilized by the facility for staffing.
During an observation on 08/29/2025 at 11:40 AM there was a binder at the nurses' station for the 100, 200, and 300 halls; it was titled, Agency Education. It contained the packet titled, Education Packet. It did not contain any telephone numbers or any information regarding the processes for accessing the automated medication dispensing system, contacting the Pharmacy to obtain access, or contacting the on-call manager or the DON. There were some guidelines for certain situations, such as 'Change in Condition,' and 'Resident Transfer' in the front of the Narcotic Medication binder. There was a sheet that listed telephone numbers for some support services or vendors, such as radiology. There was a section that listed telephone numbers for administrative staff, such as the Administrator and the Director of Nursing, but
they were not current. The names and telephone numbers were from previous personnel, not any of the current management team members.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0732
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-29.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Post nurse staffing information every day.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
F-Tag F0812
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-29.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
F-Tag F0842
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-29.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
F-Tag F0880
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-29.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
F-Tag F0919
Federal health inspectors cited RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-08-29.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of RIVERWOOD HEALTHCARE & REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-17.
RIVERWOOD HEALTHCARE & REHABILITATION CENTER in STARKE, FL 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 STARKE, FL, (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 RIVERWOOD HEALTHCARE & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.