Safety Report: Riverbank Post-Acute
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
1Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
12Requirements cited on more than one inspection
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Tag F656
Citations by topic
3Abuse, neglect & exploitation
6Infection control
4Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (16) than in the cycle before (18).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 5 | July 22, 2026; November 25, 2025; March 27, 2024; September 22, 2023; September 11, 2019 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 5 | April 13, 2026; September 10, 2025; March 15, 2025; March 27, 2024; January 17, 2024 |
| Keep all essential equipment working safely. (F908) | 3 | March 23, 2026; November 29, 2023; September 22, 2023 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 3 | September 10, 2025; March 27, 2024; September 22, 2023 |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (F726) | 2 | April 13, 2026; September 11, 2019 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | April 13, 2026; September 11, 2019 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | March 23, 2026; September 11, 2019 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | March 15, 2025; June 5, 2024 |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F921) | 2 | June 5, 2024; September 22, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | September 22, 2023; September 11, 2019 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | September 22, 2023; September 11, 2019 |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (F912) | 2 | September 22, 2023; September 11, 2019 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| March 15, 2025 | Payment Denial | Payment denial for 7 days, starting April 11, 2025 |
| March 15, 2025 | Fine | $29,322 |
| January 17, 2024 | Fine | $43,973 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 22, 2026 — 1 citation · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected July 29, 2026
April 13, 2026 — 3 citations · complaint investigation
E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · complaint · corrected April 23, 2026
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · complaint · corrected April 23, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected April 23, 2026
March 23, 2026 — 4 citations · complaint investigation
F
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F908 · complaint · corrected March 27, 2026
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected March 27, 2026
E
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F835 · complaint · corrected March 27, 2026
E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F745 · complaint · corrected March 27, 2026
November 25, 2025 — 2 citations · complaint investigation
F
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F882 · complaint · corrected December 8, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected December 8, 2025
September 10, 2025 — 3 citations · complaint investigation
E
Provide appropriate foot care.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F687 · complaint · corrected September 26, 2025
E
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected September 26, 2025
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected September 26, 2025
March 15, 2025 — 6 citations (includes serious)
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · corrected April 1, 2025
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected April 1, 2025
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected April 1, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected April 1, 2025
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected April 1, 2025
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected April 1, 2025
July 16, 2024 — 3 citations · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected August 9, 2024
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected August 9, 2024
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected August 9, 2024
June 21, 2024 — 1 citation · complaint investigation
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · complaint · corrected August 9, 2024
June 5, 2024 — 2 citations · complaint investigation
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · complaint · corrected July 5, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 5, 2024
March 27, 2024 — 3 citations · complaint investigation
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · complaint · corrected May 10, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected May 10, 2024
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected May 10, 2024
January 17, 2024 — 1 citation (includes serious) · complaint investigation
G
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Actual harm to a resident (not immediate jeopardy) · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected February 14, 2024
November 29, 2023 — 1 citation · complaint investigation
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · complaint · corrected December 27, 2023
September 22, 2023 — 15 citations
E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F921 · corrected October 20, 2023
E
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F920 · corrected October 20, 2023
E
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F908 · corrected October 20, 2023
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected October 20, 2023
E
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F849 · corrected October 20, 2023
E
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F814 · corrected October 20, 2023
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected October 20, 2023
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected October 20, 2023
E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected October 20, 2023
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected October 20, 2023
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected October 20, 2023
D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected October 20, 2023
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected October 20, 2023
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected October 20, 2023
C
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Widespread · Environmental Deficiencies · F912 · corrected October 20, 2023
September 11, 2019 — 21 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected November 5, 2019
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected November 5, 2019
E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F805 · corrected November 5, 2019
E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F802 · corrected November 5, 2019
E
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F800 · corrected November 5, 2019
E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected November 5, 2019
E
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F685 · corrected November 5, 2019
E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F676 · corrected November 5, 2019
E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F655 · corrected November 5, 2019
E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F640 · corrected November 5, 2019
E
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F638 · corrected November 5, 2019
E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F623 · corrected November 5, 2019
E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected November 5, 2019
D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F812 · corrected November 5, 2019
D
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F790 · corrected November 5, 2019
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected November 5, 2019
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected November 5, 2019
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected November 5, 2019
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected November 5, 2019
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected November 5, 2019
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected November 5, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare