River Bend Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the weight of five residents (Resident 103, 48, 54, 2, & 89). This failure had the potential of leading to malnutrition, muscles wasting and functional loss, as well as increased susceptibility to infections for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet food service standards for food storage and preparation when:Food labeling was not performed consistently,Worn kitchen equipment was still in use,An air gap was not found on the fruit/vegetable wash sink, andFive dirty and/or wet steam table pans were found stored in the cook's ready to use area. These failures had the potential of leading to food borne illnesses for the residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 13's) pain was managed when the scheduled pain medications were not administered as ordered. This failure resulted in Resident 13 experiencing unmanaged pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rates remained below 5% when seven medication errors were identified out of 31 opportunities, resulting in a medication error rate of 22.58% for a census of 91. These failures placed Resident 66 and Resident 17 at risk for altered or delayed therapeutic drug responses and reduced medication effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention control program for 80 out of 91 residents when; 1. Staff did not follow Infection Control Practices for Resident 15, Resident 58, Resident 61; and 2. The portable and window type air conditioning (AC) unit filters were not cleaned and properly maintained for the 77 residents who resided in the hall. These failures had the potential to increase the risk of transmission and spread of infection for Resident 15, Resident 58, and Resident 61, and increased airborne contaminants for 77 residents who resided in the hall.

Inspectors wroteBased on interview and record review, the facility failed to document in the medical record the information and education provided regarding the influenza (respiratory illness that is also known as the flu) and pneumococcal (pathogen that causes respiratory illness) vaccines for two of 24 sampled residents (Resident 27 and Resident 100), when Resident 27 and Resident 100's medical record showed no evidence that education was provided. This failure increased the risk for Resident 27 and Resident 100 to contract and transmit preventable illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that services were provided in accordance with professional standards for 1 of 6 sampled residents (Resident 1) when staff did not administer a prescribed antibiotic (a medication used to kill or stop the growth of bacteria) medication as ordered by the physician. This failure had the potential to result in inadequate infection treatment and worsening symptoms for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the needs of residents were accommodated for five of nine sampled residents (Resident 3, Resident 4, Resident 5, Resident 6 and Resident 7) when:Resident 3 and Resident 4 did not have a call light system that accommodated their special needs; and, 2. Resident 5, Resident 6, and Resident 7 did not have their call lights within reach. These failures had the potential to result in residents being unable to ask for needed assistance and not attaining their highest practicable physical, psychosocial, and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders and consistent monitoring were followed in accordance with professional standards for Resident 1, when Resident 1's side effects were not consistently monitored and treatments not done as ordered by the physician. This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from significant medication error when Resident 1 did not receive prescribed antihypotensive medication (used to increase low blood pressure) in accordance with the physician's order. This failure had the potential to result in Resident 1 experiencing low blood pressure and other unnecessary side effects which could have negatively affected Resident 1's health. Resident 1 was originally admitted to the facility in May 2024 with multiple diagnoses which included hypotension (low blood pressure, means that the pressure of blood circulating around the body is lower than normal). A review of Minimum Data Set (MDS, an assessment tool), dated 2/5/25, indicated Resident 1 had impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preparation in accordance with professional standards for food service safety were provided for a census of 86, when:1. A kitchen staff's personal food item was found in refrigerator opened and expired;2. Low temperature dishwasher logs showed documentation of 200 parts per million (ppm - a unit of concentration to measure pollutants in water) for June, July, and August 2025; and 3. Kitchen staff did not know how to calibrate thermometers to determine food time/temperature control during lunch tray line. These failures had the potential to cause food-borne illnesses in a vulnerable population.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment in accordance with professional standards of care for forty (40) residents in a census of 86, when the licensed nurse (LN) did not have consistent practice in enteral tube (flexible tube inserted into the gastrointestinal tract to deliver liquid nutrition or medications directly to the stomach or small intestine) medication administration, and the facility provided two versions of the policy and procedure addressing the practice with the same revision date and modified text. These failures had the potential to expose the residents on enteral tubes to unsafe medication administration and the adverse side effects of the medications. During a concurrent observation and interview on 8/13/25 commencing at 4:27 p.m., a medication pass was conducted with LN 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to meet the communication needs for three of 30 sampled residents (Resident 12, Resident 55, and Resident 60), when:1. Resident 12, non-English speaking resident, was not provided with any communication board or devices; and2. Resident 55 and Resident 60, non-verbal dependent residents, were not provided with any visual materials to express their needs. These failures had the potential to result in Resident 12, Resident 55 and Resident 60's inability to participate in daily tasks, make choices, or have their preferences and unmet needs heard. 1. During a review of Resident 12's admission Record (AR), dated 5/2025, the AR indicated Resident 12 had diagnosis of mild cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming, nail care and oral hygiene were provided to five of 30 sampled residents (Resident 12, Resident 22, Resident 27, Resident 60 and Resident 77) who were unable to carry out activities of daily living (ADLs), when:1. Resident 12's toenails were long, untrimmed, curled inward and discolored;2. Resident 22's left big toenail was long, jagged, untrimmed and curled outward; 3. Resident 27 toenails were long, jagged, untrimmed, discolored and curled inward;4. Resident 60's fingernails and toenails were long, jagged and untrimmed, his nostrils had yellowish-colored substance, his upper and lower eyelids and eyebrows had white-colored-crust-dried substance, his teeth were discolored, and his lips were cracked and dry, dry and scaly skin; and, 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's environment was free from accidents or hazards for one of 30 sampled residents (Resident 61), when Resident 61 had a traumatic fall with injury. This failure resulted in Resident 61's decline in physical and psychosocial well-being. During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility in late 2022 with diagnoses which included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 61's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/1/25, the MDS indicated Resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 25.81% error rate, with eight medication errors out of 31 opportunities observed during a medication pass for two of five residents (Resident 3 and Resident 76). These failures resulted in medications not being administered in accordance with the prescriber's orders and may have affected the residents' clinical conditions. During a concurrent observation and interview on 8/13/25 commencing at 4:27 p.m., a medication pass observation was conducted with Licensed Nurse (LN 4), LN 4 was observed preparing and administering seven medications for Resident 3. LN 4 combined and crushed together six medications: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored securely for a census of 86, when:1. An open container of glucometer test strips was not labeled with the open date;2. One eye drop medication had no legible open date;3. Keys to the controlled substance cabinets and refrigerator were not secured. These failures had the potential for residents to receive medications or treatments that were unsafe or with reduced potency or accuracy, and increased risk of access to controlled substances by unauthorized individuals. During a concurrent observation and interview on 8/14/25 at 10:55 a.m. with Licensed Nurse (LN 6) in the hallway near room [ROOM NUMBER], the medication cart was inspected and found an open box of glucometer test strips that was not labeled with an open date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from acquiring scabies (contagious skin infestation caused by mites), when the facility had three residents who tested positive for scabies (Resident 1, Resident 2, and Resident 3) and facility wide prophylaxis was not completed per public health recommendations. This failure had the potential for multiple vulnerable residents to acquire scabies and suffer the effects of infestation including infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the wound care plan was updated and revised timely for one of 3 sampled residents (Resident 1) when Resident 1's moisture related skin condition deteriorated to a pressure ulcer stage 4 (pressure injuries extended to muscle, tendon, or bone) to include interventions ordered by the physician. This failure had the potential to result in an inaccurate evaluation of the progress of wound healing for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care according to professional standards of practice for one of three sampled residents (Resident 1), when the facility did not obtain instructions for follow up care for Resident 1 who had electrodes placed for an EEG (electroencephalogram- measures electrical activity in the brain) machine and appointment for removal of electrodes was missed. This failure had the potential to have caused the scalp skin injuries after the electrodes were removed at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain timely and appropriate pharmaceutical services for one out of three sampled residents (Resident 1) when a prescribed medication was unavailable to be administered as ordered by the physician. This failure caused Resident 1 to experience worsening tremors, increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' right to personal privacy and confidentiality of his or her personal medical information when meal tray tickets were thrown into the general kitchen trash. This failure had the potential of compromising resident privacy for 54 residents receiving facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff had the knowledge and competencies to carry out dietary functions when: 1. A cook was unable to correctly read the temperature in one of the reach in freezers; 2. A Dietary Aide did not know how to check the temperature of a dishwashing machine; 3. A cook did not use a recipe when preparing pureed foods; and, 4. A cook used the wrong scoop size to measure out food quantities. These failures had the potential of leading to food borne illness or weight loss for 54 Residents receiving facility prepared food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe for pureed food for three out 20 residents (Resident 37, Resident 63 and Resident 85) receiving a pureed diet when a kitchen staff member used the wrong scoop size to measure out food quantities. This failure had the potential to place residents receiving a pureed diet at risk for malnutrition and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to conserve nutritive value and palatability for 20 residents receiving a pureed diet when the pureed bread was prepared without using a recipe. This failure had the potential of leading to poor intake and malnutrition for the 20 residents receiving pureed meals.

Inspectors wroteF812 Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 54 residents who received facility prepared foods when: 1. Proper food labeling was not followed for items in the freezers, refrigerator, dry storage, and spice shelf; 2. Expired food items were found in the refrigerator, dry storage, and spice shelf; 3. Personal milk cartons were not stored at appropriate temperatures; 4. Kitchen reach in freezers contained multiple boxes of food items that were exposed and open to the freezer environment; a plastic container of brown sugar was not sealed properly; 5. Frozen foods were not stored at appropriate temperatures; 6. A steam table pan was found stored wet; 7. No air gaps were found in the produce sink; 8. The kitchen can opener had a chipped blade; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection practices were followed when: 1. Respiratory Therapist (RT) did not perform hand hygiene during a breathing treatment for Resident 66; 2. The isolation trash can was not covered for Resident 66; 3. Oxygen tubing used by Resident 139 was not labeled and additional oxygen tubing and nebulizer facemasks were labeled with an expired date; 4. An air fan was found with black residue and lint in Resident 41's room; and 5. Three plastic trash containers were open and had no lid cover during lunch meal in the facility dining room. These failures had the potential to increase the transmission and spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain one out of three reach-in freezers in safe operating condition when the freezer was found running at unsafe temperatures. This failure had the potential to lead to growth of bacteria and food borne illness for all 54 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, clean and comfortable environment was provided for a census of 89, when: 1. Several missing slats on the window blinds, three fluorescent bulbs not functioning, and three open trash containers without lids were found in the dining room; and 2. Resident 19 had a strong odor and foul-smelling room environment. These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required in-service training, competency skills and techniques were provided for two out of two sampled Contracted Certified Nursing Assistants (CCNA) CCNA 15 and CCNA 16, when the facility was unable to provide documentation to demonstrate the CCNAs received no less than 12 hours of annual in-services. This failure had the potential to significantly compromise the quality of services provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and privacy were promoted for two of 30 sampled residents (Resident 52 and Resident 19), when: 1. Staff did not knock nor identify himself and entered Resident 52's room; and, 2. Resident 19 was left with a pungent, strong body odor and foul-smelling immediate environment. These failures resulted in negatively impacting Resident 52 and Resident 19's emotional, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for two out of 30 sampled residents (Resident 52 and Resident 85), when: 1. Resident 52's emotional issues and environmental concerns were not developed; and, 2. Resident 85 had no care plan developed and implemented for activities. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan for two of 30 sampled residents (Resident 18 and Resident 139), when: 1. Resident 18's nutrition care plan was not updated for an adaptive device; and, 2. Resident 139's pain care plan was not updated for a new pain medication. These failures had the potential to result in Resident 18 and Resident 139's not attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene were provided for two out of 30 sampled residents (Resident 19 and Resident 29), when: 1. Resident 19 was unkempt and the immediate environment had a strong foul-smelling odor; and, 2. Resident 29's fingernails were long and with jagged ends. These failures had the potential to result in the residents not attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet two of 30 sampled residents' (Resident 37 and Resident 85) activity needs when the residents did not receive in-room visits by staff. This failure increased the potential for residents to experience isolation and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt appropriate alternatives, obtain physician's orders, and obtain an informed consent prior to using bed rails (adjustable metal or rigid plastic bars that attach to the side of the bed) for 1 of 30 residents (Resident 63). This failure had the potential to result in entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), injury and/or negative physical outcomes to skin integrity or muscle function.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for two of 30 sampled residents (Resident 66 and Resident 76) when six tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for diversion and not being able to accurately monitor the amount or frequency of medications given to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were accommodated for one of 54 residents receiving facility prepared food (Resident 9) when Resident 9's request not to be served cream of wheat for breakfast was disregarded. This failure had the potential to negatively impact Resident 9's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 18 and Resident 73) were provided with necessary adaptive equipment for meals as ordered by the physician. This failure had the potential to negatively impact the resident's well-being and contribute to decreased meal intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents received Cardiopulmonary Resuscitation (CPR) when Resident 1 was found pulseless and not breathing by a Respiratory Therapist (RT) and Licensed Nurses (LN). This failure decreased the facility's potential to ensure a physician's order and Resident 1's request to receive care with the primary goal to prolong life was executed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device to alert nursing staff when a resident is in need) was within reach of one resident (Resident 1) out of a sample of four residents. This failure prevented Resident from communicating his care needs and had the potential to increase his anxiety (a feeling of fear, dread, and uneasiness).