River's Bend Health & Rehab Center

Inspectors wroteBased on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1) who displayed aggressive behavior and physically pushed another resident (Resident 2), causing a fall with a hip fracture. This failure resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1), who displayed aggressive behavior and physically kicked another resident (Resident 2).

Inspectors wroteBased on facility policy review, clinical record review, review of select facility documentation, observation, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards; and failed to provide adequate supervision and assistance devices to prevent accidents for two of 32 residents reviewed (Residents 10 and 51), which resulted in actual harm for Resident 51 as evidenced by scapholunate widening, suggesting a ligamentous injury.

Inspectors wroteBased on policy review, resident and staff interviews, observation, and record review, the facility failed to assist residents in obtaining timely dental services to obtain dentures for one of three residents reviewed (Resident 3), resulting in phyco-social harm and weight loss.

Inspectors wroteBased on facility policy, staff interviews, and clinical record reviews, it was determined that the facility failed to provide an explanation of the risks and benefits of psychotropic medications use and obtain consent prior to administering psychotropic medications for three of five residents reviewed for psychotropic medication use (Residents 7, 10, and 66).

Inspectors wroteBased on policy review, resident interviews, facility documentation review, and staff interviews, it was determined that the facility failed to make prompt efforts to resolve grievances the resident may have for six grievances reviewed (Residents 35, 41, 43, 59, 66, and 157).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 31 residents reviewed (Residents 10, 11, and 66).

Inspectors wroteBased on observations, facility policy review, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 32 residents reviewed (Residents 10, 99, and 149).

Inspectors wroteBased on review of facility contract, review of select facility documentation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision or hearing abilities for one of three resident's reviewed for vision and hearing (Resident 8).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen and in two of two pantry refrigerators (first and second floors).

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of two employees observed during medication pass (Employee 2) Findings Include: Review of facility policy, titled General Dose Preparation and Medication Administration, revised November 15, 2024, revealed that, prior to preparing or administering medications, facility staff should complete appropriate hand hygiene. Observation of Employee 2 (Registered Nurse) on March 10, 2026, at 9:41 AM, revealed Employee 2 administering medications to Resident 92, then Resident 100, then Resident 93, and finally Resident 12 without completing hand hygiene at any time during the observation. [...]

Inspectors wroteBased on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 32 residents reviewed (Resident 149).

Inspectors wroteBased on review of facility policy, Resident Council Meeting minutes, and resident and staff interviews it was determined the facility failed to consider the views of residents and act promptly on concerns regarding quality of life and issues with wandering residents entering other resident's rooms for three of three months (December 2025, January 2026, and February 2026).

Inspectors wroteBased on facility policy review, observations, and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable and home-like environment in two of eight hallways observed.

Inspectors wroteBased on facility policy review, clinical record review, review of facility provided documentation, and staff interviews, it was determined that the facility failed to provide written notice of a resident's transfer to the resident and the resident's representative for two of six residents reviewed for hospital transfer (Residents 10 and 56); failed to send notice of a residents transfer to a representative of the Office of the State Long-Term Care Ombudsman for two of six residents reviewed for hospital transfers (Residents 10 and 56); and failed to provide a written copy of the facility's bed-hold policy for three of six residents reviewed (Residents 8, 10, and 56).

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident's comprehensive care plan was implemented for one of 31 residents reviewed (Resident 10).

Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of seven residents reviewed for ADLs (Resident 51). Findings Include:Review of the facility policy, titled AM Care Policy last reviewed September 16, 2025, read, in part, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Showers and baths are scheduled two times weekly or more or less according to resident preference. Provide shaving as desired by resident. [...]

Inspectors wroteBased on facility policy reviews, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 31 residents reviewed (Resident 66).

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications for one of one resident reviewed for tube feeding (Resident 115).

Inspectors wroteBased on facility policy review, medication administration observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (4 errors in 25 observations, 15.38%).

Inspectors wroteBased on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found by EMS staff laying on the ground near the public road, which runs in front of the facility, with abrasions to his hand and foot. This failure placed an additional three residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 3, and 4).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to obtain information from previous employers and/or current employers for five of five employee files reviewed (Employees 2, 3, 4, 5, and 6).

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber in a timely manner for four of 33 residents reviewed (Residents 49, 62, 70, and 119).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 30 residents reviewed (Residents 85 and 125). Findings Include: Review of Resident 85's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid backs up into your esophagus, the tube connecting your stomach to your mouth), and hypertension (high blood pressure). Review of Resident 85's clinical record revealed she had a weight measure of 202.8 pounds on October 7, 2024, that reflected a significant weight loss from the previous weight measure. [...]

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to provide the resident and/or resident representative with a summary of the baseline care plan in a format and location developed by the facility for one of three residents reviewed for care planning (Resident 72).

Inspectors wroteBased on facility policy review, observations, clinical record review, as well as resident, resident representative, and staff interviews, it was determined that the facility failed to invite a resident and/or their representative to care plan meetings and failed to have required members of the interdisciplinary team participate in the care plan conference for two of 30 residents reviewed (Residents 14 and 58); and failed to review and revise the resident plan of care for one of 30 residents reviewed (Resident 49).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure a physician's discharge summary was completed for two of four residents reviewed for discharge (Residents 57 and 137).

Inspectors wroteBased on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of 30 residents reviewed (Residents 61 and 105).

Inspectors wroteBased on observation, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of 33 residents reviewed (Residents 79).

Inspectors wroteBased on observation, clinical record review, facility document review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive adequate supervision and assessment after an accident for one of five residents reviewed for falls (Resident 72).

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one resident reviewed for dialysis (Resident 54). Findings Include: Review of facility policy, titled Hemodialysis Care Policy, with an effective date of June 16, 2017, and a last reviewed date of April 9, 2024, revealed the Pre-dialysis process: Document assessment in the Dialysis Communication Tool. Assessment includes vital signs, pre-treatment weight (unless performed at dialysis), medications administered before treatment, time of last meal, fluid intake, any additional information. Print the tool and send with resident to dialysis (if off-site). [...]

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to provide documentation of actual disposition of medications and method of disposition for one of three residents reviewed (Resident 136).

Inspectors wroteBased on observations, review of facility policy, and interviews, it was determined that the facility failed to clean and store dishes in accordance with professional standards for food safety in the dish machine area in the kitchen area for one of one meal observed.

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of three residents reviewed (Residents 1 and 2). Findings Include: Review of facility policy, titled Neurological Checks Policy, revised July 9, 2024, revealed Neurological checks are indicated to monitor for potential irregularities in neurological status in the event of known or unknown head trauma as the result of a resident event, change in resident condition, or physician's order. When triggered by a qualifying event, a neurological check observation in the electronic health record will be initiated to conduct periodic checks and to document the results of the neurological checks. [...]

Inspectors wroteBased on clinical record review, facility document review, and staff interview, it was determined that the facility failed to ensure a system of recording the disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and to ensure an account of all controlled drugs is maintained and periodically reconciled for prompt identification of loss or potential diversion of controlled substance for one of three residents reviewed (Resident 1).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for three of three medication carts observed (B Hall, C Hall, and G Hall medication carts). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications and Biologicals, last revised August 1, 2024, revealed it stated, 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, .3. Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medication and biologicals are stored .11. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for six of 11 resident records reviewed (Residents 20, 34, 76, 81, 97, and 184).

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed-hold policy at the time of transfer for seven of 11 resident records reviewed (Residents 20, 34, 59, 76, 81, 97, and 184). Findings Include: Review of facility policy, Bed Hold Letter, revised September 26, 2020, read, in part, Business Office or designee will complete the Medicaid Bed Hold Letter and sent to the appropriate parties, certified/return receipt requested or provided directly to the responsible party, and a copy will be maintained in the Resident's financial file. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for two of 26 residents reviewed (Residents 77 and 87). Findings Include: Review of Resident 77's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), delusional disorder (type of psychotic disorder; a delusion is an unshakable belief in something that is untrue), and depression. Review of Resident 77's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (ARD-last day of the assessment period) of September 2, 2023, revealed in Section N. Medications at subsection N0450. [...]

Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for seven of 29 residents reviewed (Resident 20, 36, 42, 59, 77, 81, and 97).

Inspectors wroteBased on observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 29 residents reviewed (Resident 97).

Inspectors wroteBased on facility policy review, observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of four residents reviewed for respiratory care/oxygen services (Residents 7, 34, 41, and 45).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of 26 resident's reviewed (Resident 87).

Inspectors wroteBased on review of facility policy, employee files review, and staff interviews, it was determined that the facility failed to ensure that nursing staff with the appropriate competencies and skills sets to provide nursing and related services was provided to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three of three nursing staff reviewed (Employees 6, 12, and 13).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to perform a FBI criminal history background check prior to hire for one of five personnel files reviewed (Employee 6). Findings Include: Review of facility policy, titled Pennsylvania Resident Abuse, with a last revised date of August 30, 3023, revealed, in part, 1. a. The facility will do the following prior to hiring a new employee: .iv. Conduct a criminal background check in accordance with State law and Facility policy. Review of facility policy, titled Employee Background Screening Policy, with a last revised date of February 16, 2024, revealed, in part, Part 2: Criminal Background Check A. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop a discharge summary to anticipate resident needs for one of three residents reviewed (Resident 132). Findings Include: Review of Resident 132's clinical record revealed diagnoses that included hypertension (high blood pressure) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Continued review of Resident 132's clinical record revealed he was discharged home with his daughter on February 10, 2024. [...]

Inspectors wroteBased on clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 26 residents reviewed (Residents 41 and 92).

Inspectors wroteBased on review of facility policy, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for one of one resident reviewed for dialysis (Resident 59).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of medications for two of three closed records reviewed (Residents 132 and 133).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts (Cart A); and failed to properly label drugs in one of two medication rooms observed (Station 1). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with a last revised date of August 7, 2023, revealed, in part, 4. Facility should ensure that medications and biologicals that:(1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; [...]

Inspectors wroteBased on policy review, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one walk-in refrigerator in the kitchen and one of three nourishment pantries on the nursing units.

Inspectors wroteBased on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure care and services were provided including skin and wound assessments in accordance with professional standards of practice, resulting in development and deterioration of wounds and subsequent transfer to the hospital with a diagnosis of wound infection and sepsis, requiring an above the knee amputation for one of three residents reviewed (Resident 3).

Inspectors wroteBased on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, and failed to assess residents to identify pressure ulcers for one of four residents reviewed (Resident 3), resulting in the development of pressure ulcers.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 30 residents reviewed and failed to provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident ' s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary for four of four resident's reviewed (Residents 1, 3, 4 and 5).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to develop a comprehensive person centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for six of six records reviewed (Residents 1, 2, 3, 5, 6, and 7).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure each resident the right to personal privacy and confidentiality of his/her personal and medical records for one of one resident reviewed (Resident 2). Findings Include: Review of the facility policy, titled Release of Information, with a last revision date of December 12, 2023, revealed It is the responsibility of the Facility to protect the privileged information contained within the record. Review of Resident 1 clinical record revealed that they were in the process of applying for Medical Assistance. Based on document review, it was revealed that Resident 1's responsible party was sent a Medical Assistance application with another reident's information on it. [...]

Inspectors wroteBased on facility policy review, clinical record review, document review, and staff interviews, it was determined the facility failed to ensure that the hospice services were established in a timely manner for one of one residents receiving Hospice services reviewed (Resident 3).