River's Bend Health Services

Inspectors wroteBased on interview, record review, and policy review, the facility did not report allegations of abuse in a timely manner for 5 residents (R) (R2, R3, R4, R5, and R6) of 10 sampled residents. On 1/27/26, staff witnessed (Certified Nursing Assistant)5 display rude, loud, and rough behavior toward R6. Interviews determined R2, R3, R4, and R5 experienced similar behavior by CNA5 that day. The allegations of abuse were not reported in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-C) of 8 employees reviewed for caregiver background checks. The facility did not complete a thorough background check for CNA-C prior to hire.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of neglect to the State Agency (SA) for 1 resident (R) (R1) of 7 sampled residents. An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. NHA-A did not report the allegation of neglect to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of neglect for 1 resident (R) (R1) of 7 sampled residents. An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. The facility did not thoroughly investigate the allegation of negelct.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R48) of 19 sampled residents had the right to make healthcare decisions in accordance with applicable law. R48 was admitted to the facility without an activated Power of Attorney for Healthcare (POAHC) and was not provided the right to sign consent for admission or an advance directive that indicated R48 did not wish to be resuscitated (DNR). In addition, R48's Power of Attorney (POA) paperwork did not allow R48's designated health care agent to admit R48 to long-term care for longer than a short-term stay.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R3 and R41) of 19 sampled residents received staff assistance as needed to complete activities of daily living (ADLs). R3 did not receive weekly showers as scheduled. R41 did not receive weekly showers as scheduled.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a pneumococcal vaccine was offered for 1 resident (R) (R5) of 5 sampled residents. R5 was not offered the PCV20 vaccine per the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a COVID-19 vaccine was offered for 1 resident (R) (R5) of 5 sampled residents. R5 was not offered a COVID-19 vaccine per the facility's policy.

Inspectors wroteBased on staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R1) of 1 sampled resident. R1 reported an allegation of staff-to-resident abuse. The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 1 sampled resident. R1 reported an allegation of staff-to-resident abuse. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R3) of 3 sampled residents. The facility did not ensure dirt, debris, food, and spills on R3's floor were cleaned in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of a fall for 1 resident (R) (R2) of 4 sampled residents. R2 had a witnessed fall on 12/4/24. R2's POAHC (POAHC-G) was not notified of the fall in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not individualize and revise the comprehensive plan of care for 1 resident (R) (R2) of 4 sampled residents. R2's plan of care did not indicate R2's activities of daily living (ADL) needs. In addition, R2's plan of care was not updated after a fall on 12/4/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with the facility's policy. One of 5 medication carts was unlocked and unattended. and 3 of 5 medication carts and 2 of 3 medication storage rooms contained expired medication and medical supplies. In addition, the facility did not ensure an inhaler was labeled in accordance with the manufacturer's recommendations for 1 Resident (R) (R45) of 6 sampled residents observed during medication administration. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. On 8/26/24, a medication cart on the 100 wing was unlocked and unattended. On 8/26/24, medication carts and medication storage rooms contained expired medications and medical supplies. On 8/27/24, staff administered an undated inhaler to R45.

Inspectors wroteBased on resident and staff interview, the facility did not consistently provide or offer a substantial evening snack to residents. The timeframe from the supper meal to the breakfast meal was greater than 14 hours. This had the potential to affect more than 4 of the 69 residents residing in the facility. A substantial snack was not regularly offered to residents which created a gap of more than 14 hours between the supper and breakfast meals.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. The 300 unit refrigerator was not in a clean condition and contained items that were not labeled or dated and were expired. In addition, the refrigerator temperature log was not completed and items in the nourishment room were not labeled or dated. Milk and juice were not held at a cold temperature during lunch service.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. This had the potential to affect more than 4 of the 69 residents residing in the facility. R36 was on enhanced barrier precautions (EBP) due to a permacath. On 8/27/24, staff did not wear personal protective equipment (PPE) during high-contact resident care. In addition, there was not a sign posted near R36's room that indicated R36 was on EBP. On 8/27/24, staff transported unbagged soiled linens in a resident hallway.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a physician's order was obtained and a self-administration of medication assessment was completed for 1 Resident (R) (R68) of 7 sampled residents. On 8/26/24, Registered Nurse (RN)-K left medication at R68's bedside for R68 to self-administer. R68 did not have a physician's order or self-administration of medication assessment that indicated R68 could safely and accurately self-administer medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R223 and R173) of 4 sampled residents signed and received copies of the Notice of Medicare Non-Coverage (NOMNC) form and/or Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which are used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions. The facility did not provide an ABN form (a document that explains financial liability, including the facility's daily rate for services) to R223 when R223's Medicare benefits ended on 2/25/23 and R223 remained in the facility. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R223, R20, and R70) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R223 was transferred to the hospital on 1/26/23. Neither R223 or R223's emergency contact were provided with a written transfer notice for R223's hospital transfer. R20 was transferred to the hospital on 5/17/24. Neither R20 or R20's emergency contact were provided with a written transfer notice for R20's hospital transfer. R70 was transferred to the hospital on 5/23/24. Neither R70 or R70's emergency contact were provided with a written transfer notice for R70's hospital transfer.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R223, R20, and R70) of 3 residents reviewed for hospitalization received notified of the facility's bed hold policy when transferred to the hospital. R223 was transferred to the hospital on 1/26/23. Neither R223 or R223's emergency contact were provided with a bed hold notification for R223's hospital transfer. R20 was transferred to the hospital on 5/17/24 and 7/31/24. Neither R20 or R20's emergency contact were provided with a bed hold notification for R20's hospital transfers. R70 was transferred to the hospital on 5/23/24. Neither R70 or R70's emergency contact were provided with a bed hold notification for R70's hospital transfer.

Inspectors wrote2. From 8/26/24 to 8/28/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including morbid obesity, mild intermittent asthma, type 2 diabetes, and edema. R21's MDS assessment, dated 6/11/24, had a BIMS score of 13 out of 15 which indicated R21 had intact cognition. R21 had orders for Lasix (a diuretic medication) for edema and daily weight monitoring. R21's nutrition care plan, with a revision date of 6/8/21, contained an intervention to review weights and notify the Medical Doctor (MD) and responsible party of significant weight changes. On 8/26/24 at 9:55 AM, Surveyor interviewed R21 who stated R21 had concerns related to dining and nutrition. R21's medical record indicated R21 had physician orders for daily weight monitoring as of 3/12/23 and was prescribed 60 mg (milligrams) of Lasix in the AM. [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not maintain continuous positive airway pressure (CPAP)/biphasic positive airway pressure (BiPAP) equipment per the facility policy and manufacturer's recommendations for 1 Resident (R) (R21) of 1 sampled resident. R21 had a CPAP/BiPAP machine for obstructive sleep apnea. R21 did not have a cleaning schedule for the machine/equipment or instructions for filling the humidifying chamber.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R1) of 5 sampled residents was free from a significant medication error. R1 had a physician order, dated [DATE], to hold R1's 125 microgram (mcg) digoxin tablet (administered once daily for heart failure) and repeat laboratory blood work due to an elevated digoxin level. The order did not contain a duration or time frame. The order was not transcribed or clarified and R1 received 125 mcg of digoxin daily from [DATE] through [DATE].

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 62 residents residing in the facility. Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Kitchen preparation areas were not clean. Warewashing temperatures were not monitored to ensure manufacturer's minimum wash and rinse temperatures were achieved to prevent the spread of foodborne illness. Food holding temperatures were not monitored or documented.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide a sanitary environment to help prevent the transmission of communicable disease and infection for Resident (R) (R57) and multiple other residents in the facility. Multiple residents were not offered hand hygiene prior to meal service in the dining room on 7/24/23 and 7/25/23. Multiple residents were not offered hand hygiene prior to meal service on the 100 unit on 7/24/23. Certified Nursing Assistant (CNA)-H did not perform hand hygiene or change soiled gloves during the provision of care for R57. In addition, R57's Foley catheter drainage bag was observed on the floor without a barrier between the bag and the floor.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Power of Attorney for Health Care (POAHC) document was obtained or offered to create (in the absence of an existing document) for 2 Residents (R) (R48 and R50) of 17 sampled residents. R48 was admitted to the facility in February of 2022. R48 did not have a POAHC document in R48's medical record. R50 was admitted to the facility in March of 2022. R50 did not have a POAHC document in R50's medical record.