Riverbend Post Acute Rehabilitation

Inspectors wroteBased on interviews, record review, and observation, the facility failed to ensure a safe, clean home-like environment for the residents. Findings Included:- During an observation on 05/05/26 at 08:10 AM on the second floor of the facility, the ice room revealed a dirty towel underneath the door into the room. A tray of clean cups was next to a tray on the counter with multiple cups, plates, and food from a previous meal, and dirty towels were on the sink next to the tray of clean cups. The bottom of the cabinet underneath the handwashing sink was sunken and had multiple wet & soiled towels and a black substance on the floor of this cabinet. The cabinet doors had water damage at the top of the door. The sink was soiled with food debris. A fan full of dust on the screen and blades was blowing and oscillating and blew directly onto the tray of clean cups on the counter. [...]

Inspectors wroteBased on interviews, record reviews, and observation, the facility staff failed to implement adequate infection control practices related to lack of hand hygiene, cleaning of shared equipment, and sanitary storage of respiratory equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R) 76 was assessed for the ability to safely self-administer oral medications before staff left medications in a medication cup in the resident's room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify the advanced directive (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves) displayed in Resident (R) 16's clinical record accurately reflected her advanced directives for Do Not Resuscitate Directive (DNR- a legal document or order that means the person does not desire resuscitative measures in the event of cardiac arrest).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents were free from all forms of abuse when Resident (R) 132 grabbed R127 by the neck on 04/13/26.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure Resident (R) 122 received the assistance he needed with eating. Findings Included:- R122's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis (muscular weakness of one half of the body) with cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hypertension (HTN-elevated blood pressure, and obesity, need for assistance with personal care, and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Resident (R) 31 the necessary activities of daily living (ADL) cares including hygiene assistance with cleaning his fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent activities for Resident (R) 10.

Inspectors wroteThe facility census totaled 126 residents. Based on observation, interview, and record review, the facility failed to ensure a safe environment free from accidents and hazards when staff left a cognitively impaired resident by herself in the shower, resulting in a fall with injury. (Resident 127)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when staff failed to properly secure a medication cart.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a functional call light system for Resident (R) 111 while he was on or in bed, in order to convey his needs to staff.

Inspectors wroteBased on interviews, record reviews, and observation, the facility staff failed to ensure a safe, sanitary, and functional environment on one of the stairwells.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 25 residents, with seven reviewed for reasonable accommodation of needs related to call lights and wheelchair foot pedals. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 84 had a call light he could functionally activate for staff assistance and ensure R96, R47, and R81 had foot pedals on their wheelchairs while being pushed. The facility additionally failed to provide R10's sensory hand item. Findings Included:- On 11/18/25 at 08:55 AM, R84 (severely cognitively impaired resident) sat in his bed with his bedside table over him. He stated he was done with his breakfast tray and needed staff to assist him. R84's call light was placed inside the dresser next to his bed and out of his reach. R84's low air-loss mattress was set to 200 pounds (lbs). [...]

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents, with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. The facility additionally failed to follow Resident (R) 61 and R67's implemented fall interventions per their care plans. Findings Included: - On 11/17/25 at 07:10 AM, a walkthrough was completed in the facility's secured 2nd floor, and the following was observed: An inspection of an unsecured linen closet next to the nurse's station next to the elevator, revealed a container of purple disinfectant wipes on top of the room's counter. [...]

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 67 had a physician's order and was assessed for the ability to safely self-administer an inhaler medication.

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed, due to her posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), to provide only female caregivers that were requested, for Resident (R) 82.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 25 residents, with one resident reviewed for the discharge process. Based on record review and interviews, the facility failed to provide a final summary of Resident (R) 128's status at discharge.

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for two residents, Resident (R) 67 for smoking, and for R82 for posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress).

Inspectors wroteThe facility identified a census of 123 residents. The sample included 25 residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 10 with showers as scheduled. Findings Included:- R10's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cerebrovascular accident (CVA: [...]

Inspectors wroteThe facility identified a census of 123 residents. The sample included 25 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 84's pressure-reducing interventions were implemented correctly when R84's low air-loss mattress (specialized air mattress used to prevent pressure related wounds) was not set within his current weight range. The facility additionally failed to float R10's heels as directed by wound treatment. [...]

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 82 received trauma-informed care to eliminate or mitigate triggers that may cause traumatization related to a diagnosis of post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress).

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents, with seven residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to hold Midodrine (a medication for low blood pressure) for Resident (R) 26 and R97 and failed to hold insulin (controls the amount of sugar in the blood by moving into the cells) as the physician ordered for R67.

Inspectors wroteThe facility had a census of 123 residents. The sample included 25 residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, interview, and record review, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 34, which included a plan of care and a description of the services provided, which included visit frequency for certified nurse aides, chaplain, medications, and medical equipment provided.

Inspectors wrote- R5's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hyperthyroidism (a condition characterized by hyperactivity of the thyroid gland), muscle weakness, and contracture right ankle. R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R5 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS recorded he required moderate staff assistance with transfers and activities of daily living (ADL). [...]

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 35s, R5s, R88s, R17s, R59s, R13s, R6s, R110s, R10s, R16s, and R64s insulin (a hormone that lowers the level of glucose in the blood) flex pens and vials with the opened date and when expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 5 who had a diabetic neuropathy ulcer (wound on the skin, typically the feet, that develops due to nerve damage (neuropathy) and decreased sensation caused by diabetes) on his right great toe and right second toe. This placed the resident at risk for possible exposure to infection.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include resident-centered functional abilities for Resident (R) 41 and R69. This placed the residents at risk for unmet care needs.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents, with one reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide consistent bathing and grooming for one resident, Resident (R) 43. This placed the resident at risk for complications related to poor hygiene and impaired dignity.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents, with four reviewed for dementia (a progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to address one resident, Resident (R) 36's dementia care needs, when R36 continued to go through staff members' belongings that were kept at the nurse's station. This placed R36 at risk for decreased quality of life and accidents.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician-ordered parameters for Resident (R) 13. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 113 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to prevent a medication administration error for Resident (R) 13, whose blood pressure was out of the physician's ordered parameters, and she received her blood pressure medication. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 112 residents. The sample included 23 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure areas containing hazardous materials out of reach of seven cognitively impaired /independently mobile residents in the secured unit. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - The facility identified Residents (R) 14, R45, R47, R63, R103, R105, and R110 were cognitively impaired residents within the secured 2nd-floor. On 01/21/25 at 07:30 AM, an inspection of the 2nd-floor nursing station revealed an alcohol-based disinfectant container of alcohol-based disinfectant wipes on the outside counter of the nurse's station. [...]

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 32's right to be treated with respect, and dignity when her privacy curtain or door was closed when she was uncovered and exposed from the waist down. This deficient practice placed R32 at risk for negative psychosocial outcomes and decreased dignity.

Inspectors wroteThe facility had a census of 112 residents. The sample included 23 residents with five reviewed for accommodation of needs related assistive devices. Based on observation, record review, and interview the facility failed to utilize wheelchair foot pedals for Resident (R) 14, R47, and R82. This placed the resident at risk for preventable accidents and injuries. Findings Included: - On 01/21/25 at 07:45 AM, R14 (a severely cognitively impaired resident) was wheeled to the small dining room for breakfast. Her wheelchair had no foot pedals and her feet slid on the ground as she was pushed. On 01/21/25 at 09:20 AM, R14 was pushed by staff from the second-floor small dining room to her room. R14's wheelchair lacked foot pedals as her feet slid on the ground multiple times while being pushed to her room. [...]

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 13's physician with refused daily weights. This deficient practice placed R13 at risk for unmet needs.

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure reducing heel supportive device was in place for Resident (R) 51 who had a pressure-related injury on his right buttocks. This deficient practice placed R51 at risk for complications related to further skin breakdown.

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with five residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)26's orthotic (support or brace for limbs) was in place. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Findings Included: [...]

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 27's continuous positive airway pressure (CPAP - ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This deficient practice placed R27 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 51 had a documented risk assessment for the use of side rails, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R51 at risk for uninformed decision and impaired safety related to the risks associated with the use of side rails.

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with four residents reviewed for frequency of physician visits. Based on observation, record review, and interviews, the facility failed to ensure the attending physician conducted the required visits for Resident (R) 51. This deficient practice placed R51 at risk of unrealized changes in condition leading to unnecessary complications in his wellbeing.

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents with four reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R) 14 to promote her highest practicable level of well-being. This deficient practice placed R14 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of dementia, cognitive-communication disorder, repeated falls, muscle weakness, need for assistance with personal care, and scoliosis (curvature of the spine). [...]

Inspectors wroteThe facility identified a census of 112 residents. The sample included 23 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 27's continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) mask was stored appropriately when not in use. The facility failed to ensure R315's tracheal (a surgical procedure that creates an open in the neck and windpipe to help a person breathe) tubing was stored appropriately when not in use. The facility failed to ensure R48's nasal cannula (a hollow tube device used to provide supplemental oxygen) was appropriately stored when not in use. These deficient practices placed R27, R315, and R48 at risk of infection development and possible respiratory complications.

Inspectors wroteThe facility identified a census of 112 residents. The sample included three residents reviewed for neglect. The facility failed to ensure Resident (R) 1 remained free from neglect when staff failed to ensure R1 received adequate care and services required to prevent harm or injury to her physical and psychosocial wellbeing. R1, who had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) and an indwelling urinary catheter (a flexible tube inserted through into the bladder to drain urine), was legally blind and dependent on staff for hygiene was outside without staff for extended periods of time with no brief or underwear, and with urinary catheter tubing exposed. [...]

Inspectors wroteThe facility identified a census of 110 residents. The sample included three residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented nursing services consistent with standards of care when staff failed to follow a physician's order to notify emergency medical services (EMS) when Resident (R) 1 had chest pain and required a second dose of nitroglycerine (NTG-medication used to relieve an angina attack that is already occurring) and failed to assess vital signs to monitor resident status. This deficient practice placed R1 at risk for delayed emergency care and complications related to the use of NTG.