River Bend Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at River Bend Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF580Jun 13, 2025

  Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician when a resident (Resident #69) reported she had fallen and was experiencing acute pain after the reported fall. Due to ineffective communication between staff a medical provider was not notified of the fall until the following day which delayed x-rays, medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. […]

• Actual harm, isolatedF600Jun 13, 2025

  Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's right to be free from neglect after Resident #69 had a fall during a staff assisted transfer on 6/27/25 (Saturday). The Nursing Supervisor went to assess Resident #69 after a nurse aide told her the resident reported she had fallen and was having pain in her right knee. Resident #69 told the Nursing Supervisor she was in pain and said her knee was hurting. The Nursing Supervisor did not report the fall or pain to a medical provider. Resident #69 spoke Spanish and there was no evidence that staff utilized an interpreter to determine what had occurred or her level of pain. […]

• Actual harm, isolatedF684Jun 13, 2025

  Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to recognize a resident experienced a fall during a staff transfer that resulted in acute pain to her right knee/ leg on 6/7/25. The nurse aides did not report Resident #69 falling to a nurse and Resident #69 was not assessed by a nurse or medical provider before she was moved and transferred back to her bed. In addition, nursing staff did not complete or document comprehensive assessments of the resident and did not recognize Resident #69 needed medical evaluation and treatment. […]

• Actual harm, isolatedF689Jun 13, 2025

  Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a resident who reported she fell during a transfer with staff. Resident #69 stated she was assisted off the toilet by two staff members, had difficulty holding on to the assist rail because her right hand did not work, fell on her right knee and had pain her in right knee immediately. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. […]

• Actual harm, isolatedF697Jun 13, 2025

  Based on record review, and staff, resident, family, and Nurse Practitioner (NP) interviews, the facility failed to provide effective pain management for a resident who had acute pain after a reported fall on 6/27/25 (Saturday). Resident #69 spoke Spanish and reported through an interpreter two days after the fall that she fell on her right knee during an assisted transfer and had pain immediately which she rated at a pain scale of 9 (Pain scale of 0 is no pain and pain scale of 10 is the worst pain). Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time ibuprofen (a nonsteroidal anti-inflammatory drug) was ordered for pain. […]