River Bend Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF755Oct 24, 2025

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents (Resident #1) reviewed for drug administration. Resident #1 was administered 5 tablets of Carbidopa-Levodopa 25-100mg on 10/21/2025 at noon. The physician order was Carbidopa-Levodopa 25-100mg give 1.5 tablets at 11 a.m. Resident #1 was transferred to the hospital on [DATE] for altered mental status. The noncompliance was identified as PNC. […]

• Actual harm, isolatedF689May 1, 2024

  Based on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed who required having leg rests and foot pedals on their wheel chairs for quality of care. The facility failed to ensure Resident #1 had her leg rests and foot pedals on her wheelchair when she went to an appointment on 04/17/2024 and her unsupported right foot slid off from her other foot which was supporting it and was caught under the moving wheelchair pushed by the Maintenance Director and resulted in a fractured femur (thigh and upper hind limb bone, longest strongest bone in the body) . […]

• Actual harm, isolatedF760Feb 17, 2023

  Based on interview and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 5 residents (Resident #3) reviewed for significant medication errors in that: LVN D mistakenly administered Resident #4's evening medications to Resident #3 on 2/13/23. Resident #3 was transferred to a local hospital for observation the next day, 2/14/23. This deficient practice could affect residents who receive medication from the facility and place them at risk for adverse reactions, decline, and hospitalization . […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure 4 pitchers of beverages were covered and dated when prepared. 2. The facility failed to ensure box of powder sugar was dated with open date. 3. The facility failed to ensure opened bag of spaghetti was properly sealed with an opened date. 4. The facility failed to ensure opened bag of elbow noodles was dated with an opened date. 5. The facility failed to ensure food temperatures were taken in a sanitary fashion. 6. […]

• No harm, potential for more than minimal, widespreadF812Oct 27, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. The top of the dish machine was soiled with a sand-like substance. 2. The door of the freezer near the dish room was soiled. 3. Three containers of ground meat wrapped in plastic were thawing on a countertop. 4. Powdered milk container in the pantry was labeled milk and also labeled rice. 5. The containers of loose sugar and flour had lids that were not secure. 6. The large walk-in refrigerator had debris in the floor and contained: -two thermometers with different temperature readings -a container of heads of lettuce with multiple brown spots. […]