River Bend Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 16, 2022

  Based on interview and record review, the facility failed to prevent sexual abuse from occurring when a female staff member had sexual relations with a male resident. The staff member reported the sexual occurrences and locations to the Administrator. (Resident F, Staff Member 1). This Immediate Jeopardy began on May 21, 2022, when the facility failed to prevent sexual abuse from occurring when a female staff member had sexual relations with a male resident. The Administrator, DON (Director of Nursing), Regional Administrator, and Regional Nurse were notified of the Immediate Jeopardy on June 14, 2022 at 1:20 P.M. Central time. […]

• Actual harm, isolatedF689Sep 10, 2024

  Based on observation, interview, and record review, the facility failed to ensure adequate safety measures were in place for safe transport for 1 of 3 residents reviewed for accidents. This deficient practice resulted in Resident B obtaining injuries that resulted in medical intervention and fractures. (Resident B) Finding includes: On 9/9/24 at 10:30 a.m., two state reportable's for Resident B were reviewed and included, but were not limited to: State Reportable 1 Incident date: 8/28/24 Incident time: 2:01 p.m. Description added: 8/29/2024 Resident was out to an appointment. As the driver was taking her into the appointment the resident's foot caught beneath the wheelchair and twisted. […]

• No harm, potential for more than minimal, patternF761Jan 30, 2026

  Based on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 4 of 4 medication carts observed. (North Hall Medication Cart, South Hall Medication Cart, Stocker 1 Medication Cart, Insulin Administration Cart, Resident W, Resident 13, Resident M) Findings include: Findings include:1.On 1/22/26 at 8:59 A.M., during a random observation of the North Hall Medication the following was observed:1/2 small round white pill2 medium round white pills1/2 large round white pill1 white capsule with the numbers (#) A-4691 large size stretch band2. […]

• No harm, potential for more than minimal, patternF842Jan 30, 2026

  Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 3 of 5 residents reviewed for hospitalizations, 1 of 1 residents reviewed for tube feeding, and 1 of 1 residents reviewed for urinary catheter. (Resident D, Resident C, Resident Y, Resident M, and Resident R)Findings include: 1. On 1/23/26 at 2:46 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis and quadriplegia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/20/25, indicated that Resident C was cognitively intact and was dependent on staff (staff does all the work) for all Activities of Daily Living (ADLs). […]

• No harm, potential for more than minimal, patternF921Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during four random observations. Odors were present in the facility. (Main lobby, Stocker Unit 1, Stocker Unit 2, Conference Room) Findings include: 1. On 1/22/26 at 9:40 A.M., The hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. 2. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent smell consistent with sewer gas. 3. […]