River Bluff Nursing Home

In the surveyor’s words

From the most serious findings on record at River Bluff Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF692Jun 24, 2026

  Based on observation, interview and record review, the facility failed to assess and monitor a resident after a significant weight loss and failed to ensure a resident's nutritional supplements were implemented after a significant weight loss. This failure resulted in the residents having continued weight loss. This applies to 2 residents (R77, R67) reviewed for weight loss in a sample of 36. The findings include: 1. R77's Face Sheet printed on 6/24/26 showed R77 was initially admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, and type 2 diabetes. […]

• Actual harm, isolatedF689Feb 5, 2026

  Based on interview and record review the facility failed to care for and transfer a resident in a safe manner to prevent a resident injury for 1 of 3 residents (R1) reviewed for resident safety and supervision in the sample of 3. This failure resulted in R1 falling while being cared for by facility staff. R1 was hospitalized due to the fall where he was diagnosed with an unstable vertebral (spine) fracture. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards in his wheelchair, just after he was transferred into the chair, by facility staff. R1 began complaining of pain to his back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. […]

• Actual harm, isolatedF697Feb 5, 2026

  Based on interview and record review the facility failed to effectively manage and treat a resident's pain after the resident fell in the facility. The facility failed to notify the attending physician/nurse practitioner of this resident's worsening pain. These failures apply to 1 of 3 residents (R1) reviewed for pain management in the sample of 3. These failures resulted in R1 experiencing worsening, severe lower back pain caused by a thoracic vertebral (spine) fracture he sustained when he fell in the facility. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards onto the floor while seated in his wheelchair as he was being cared for by staff. R1 fell directly onto his back. R1 began complaining of pain to his lower back on 2/1/26. […]

• Actual harm, isolatedF689May 14, 2024

  Based on interview and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling and fracturing her left hip. The findings include: R1's Face Sheet (Admission Record) showed an admitted [DATE] with diagnoses to include dementia, depression, and left femur fracture (admitting diagnosis). R1's 3/19/24 Significant Change Assessment Minimum Data Set (MDS) showed severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. The MDS showed she was dependent upon staff for transfers from bed to chair transfers and she had not walked. […]

• Actual harm, isolatedF686Mar 7, 2024

  Based on observation, interview, and record review the facility failed to identify a pressure injury prior to becoming a deep tissue injury, failed to obtain treatment orders for a new pressure injury, and failed to implement pressure relieving interventions for a resident with multiple pressure injuries for 1 of 7 residents (R117) reviewed for pressure injury in the sample of 31. These failures resulted in R117 suffering a deep tissue injury to the right heel, a Stage 2 pressure injury to the right buttock, and a Stage 1 to the left lateral ankle. […]