River's Bend Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at River's Bend Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 1, 2026

  Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1) who displayed aggressive behavior and physically pushed another resident (Resident 2), causing a fall with a hip fracture. This failure resulted in an Immediate Jeopardy situation.Findings include: Review of the facility policy, titled Resident Observation Policy, with a last revised date of May 28, 2021, and a last review date of January 28, 2026, revealed, in part, Procedure: A. […]

• Immediate jeopardy, isolatedF689Jul 8, 2025

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found by EMS staff laying on the ground near the public road, which runs in front of the facility, with abrasions to his hand and foot. […]

• Actual harm, isolatedF689Mar 12, 2026

  Based on facility policy review, clinical record review, review of select facility documentation, observation, and staff interviews, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards; and failed to provide adequate supervision and assistance devices to prevent accidents for two of 32 residents reviewed (Residents 10 and 51), which resulted in actual harm for Resident 51 as evidenced by scapholunate widening, suggesting a ligamentous injury.Findings include: Review of facility policy, titled Fall Prevention and Management Policy last reviewed July 7, 2025, read, in part, Fall risk assessments are to be completed at admission, quarterly, and as needed. […]

• Actual harm, isolatedF791Mar 12, 2026

  Based on policy review, resident and staff interviews, observation, and record review, the facility failed to assist residents in obtaining timely dental services to obtain dentures for one of three residents reviewed (Resident 3), resulting in phyco-social harm and weight loss. Findings include:Review of the facility policy, titled Dental Services Policy with a last review date of January 21, 2026, revealed 12. Facility will promptly, within 3 days, refer residents with lost or damaged dentures for dental services.Review of Resident 3's clinical record revealed diagnosis that included dementia (loss of cognitive functioning that interferes with daily life) and chronic kidney disease (a long- term condition in which the kidneys gradually lose their ability to function properly).During an… […]

• Actual harm, isolatedF684Jan 2, 2024

  Based on facility policy review, clinical record review, hospital record review and staff interviews, it was determined that the facility failed to ensure care and services were provided including skin and wound assessments in accordance with professional standards of practice, resulting in development and deterioration of wounds and subsequent transfer to the hospital with a diagnosis of wound infection and sepsis, requiring an above the knee amputation for one of three residents reviewed (Resident 3). Findings include: Review of facility policy, titled Skin and Wound Care Best Practices, with a last revised date of June 10, 2022, revealed, in part, the following: CNA's (Certified Nurse Aide) fill in shower sheet with each bath/shower and review with licensed nurse . […]