River's Bend Retirement Community

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Dec 8, 2021

  Based on observation, interview, record review, facility policy review and review of the Centers for Disease Control (CDC) documentation, it was determined the facility failed to maintain its infection control and prevention program in accordance with CDC guidelines for COVID-19. CDC guidelines stated for counties with substantial or high transmission rates of COVID-19, staff were to wear eye protection when caring for patients (residents). The facility failed to ensure its staff wore the appropriate eye protection during all patient encounters as indicated in the CDC guidance. […]

• No harm, potential for more than minimal, isolatedF761Nov 17, 2025

  Based on observation, interview, record review and facility policy review, the facility failed to ensure drugs and biologicals were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable, for 2 of 3 medication carts reviewed and for a total of 6 out of 13 sampled residents (Resident (R)5, R8, R17, R18, R30, and R39).The findings include: Review of the facility's policy titled, Storage of Medications Policy, undated, revealed it was the facility's policy to not use discontinued, outdated, or deteriorated drugs or biologicals and all such drugs should be returned to the dispensing pharmacy or destroyed. Further review of the policy revealed nursing staff were responsible for maintaining medication storage. […]

• No harm, potential for more than minimal, isolatedF656Sep 8, 2023

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for one (1) of six (6) sampled residents (Resident #25). Observations and record review revealed Resident #25 had an indwelling urinary catheter, however, there was no documented evidence a care plan had been implemented to include catheter care. The findings include: Review of the facility's policy, Care Plans, dated 09/23/2022, revealed, Plans of Care were developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident. […]

• No harm, potential for more than minimal, isolatedF689Sep 8, 2023

  Based on observation, interview, record review, facility policy review and review of the facility's investigation, it was determined the facility failed to ensure one (1) of six (6) sampled residents received adequate supervision to prevent elopement from the facility. Record review revealed Resident #18 exited the facility through the front door as an employee was leaving for lunch on 07/07/2023. Resident #18 exited the facility on 07/07/2023 at approximately 1:30 PM. After the incident, the Wander Risk Assessment was completed again at which time the resident scored six to eleven (6-11) points, which indicated the resident had a moderate risk and the need for an Elopement Care Plan which was initiated with interventions put into place. […]

• No harm, potential for more than minimal, isolatedF880Sep 8, 2023

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of six (6) sampled residents (Resident #7 and Resident #25). Observations of Resident #7 and #25, on 09/06/2023 and 09/07/2023, revealed the resident's catheter bags were not properly secured and were touching the floor. […]