Riverbank Post-Acute

In the surveyor’s words

From the most serious findings on record at Riverbank Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 15, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the safety and well-being for 1 (Resident #37) of 1 sampled resident reviewed for smoking. Specifically, the facility failed to failed to implement further interventions to ensure the safety of the resident and others when the resident continued to smoke after there was indication that the resident agreed to smoking cessation and failed to implement interventions when the resident refused to turn in their lighter. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. […]

• Actual harm, isolatedF656Jan 17, 2024

  Based on interview and record review, the facility failed to develop and implement a person-centered care plan that included interventions for one of four sampled residents (Resident 1) to prevent choking. There was no care plan developed or implemented for Resident 1's known behavior of rapidly stuffing food in her mouth. On [DATE], Resident 1 had a choking incident and was hospitalized . This failure resulted in an avoidable second choking incident resulting in Resident 1 expiring on [DATE]. Findings: During a review of Resident 1's admission Face Sheet (FS), dated [DATE], the document indicated Resident 1 had diagnoses of bipolar disorder (shifts in a person's mood, energy, activity levels, and concentration), and anxiety (worry or nervousness) disorder. […]

• Actual harm, isolatedF689Jun 24, 2021

  Based on interview and record review, the facility failed to develop and implement adequate supervision and assistive devices for the prevention of falls for one of three sampled residents (Resident 1) when Resident 1 was identified as a high fall risk (assessment of the likelihood of a resident falling) and experienced falls on [DATE], [DATE] and [DATE]. The facility did not implement interventions to keep Resident 1 safe and free from falls and injuries. These failures resulted in Resident 1 sustaining an avoidable fall on [DATE] and subsequently obtained a fracture (broken bone) to the right forearm experiencing pain and suffering. Findings: During a review of Resident 1's Admission Record, dated [DATE], indicated, Resident 1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF908Mar 23, 2026

  Based on observation, interview, and record review the facility failed to ensure the ice machine was in safe operating condition when the ice machine malfunctioned and the facility did not provide the residents with ice for two days, 3/21/26 and 3/22/26.This failure had the potential for the residents to decrease the amount of fluid they consumed risking dehydration (condition when body loses more fluids than it takes in) and urinary tract infections (UTI-infection caused by bacteria entering the urinary system [bladder, urethra, or kidneys] leading to painful urination).During a concurrent observation and interview on 3/23/26 at 10:51 a.m. with Resident 6, Resident 6 was lying in bed, there was an indwelling catheter bag hanging at her bedside. […]

• No harm, potential for more than minimal, widespreadF882Nov 25, 2025

  Based on observation, interview and record review the facility failed to ensure the facility employed an infection preventionist (professionals who works to stop the spread of infections within a healthcare facility) to meet the facility's infection control needs when the facility did not have a trained and certified infection preventionist for over two weeks and the staff failed to follow proper infection control procedures including failing to follow the facility's infection control policy and procedure for performing fingerstick blood glucose, one of three CNA's did not perform hand hygiene when entering and exiting a resident room after touching the residents environment and enhanced barrier precaution signs were not hung by the PPE carts for two rooms.These failures had the potential… […]