Riverbend Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Riverbend Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 3, 2021

  Based on interviews and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (#75) of two out of 39 sample residents. Resident #75 admitted to the facility with a left [CONDITION(S)], required extensive staff assistance for toileting, transfers and bed mobility. The resident was identified as being at moderate risk for developing pressure ulcers at admission. […]

• Actual harm, isolatedF689Nov 3, 2021

  Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#84 and #33) of six residents out of 39 total sample residents. Resident #84 with diagnosis of Alzheimer's disease was admitted to the facility with a known fall risk. The resident had an unwitnessed fall on 9/20/21 in which he sustained a skin tear and had left hip pain. The intervention for the fall was to move the resident closer to the nurse's station for better visual observation. The resident was not moved closer to the nurse's station due to COVID-19 isolation protocols. However, the facility did not implement increased supervision after the fall that occurred on 9/20/21. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observations and interviews, the facility failed to ensure that food and beverages were stored, distributed, and served in accordance with professional food safety standards in the main kitchen.Specifically, the facility failed to ensure:-The kitchen was kept in a sanitary manner; and,-Condiments were labeled when opened. Findings include:I. Failure to ensure the kitchen was clean and kept in a sanitary mannerA. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 5/6/26. It revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. […]

• No harm, potential for more than minimal, widespreadF880Feb 9, 2023

  Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure dispensed medications were administered in a sanitary manner; -Ensure multiple use equipment was sanitized between residents; and, -Ensure environmental service staff followed appropriate hand hygiene practices, ensure high touch areas were cleaned daily. Findings include: I. Professional references The Disinfection of Medical Equipment, updated 5/24/19, retrieved on 2/13/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. […]

• No harm, potential for more than minimal, widespreadF867Nov 3, 2021

  Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, quality of care and infection control. Findings include: I. Cross-referenced citations Cross-reference F600: The facility failed to ensure one resident was free from physical abuse. Cross-reference F686: The facility failed to prevent pressure injuries for a resident who was considered high risk. […]