Riverbend Heights Health & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 21, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision for one sampled resident (Resident #13) with a known history of self-harming behavior. The facility failed to ensure the resident did not have access to razors, resulting in he/she using a razor to cut his/her left leg in approximately four areas on his/her upper, left thigh. One of the thigh wounds was so deep that fatty tissue was exposed and required sutures. The facility census was 109 residents. The Administrator was notified on 12/17/21 at 3:34 P.M. of an Immediate Jeopardy (IJ) which began 12/16/21. The IJ was removed on 12/20/21 as confirmed by surveyor onsite verification. […]

• Immediate jeopardy, isolatedF689Mar 11, 2021

  Based on observation, interview and record review, the facility failed to provide supervision to prevent elopement for one sampled resident (Resident #40) out of 20 sampled residents, who were identified at risk on the facility elopement risk assessment and whom presented as exit seeking by wandering. On 5/6/21 at 9:00 P.M., the resident eloped from the the secured unit and went out the North door. The secured unit staff did not hear the alarm and did not know the resident was outside. The resident on return was placed on 15 minute checks. The resident room location was outside of the nursing station view behind plastic sheeting. On 5/6/21 at 11:00 P.M., the East door alarm sounded. […]

• Immediate jeopardy, isolatedF760Mar 11, 2021

  Based on interview and record review, the facility failed to ensure one sampled resident (Resident #6) was free from a significant medication error by giving a medication without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's Adverse Consequences and Medication Errors dated 4/2014 showed: -Residents receiving any medication that has a potential for an adverse consequence (an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) will be monitored to ensure that any such consequences are promptly identified and reported. […]

• Actual harm, isolatedF600Nov 2, 2023

  Based on observation, interview and record review, the facility failed to ensure two sampled residents (Resident #3 and #4) remained free from abuse. On 9/29/23, Resident #3 hit Resident #4 resulting in Resident #3 sustained a fractured right leg and cut to his/her right arm and Resident #4 sustained a cut to his/her nose, a cut on the foot and bruising to his/her face out of nine sampled residents. The facility census was 102 residents. Review of the Abuse Prevention Program Policy dated 12/16 showed: -Policy Statement: --The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• Actual harm, isolatedF888Dec 21, 2021

  Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to ensure all staff were either vaccinated for COVID-19 (a disease caused by a virus names [CONDITION(S)]-CoV-2), or had an approved or pending exemption. This failure included the tracking and secure documentation of information provided by staff who have requested exemption and ongoing monitoring for compliance of facility staff vaccination/exemption status. The facility census was 99 residents. […]