Riverbend Post Acute Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 5, 2021

  The facility identified a census of 100. The sample included 27 residents with 12 residents reviewed for abuse. The facility identified the Kensington unit as the dementia unit, with a census of 37 residents. Based on record review, observation, and interviews the facility failed to ensure the residents were free from abuse and neglect. Resident (R) 84, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On another occasion, R84 acted aggressively, then punched R47. Approximately two hours later, R84 hit R71. R21, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to prevent abuse by R84 and R21 placed those residents on the dementia unit in immediate jeopardy. […]

• Immediate jeopardy, patternF610Aug 5, 2021

  The facility identified a census of 100. The sample included 27 residents with 12 residents reviewed for abuse. Based on record review, observation, and interviews, the facility failed to protect 37 residents on the Kensington unit (secured dementia unit) from abuse and neglect while investigating episodes and/or allegations of abuse and neglect. The facility further failed to fully investigate, identify, and implement interventions in response to instances of resident to resident abuse. Resident (R) 84, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On another occasion, R84 acted aggressively. Staff failed to implement an immediate intervention, subsequently R84 punched R47. […]

• Immediate jeopardy, isolatedF600Jun 4, 2024

  The facility identified a census of 112 residents. The sample included three residents reviewed for neglect. The facility failed to ensure Resident (R) 1 remained free from neglect when staff failed to ensure R1 received adequate care and services required to prevent harm or injury to her physical and psychosocial wellbeing. R1, who had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) and an indwelling urinary catheter (a flexible tube inserted through into the bladder to drain urine), was legally blind and dependent on staff for hygiene was outside without staff for extended periods of time with no brief or underwear, and with urinary catheter tubing exposed. […]

• Actual harm, isolatedF626Oct 26, 2022

  The facility identified a census of 98 residents. The sample included eight residents with one reviewed for discharge. Based on interviews and record review, the facility failed to allow Resident (R)1 to return to the facility after the facility non-emergently transferred him to the Emergency Department (ED) for a psychiatric evaluation, on 06/27/22. The facility further failed to allow R1 to return to the facility pending and during the appeals process as required. As a result of this failure, R1 remained in an inpatient hospital setting since the transfer on 06/27/22, greater than four months, as the hospital could not find alternative placement. Due to these failures, cognitively impaired R1, who was unable to make decisions, remained homeless. […]

• No harm, potential for more than minimal, widespreadF727Aug 5, 2021

  The facility reported a census of 100 residents. Based on interview and record review, the facility failed to provide Registered Nurse (RN) services for at least eight consecutive hours, seven days a week. Findings included: - Review of the daily nursing staff posting sheets and the facility's Whentowork.com-Published Schedule, provided by the facility as the actual working schedule, revealed the following dates which lacked a RN for eight consecutive hours: 03/21/21-Sunday 04/04/21-Sunday 04/18/21-Sunday 05/09/21-Sunday 07/18/21-Sunday On 08/05/21 at 4:10 PM Administrative Nurse D stated she was aware there were some days the facility did not have the required eight consecutive hours of RN coverage. […]