Inspection Reports for River Bend Nursing and Rehabilitation
3400 STOCKER DR, EVANSVILLE, IN, 47720
Back to Facility ProfileInspection Report Summary
The most recent inspections on January 14, 2025, found River Bend Nursing and Rehabilitation in compliance with all applicable emergency preparedness, life safety, and recertification requirements, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to emergency preparedness, fire safety, resident care planning, medication management, infection control, and environmental safety. Several complaint investigations were substantiated, including issues with resident transport safety resulting in fractures, inadequate care planning for residents with feeding tubes, failure to prevent resident abuse, and medication storage and disposal problems. Enforcement actions such as staff termination and corrective education were implemented, but fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, as recent inspections show compliance following prior citations for similar issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
20.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
383% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
102% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 11/14/2024.
Findings
River Bend Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 57
Census Bed Type Total: 57
Census Payor Type Total: 57
Inspection Report
Re-Inspection
Census: 58
Capacity: 113
Deficiencies: 0
Date: Jan 14, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/02/24.
Findings
At this Post Survey Revisit, River Bend Nursing and Rehabilitation was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems.
Inspection Report
Life Safety
Census: 63
Capacity: 113
Deficiencies: 14
Date: Dec 2, 2024
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification Survey was conducted by the Indiana Department of Health to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness requirements including outdated arrangements with other LTC facilities, lack of annual emergency preparedness training, incomplete emergency power system inspections, missing signage on delayed egress doors, hazardous area doors without self-closing devices, incomplete kitchen fire suppression training and appliance placement, unsecured smoke detectors, incomplete fire watch and sprinkler system out-of-service policies, corridor doors not closing properly, missing annual fire door inspections, incomplete electrical receptacle testing, and use of multi-plug adapters inappropriately.
Deficiencies (14)
Failed to ensure emergency preparedness policies included updated arrangements with other LTC facilities.
Failed to conduct annual training for the Emergency Preparedness Program.
Failed to maintain weekly inspection records for emergency power generator for 41 of 52 weeks.
Failed to ensure delayed egress door had required signage.
Failed to ensure hazardous area doors had self-closing devices and were not propped open.
Failed to instruct kitchen staff on proper use of UL 300 hood fire suppression system and appliance placement.
Failed to secure ceiling mounted smoke detectors properly.
Failed to provide complete fire watch policy including required notifications.
Failed to provide complete sprinkler system out-of-service policy.
Failed to ensure corridor doors easily closed and latched.
Failed to complete annual inspection and testing of all fire door assemblies.
Failed to ensure annual testing of nonhospital-grade electrical receptacles in resident rooms.
Failed to maintain weekly inspection records for emergency generator batteries.
Used multi-plugged adapters as substitute for fixed wiring in beauty shop.
Report Facts
Facility capacity: 113
Census: 63
Weeks missing generator inspection: 41
Number of delayed egress locks observed: 10
Number of hazardous area doors without self-closing devices: 3
Number of smoke detectors unsecured: 5
Number of corridor doors not closing properly: 2
Number of fire door assemblies inspected: 0
Number of nonhospital-grade electrical receptacles tested: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Ross | Administrator | Named in relation to findings and exit conference |
| Maintenance Director | Named in relation to multiple findings and interviews |
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 20
Date: Nov 14, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00445556.
Complaint Details
Complaint IN00445556 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare notices, incomplete transfer and discharge paperwork, failure to notify Ombudsman, lack of bed hold policy notification, incomplete care plans, inadequate infection control practices, medication errors, improper food storage and temperature control, and lack of specialized programming for residents with developmental disabilities.
Deficiencies (20)
Failed to ensure SNF-ABN and NOMNC forms were provided following the end of Medicare skilled services for 2 residents.
Failed to provide proper transfer paperwork for a resident emergently transferred to hospital.
Failed to notify Ombudsman office of resident transfer to hospital.
Failed to provide notice of bed hold policy to residents or representatives for hospitalizations.
Failed to ensure development of comprehensive care plans for behaviors, accidents, and nutrition for 3 residents.
Failed to ensure care plan conferences were completed quarterly for 2 residents.
Failed to provide person centered engagement activities for 1 resident with dementia.
Failed to ensure proper treatment to maintain vision abilities for 1 resident with vision impairment.
Failed to appropriately care for and maintain a resident's suprapubic catheter leading to infection and multiple UTIs.
Failed to ensure routine medications were available and dispensed according to physician's orders for 2 residents.
Failed to ensure insulin pens were primed before administration for 2 residents.
Failed to ensure proper storage of medications; loose pills found in medication carts.
Failed to ensure food was served at palatable temperatures and taste for 1 tray tested.
Failed to ensure food was stored, labeled, and dated properly and refrigerator temperatures recorded.
Failed to ensure consistent documentation for wound care treatments for 1 resident.
Failed to follow proper infection prevention and control practices for residents with urinary tract infection, pressure injury, and urinary catheter.
Failed to provide a safe and sanitary environment; urine odors, pest infestations, and deteriorated air conditioning units observed.
Failed to maintain personnel records documenting annual inservice training on residents' rights for 4 staff.
Failed to provide documentation of annual dementia-specific training for 4 staff.
Failed to ensure implementation of a program for residents with intellectual and/or developmental disabilities for 4 residents.
Report Facts
Survey dates: 6
Census: 60
Total capacity: 60
Medication error rate: 8
Weight loss: 20.25
Temperature: 117
Temperature: 60.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Ross | Administrator | Signed report and provided policies |
| LPN 3 | Observed medication administration and infection control deficiencies | |
| RN 5 | Registered Nurse | Provided information on catheter care and medication storage |
| CNA 15 | Certified Nursing Aide | Observed providing care with infection control issues |
| CNA 21 | Certified Nursing Aide | Observed providing care with infection control issues |
| CNA 25 | Certified Nursing Aide | Observed providing care with infection control issues |
| QMA 9 | Qualified Medication Aide | Observed medication administration |
| Social Services Director | Provided information on complaint, intellectual disability program, and transfer notifications | |
| Dietary Assistant 11 | Lacked documentation of residents' rights and dementia training | |
| CNA 15 | Lacked documentation of residents' rights and dementia training | |
| QMA 17 | Lacked documentation of residents' rights and dementia training | |
| CNA 8 | Lacked documentation of residents' rights and dementia training |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437526 regarding allegations of inadequate safety measures during resident transport.
Complaint Details
Complaint IN00437526 was substantiated with federal/state deficiencies cited at F689 related to two state reportable incidents involving Resident B sustaining fractures to left and right ankles during transport due to missing footrests and unsecured seatbelt. The driver was terminated and corrective actions implemented.
Findings
The facility failed to ensure adequate safety measures for safe transport of one resident, resulting in two incidents where the resident sustained fractures to both ankles due to improper use of wheelchair footrests and seatbelts during transport to appointments. The driver involved was terminated and staff were re-educated on transport safety policies.
Deficiencies (1)
Failure to ensure adequate safety measures for safe transport of resident resulting in fractures due to missing footrests and improper seatbelt use.
Report Facts
Census: 59
SNF Beds: 4
SNF/NF Beds: 55
Medicare Residents: 4
Medicaid Residents: 45
Other Payor Residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements and policies related to incidents and investigation | |
| Director of Nursing | Provided statements and involved in notification and investigation | |
| Van Driver | Involved in incidents leading to resident injuries; terminated after investigation |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 4
Date: Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434734 regarding medication management and disposal practices at the facility.
Complaint Details
Complaint IN00434734 was substantiated with federal and state deficiencies cited related to medication management and storage practices.
Findings
The facility failed to ensure timely disposal of medications for discharged residents, proper disposal of discontinued medications, double locking of controlled medications in refrigerators, and maintenance of refrigerator temperature logs. Several medication storage issues were observed including unlocked padlocks on medication refrigerators, ice buildup with medications stuck in the freezer, and medications belonging to discharged or deceased residents remaining in storage.
Deficiencies (4)
Failure to ensure medications were disposed of in a timely manner for discharged residents and discontinued medications.
Controlled medications were not double locked in the medication refrigerator.
Refrigerator freezer had ice buildup with unidentifiable medication packages stuck in the ice.
Lack of temperature log sheet for medication refrigerator.
Report Facts
Census: 65
Total Capacity: 65
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Provided information about medication disposition practices during the survey |
| DON | Director of Nursing | Provided information on facility procedures for drug disposition and corrective actions |
| Administrator | Provided current pharmacy policy and procedure during the survey |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
Paper compliance review for the Investigation of Complaints IN00434734 completed on June 5, 2024.
Complaint Details
Investigation of Complaints IN00434734; facility found in compliance.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaints IN00434734 survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Investigation of Complaints IN00434111 completed on May 14, 2024.
Complaint Details
Investigation of Complaints IN00434111 was completed and the facility was found to be in compliance.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaints IN00434111.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 1
Date: May 13, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00434111, IN00434160, and IN00434015). Deficiencies related to complaint IN00434111 were cited, while no deficiencies were found related to the other two complaints.
Complaint Details
Complaint IN00434111 was substantiated with federal and state deficiencies cited. Complaints IN00434160 and IN00434015 were not substantiated with no deficiencies cited.
Findings
The facility failed to develop and implement a comprehensive care plan for one resident (Resident B) with an enteral feeding tube. Physician orders for enteral feeding and treatments were not completed as ordered, and documentation was lacking. The resident's care plan did not include timely focus on the feeding tube prior to 5/13/24. The facility implemented corrective actions including revising orders and care plans and educating staff.
Deficiencies (1)
Failed to develop and implement a comprehensive care plan for a resident with an enteral feeding tube, and physician orders for enteral feeding and treatments were not completed as ordered.
Report Facts
Census Bed Type - SNF: 12
Census Bed Type - SNF/NF: 61
Total Census Bed Type: 73
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 43
Census Payor Type - Other: 20
Total Census Payor Type: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Morgan | Interim HFA | Signed the report |
| RN 3 | Interviewed regarding Resident B's enteral feeding practices |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: May 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432575.
Complaint Details
Complaint IN00432575 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 66
Census Bed Type: 54
Census Bed Type: 12
Census Payor Type: 10
Census Payor Type: 39
Census Payor Type: 17
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431104.
Complaint Details
Complaint IN00431104 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Bed Type Total: 65
Census Bed Type SNF/NF: 56
Census Bed Type SNF: 9
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 42
Census Payor Type Other: 16
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 1
Date: Mar 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429533, IN00428768, and IN00428560 related to allegations of abuse at the facility.
Complaint Details
The investigation was triggered by complaints IN00429533, IN00428768, and IN00428560. The allegations were substantiated with federal/state deficiencies cited at F600 related to abuse. Police and Adult Protective Services were involved, and a case number was provided. Both residents involved were interviewed and psychosocial support was provided. Resident D was placed on 1:1 supervision and transferred to a psych facility. Resident E denied feeling unsafe or afraid.
Findings
The facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed. A resident (Resident D) was observed inappropriately touching another resident (Resident E). The facility took corrective actions including separating the residents, notifying authorities and families, providing psychosocial support, and implementing 1:1 supervision for Resident D until transfer to a psych facility.
Deficiencies (1)
Failure to ensure residents were free from abuse, specifically inappropriate touching of one resident by another.
Report Facts
Census: 62
Total Capacity: 62
Medication doses: 10
Supervision duration: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
Paper compliance review for the Investigation of Complaints IN00429533, IN00428768, and IN00428560 completed on March 1, 2024.
Complaint Details
Investigation of Complaints IN00429533, IN00428768, and IN00428560 found the facility to be in compliance.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaints IN00429533, IN00428768, and IN00428560.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
This visit was for the investigation of complaints IN00422448, IN00422537, and IN00426865.
Complaint Details
Complaints IN00422448, IN00422537, and IN00426865 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for any of the complaints investigated. The facility was found to be in compliance with relevant regulations.
Report Facts
Census by bed type: 65
Census by Payor Source: 65
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
Paper compliance review for a Post Survey Revisit (PSR) to the PSR to the Recertification and State Licensure conducted on November 2, 2023.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CRC Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to PSR to Recertification and State Licensure.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
Paper compliance review for a Post Survey Revisit (PSR) to the Investigation of Complaint IN00417400 completed on November 2, 2023.
Complaint Details
Investigation of Complaint IN00417400 was completed and the facility was found to be in compliance.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00417400.
Inspection Report
Re-Inspection
Census: 62
Capacity: 113
Deficiencies: 0
Date: Nov 27, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 10/05/23.
Findings
At this PSR, River Bend Nursing and Rehabilitation was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Re-Inspection
Census: 64
Capacity: 64
Deficiencies: 2
Date: Nov 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 9/11/23, conducted in conjunction with the Investigation of Complaints IN00420446, IN00417400 and a Covid-19 Focused Infection Control Survey.
Complaint Details
This visit included investigation of Complaints IN00420446 and IN00417400.
Findings
The facility was found deficient for failing to post accurate nurse staffing information daily, and for inadequate infection control practices during tracheostomy care, including failure to use sterile gloves properly and hand hygiene between glove changes. The facility failed to implement systemic plans of correction to prevent recurrence of these deficiencies.
Deficiencies (2)
Failed to ensure posted nurse staffing sheets contained the correct information and were posted at all entrances daily for 4 of 4 days during the survey.
Failed to ensure infection control practices were followed for 2 residents observed for tracheostomy care; sterile gloves were not worn properly, staff failed to wash or sanitize hands between glove changes, and the facility's Trach Care Policy did not follow the latest CDC guidelines.
Report Facts
Census: 64
Total Capacity: 64
Survey Dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Malvern | Administrator | Administrator interviewed regarding nurse staffing posting and infection control policies |
| RN 16 | Registered Nurse | Observed performing tracheostomy care with noted deficiencies in sterile glove use and hand hygiene |
| CNA 17 | Certified Nurse Aide | Assisted RN 16 during tracheostomy care |
| LPN 42 | Licensed Practical Nurse | Observed performing tracheostomy care with noted deficiencies in hand hygiene and glove use |
| DON | Director of Nursing | Interviewed regarding infection control policies and staff education |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
This visit was for the investigation of complaints IN00420446, IN00417400 and a Covid-19 Focused Infection Control Survey, conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on 9/11/23.
Complaint Details
Complaint IN00417400 was substantiated with a federal/state deficiency cited at F686 related to pressure ulcer care. Complaint IN00420446 had no deficiencies related to the allegations.
Findings
The facility failed to provide effective interventions to prevent the development of a stage 2 pressure ulcer on the left great toe for one resident (Resident G). The resident did not receive required skin assessments, wound care orders, or consistent turning and repositioning, resulting in a pressure ulcer. The facility lacked documentation and timely notification to the physician and family.
Deficiencies (1)
Failure to provide effective interventions to prevent a stage 2 pressure ulcer on the left great toe for Resident G due to lack of assessments and not following the plan of care.
Report Facts
Census: 64
Total Capacity: 64
Pressure ulcer size: 0.3
Pressure ulcer size: 0
Pressure ulcer area: 0.09
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Observed dressing change and provided progress note on Resident G's wound |
| RN 5 | Registered Nurse | Provided CNA Assignment Form indicating turning and repositioning instructions for Resident G |
| DON | Director of Nursing | Performed weekly skin assessments, provided interviews regarding wound care and documentation requirements |
| CNA 3 | Certified Nurse Aide | Interviewed regarding interventions for Resident G including cream application and turning schedule |
Inspection Report
Annual Inspection
Census: 63
Capacity: 113
Deficiencies: 23
Date: Oct 5, 2023
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and fire safety codes.
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness training, emergency power system maintenance, fire alarm system testing, smoke barrier integrity, corridor door functionality, fire drills, and oxygen transfilling room fire barrier. Corrective actions and systemic changes were planned or implemented.
Deficiencies (23)
Failed to conduct annual Emergency Preparedness training and demonstrate staff knowledge of emergency procedures.
Failed to conduct required emergency preparedness exercises including community-based drills.
Failed to maintain weekly emergency generator inspections for 2 of 52 weeks and monthly load testing for 3 of 12 months.
Failed to replace 41 of 41 battery operated smoke alarms in resident rooms within 10 years.
Failed to test 18 battery operated smoke alarms monthly in Stocker II east smoke compartment.
Laundry area dryer room enclosure was substantially covered with lint and leaves.
Means of egress doors in Stocker additions equipped with magnetic locks requiring keypad codes that were not posted.
Delayed egress locking arrangement on Harmony Unit exit door did not release after 15 seconds of panic bar activation.
Harmony Unit main level southeast exit door required heavy force to open despite code entry.
Exit discharge outside lower level Harmony Unit short hall exit was a grass hill, not a hard packed all-weather surface.
Battery backup emergency lights at generator and Harmony Unit south corridor near room 104 did not illuminate when tested.
Laundry room dryer enclosure had drywall removed exposing wood studs without flame spread rating.
Failed to test sensitivity of 27 of 102 smoke detectors within past 24 months; 8 heat detectors recommended for replacement due to age.
Fire alarm control panel displayed incorrect time and date.
Fire watch policy incomplete and lacked Indiana Department of Health contact information; fire watch documentation missing for 10/3/23 event.
Failed to inspect one of two automatic sprinkler piping systems every five years; fire department connections lacked signage; spare sprinkler heads not properly secured.
Smoke barrier walls had unsealed penetrations compromising smoke resistance.
Resident room 215 corridor door did not close completely and latch, allowing smoke passage.
Smoke barrier doors in Harmony Unit had a malfunctioning door coordinator causing improper closing sequence.
Cooktop stove/oven in Physical Therapy gym lacked a deactivation switch and was left powered on when not in use.
Oxygen transfilling room ceiling had a six inch hole compromising one hour fire resistive barrier.
Fire drills were not held at varied times for 1 of 3 shifts during 3 of 4 quarters.
Power strip cord in generator transfer room was dangling, risking mechanical stress.
Report Facts
Facility capacity: 113
Census: 63
Deficiencies cited: 27
Deficiencies cited: 41
Deficiencies cited: 18
Deficiencies cited: 8
Deficiencies cited: 2
Deficiencies cited: 4
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 1
Deficiencies cited: 3
Deficiencies cited: 2
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 13
Date: Sep 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00413510.
Complaint Details
Complaint IN00413510 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including comprehensive resident assessments, care plan revisions, respiratory care, nursing staffing, medication regimen reviews, psychotropic medication management, medication labeling and storage, food temperature and safety, sanitation, infection control, and environmental conditions.
Deficiencies (13)
Failure to complete resident discharge MDS assessments timely.
Care plans were not revised after a change in status for 3 of 7 residents reviewed.
Failure to ensure proper tracheal suctioning and oxygen services according to physician orders for 2 residents.
Failed to maintain 8 hours of RN coverage in a 24-hour period for 10 days in the quarter reviewed.
Failed to ensure complete and accurate posted nurse staffing records for 5 of 6 days of the survey.
Medication regimen recommendations were not reviewed or addressed by a physician for 6 residents.
Failed to ensure psychotropic medications had documented gradual dose reductions and PRN antianxiety medications were reviewed every 14 days for 4 residents.
Medication carts contained loose pills in the bottom of medication drawers.
Food was served at inappropriate temperatures; hot food served cool and cold food served above recommended temperature.
Failed to store, distribute, and serve food in accordance with professional food service safety standards; including dirty kitchen floor, improper refrigerator temperatures, mold, and unlabeled/undated food items.
Dumpster was left uncovered with used gloves around it.
Failed to properly prevent and contain COVID-19 infection control for residents and staff; improper PPE use and tracheostomy care.
Failed to provide a safe, functional, sanitary, and comfortable environment; including dead bugs in light covers, water stains on ceiling tiles, missing baseboards, paint smears, and rusty ceiling vents.
Report Facts
Census: 58
RN coverage hours missing: 10
Loose pills: 21
Dishwasher temperature: 150
Dishwasher temperature: 165
Refrigerator temperature: 42
Food temperature: 105
Food temperature: 114
Food temperature: 62
Dead bugs: 6
Rusty vents: 10
Gloves around dumpster: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Garrett | Administrator | Signed report and provided policies and interviews |
| RN 10 | Registered Nurse | Observed suctioning tracheotomy with improper glove use |
| RN 15 | Registered Nurse | Observed suctioning and trach care with clean gloves, indicated clean technique |
| RN 28 | Registered Nurse | Observed entering COVID resident room without proper PPE |
| LPN 6 | Licensed Practical Nurse | Observed medication cart with loose pills |
| LPN 18 | Licensed Practical Nurse | Observed medication cart with loose pills |
| Cook 4 | Cook | Observed with hair out of hair covering, unsure of dishwasher temp |
| Cook 10 | Cook | Observed with hair out of hair covering |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
This visit was for the investigation of complaints IN00413006 and IN00413121.
Complaint Details
Complaint IN00413006 and IN00413121 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 40
Census Bed Type - SNF: 23
Census Total: 63
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 12
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
Paper compliance review for a Post Survey Revisit (PSR) to the Investigation of Complaint IN00403979 and IN00406108 completed on April 14, 2023.
Complaint Details
Investigation of Complaint IN00403979 and IN00406108; deficiencies cited were unrelated and found to be in compliance upon follow-up.
Findings
River Bend Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to unrelated deficiencies cited during the Investigation of Complaint IN00403979 and IN00406108.
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 1
Date: Apr 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00403979 and IN00406108. Both complaints resulted in no deficiencies related to the allegations, but unrelated deficiencies were cited.
Complaint Details
Complaint IN00403979 and Complaint IN00406108 were investigated. No deficiencies related to the allegations were cited for either complaint. The narcotics misappropriation issue was unrelated to the complaints.
Findings
The facility failed to ensure a resident was free from misappropriation of their property related to narcotics. Specifically, narcotics were unaccounted for after delivery to the facility for one resident. The investigation revealed missing Lortab pills and discrepancies in narcotic handling and documentation.
Deficiencies (1)
Failed to ensure a resident was free from misappropriation of their property related to narcotics; narcotics were unaccounted for after delivery to the facility.
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 11
Medicaid Census: 41
Other Payor Census: 8
Missing Lortab Pills: 30
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
This visit was for the investigation of complaints IN00400352 and IN00402504.
Complaint Details
Complaint IN00400352 and Complaint IN00402504 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00400352 and IN00402504 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 59
Census Bed Type - SNF/NF: 52
Census Bed Type - SNF: 7
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Jul 29, 2022
Visit Reason
This visit was a PSR to investigate multiple complaints (IN00382749, IN00382775, IN00382337, IN00381911, IN00378390) and included a COVID-19 Focused Infection Control Survey completed on 6/16/22.
Complaint Details
Complaints IN00382749, IN00382775, IN00382337, IN00381911, and IN00378390 were investigated and found to be corrected.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of the listed complaints, all of which were corrected.
Report Facts
Census: 49
Census bed type - SNF: 3
Census bed type - SNF/NF: 46
Census payor type - Medicare: 3
Census payor type - Medicaid: 42
Census payor type - Other: 4
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