Inspection Reports for
Riverbend Health and Rehabilitation Center
821 DUFFIELD CT, LOVELAND, CO, 80534-5228
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of sexual abuse between two residents, Resident #59 and Resident #62, and concerns about medication administration errors and food quality.
Complaint Details
The complaint investigation focused on an incident where Resident #62 touched Resident #59 inappropriately. The facility's internal investigation initially found the incident unsubstantiated, but the survey determined sexual abuse occurred. Interventions and supervision for Resident #62 were inadequate prior to the survey. The incident was not properly documented in residents' records.
Findings
The facility failed to protect Resident #59 from sexual abuse by Resident #62 and did not implement adequate interventions to prevent recurrence. Additionally, the facility had a medication administration error rate of 6.25%, exceeding the acceptable 5%, and failed to ensure food was palatable, served at appropriate temperatures, and met residents' preferences.
Deficiencies (3)
Failed to protect Resident #59 from sexual abuse by Resident #62 and failed to implement interventions to prevent recurrence.
Medication administration observation error rate was 6.25%, exceeding the 5% threshold.
Failed to ensure residents consistently received food that was palatable in taste, texture, and temperature.
Report Facts
Medication administration error rate: 6.25
Medication administration opportunities: 32
Resident sample size: 35
BIMS score: 3
BIMS score: 5
BIMS score: 15
Temperature of mashed potatoes: 110
Temperature of pork loin: 115.5
Temperature of mashed potatoes and gravy: 136
Temperature of pureed pork loin: 124.7
Temperature of pureed green beans: 127
Temperature of green beans substitute: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding sexual abuse incident and resident behaviors |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident behaviors and consent assessments |
| NHA | Nursing Home Administrator | Interviewed regarding sexual abuse incident investigation and facility actions |
| RN #4 | Registered Nurse | Interviewed regarding resident supervision and abuse reporting |
| CNA #5 | Certified Nurse Aide | Interviewed regarding resident behaviors and abuse reporting |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors |
| DON | Director of Nursing | Interviewed regarding medication administration policies and staff compliance |
| DS | Dietary Supervisor | Interviewed regarding food service and resident complaints |
| DM | District Manager | Interviewed regarding food service and menu planning |
| CNA #2 | Certified Nurse Aide | Interviewed regarding meal tray condiment procedures |
| CNA #3 | Certified Nurse Aide | Interviewed regarding meal order collection and resident preferences |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, self-determination, safety, medication administration, dental care, nutrition, infection control, and immunizations at Riverbend Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during mealtime, inconsistent provision of showers according to resident preferences, unsafe and unsanitary resident room conditions, medication errors exceeding acceptable rates, delayed dental care, failure to follow menus for therapeutic diets, inadequate infection prevention and control practices, and failure to provide pneumococcal vaccinations as per guidelines.
Deficiencies (8)
Failed to promote and maintain resident dignity by not offering Resident #27 her breakfast meal.
Failed to ensure residents' right to make choices about aspects of their lives, specifically inconsistent showers for Residents #28 and #37.
Failed to ensure a safe, clean, comfortable and homelike environment for 14 of 24 out of 57 resident rooms due to maintenance and housekeeping deficiencies.
Failed to ensure medication error rate was less than 5 percent; medication error rate was 9.68 percent for Residents #20 and #76.
Failed to provide timely dental care; Resident #41 had missing dentures and referral to dentist was delayed beyond three days.
Failed to ensure menus were followed to meet residents' nutritional needs; no menu extensions for finger food diet and repetitive items for lacto-ovo-vegetarian diet.
Failed to maintain an infection prevention and control program; medication administered in unsanitary manner, multiple use equipment not sanitized between residents, and housekeeping staff failed to follow hand hygiene and cleaning protocols.
Failed to implement policies and procedures for pneumococcal immunizations; Residents #26, #27, #41, and #42 did not receive recommended pneumococcal 23-valent polysaccharide vaccine (PPSV23).
Report Facts
Medication error rate: 9.68
Resident rooms affected: 14
Resident rooms total: 57
Residents affected by dignity deficiency: 1
Residents affected by choice deficiency: 2
Residents reviewed for immunizations: 5
Residents missing pneumococcal vaccine: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in finding related to failure to offer Resident #27 breakfast and throwing meal away. |
| NHA | Nursing Home Administrator | Interviewed regarding dignity, shower schedules, environmental concerns, and immunization policies. |
| RN #1 | Registered Nurse | Observed and interviewed regarding medication administration errors and infection control failures. |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors. |
| DON | Director of Nursing | Interviewed regarding medication errors, immunizations, and infection control. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #41 dental care and infection control practices. |
| HSK #1 | Housekeeper | Observed and interviewed regarding housekeeping deficiencies and infection control. |
| HSK #2 | Housekeeper | Observed and interviewed regarding housekeeping deficiencies and infection control. |
| HSKS | Housekeeping Supervisor | Interviewed regarding housekeeping policies and staff education. |
| SSD | Social Service Director | Interviewed regarding dental care for Resident #41. |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 10
Date: Nov 3, 2021
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements, including resident care, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to timely notify physicians and family of resident falls, failure to maintain a safe and clean environment, failure to prevent resident-to-resident abuse, delayed medication administration, inadequate pressure ulcer prevention and care, failure to prevent accidents and conduct neurological assessments after falls, failure to ensure staff competencies, improper medication storage, inadequate infection control during meal assistance, and ineffective quality assurance program implementation.
Deficiencies (10)
Failure to timely notify physician and legal representative of resident falls.
Failure to maintain a safe, clean, comfortable, homelike environment including proper disposal of soiled briefs and expired food items.
Failure to prevent resident-to-resident physical abuse and failure to report abuse timely and accurately.
Failure to administer blood pressure medications within the ordered time frames.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to ensure resident environment was free from accident hazards and failure to conduct neurological assessments after falls.
Failure to ensure medication storage refrigerators maintained proper temperature and removal of expired or undated medications.
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents.
Failure to ensure staff practiced appropriate hand hygiene during meal service.
Failure to maintain an effective quality assurance program to identify and address facility compliance concerns.
Report Facts
Residents affected: 5
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 4
Facility census: 78
Temperature: 31
Temperature: 38
Days expired: 12
Days expired: 36
Fall risk score: 10
Fall risk score: 13
BIMS score: 2
BIMS score: 3
BIMS score: 6
BIMS score: 7
BIMS score: 9
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #4 | Licensed Practical Nurse | Interviewed regarding fall notification procedures |
| Licensed practical nurse #5 | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks |
| Licensed practical nurse #6 | Licensed Practical Nurse | Interviewed regarding fall notification and neurological checks |
| Registered nurse #2 | Registered Nurse | Interviewed regarding fall notification and neurological checks |
| Nursing home administrator | Administrator | Interviewed regarding multiple deficiencies and quality assurance program |
| Director of nursing | Director of Nursing | Interviewed regarding multiple deficiencies and quality assurance program |
| Unit manager #2 | Unit Manager | Interviewed regarding neurological assessments |
| Certified nurse aide #8 | Certified Nurse Aide | Interviewed regarding hand hygiene during meal assistance |
| Certified nurse aide #5 | Certified Nurse Aide | Interviewed regarding staff training and competencies |
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