Inspection Report Summary
The most recent inspection on June 11, 2025, identified deficiencies related to medication administration records and medication availability. Earlier inspections showed a pattern of issues involving medication management, kitchen sanitation, resident safety including elopement prevention, and staff-to-resident interactions such as verbal abuse. Complaint investigations substantiated deficiencies in these areas, including physical and verbal abuse by staff, unsafe environments leading to resident elopements, and sanitation concerns in food preparation areas. Enforcement actions included staff suspension and termination in abuse cases, but fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with medication and safety practices, with some corrective actions taken, but similar issues have recurred over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
80 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Jun 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460885, which involved allegations related to medication administration and pharmacy services.
Findings
The facility failed to ensure accurate medication administration records for Resident E, including missed documentation of multiple medications on 6/8/25. Additionally, the facility failed to ensure Resident B had medications available as ordered, specifically an Estradiol transdermal patch that was unavailable in April 2025.
Complaint Details
Complaint IN00460885 was investigated with state deficiencies cited related to medication administration and pharmaceutical services. The complaint was substantiated with findings at tags R0243 and R0297.
Deficiencies (2)
| Description |
|---|
| Failed to ensure Resident E's medication administration record reflected all prescribed medications, with missed documentation of Trazodone, Donepezil, and Quetiapine on 6/8/25. |
| Failed to ensure Resident B's medications were available for administration, specifically the Estradiol transdermal patch was not available and lacked documentation of physician and pharmacy notification. |
Report Facts
Residents reviewed for medication administration: 3
Residents reviewed for pharmacy services: 3
Residential Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricki Elston | Executive Director | Provided documentation and interview related to medication administration and pharmacy services findings. |
| Licensed Practical Nurse (LPN) 5 | Interviewed regarding medication administration record signing procedures. |
Inspection Report
Original Licensing
Census: 84
Deficiencies: 0
Apr 9, 2025
Visit Reason
This visit was for a State Residential Licensure survey conducted on April 9, 2025.
Findings
Riverbend was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451847.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00451847 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
Jan 14, 2025
Visit Reason
This visit was for the investigation of complaints IN00442957, IN00444477, IN00447297, and IN00448084 at the Riverbend facility.
Findings
The facility was found deficient in sanitation and safety standards related to kitchen cleanliness and maintenance, and pharmaceutical services related to narcotic medication counts during shift changes. Some complaints were substantiated with deficiencies cited, while others were not.
Complaint Details
Complaint IN00442957 and IN00448084 resulted in deficiencies related to sanitation and safety standards. Complaint IN00447297 resulted in a deficiency related to pharmaceutical services. Complaint IN00444477 had no deficiencies related to the allegations.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the kitchen area was clean and maintained, with multiple issues such as missing tiles, dust, grease splatter, and damaged cabinetry observed. |
| The facility failed to ensure narcotic medications and narcotic cards were counted during shift change for 1 of 3 days reviewed. |
Report Facts
Residential Census: 82
Survey Dates: Inspection conducted on January 14, 15, and 16, 2024.
Deficiency Completion Date: Plan of correction completion date is February 3, 2025.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Jun 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433811 at the Riverbend facility.
Findings
No deficiencies related to the complaint allegation were cited; however, an unrelated deficiency was found regarding a resident's rights being compromised when a staff member treated a resident disrespectfully during medication administration.
Complaint Details
Complaint IN00433811 was investigated and found to have no deficiencies related to the allegation. The complaint involved a Qualified Medication Aide being in Resident C's face and telling her she had to take her medications immediately, which caused the resident distress.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure a resident's rights remained intact for 1 of 4 residents reviewed for dignity, specifically Resident C was treated disrespectfully by a Qualified Medication Aide during medication administration. |
Report Facts
Residential Census: 87
Medication dosage: 0.5
Medication dosage: 0.25
Medication dosage: 12.5
Monitoring timeframe: 72
In-service frequency: 3
In-service frequency: 4
Interview frequency: 3
Observation frequency: 3
Duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricki Elston | Executive Director | Signed the report and provided a copy of the Indiana Residents Rights document |
Inspection Report
Renewal
Census: 90
Deficiencies: 1
Apr 15, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 15 and 16, 2024, to assess compliance with state regulations for the facility.
Findings
The facility failed to maintain sanitary conditions in two food preparation areas (Main Kitchen and Dementia Unit Kitchen), with issues such as grease buildup, food debris, and equipment in disrepair observed. Cleaning schedules were updated and corrective actions were implemented to address these deficiencies.
Deficiencies (1)
| Description |
|---|
| Facility kitchens were not maintained in a sanitary manner, including grease buildup on stove burners and ovens, food debris under sinks and refrigerators, and cracked oven pans. |
Report Facts
Residential Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melusine McDaniel | Operations Specialist | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Follow-Up
Census: 90
Deficiencies: 0
Jan 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to Investigation of Complaint IN00421583 completed on November 16, 2023, and was conducted in conjunction with the PSR to Investigation of Complaint IN00422665 completed on December 18, 2023.
Findings
Riverbend was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00421583. Both complaints IN00421583 and IN00422665 were corrected.
Complaint Details
This visit was related to complaint investigations IN00421583 and IN00422665, both of which were corrected.
Report Facts
Residential Census: 90
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Jan 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to Investigation of Complaint IN00422665 completed on December 18, 2023, conducted in conjunction with the PSR to Investigation of Complaint IN00421583 completed on November 16, 2023.
Findings
Riverbend was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00422665, and both complaints IN00422665 and IN00421583 were corrected.
Complaint Details
This visit was related to complaints IN00422665 and IN00421583, both of which were corrected.
Report Facts
Residential Census: 90
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 2
Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422665 regarding allegations of staff to resident abuse at the facility.
Findings
The facility failed to ensure that staff to resident physical and verbal abuse did not occur for 1 of 3 residents reviewed (Resident B). The investigation found that CNA 3 verbally abused and physically mishandled Resident B, including cursing, forcefully pulling, and pushing the resident. The CNA resigned following the incident. No bruising or physical injuries were found on Resident B after assessment, and no psychosocial distress was noted during monitoring.
Complaint Details
Complaint IN00422665 was substantiated with state deficiencies cited at R0052 and R0053 related to physical and verbal abuse by CNA 3 towards Resident B. The CNA was observed cursing and forcefully handling Resident B. The CNA resigned after the incident. The facility conducted assessments and monitoring with no signs of injury or distress found. Abuse and Residents Rights in-services were completed with all staff, and ongoing monitoring and training were planned.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure staff to resident physical abuse did not occur for 1 of 3 residents reviewed for abuse (Resident B). |
| Facility failed to ensure staff to resident verbal abuse did not occur for 1 of 3 residents reviewed for abuse (Resident B). |
Report Facts
Residential Census: 89
Monitoring duration: 72
In-service training dates: 2
Interview frequency: 3
Interview frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ricki Elston | Executive Director | Signed the report |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Nov 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421583, which was substantiated with a state deficiency cited related to the allegation.
Findings
The facility failed to provide a safe environment and prevent an elopement for one resident (Resident B) due to alarm failures on two exit doors. The resident eloped through doors with malfunctioning magnetic locks and alarms, resulting in the resident being found outside near a pond and a road. The facility took corrective actions including door repairs, alarm system upgrades, staff training, and increased door checks.
Complaint Details
Complaint IN00421583 was substantiated. The deficiency related to the allegation was cited at R0052.
Deficiencies (1)
| Description |
|---|
| Failed to provide a safe environment and prevent an elopement for 1 of 3 residents reviewed for neglect due to alarm failures on exit doors. |
Report Facts
Residential Census: 87
Scratches on resident: 2
Temperature: 56
Door checks frequency: 3
Door checks frequency: 2
Door checks frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melusine McDaniel | Operations Specialist | Signed the report |
| Memory Care Director | Interviewed regarding door and alarm checks and issues | |
| DON | Director of Nursing | Interviewed regarding the incident and alarm system issues |
| Maintenance Director | Interviewed regarding door lock and alarm system failures | |
| QMA 2 | Qualified Medication Aide | Noted resident missing and door ajar during incident |
| CNA 3 | Certified Nurse Aide | Assisted in searching for resident and found resident outside |
| CNA 4 | Certified Nurse Aide | Assisted in searching for resident and found resident outside |
| CNA 5 | Certified Nurse Aide | Assisted in searching for resident and found resident outside |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Oct 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415374.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00415374 was investigated and found to have no deficiencies related to the allegation.
Inspection Report
Follow-Up
Census: 93
Deficiencies: 0
Jul 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00407967 completed on May 31 and June 1, 2023.
Findings
Riverbend was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00407967.
Complaint Details
Complaint IN00407967 was corrected.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Jun 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407967, which involved allegations related to resident neglect and inadequate resident evaluation.
Findings
The facility failed to provide a safe environment preventing elopement for one resident (Resident B) and failed to ensure adequate assessment of a resident who experienced a fall (Resident D). Multiple windows lacked proper stoppers, and post-fall assessments were incomplete.
Complaint Details
Complaint IN00407967 was substantiated with state deficiencies cited related to neglect and evaluation of residents.
Deficiencies (2)
| Description |
|---|
| Failed to provide a safe environment and prevent an elopement resulting in a resident being found outside the facility. |
| Failed to ensure adequate assessment of a resident who experienced a fall. |
Report Facts
Residents reviewed for neglect: 3
Residents reviewed for evaluation: 3
Safety audits frequency: 1
Window audits frequency: 2
Door code change frequency: 6
Elopement drills frequency: 3
Resident monitoring frequency post-hospital return: 15
Fall audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Jackson | Executive Director | Signed the report. |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding Resident B elopement incident and location found. |
| WD | Wellness Director | Interviewed regarding Resident B elopement, staff in-service, and fall management. |
| Maintenance Director | Interviewed regarding window audits and security measures. | |
| Memory Care Director | Interviewed regarding daily safety checks of windows and elopement prevention. | |
| CNA 4 | Certified Nurse Aide | Provided statement about last seeing Resident B. |
| CNA 5 | Certified Nurse Aide | Provided statement about last seeing Resident B. |
| CNA 6 | Certified Nurse Aide | Reported assisting Resident D after fall but failed to notify nurse or QMA. |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
May 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406694 and IN00407003 at Riverbend Assisted Living.
Findings
No deficiencies related to the allegations in complaints IN00406694 and IN00407003 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Investigation of Complaints IN00406694 and IN00407003 found no deficiencies related to the allegations; facility was compliant.
Report Facts
Residential Census: 93
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405215 regarding allegations related to residents' rights and care.
Findings
The facility failed to ensure appropriate nail care for Resident C, a diabetic with peripheral vascular disease, as evidenced by lack of nail care documentation and observed thick, yellowed, and curling toenails. Staff interviews confirmed no nail care was provided and podiatry services were inconsistently arranged.
Complaint Details
Complaint IN00405215 was substantiated with a state deficiency cited at R0060 related to residents' rights and failure to provide appropriate nail care.
Deficiencies (1)
| Description |
|---|
| Failure to provide appropriate nail care for 1 of 3 residents reviewed (Resident C). |
Report Facts
Residential Census: 91
Survey Dates: April 4 and 5, 2023
Plan of Correction Completion Date: April 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| William Gregory Jackson | Executive Director | Signed the report |
| Director of Nursing | Interviewed regarding podiatry services and nail care | |
| CNA 3 | Interviewed about nail care and resident observations | |
| LPN 4 | Interviewed about nail care provision | |
| LPN 5 | Interviewed about nail care provision | |
| CNA 6 | Interviewed about nail care observations |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Nov 16, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393938.
Findings
The complaint IN00393938 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00393938 was substantiated with no deficiencies cited related to the allegations.
Report Facts
Residential Census: 107
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Oct 5, 2022
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00390950.
Findings
The facility was found to have substantiated verbal abuse involving a staff member yelling at a resident, and deficiencies in kitchen sanitation and medication documentation practices were also identified.
Complaint Details
Complaint IN00390950 was substantiated with a state deficiency cited at R0053 related to verbal abuse by a CNA who yelled at Resident C. The CNA was suspended and then terminated. Residents were assessed with no injuries noted.
Deficiencies (3)
| Description |
|---|
| Failed to ensure residents were safe from verbal abuse for 1 of 7 residents reviewed for abuse (Resident C). |
| Failed to ensure all kitchen equipment and storage areas were clean and in good repair during 2 of 2 kitchen observations, potentially affecting all 105 residents. |
| Failed to ensure staff documented the inventory of narcotics upon administration for 4 of 42 residents of narcotic medications (Residents D, E, F, and G). |
Report Facts
Residents present: 105
Deficiencies cited: 3
Medication discrepancies: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerrie Keck | ED | Laboratory Director or Provider/Supplier Representative who signed the report |
| CNA 3 | Certified Nurse Aide | Named in verbal abuse finding; suspended and terminated after investigation |
| QMA 4 | Qualified Medication Aide | Witnessed CNA yelling at resident |
| QMA 5 | Qualified Medication Aide | Witnessed CNA yelling at resident |
| QMA 7 | Qualified Medication Aide | Reported CNA 3 had a bad way of talking to residents |
| QMA 8 | Qualified Medication Aide | Witnessed verbal abuse incident |
| DON | Director of Nursing | Provided information about incident and medication administration procedures |
| Dietary Manager | Provided information and corrective action plan regarding kitchen sanitation deficiencies | |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding medication documentation discrepancies |
| QMA 11 | Qualified Medication Aide | Interviewed regarding narcotic medication documentation |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Aug 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382987, which was substantiated with a related state deficiency cited.
Findings
The facility failed to ensure dietary staff wore hair coverings during meal service and failed to ensure a staff member wore a face mask while serving food during one of two observations. Interviews confirmed non-compliance with PPE requirements despite existing policies.
Complaint Details
Complaint IN00382987 was substantiated with a related state deficiency cited at R0273.
Deficiencies (1)
| Description |
|---|
| Dietary staff were not wearing hair coverings during meal service and a staff member did not have a face mask in place while serving food. |
Report Facts
Residential Census: 108
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