Pennsylvania Department of Health
RIVER'S BEND HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVER'S BEND HEALTH & REHAB CENTER
Inspection Results For:

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RIVER'S BEND HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on July 1, 2026, it was determined that River's Bend Health &; Rehab Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

�483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

�483.12(a) The facility must-

�483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to protect the resident's right to be free from physical abuse by a resident (Resident 1) who displayed aggressive behavior and physically pushed another resident (Resident 2), causing a fall with a hip fracture. This failure resulted in an Immediate Jeopardy situation.

Findings include:

Review of the facility policy, titled "Resident Observation Policy", with a last revised date of May 28, 2021, and a last review date of January 28, 2026, revealed, in part, "Procedure: A. The charge nurse will contact the DON (Director of Nursing) who, if necessary, will consult with administrative staff and/or the Director of Mental Health, if applicable, to determine the appropriate observation/interventions if the resident meets on of the following criteria: 2. Resident is a danger to others, to include but not limited to, homicidal comments/threats/actions; 4. Resident is acting out behaviorally, to include but not limited to, throwing items, continuous screaming/disruptive behavior; B.) DON will assign a staff member to complete the appropriate observation/interventions which may include but are not limited to, every 15 or 30 minute checks or 1:1 monitoring".

Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (an ongoing, progressive lung condition that restricts airflow and makes breathing difficult) and hyperlipidemia (high amounts of fats in the blood).

Review of Resident 1's care plan revealed a problem focus area for behavioral symptoms, which included the following behaviors: Resident experiences wandering in hallways and into other rooms, Resident has behaviors of taking roommate's clothing and wearing them despite name tag on clothing, aggressor in resident-to-resident altercation, perception of missing money; makes accusatory statements towards staff and peers; Resident has behaviors of yelling out; Resident refuses care and medications; with a start date of January 27, 2026, and an edited date of June 30, 2026. Interventions included 1:1 Nursing Supervision.

Review of Resident 1's clinical record revealed a progress note on May 7, 2026, at 7:16 PM, where the Resident had to be re-directed from hitting another resident in the evening, calling the other resident names using profane language. Resident 1 followed an employee to the medication cart and started pushing the employee and stated, "I'm going to punch you in the face."

Review of Resident 1's clinical record revealed a progress note on May 10, 2026, at 8:11 PM, that stated Resident 1 was aggressive towards staff and residents, in which a 1:1 was initiated for safety measures. Resident was stating that other residents stole his money, and went to another resident who was standing by the door to her room and stated, "where is my money you b***h" and walked to where she was standing and kicked her on her left thigh, leaving a red mark.

Review of Resident 1's clinical record revealed a progress note on May 23, 2026, at 11:46 PM, that revealed he was noted with some episodes of anxiety, several exit seeking behaviors and being verbally aggressive towards other residents.

Review of a nursing progress note on June 3, 2026, at 2:20 PM, revealed Resident 1 was being monitored for close supervision and 15-minute checks. Resident 1 was noted to have increased aggression towards staff and residents, and was also noted to have increased exit seeking behaviors with attempts made to exit the facility. Resident 1 has since been placed on a 1:1 supervision. IDT (interdisciplinary team) in agreement that the Resident to be removed from 1:1 monitoring to close observation with 15-minute checks.

Review of the facility provided incident report revealed a resident-to-resident altercation between Resident 1 and Resident 2 on June 15, 2026, at approximately 8:00 PM. Further review of the incident report revealed Resident 1 became agitated perceiving he was missing money. Resident 1 approached Resident 2 and became verbally aggressive and subsequently pushed Resident 2 prior to staff being able to intervene. Resident 2 sustained a fall and complained of leg pain and was transferred to the hospital for evaluation and treatment.

Hospital imaging revealed that Resident 2 sustained a right hip fracture that required surgical intervention.

Review of a nursing progress note on June 15, 2026, at 11:32 PM, revealed Resident 1 had entered into Resident 2's room and pushed her into the wall, causing her to fall to the floor. Staff reported Resident 1 had become agitated, exit-seeking, and was swearing at staff and other residents for some time prior to this event. Staff were monitoring Resident 1 as he walked toward his room. Resident 1 saw Resident 2 in the next room looking out the door to see who was causing the commotion, Resident 1 entered the room and pushed Resident 2. Resident 2 fell and needed to be transported to the emergency department.

Review of Resident 2's clinical record revealed a nursing progress note on June 17, 2026, at 8:56 PM, that Resident 2 returned from the hospital after surgical repair of her hip with a dressing and a bruise on her right hip.

In a written statement dated June 15, 2026, by Employee 1 (Nurse), revealed that they were at the nursing station around 5:00 PM when Resident 1 was being uneasy and started exit seeking behavior, stating that he was waiting for a bus. Resident 1 started escalating without any provocations and was noted at one point cursing out a nursing aid who was doing her charting on the computer. Resident 1 attempted to grab a gown from another aid who was passing by the station. Resident 1 started accusing staff of stealing his money at this point. Around 6:00 PM he escalated, walking to other resident rooms when staff re-directed him. Attempts to redirect Resident 1 were not effective.

In a written statement dated June 15, 2026, by Employee 2 (Nurse Aide [NA]), revealed around dinner time Resident 1 was very wandering and aggressive with other residents and workers.

In a written statement dated June 15, 2026, by Employee 3 (NA), revealed they witnessed Resident 1's behavior around 5:30 PM when he started cursing at the residents and staff, walking around grabbing anything in his way, and when stopped he would abuse and curse and got so aggressive he was trying to fight.

In a written statement dated June 15, 2026, by Employee 4 (Nurse), revealed around 7:00 PM Resident 1 was agitated and walking up and down the hallways. Resident 1 attempted to enter other resident rooms and was cursing using inappropriate language.

Resident 1 had a 1:1 Nursing Supervision order from May 26, 2026 and it was discontinued on June 2, 2026.

Review of Resident 1's June 2026 Medication Administration Record (MAR) revealed 15 minute checks with a start date of June 3, 2026, and discontinued on June 11, 2026. Additional review revealed an order for a 1:1 Nursing observation, with a start date of June 19, 2026, after the resident-to-resident abuse. There were no orders for the Resident to be on 15 minute checks or on a 1:1 on June 15, 2026.

On June 30, 2026, at 12:36 PM, the Nursing Home Administrator (NHA) and the DON were notified that the facility failed to put effective interventions in place for Resident 1 to ensure the safety of other residents and prevent physical abuse, which resulted in an Immediate Jeopardy situation. The Immediate Jeopardy template was provided. The facility was informed that a correction action plan was required.

The facility initiated immediate interventions on June 15 and 16, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included the following:

On June 15, 2026, both parties were immediately separated, and initial psycho-social support was provided by nursing staff.

On June 15, 2026, head-to-toe assessment on Resident 2 revealed right leg pain with limited range of motion (ROM), new orders were provided to transfer Resident 2 to the Emergency room to evaluate and treat status post-fall.

On June 15, 2026, an investigation was initiated and witness statements were obtained.

On June 15, 2026, the Medical Director and Responsible Parties for both residents were notified of the event.

On June 15, 2026, Resident 1 was placed on a 1:1 at all times until further notice.

On June 16, 2026, a psychiatric consult with medication review was requested from in-house psych providers.

On June 16, 2026, the DON/designee interviewed all capable residents with a BIMS (brief interview for mental status) of 12 or greater, to determine if they were ever abused or handled roughly by any staff or resident in the facility and if they felt safe.

On June 16, 2026, the DON/designee completed house-wide body audits on all incapable resident with a BIMS less than 12 to assess for signs and symptoms of abuse.

On June 16, 2026, the IDT team identified other residents that experience aggressive behaviors to ensure their care plan contains the behaviors and effective behavioral interventions.

On June 16, 2026, the NHA/designee educated all staff on the abuse policy and closely monitoring any resident experiencing agitation to prevent a verbal/physical altercation.

To monitor and maintain on-going compliance NHA/designee will complete an audit on five random capable residents, BIMS of 12 or greater, to ensure they were not abused or rough handled in the facility and feel safe. The DON/designee will complete an audit on five random incapable resident, BIMS less than 12, body audits to ensure there are no areas of concern consistent with abuse, The Social Service Director (SSD)/designee will complete an audit of three random residents that experience agitation behaviors to ensure their care plans contain the behavior and effective behavioral interventions, any care plans lacking information will be updated immediately. Any areas of concern will be reported immediately. Audits will continue weekly x4 and then monthly x2.

The results of the audits were forwarded to the facility QAPI committee for further review and recommendations.

The facility demonstrated past non-compliance by initiating immediate interventions, audits and education, which was completed by June 16, 2026. Documents and actions provided by the facility to address the Immediate Jeopardy were reviewed and no concerns were identified.

Audits were reviewed to ensure the above appropriate measures and actions were in place.

Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of the education.

Observations made during the on-site survey on June 30, 2026, revealed there were no additional physical resident-to-resident altercations that had occurred in the facility.

The Immediate Jeopardy was lifted on June 30, 2026, at 3:56 PM, after ensuring that the immediate action plan had been implemented.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/07/2026

Past noncompliance: no plan of correction required.

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on review of staffing documents and staff interview, it was determined that the facility failed to ensure the total number of nursing care hours provided in each 24-hour period be a required minimum of 3.20 hours of direct care for each resident for two of seven days reviewed (June 13 and 14, 2026).

Findings Include:

Review of facility provided staffing information dated June 8 through 14, 2026, revealed that the facility provided only 3.14 hours of direct care for each resident on June 13, 2026, and 3.18 hours on June 14, 2026.

During an interview with the Nursing Home Administrator on July 1, 2026, at 3:11 PM, she confirmed that the facility did not meet the PPD on the aforementioned dates.

Plan of Correction - To be completed: 07/09/2026

Plan of Correction:
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Step 1.

The facility cannot retroactively provide the minimum number of nursing care hours for cited dates.

Step 2.

The facility will continue to schedule staff to meet or exceed the mandated nursing care hours provided in a 24-hour period. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios.

Step 3.

RDCS/designee reeducated the NHA, DON, Payroll/HR, and Scheduler on staffing regulations and ratios. Facility will utilize PRN staff and external agency to supplement these staffing needs. Staff recruitment efforts continue. Shift bonuses will be offered to staff. PRN staff will be contacted via call or text message in the event of a call off. Staffing agencies will be contacted. If necessary, staff mandation will occur.

Step 4.

NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum nursing hours needed for the facility. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be reviewed at QAPI.

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