Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverbend Health And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen Sanitation and Food Labeling Deficiencies: Surveyors observed dust on the tray line shelf with clean pans and lids stored on it, rust and stains on kitchen fixtures and ventilation surfaces, a hole in a door frame, a missing handle on the chemical storage room door, stained sink areas, dirty rags stored under the sink, ceiling stains over the stove, and missing floor tiles in the dishwashing room. Surveyors also found several opened sauces and dressing in the walk-in refrigerator that were not dated, despite the facility policy requiring foods to be labeled and dated.
A facility failed to protect residents from the wrongful use of their narcotic medications after the DON discovered a nurse discussing an unavailable scheduled narcotic for one resident and then found major discrepancies between pharmacy delivery logs and facility narcotic logs. An LPN had completed a resident’s oxycodone card early, and the investigation identified hundreds of unaccounted-for oxycodone and Norco pills across multiple residents, with the same LPN involved in repeated count discrepancies.
A resident who was cognitively intact kept Visine eye drops and DeepSea nasal saline in her bedside drawer and said she used them herself every day. Record review showed no EMAR documentation for either product, no self-administration assessment, and no active physician order. RN and DON interviews confirmed both products were medications requiring an order and assessment before being kept in the resident's possession.
Failure to provide quarterly resident trust fund statements. A cognitively intact resident with multiple chronic conditions said she never received a written statement for her personal funds account after admission and instead only received verbal balance updates when she asked the business office. Facility policy and the resident’s authorization form both required quarterly statements, but the BOM did not send statements or have documentation showing they were issued.
Failure to Protect a Resident from Repeated Verbal Abuse: The facility failed to keep one resident free from repeated verbal abuse by another resident. Records and interviews showed a resident with schizoaffective disorder and moderate cognitive impairment repeatedly called another resident derogatory names in the dining room, causing emotional distress. The victimized resident had anxiety and depression and reported the behavior had continued over time, but the incident was not documented in the care plan or progress notes.
A facility failed to follow respiratory care orders for two residents. One resident with significant respiratory diagnoses had an O2 order for 3 LPM continuously, but the concentrator was repeatedly found set at 4 LPM without documented provider notification. Another resident with a BiPAP order for nightly water changes and mask cleaning had equipment left uncovered on a bedside dresser, with condensation in the chamber and no evidence staff completed the ordered cleaning; the resident said she handled the cleaning herself as able.
Medication storage and labeling were not maintained for one medication cart and two storage rooms. Surveyors found a used inhaler for a resident without an open date, expired floor stock medications, eye drops for a discharged resident still stored in the refrigerator, and two opened Tubersol vials without open dates. RN and DON stated the items should have been dated, removed, or discarded as required.
The facility failed to provide residents with food that was palatable in taste, texture, and temperature. Residents reported issues such as cold and bland food, undercooked items, and a lack of variety. Observations confirmed these complaints, with food being served at inappropriate temperatures and lacking flavor. Staff interviews revealed a lack of awareness and inconsistent processes in addressing residents' food preferences and complaints.
A resident with severe cognitive impairment was inappropriately touched by another resident during a group activity, and the facility failed to implement timely interventions to prevent further incidents. The care plan was not updated promptly, and there was a lack of proper documentation and follow-up. Staff interviews revealed inconsistencies in awareness and handling of the incident, and the facility's policy on intimacy and consent was not adequately followed.
A long-term care facility was found to have a medication error rate of 6.25%, exceeding the acceptable threshold. An LPN administered Levothyroxine Sodium incorrectly to two residents, not adhering to physician orders to give the medication on an empty stomach before breakfast. The LPN cited workload as a reason for the errors, while the DON emphasized the importance of following physician's orders.
Kitchen Sanitation and Food Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that the main kitchen was kept in a sanitary manner. During the initial kitchen walkthrough, surveyors observed an accumulation of dust on the lower shelf of the tray line table, with multiple clean pans and lids nested directly on the dusty surface. They also observed a rusty pipe extending from the south wall where there was a gap between the wall and the pipe, a rusted ventilation outlet with visible brown stains in the food preparation area, a hole in the door frame leading to the kitchen manager's office, and a kitchen chemical storage room door with a missing handle. Additional observations in the kitchen included white stains and condensation on the three-compartment sink, an overflow of dirty cleaning rags in a plastic container underneath the sink, dark yellowish stains across the ceiling above the stove directly over the food preparation area, and missing floor tiles in the dishwashing room. The facility's Kitchen Sanitation and Cleaning policy stated that dietary staff were expected to use good hygienic practices, follow cleaning and sanitation procedures, and clean food-contact surfaces before, during, and after food preparation. The facility also failed to ensure that opened beverages were properly labeled. In the walk-in refrigerator, surveyors observed two opened Kogi bar-b-que sauces, an opened Caesar salad dressing, and an opened enchilada sauce that were not dated. The facility's Food Storage policy stated that foods shall be labeled, dated, and covered, and that dates used may be a date prepared/opened and/or used by date.
Missing Narcotic Medications and Log Discrepancies
Penalty
Summary
The facility failed to protect residents from the wrongful use of their narcotic medications, with survey findings identifying missing controlled substances for five residents. The investigation began when the DON overheard a nurse discussing that one resident’s scheduled narcotic was unavailable. The DON confirmed that no narcotic medication was available for that resident, and the dispensing pharmacy reported that a sufficient supply had been sent to the facility earlier, indicating the medication should have been on hand. Further review of narcotic records showed that an LPN had completed one resident’s oxycodone medication card and removed it from the medication cart earlier than it should have been completed. The DON then expanded the investigation and found discrepancies between the pharmacy’s narcotic delivery logs and the facility’s narcotic logs for five residents. The facility’s investigation identified approximately 350 to 500 oxycodone and Norco narcotic medications that were unaccounted for over a period of time. The investigation documented that the same LPN was involved in multiple narcotic count discrepancies. Specific missing medications identified by the facility included 36 oxycodone HCL 10 mg pills for one resident, 58 oxycodone HCL 5 mg pills for another resident, 130 Norco 10-325 mg pills for a third resident, 102 oxycodone HCL 5 mg pills for a fourth resident, and 128 oxycodone HCL 5 mg pills for a fifth resident. The report also states that the resident whose medication was first identified as missing did not have unresolved pain at the time the issue was discovered.
Self-Administration of Medications Not Properly Assessed
Penalty
Summary
The facility failed to ensure self-administration of medications was clinically appropriate for one resident. Resident #65, who was cognitively intact with a BIMS of 15 and had diagnoses including osteoarthritis, spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder, and muscle weakness, was observed sitting in her room with a partially opened bedside drawer containing a bottle of Visine eye drops and a bottle of DeepSea nasal saline. She stated that she used both medications by herself, kept them in her drawer, used them frequently every day, and believed staff were aware of them. Record review showed no documentation in the EMAR that the Visine eye drops or DeepSea nasal saline had been administered during the month reviewed, and the EMR did not show an assessment for self-administration of either product. The CPO also did not contain an active physician's order for the Visine eye drops or the DeepSea nasal saline. Staff interviews confirmed that both products were considered medications requiring a physician's order and a resident assessment before being kept in the resident's possession for self-administration.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide evidence that a quarterly statement was given to a resident for personal funds managed by the nursing home. The deficiency involved Resident #65, who was cognitively intact with a BIMS score of 15 out of 15, had diagnoses including osteoarthritis, spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder, and muscle weakness, and was admitted to the facility over a year and a half earlier. The resident stated she was her own financially responsible person but said she had never received a statement for her personal funds account since admission, and that she instead went to the business office to ask verbally for her balance. Facility policy stated that resident trust fund statements were to be sent to the resident or legal representative within 30 days after the end of each quarter, and the authorization form stated the resident would receive a statement at least quarterly. The business office manager said she prepared account balances for residents with trust accounts but did not send balance statements to residents or representatives, and she had no documentation showing when Resident #65 received statements. The NHA acknowledged that quarterly statements should have been issued and documented for all residents whose money was managed by the facility, including Resident #65.
Failure to Protect a Resident from Repeated Verbal Abuse
Penalty
Summary
The facility failed to keep Resident #65 free from verbal abuse by Resident #60. The deficiency was based on record review and interviews showing that Resident #60 repeatedly directed derogatory name-calling toward Resident #65 in the dining room, including calling her a fat expletive, and that Resident #65 reported the behavior caused her significant emotional distress. Resident #65 stated the verbal abuse had been ongoing since shortly after her admission and that she had reported it to staff and social services, but the behavior continued. Resident #60 had diagnoses including schizoaffective disorder, bipolar type, and a cerebrovascular accident, and her MDS showed moderate cognitive impairment with a BIMS score of 10 out of 15. Her care plans documented a history of verbal aggression, poor impulse control, and triggers related to others being in her space, but the episode involving Resident #65 was not identified in the care plan. The record review also did not show documentation of the incident in progress notes, even though the facility investigation acknowledged a verbal altercation and Resident #60 was moved to another hall after the incident. Resident #65 had diagnoses including generalized anxiety disorder, major depressive disorder, morbid severe obesity, and a history of joint replacement surgery. Her MDS showed she was cognitively intact with a BIMS score of 15 out of 15 and that she felt down, depressed, or hopeless on several days during the assessment period. Her trauma care plan addressed a history of verbal abuse from an ex-husband, but it did not include the verbal aggression from Resident #60. Interviews with other residents and staff described repeated incidents of Resident #60 calling Resident #65 names and making mean gestures in the dining room, while the facility’s investigation ultimately documented the incident as unsubstantiated despite these accounts.
Respiratory Care Orders Not Followed for Oxygen and BiPAP Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. One resident with acute and chronic respiratory failure with hypercapnia, pulmonary edema, pneumonia, COPD, and CHF had a physician order for oxygen by nasal cannula at 3 LPM continuously, but the oxygen concentrator was observed set at 4 LPM over multiple observations. The resident stated the oxygen had been turned up after physical therapy and remained at 4 LPM afterward. Staff confirmed the order was for 3 LPM and stated the physician should have been notified when the oxygen requirement increased, but no documentation was found showing that notification occurred. A second resident with diagnoses including osteoarthritis, spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder, and muscle weakness had a physician order to change distilled water in the BiPAP and clean the BiPAP mask with soap and water, then let it air dry every night shift. Observations showed the BiPAP machine, tubing, humidifier chamber, and mask left uncovered on top of the bedside drawer, with visible condensation and a small amount of water remaining in the chamber. The mask’s inside surface was directly touching the dresser surface, and the resident stated staff did not clean the BiPAP machine and mask. Record review showed the resident’s care plan did not include the ordered BiPAP maintenance, and the resident stated she cleaned the equipment herself only when able and did not follow a specific schedule. Staff interviews confirmed there was no documentation that the BiPAP mask had been cleaned as ordered, and the DON stated the order was supposed to be completed by the overnight shift, not by the resident. The DON also stated the resident should have been assessed if she preferred to clean the mask herself, but the report documents that the ordered maintenance and storage practices were not being followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Proper medication storage and labeling were not maintained for one medication cart and two medication storage rooms. During observation of the front east medication cart with RN #2, surveyors found a used Breo Ellipta inhaler for Resident #1 that was not labeled with the date it was opened. The cart also contained a floor stock bottle of liquid Delsym Pediatric Cough/12-hour medication and a box of Rugsby Hemorrhoid Suppositories that were both expired. RN #2 stated the inhaler should have been dated when opened and removed for disposal if no open date was present, and that the expired medications should have been discarded on their expiration dates. In the front office medication storage refrigerator, surveyors observed a bottle of Latanoprost eye drops for Resident #104, who had been discharged, and the DON stated it should have been removed and discarded when the resident left the facility. In the vaccine storage refrigerator, surveyors found two opened vials of multi-dose Tubersol that were not labeled with the date they were opened. The DON stated the vials should have been dated when opened and discarded after 30 days, and noted that Tuberculin vaccine used outside the acceptable date range could be less effective.
Deficiency in Food Quality and Service
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, and temperature. Interviews with residents revealed multiple complaints about the quality of food, including it being served cold, lacking variety, and being bland. Specific issues included undercooked potatoes, cold eggs, and repetitive menus. Residents also reported that the food was often not cooked properly, with some items being burnt or not fully cooked. Additionally, there were complaints about the lack of condiments and the difficulty in cutting and chewing the meat. The facility's resident council and food committee meetings documented ongoing concerns about the food quality, with no documented follow-up or resolution to these issues. The resident council minutes from several months indicated that food was consistently served cold, and the food committee notes highlighted specific complaints about overcooked or tough meat and a desire for more fresh fruit and larger portions. Despite these documented concerns, there was no evidence of corrective actions being taken to address the residents' complaints. Observations during meal preparation and service confirmed the residents' complaints. The surveyors noted that the food was not served at appropriate temperatures, with items like pork loin and mashed potatoes being lukewarm and lacking flavor. The facility also ran out of certain menu items, leading to substitutions that were not communicated to the residents. Staff interviews revealed a lack of awareness of the residents' food complaints and inconsistencies in the process of providing condiments and collecting meal preferences. The facility's dietary supervisor and district manager were unaware of the residents' dissatisfaction, and there was no structured process for addressing these issues.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, leading to a deficiency in ensuring residents' safety from abuse. The incident involved a resident with severe cognitive impairment who was touched inappropriately by another resident during a group activity. The facility's internal investigation initially concluded the incident as unsubstantiated, despite evidence of inappropriate touching. The facility did not implement timely interventions to prevent further incidents. The care plan for the resident who committed the inappropriate act was not updated promptly to address the risk of inappropriate touching of female residents. Additionally, there were no progress notes in the electronic medical record regarding the incident, indicating a lack of proper documentation and follow-up. Interviews with staff revealed inconsistencies in their awareness and handling of the incident. Some staff members were unaware of the severity of the incident, and there was a lack of immediate action to place the resident under closer supervision. The facility's policy on intimacy and consent was not adequately followed, and there was no documentation of consent from the resident who was touched, raising concerns about the facility's procedures in handling such incidents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 6.25%. This deficiency was identified during medication administration observations, where two errors were noted out of 32 opportunities. The errors involved the improper administration of Levothyroxine Sodium tablets to two residents. The facility's policy requires medications to be administered accurately and in accordance with physician orders, which was not adhered to in these instances. Resident #49, an 87-year-old with Alzheimer's disease and hypothyroidism, was administered Levothyroxine Sodium while eating breakfast, contrary to the physician's order to take it on an empty stomach 30 minutes before food. Similarly, Resident #14, a 76-year-old with bipolar disorder and hypothyroidism, received her Levothyroxine Sodium after breakfast and with other medications, against the prescribed instructions. LPN #1, responsible for these administrations, cited the high number of residents as a challenge in adhering to the medication schedule. The DON confirmed that nursing staff are expected to follow physician's orders when administering medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Loveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Shore Health & Rehab Facility | 1.6 mi | ★★★★★ | 1 | 0 |
| Green House Homes At Mirasol, The | 1.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society -- Loveland Village | 2.1 mi | ★★★★★ | 15 | 0 |
| Berthoud Care And Rehabilitation | 6.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society -- Fort Collins Village | 6.5 mi | ★★★★★ | 12 | 0 |
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