River's Bend Health: Abuse Response Failures - WI
River's Bend Health Services never investigated.
The resident, identified as R1 in inspection records, has intact cognition and serves as their own decision maker despite diagnoses including depression, anxiety, prolonged grief disorder, and borderline personality disorder. R1 had recently been hospitalized for surgery with psychiatric symptoms worsening afterward.
On November 24, R1 told a state inspector that Scheduler C and Driver D accompanied them to a physician appointment where the two staff members argued during transport, "including yelling at each other and using vulgar profanities." R1 said both staff members then "yelled at R1 in a threatening manner not to tell anyone about the argument which made R1 feel uncomfortable."
R1 reported the incident to facility staff but told the inspector that "no one followed-up with R1" and R1 "did not think the facility investigated the incident."
The facility's grievance file contained no record of R1's abuse allegation.
Director of Nursing B confirmed the argument occurred between the scheduler and driver during transport. The nursing director said the incident was reported to the former nursing home administrator, who "would have investigated the incident." But the nursing director "did not have any further information regarding the investigation."
When the state inspector requested the facility's investigation file for R1's abuse allegation, Administrator A approached the inspector at 2:37 PM and admitted the facility had no investigation.
"An investigation should have been initiated after R1 reported that R1 was yelled at by SCH-C and DRV-D and felt uncomfortable due to vulgar language that was used," Administrator A told the inspector.
The administrator also acknowledged that both the scheduler and driver "should have been suspended pending results of the investigation."
Administrator A revealed that arguments between the scheduler and driver "occurred on multiple occasions" — information discovered only after the state inspector's visit prompted interviews that same day.
The facility's own abuse prevention policy, dated July 15, 2022, requires "immediate investigation" when allegations of abuse occur. The written procedures specifically mandate "identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation."
The policy requires investigations to focus on "determining if abuse, neglect, exploitation, or mistreatment has occurred, the extent and cause, and providing complete and thorough documentation of the investigation."
None of this happened.
Both the scheduler and driver are no longer employed at the facility, but the timing of their departure and whether it related to the unreported incidents remains unclear from inspection records.
R1's medical history reveals a complex psychiatric profile requiring ongoing follow-up care. The resident's Minimum Data Set assessment from September 12 showed a perfect score of 15 out of 15 on cognitive testing, confirming R1's mental capacity to understand and report what happened during the transport.
The resident's recent surgical hospitalization had triggered an "exacerbation of psychiatric symptoms post-operatively," making the threatening behavior by transport staff particularly concerning for someone already struggling with multiple mental health conditions.
Federal nursing home regulations require facilities to protect residents from abuse and investigate all allegations thoroughly. The failure to document, investigate, or follow up on R1's complaint violated these protections.
The inspection classified the violation as causing "minimal harm or potential for actual harm" but noted it affected "few" residents — though the administrator's admission that arguments between the same staff members happened repeatedly suggests other residents may have experienced similar incidents that went unreported or uninvestigated.
Administrator A's acknowledgment that the staff members should have been suspended pending investigation highlights the facility's awareness of proper procedures. The policy existed. The administrator knew what should have happened.
It simply didn't happen.
R1 trusted the facility enough to report feeling threatened and uncomfortable after the medical transport. The resident followed proper channels by telling staff about the incident.
The facility responded with silence.
The state inspector's arrival on November 24 finally triggered the interviews and fact-finding that should have occurred immediately when R1 first reported the threatening behavior. By then, both staff members had already left their positions, making any meaningful investigation or corrective action impossible.
R1 continues living at River's Bend Health Services, a resident whose complaint about staff threats was ignored until a federal inspector asked to see the investigation file that never existed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River's Bend Health Services from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
River's Bend Health Services in Manitowoc, WI was cited for abuse-related violations during a health inspection on November 24, 2025.
River's Bend Health Services never investigated.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.