Health inspection·August 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/21/24 at 2:40 p.m. with LN 1, when asked what the process was when staff entered a resident's room, LN 1 stated, We always knock first, you announce yourself, ask permission to come in .then they will know .I mean, just for respect and privacy and dignity if they were sleeping or doing something. During an interview on 8/22/24 at 9:30 a.m. with the Director of Nursing (DON), the DON stated, When staff goes in a room .knock on the door before going in .introduce yourself .I think that we should address them. It's their home .I believe that you should not come in if the resident does not want you to come in to respect their privacy and dignity. 2. Resident 19 was admitted in early of 2020 with diagnoses which included PTSD, blindness, and anxiety. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had moderate memory impairment and did not reject ADL (activities of daily living) assistance. During a review of Resident 19's NCP, dated 5/9/23, the NCP indicated, ADL SELF CARE DEFICIT: [Resident 19] is at risk for self-care deficit r/t [related to] decreased/impaired mobility. During a concurrent observation and interview on 8/19/24 at 2:33 p.m. in Resident 19's room, Resident 19 was in bed, awake, alert and verbally responsive, appeared disheveled, half naked and wearing a dirty incontinence brief. Resident 19's body had a very strong-smelling pungent odor and the immediate environment also had a foul-smelling strong odor, the sheets were disorganized, and the floor below the bed was dirty. When asked how he was doing, Resident 19 stated, I live like a homeless. The nurses here, they don't attend to me and they leave me filthy .From an [AGE] year-old .this is what I get, filthy and dirty .I wish they could tell me that someone will come and talk to me so I can prepare myself, not like this. These people don't know what they are doing. During an interview on 8/19/24 at 2:35 p.m. with LN 1, LN 1 entered Resident 19's room and verified Resident 19's filthy situation and strong odor with the immediate room environment's foul-smelling strong odor, and stated, I can see he is dirty right now. It's very unhealthy leaving him like that . During an interview on 8/22/24 at 9:30 a.m. with the DON, the DON stated, It's all about what is needed for the resident .I'm on cleanliness and don't leave the resident filthy, smelly and dirty in order to promote their dignity. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/16, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .a dignified existence .privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 2 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents' right to personal privacy and confidentiality of his or her personal medical information when meal tray tickets were thrown into the general kitchen trash. Residents Affected - Some This failure had the potential of compromising resident privacy for 54 residents receiving facility prepared meals. Findings: During a concurrent observation and interview on 8/20/24 at 9:36 a.m. near the dish washing sink, with Dietary Aide 1 (DA 1), DA 1 was preparing the breakfast meal trays to be washed and, while doing so, threw the resident meal tray tickets into the kitchen's general trash. When asked what is done with the resident meal tray tickets, he pointed to the trash and stated, I throw them in here. A review of the facility's meal tray tickets for 8/20/24 were noted to include the following information: resident name, room number, diet order, food allergies, food preferences, and special dietary needs. During an interview on 8/20/24 at 9:39 a.m. with the District Kitchen Supervisor (DKS), the DKS confirmed that meal tray tickets were being thrown in the trash and indicated that tray tickets needed to be shredded to maintain residents' privacy. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/16, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .privacy and confidentiality .The unauthorized release, access, or disclosure of resident information is prohibited. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 3 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure comprehensive care plans were developed and implemented for two out of 30 sampled residents (Resident 52 and Resident 85), when: Residents Affected - Few 1. Resident 52's emotional issues and environmental concerns were not developed; and, 2. Resident 85 had no care plan developed and implemented for activities. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 52 was admitted in early 2024 with diagnoses which included post-traumatic stress disorder (PTSD), depression, and chronic pain. During a review of Resident 52's Minimum Data Set (MDS, an assessment tool), dated 7/25/24, the MDS indicated Resident 52 had no memory impairment and had episodes of feeling down, depressed, and hopeless. During a concurrent observation and interview on 8/19/24 at 11:10 a.m. in Resident 52's room, Resident 52 sat on the edge of the bed, awake, alert and verbally responsive. Resident 52 stated, I have been here six months .People here don't respond to my problems. My main problem when I called about three weeks was the doors slamming too loud when they close them .Every time they close the door, there is that loud noise. They slam the door so hard that I feel so scared. I have PTSD and I recall what happened to me whenever I hear that banging sound .I have already told the nurses about the doors being closed so loud, and they don't listen. The loud banging happens throughout the day, and especially at night .When I specifically said how can we fix the doors, they said nothing. No response at all. I cannot close my door because I am claustrophobic [fear of enclosed spaces] because of my PTSD .I am miserable with the .slamming doors. During an interview on 8/20/24 at 8:40 a.m. with Maintenance (MAIN), MAIN stated, I am aware of the loud noise the door makes when closing, because that has been a long time problem near the [Resident 52's] room. It has been a problem by [Resident 52] .I brought the issue with the administrator but they have not done anything. There are three doors next to the room. The plan of the DON [Director of Nursing] was to move [Resident 52] to another room but it has not happened. That has been a while. During an interview on 8/20/24 at 2:30 p.m. with Licensed Nurse 4 (LN 4), LN 4 stated, [Resident 52] wants to keep her door open but she doesn't like the noise and the slamming doors .She complained about this banging doors weeks ago .She wants to stay in her room .I also updated the maintenance guy about the doors. During an observation on 8/20/24 at 2:35 p.m. in the hallway near Resident 52's room, staff opened and closed the three doors, the exit door, the laundry room door and the shower room door adjacent to the resident's room. The exit door on the main hallway closed with a loud banging sound. The laundry room door closed with a loud sound. The shower room door closed quietly when staff slowly closed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 4 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 the door. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/20/24 at 2:40 p.m. with LN 1, LN 1 stated, The door stopper is not good on the exit door and the laundry room door .[Resident 52] mentioned to me .She's very alert and oriented .I heard that she's always mad about the doors and she already complained about them like two to three months ago. Residents Affected - Few During an interview on 8/21/24 at 9:20 a.m. with the Social Services Director (SSD), when asked about Resident 52's emotional and environmental concerns, the SSD stated, I am not aware of the issues on the loud noises and slamming doors .there is no care plan for that. I am not aware of that situation .so it's not included in her care plan. I am aware that she has PTSD. During an interview on 8/21/24 at 10:45 a.m. with LN 1, LN 1 stated, When there is a new problem for a resident, we develop a care plan right away. There should have always be a care plan for any issue or problem. 2. Resident 85 admitted to the facility in mid-2024 with diagnoses which included lumbar vertebral (lower back) fracture, difficulty in walking, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), and generalized anxiety disorder. During a concurrent observation and interview on 8/20/24 at 11:06 a.m. with Certified Nursing Assistant (CNA) 12, regarding Resident 85, Resident 85 was lying in bed. When asked if Resident 85 attended activities, CNA 12 stated, She does not go to activities .they do not get her up .she just stays in her bed. During a review of Resident 85's, ACTIVITIES-INITIAL REVIEW [assessment], dated 8/8/24, the assessment indicated, Complete on admission. Use this data to design an activities program that meets the residents needs and preferences. Update the care plan on completion .will do in room visits 3x week . During a concurrent interview and record review on 8/21/24 at 2:18 p.m. with the Activities Director (AD), the AD reviewed the activities assessment and confirmed Resident 85 was to receive in room visits 3x week. The AD was asked if Resident 85 should have a care plan (CP) for activities, and stated, Yes, there should be one. When asked to review the CP, the AD was unable to locate one and stated, I have not done her care plan, there should be one. When asked why it was important to create a CP, the AD stated, To make sure we are accommodating them. Not have them isolated so they don't fall into depression . During an interview on 8/22/24 at 9:30 a.m. with the DON, the DON stated, If there is a new issue and we have a problem facing a resident .definitely the nurses within 24 hours should have a care plan developed and in place. I think the situation or whatever it is needed to be addressed is implemented and then you collaborate as a team to figure out what you're going to do .at least you've got a care plan developed at the start. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 5 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for two of 30 sampled residents (Resident 18 and Resident 139), when: 1. Resident 18's nutrition care plan was not updated for an adaptive device; and, 2. Resident 139's pain care plan was not updated for a new pain medication. These failures had the potential to result in Resident 18 and Resident 139's not attaining their highest practicable well-being. Findings: 1. Resident 18 was admitted to the facility in late 2015 with diagnoses which included stroke, diabetes (uncontrolled blood sugar levels), left sided hemiplegia (paralysis on one side of the body), dysphagia (swallowing difficulty), and muscle weakness. During a review of Resident 18's Nursing Care Plan (NCP), dated 5/20/20, the NCP indicated, Adaptive equipment: Sipper cups and Divided plate for all meals .No changes have been made since the last review. During a review of Resident 18's NCP, dated 8/19/20, the NCP indicated, SELF CARE DEFICIT: due to: Need assistance IN ADL[activities of daily living]: Resident's ability to perform ADL at highest practicable level will be promoted with interventions .No changes have been made since the last review. During a review of Resident 18's Clinical Physician Orders (CPO), dated 1/12/24, the CPO indicated, Consistent Carbohydrate (CCD) diet, Dysphagia advance texture, Thin Liquids consistency .1:1 FEEDER. 2 handled cup, divided plate. During a review of Resident 18's Minimum Data Set (MDS, an assessment tool), dated 5/21/24, the MDS indicated, Eating: The ability to use suitable eating utensils to bring food to the mouth .resident completes activity. During a review of Resident 18's NCP dated 5/28/24, the NCP indicated, Nutrition risk: for weight loss related to poor meal intake. There was no documented evidence the NCP was revised or updated. During a concurrent observation and interview on 8/19/24 at 12:04 p.m. in the dining room with Licensed Nurse 2 (LN 2) and LN 3, Resident 18 started having her lunch meal. When asked what kind of cup did Resident 18 have in her meal tray, LN 2 stated, That's a sippy cup. That's not a two handed cup. Resident 18's meal ticket indicated, Divided Plate; Two Handled Cup. When asked if the cup was okay with her, Resident 18 shook head, and stated, No. LN 3 verified the cup, and stated, No. It's not a two handed cup. We are going to take another replacement from the kitchen. During an interview on 8/21/24 at 11 a.m. with the MDS Coordinator (MDSC), the MDSC verified the care plan for Resident 18 included the use of adaptive devices ordered which included the two handled cup, and stated, The two handled cup was not included as an intervention in the nutrition care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 6 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 The care plan was not revised and updated. Level of Harm - Minimal harm or potential for actual harm 2. Resident 139 was admitted to the facility in the middle of 2022 with diagnoses which included stroke, decreased mobility, chronic obstructive pulmonary disease (CODP, lung disease), respiratory failure, stroke, and swallowing difficulty. Residents Affected - Few During a review of Resident 139's NCP, dated 8/19/20, the NCP indicated, [Resident 139] expressed alteration in Comfort and Daily Activity due to presence of pain. During a review of Resident 139's NCP, dated 4/27/23, the NCP indicated, [Resident 139] is at risk for pain r/t [related to]: decreased mobility, COPD .low back pain. During a review of Resident 139's MDS, dated [DATE], the MDS indicated Resident 139 had no memory impairment and had verbalized pain. During a review of Resident 139's CPO, dated 8/14/24, the CPO indicated, Tramadol .Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. During a review of Resident 139's Pain Interview Assessment ([NAME]), dated 8/16/24, the [NAME] indicated, Pain Presence: Yes; Pain Intensity: Moderate; Pain Management: Tramadol .[Resident 139] did say she had some pain in her back . During a concurrent observation and interview on 8/19/24 at 9:44 a.m. in Resident 139's room, Resident 139 was in bed, awake and alert and verbally responsive, appeared restless and uncomfortable and grimacing. When asked how she was doing, Resident 139 stated, .I also have pain but I don't know if I had pain medications. I have been here waiting for a long time. During a concurrent observation and interview on 8/19/24 at 9:50 a.m. in Resident 139's room, the Director of Staff Development (DSD) entered the room and stated, I'm the DSD and I am not the nurse for the resident. When asked what to do with the Resident 139's pain, the DSD stated, I will tell the nurse for her complaint of pain. Resident 139 stated, She won't tell. During a concurrent observation and interview on 8/21/24 at 9:13 a.m. in Resident 139's room, Resident 139 was in bed, awake, alert and verbally responsive and grimacing. When asked how she was doing, Resident 139 frowned, and stated, I still hurt. They never gave me my pain medication. They won't do anything with my pain. During an interview on 8/21/24 at 9:15 a.m. with CNA 14, when asked if she had seen Resident 139, CNA 14 stated, [Resident 139] had told me about her pain. I already told the nurse and the nurse knows something about it. During an interview on 8/21/24 at 9:17 a.m. with LN 4, LN 4 stated, [Resident 139] has PRN [as needed] medication for the pain .[CNA 14] told me about the patient with pain. During an interview on 8/21/24 at 9:28 a.m. with LN 1, when asked about Resident 139's pain, LN 1 stated, Typically, when a resident complains of pain, absolutely, we address that right away. We do an assessment and we administer medication and follow the physician's orders. We don't wait. During an interview on 8/21/24 at 9:59 a.m. with LN 4, LN 4 stated, When a new medication order is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 7 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm received from the doctor .If the new medication is a new intervention, and there is already an old care plan for pain, we have to revise and update the care plan. LN 4 verified the care plan for Resident 139 on 5/24/22 which indicated no intervention for administration of medication as ordered and confirmed the Tramadol was ordered 8/14/24, and stated, The care plan was not updated, It should be revised for the new medication ordered as an intervention. Residents Affected - Few During an interview on 8/21/24 at 2:25 p.m. with the MDSC, the MDSC verified there was no revision of the pain care plan after the order of tramadol was received, and stated, There was no added intervention for the pain for medication as ordered. During an interview on 8/22/24 at 9:30 a.m. with the Director of Nursing (DON), the DON stated, Whatever it is needed to be addressed is implemented .then you can adjust it and you can revise it when a new intervention comes in .Every resident has the right to be provided with adequate care. We do not wait until we see their decline or their environment becomes unacceptable. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 8 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good grooming and personal hygiene were provided for two out of 30 sampled residents (Resident 19 and Resident 29), when: Residents Affected - Few 1. Resident 19 was unkempt and the immediate environment had a strong foul-smelling odor; and, 2. Resident 29's fingernails were long and with jagged ends. These failures had the potential to result in the residents not attaining their highest practicable well-being. Findings: 1. Resident 19 was admitted in early 2020 with diagnoses which included post-traumatic stress disorder (PTSD), blindness, and anxiety. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 7/19/24, the MDS indicated Resident 19 had moderate memory impairment and did not reject ADL (activities of daily living) assistance. During a review of Resident 19's Nursing Care Plan (NCP), dated 5/9/23, the NCP indicated, ADL SELF CARE DEFICIT: [Resident 19] is at risk for self-care deficit r/t [related to] decreased/impaired mobility. During a concurrent observation and interview on 8/19/24 at 2:33 p.m. in Resident 19's room, Resident 19 was in bed, awake, alert and verbally responsive, appeared disheveled, half naked and wearing a dirty incontinence brief. Resident 19's body had a very strong-smelling pungent odor and the immediate environment had also a foul-smelling strong odor, sheets were disorganized, and the floor below the bed was dirty. When asked how he was doing, Resident 19 stated, I live like a homeless. The nurses here, they don't attend to me and they leave me filthy .From an [AGE] year-old .this is what I get, filthy and dirty .I wish they could tell me that someone will come and talk to me so I can prepare myself, not like this. These people don't know what they are doing. During an interview on 8/19/24 at 2:35 p.m. with Licensed Nurse (LN 1), LN 1 entered Resident 19's room and verified Resident 19's filthy situation and strong odor and the immediate room environment's foul-smelling strong odor, and stated, I can see he is dirty right now. It's very unhealthy leaving him like that . During a concurrent observation and interview on 8/20/24 at 2:50 p.m. in Resident 19's room, Resident 19 in bed, awake and alert and verbally responsive. The room environment appeared cleaner and Resident 19 looked cleaner and much less odor compared to the day before. LN 1 stated, Every now and then, he has different choices of staff .but they should not have left him smell like that to preserve his dignity. During an interview on 8/22/24 at 9:30 a.m. with the Director of Nursing (DON), the DON stated, Every resident has the right to be provided with adequate care including medications, activities of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 9 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm daily living, adaptive devices and comfortable environment. We do not wait until we see their decline or their environment becomes unacceptable. 2. Resident 29 was admitted in late 2021 with diagnoses which included respiratory failure, traumatic brain injury, and seizure (abnormal body movements). Residents Affected - Few During a concurrent observation and interview on 8/19/24 at 11:40 a.m. in Resident 29's room, Resident 29's fingernails were noticeably long and jagged. When asked if Resident 29 would like his nails trimmed, he nodded his head yes. During an interview on 8/19/24 at 11:45 a.m. with LN 6, LN 6 confirmed Resident 26's nails were long and stated, They should be cut on his shower days, these [nails] could cut the skin. During an interview on 8/22/24 at 10:55 a.m. with the Director of Nursing (DON), the DON stated, I expect the staff to care for the nails on shower days and as needed so they [residents] don't scratch themselves. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care, dated 2/18, the P&P indicated, The purpose of the procedure are to clean the nail beds, to keep nails trimmed, and prevent infections .Nail care includes daily cleaning and regular trimming. During a review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, dated 3/18, the P&P indicated, Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including .hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 10 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to meet two of 30 sampled residents' (Resident 37 and Resident 85) activity needs when the residents did not receive in-room visits by staff. Residents Affected - Few This failure increased the potential for residents to experience isolation and depression. Findings: Resident 37 admitted to the facility in late 2019 with diagnoses which included cerebral infarction (stroke, medical condition that occurs when blood flow to the brain is disrupted), aphasia (language disorder that makes it difficult for people to communicate), and quadriplegia (a form of paralysis that affects arms and legs). During a review of Resident 37's care plan (CP), initiated 5/10/22, the CP indicated, .Will continue in room visits 3 x week . During a review of Resident 37's, Activities- Quarterly [assessment] ., dated 5/17/24, the assessment indicated, Resident receives 1:1 in room visits with the activity staff .staff will continue to do in room visit. During a review of Resident 37's, CUSTOM IDT [Interdisciplinary Team] CARE CONFERENCE FORM .ACTIVITIES, dated 8/13/24, the form indicated, .1:1 visits .will offer reading and singing, encourage to participate with peers . During a review of Resident 37's physician's orders (PO), dated 8/16/24, the PO indicated, Patient has decision making capacity: Yes. During a concurrent observation and interview on 8/20/24 at 2:12 p.m. with Resident 37, Resident 37 was lying in bed and with his laser pointer and alphabet board indicated, I do not have enough to do. During a concurrent interview and record review on 8/21/24 at 2:21 p.m. with the Activities Director (AD) of Resident 37's electronic health record (EHR). The AD was asked about Resident 37's activities, and stated, He was coming into the activities room, he has started to decline . The AD confirmed the care plan indicated in room visits. The AD confirmed the IDT indicated 1:1 visits. When asked to review the EHR for activities that were provided to Resident 37, the EHR did not indicate any activity visits had occurred. The AD confirmed there were not documented activity visits. When asked why activities were important, the AD stated, They are important, he can fall into depression, he will be isolated. Resident 85 admitted to the facility in mid-2024 with diagnoses which included lumbar vertebral (lower back) fracture, difficulty in walking, Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), and generalized anxiety disorder. During a review of Resident 85's, ACTIVITIES-INITIAL REVIEW, [assessment], dated 8/8/24, the assessment indicated, .will do in room visits 3x week . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 11 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 8/20/24 at 11:06 a.m. with Certified Nursing Assistant (CNA) 12 of Resident 85. Resident 85 was lying in bed. When asked if Resident 85 attended activities, CNA 12 stated, She does not go to activities .they do not get her up .she just stays in her bed. During a concurrent interview and record review on 8/21/24 at 2:08 p.m. with the AD, the AD reviewed the activities assessment and confirmed it indicated Resident 85 was to receive in room visits 3x week. When asked to review the EHR for activities provided to Resident 85, the EHR indicated she had only received one activity in-room visit on 8/19/24. The EHR did not indicate any other visits had occurred. The AD confirmed there was only one documented activity visit since her admission. When asked why activities were important, the AD stated, They need more 1:1 visits to make sure they know they are not here alone. [Resident 85] has been wanting companionship, she does not like to be alone. During a review of the facility's policy and procedure (P&P) titled, Preparation for Activities, dated 6/18, the P&P indicated, The Activity Director/Coordinator is responsible for the scheduling of activity functions and programs .Residents requiring assistance to and from scheduled activities are assisted . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 12 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt appropriate alternatives, obtain physician's orders, and obtain an informed consent prior to using bed rails (adjustable metal or rigid plastic bars that attach to the side of the bed) for 1 of 30 residents (Resident 63). This failure had the potential to result in entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail), injury and/or negative physical outcomes to skin integrity or muscle function. Findings: Resident 63 was admitted on [DATE] with medical diagnoses including sequelae of cerebral infarction (occurs when blood flow to the brain is blocked or a blood vessel in the brain bursts), muscle wasting and atrophy (muscles weakening and shrinking), and dysphagia (difficulty swallowing). During a review of Resident 63's Minimum Data Set (MDS, an assessment tool), dated 8/5/24, the MDS indicated Resident 63 had memory impairment. During an observation on 8/19/24 at 12:24 p.m. in Resident 63's room, Resident 63's left and right top bed rails were locked and in use in the upright position. During an observation on 8/21/24 at 9:06 a.m. in Resident 63's room, Resident 63's left and right top bed rails were locked and in use in the upright position. During a concurrent observation, interview, and record review on 8/21/24 at 9:14 a.m. with Licensed Nurse 5 (LN 5) in Resident 63's room, LN 5 verbally confirmed both of Resident 63's left and right top bed rails were locked and in use. LN 5 stated the normal process would be to get an order from the doctor and get a consent from the resident and/or responsible party before using bed rails. LN 5 also stated a care plan would be needed. Resident 63's medical record was reviewed with LN 5. LN 5 stated, should be in the orders .but it's not there. LN 5 verbally confirmed no consent or care plan was found in Resident 63's medical record. LN 5 also checked the hard copy of the medical record at the nurse's station; LN 5 also could not find an informed consent for bed rails and stated, it should be in the back with the consents, but it's not there. During a concurrent interview and record review on 8/21/24 at 9:21 a.m. with LN 1, Resident 63's medical record was reviewed. LN 1 verbally confirmed there was no informed consent, physician's orders, or care plan for bed rails. During a review of the facility's policy and procedure (P&P) titled, Bed Safety, dated December 2007, the P&P indicated, The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails .Side rails may be used if .and no other reasonable alternatives can be identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 13 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure an accurate inventory of narcotics (a medication that is used to relieve pain) for two of 30 sampled residents (Resident 66 and Resident 76) when six tablets of narcotics were not entered into the residents Medication Administration Record (MAR, document that serves as a legal record of the drugs administered to a resident). This failure had the increased potential for diversion and not being able to accurately monitor the amount or frequency of medications given to residents. Findings: Resident 66 was admitted to the facility in mid-2024 with diagnoses which included cancer of the head and neck. During a review of Resident 66's physician orders (PO) dated 8/1/24-8/31/24, the PO indicated, Norco Oral Tablet 10-325 MG [mg, a unit of measurement] [Hydrocodone-Acetaminophen] Give 1 tablet .every 6 hours as needed for .pain. During a review of Resident 66's CONTROLLED DRUG RECORD [CDR], Individual Patient's Narcotic Record [a form that keeps count of the number of narcotics dispensed to a resident], entries dated from 8/2/24-8/19/24, the CDR indicated one tablet of Norco was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 8/14/24 at 8:30 p.m. and one table of Norco was removed on 8/15/24 at 2:30 a.m. During a review of Resident 66's MAR dated 8/1/24-8/31/24, the MAR did not show documentation of Norco being administered on 8/14/24 at 8:30 p.m. or on 8/15/24 at 2:30 a.m. There was a total of two Norco's that were signed out from the narcotic medication card but were not documented as given to Resident 66. Resident 76 was admitted to the facility in early 2024 with diagnoses which included muscular dystrophy (a group of genetic diseases that cause progressive weakness and degeneration of skeletal muscles). During a review of Resident 76's PO, last reviewed 8/21/24, the PO indicated, oxyCODONE (sic) .Oral Tablet 5 MG .Give 2 tablet .every 4 hours as needed for severe pain . During a review of Resident 76's CDR, entries dated from 8/13/24-8/20/24, the CDR indicated two tablets of Oxycodone were removed from the medication card on 8/15/24 at 8:55 p.m. and two tablets were removed on 8/16/24 at 6:50 a.m. There was a total of four oxycodone tablets that were signed out from the narcotic medication card but were not documented as given to Resident 76. During a review of Resident 76's MAR, dated 8/1/24-8/31/24, the MAR did not show documentation of Oxycodone being administered on 8/15/24 at 8:55 p.m. or on 8/16/24 at 6:50 a.m. There was a total of two Norco's that were signed out from the narcotic medication card but were not documented as given to Resident 66. During an interview on 8/22/24 at 11:23 a.m. with the Director of Nursing (DON), the DON was asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 14 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the process for narcotic administration. The DON stated, .If it [pain level] meets the criteria of a narcotic you sign for it and then when they take it you document on the MAR. The DON confirmed the CDR documentation did not match the MAR documentation for Resident 66 and Resident 76 and stated, There are no signatures on the MAR that match the narcotic sheet. When asked the importance behind accurately accounting for narcotic administration the DON stated, They need to make sure the residents have been administered the medications. When asked if inaccurate documentation increased the risk for diversion of narcotics, the DON stated, Absolutely. During a review of the facility's policy and procedure (P&P) titled, Reconciliation of Medications on Admission, dated 7/17, the P&P indicated, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 15 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure kitchen staff had the knowledge and competencies to carry out dietary functions when: Residents Affected - Some 1. A cook was unable to correctly read the temperature in one of the reach in freezers; 2. A Dietary Aide did not know how to check the temperature of a dishwashing machine; 3. A cook did not use a recipe when preparing pureed foods; and, 4. A cook used the wrong scoop size to measure out food quantities. These failures had the potential of leading to food borne illness or weight loss for 54 Residents receiving facility prepared food. Findings: 1. During an interview on 8/19/24 at 10:23 a.m. near the kitchen's rear exit, with [NAME] 1 (CK 1), CK 1 was asked to check the temperature of the reach in freezer near the kitchen's rear exit. CK 1 was unable to differentiate between Fahrenheit (F, a unit of measurement for temperature) and Celsius (C, a unit of measurement for temperature) on the temperature probe used in the reach in freezer. CK 1 was also unable to state what temperature the reach in freezer should be. When asked about the importance of proper freezing temperatures, CK 1 stated, Food can get bacteria if food is not freezing correctly, and it affects residents. During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods, dated 2/23, the P&P indicated, .Freezer temperatures will be maintained at a temperature of 0 F or below. 2. During a review of the facility's document title, Low Temp Dish Machine, undated, the document indicated, Step 2: Run the dish machine a few times with no dishes to meet required temperatures. Step 3: Check Temperatures: 1st Cycle 120 degrees or higher, 2nd Cycle 120 degrees or higher. During a concurrent observation and interview on 8/20/24 at 9:36 a.m. with the Dietary Aide (DA 1), DA 1 was using a chemical based dishwashing machine to clean dirty dishes from the breakfast meal. When asked about dishwashing temperatures, DA 1 was unable to state the desired temperatures for the dishwashing machine manifold (portion of the dishwashing machine where hot water is delivered to dirty dishes) and was unable to find the temperature gauge for the manifold. 3. During a concurrent observation and interview on 8/20/24 at 10:03 a.m. in the food preparation area, with [NAME] (CK 2), CK 2 was observed pureeing slices of bread in a blender. CK 2 added an unmeasured amount of milk, bread, and water to the blender container then blended the ingredients. CK 2 then poured the pureed bread into a metal food container and started adding an unmeasured amount of food thickener. CK 2 indicated that, when making purees, he makes them without a recipe and goes by feel. During an interview on 8/20/24 at 1:52 p.m. with the Registered Dietitian (RD), the RD stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 16 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Cooks should follow recipes and measure out ingredients. Not following the pureed recipe could alter the nutrition that residents receive .The bread puree recipe should be more specific and be followed. It can affect a resident's swallowing if they have a swallowing difficulty. Pureed foods should be made consistently and according to policy. During a review of the facility's P&P titled, Trayline Accuracy/Menu Compliance, dated 2010, the P&P indicated, Food preparation is important: standardized quantity recipes should be used to provide consistency of product. Recipes should be followed for the number of servings to be prepared so that seasoning, taste, and appearance are consistent throughout the month .If the dietary staff does not follow the menu or recipe as written, then there is no assurance of adequacy or accuracy. 4. During a review of the facility's [Facility name] Diet Guide Sheet (DGS), undated, the DGS indicated that residents on the dysphagia (difficulty swallowing) mechanical (food texture modified in a way to help residents swallow easier) and dysphagia puree diets should receive a #8 (1/2 cup) serving of pureed potatoes and a #8 serving of pureed cream style corn. During a concurrent observation and interview on 8/20/24 at 12:02 p.m. in the food preparation area of the kitchen, with [NAME] 2 (CK 2) and District Kitchen Supervisor (DKS), CK 2 used a 3/8 scoop to measure the pureed potatoes and a ¼ scoop to measure out the pureed corn which caused residents on a pureed diet to receive the incorrect portion sizes for lunch. When asked about the different scoop sizes, CK 2 stated, I didn't know that. DKS then stated, The proper scoop size should be used. It's important so residents get their proper nutrition. During an interview on 8/20/24 at 1:52 p.m with the Registered Dietitian (RD), the RD stated, Cooks should follow recipes and measure out ingredients. During an interview on 8/21/24 at 10:25 a.m. with the Dietary Supervisor (DS), the DS stated, If the staff are unable to use the right scoops and don't know the temperature and dishwashing temperature, it can affect resident care and outcomes. During a review of the facility's P&P titled, Trayline Accuracy/Menu Compliance, dated 2010, the P&P indicated, If the dietary staff does not follow the menu or recipe as written, then there is no assurance of adequacy or accuracy .Portion control: Foods should be served according to the portions noted on the menus and recipes. Care should be taken before each meal to make sure that the correct scoops, ladles, and spoodles are available and in the appropriate menu items ready for the meal to begin. During a review of the facility's P&P titled, In-Service Training Program, dated 5/19, the P&P indicated, .Annual in-services .Ensure the continuing competence of staff and their appropriate discipline .Include training that addresses the specific skills and knowledge related to their department and job function. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 17 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the recipe for pureed food for three out 20 residents (Resident 37, Resident 63 and Resident 85) receiving a pureed diet when a kitchen staff member used the wrong scoop size to measure out food quantities. This failure had the potential to place residents receiving a pureed diet at risk for malnutrition and weight loss. Findings: During a review of the facility's [Facility Name Diet Guide Sheet] (DGS), undated, the DGS indicated that residents on the dysphagia (difficulty swallowing) mechanical (food texture modified in a way to help residents swallow easier) and dysphagia puree diets should receive a #8 scoop (1/2 cup) serving of pureed potatoes and a #8 scoop serving of pureed cream style corn. During a concurrent observation and interview on 8/20/24 at 12:02 p.m. in the food preparation area of the kitchen, with [NAME] 2 (CK 2) and District Kitchen Supervisor (DKS), CK 2 used a 3/8 scoop to measure the pureed potatoes and a ¼ scoop to measure out the pureed corn which caused residents on a pureed diet to receive the incorrect portion sizes for lunch. When asked about the different scoop sizes, CK 2 stated, I didn't know that. The DKS then stated, The proper scoop size should be used. It's important so residents get their proper nutrition. During an interview on 8/20/24 at 1:52 p.m. with the Registered Dietitian (RD), the RD stated, Cooks should follow recipes and measure out ingredients. During a review of the facility's Policy and Procedure (P&P) titled, Trayline Accuracy/Menu Compliance, dated 2010, the P&P indicated, If the dietary staff does not follow the menu or recipe as written, then there is no assurance of adequacy or accuracy .Portion control: Foods should be served according to the portions noted on the menus and recipes. Care should be taken before each meal to make sure that the correct scoops, ladles, and spoodles are available and in the appropriate menu items ready for the meal to begin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 18 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to conserve nutritive value and palatability for 20 residents receiving a pureed diet when the pureed bread was prepared without using a recipe. Residents Affected - Some This failure had the potential of leading to poor intake and malnutrition for the 20 residents receiving pureed meals. Findings: During a concurrent observation and interview on 8/20/24 at 10:03 a.m. in the food preparation area, with the [NAME] (CK 2), CK 2 was observed pureeing slices of bread in a blender. CK 2 added an unmeasured amount of milk, bread, and water to the blender container then blended the ingredients. CK 2 then poured the pureed bread into a metal food container and started adding an unmeasured amount of food thickener. CK 2 indicated that, when making purees, he makes them without a recipe and goes by feel. During a concurrent observation and interview on 8/20/24 at 12:35 p.m. near the kitchen entrance, with the Dietary Supervisor (DS), the DS brought two lunch test trays that contained one regular consistency meal and one pureed consistency meal. The pureed meal was sampled, and the pureed bread had a thick and sticky consistency indicating that too much thickener was used during preparation. When asked about the bread puree consistency, the DS stated, The thickening [of pureed foods] should follow a recipe . During an interview on 8/20/24 at 1:52 p.m. with the Registered Dietitian (RD), the RD stated, Cooks should follow recipes and measure out ingredients. Not following the pureed recipe could alter the nutrition that residents receive .The bread puree recipe should be more specific and be followed. It can affect a resident's swallowing if they have a swallowing difficulty. Pureed foods should be made consistently and according to policy. During a review of the facility's policy and procedure (P&P) titled, Trayline Accuracy/Menu Compliance, dated 2010, the P&P indicated, Food preparation is important: standardized quantity recipes should be used to provide consistency of product. Recipes should be followed for the number of servings to be prepared so that seasoning, taste, and appearance are consistent throughout the month .If the dietary staff does not follow the menu or recipe as written, then there is no assurance of adequacy or accuracy. During a review of the facility's P&P titled, Diet and Nutrition Care Manual, dated 2019, the P&P indicated, All foods must be the consistency of moist mashed potatoes or pudding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 19 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to ensure food preferences were accommodated for one of 54 residents receiving facility prepared food (Resident 9) when Resident 9's request not to be served cream of wheat for breakfast was disregarded. This failure had the potential to negatively impact Resident 9's nutritional status. Findings: Resident 9 was admitted to the facility in the middle of 2024 with diagnoses which included acute and chronic respiratory failure with hypoxia (a lack of oxygen in the blood), pneumonia (infection of the lungs), and muscle wasting and atrophy (wasting away of a body part). During a review of Resident 9's Minimum Data Set (MDS, an assessment tool), dated 7/26/24, the MDS indicated Resident 9 had a Brief Interview for Mental Score (BIMS) of 13 indicating Resident 9 had no cognitive impairment. During a review of Resident 9's meal tray ticket for breakfast on 8/20/24, the tray ticket indicated, No cream of wheat Oatmeal please 3 butter packets. During a concurrent observation and interview on 8/20/24 at 8:15 a.m. with Resident 9, Resident 9's breakfast tray had a bowl of cream of wheat. Resident 9 stated, I wanted oatmeal, but I was given cream of wheat. During an interview on 8/21/24 at 10:25 a.m. with the Dietary Supervisor (DS), the DS confirmed that Resident 9 received cream of wheat instead of oatmeal for his breakfast on 8/20/24. The DS stated, .He should have gotten oatmeal. During a review of the facility's policy and procedure (P&P) titled, Trayline Checklist, dated 2010, the P&P indicated, Beverages and extra request items available Alternate meat, starch, and vegetable available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 20 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 18 and Resident 73) were provided with necessary adaptive equipment for meals as ordered by the physician. Residents Affected - Few This failure had the potential to negatively impact the resident's well-being and contribute to decreased meal intake. Findings: 1. Resident 18 was admitted to the facility in late 2015 with diagnoses which included stroke, diabetes (uncontrolled blood sugar levels), left sided hemiplegia (paralysis on one side of the body), dysphagia (swallowing difficulty), and muscle weakness. During a review of Resident 18's Nursing Care Plan (NCP), dated 8/19/20, the NCP indicated, SELF CARE DEFICIT: due to: Need assistance IN ADL [activity of daily living]: Resident's ability to perform ADL at highest practicable level will be promoted with interventions. During a review of Resident 18's Clinical Physician Orders (CPO), dated 1/12/24, the CPO indicated, Consistent Carbohydrate (CCD) diet, Dysphagia advance texture, Thin Liquids consistency .1:1 FEEDER. 2 handled cup, divided plate. During a review of Resident 18's Minimum Data Set (MDS, an assessment tool), dated 5/21/24, the MDS indicated, Eating: The ability to use suitable eating utensils to bring food to the mouth .resident completes activity. During a concurrent observation and interview on 8/19/24 at 12:04 p.m. in the dining room with Licensed Nurse 2 (LN 2) and LN 3, Resident 18 started having her lunch meal. When asked what kind of cup did Resident 18 have in her meal tray, LN 2 stated, That's a sippy cup. That's not a two handed cup. Resident 18's meal ticket indicated, Divided Plate; Two Handled Cup. When asked if the cup was okay with her, Resident 18 shook head, and stated, No. LN 3 verified the cup, and stated, No. It's not a two handed cup. During an interview on 8/21/24 at 11 a.m. with the MDS Coordinator (MDSC), the MDSC verified the care plan for Resident 18 included the use of adaptive devices ordered which included the two handled cup, and stated, The two handled cup was not included as an intervention in the nutrition care plan. 2. Resident 73 was admitted to the facility in late 2023 with diagnoses which included encephalopathy (brain disease that alters brain function and structure), diabetes (uncontrolled blood sugar levels), dysphagia (swallowing difficulty), and reduced mobility. During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73 had moderate memory impairment and had complained of difficulty swallowing, and was dependent with eating. During a review of Resident 73's NCP, dated 7/23/24, the NCP indicated, Plastic eating utensils. During a concurrent observation, interview, and record review on 8/19/24 at 12:07 p.m. in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 21 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility dining room, Resident 73 was assisted by Restorative Nursing Aide 2 (RNA 2). Resident 73 tried to hold the silverware to eat her food, and prompted by RNA 2, had difficulty holding the silverware. Resident 73's meal ticket indicated, Plastic Fork, Plastic Spoon. RNA 2 confirmed Resident 73 had metal silverware. During an interview on 8/21/24 at 11 a.m. with the MDSC, the MDSC verified the care plan for Resident 73, and stated, [Resident 73] has care plan for the use of plastic utensils. During an interview on 8/22/24 at 9:30 a.m. with the Director of Nursing (DON), the DON stated, Every resident has the right to be provided with adequate care including medications, activities of daily living, adaptive devices and comfortable environment. We do not wait until we see their decline or their environment becomes unacceptable. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated 12/22, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well- being .The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 22 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F812 Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 54 residents who received facility prepared foods when: 1. Proper food labeling was not followed for items in the freezers, refrigerator, dry storage, and spice shelf; 2. Expired food items were found in the refrigerator, dry storage, and spice shelf; 3. Personal milk cartons were not stored at appropriate temperatures; 4. Kitchen reach in freezers contained multiple boxes of food items that were exposed and open to the freezer environment; a plastic container of brown sugar was not sealed properly; 5. Frozen foods were not stored at appropriate temperatures; 6. A steam table pan was found stored wet; 7. No air gaps were found in the produce sink; 8. The kitchen can opener had a chipped blade; and 9. A kitchen staff member was not wearing a beard restraint. These failures had the potential to lead to food borne illness for the 54 residents receiving facility prepared meals. Findings: 1. During the initial kitchen tour on 8/19/24 beginning at 8:18 a.m. with the Dietary Supervisor (DS) present and confirmed findings, the following items were found stored un-labeled or undated: - In the reach in freezers: a box of tater tots, a box of corn, a box of pie crusts, a box of asparagus, two bags of frozen breaded meat, a box of sausage patties, three boxes of beef patties, and a box of turkey patties. - In the reach in refrigerator: a bag of cheddar cheese, a plastic container with sticks of butter, two containers of beef base, and a container of salad dressing. - In the dry storage area: three trays of prepared cereal in bowls, an opened bag of ranch dressing mix, an opened bag of tortillas, a box of cornbread mix, a container of brown sugar, five boxes of oatmeal cookies, and four cans of tuna. - In the spice shelf: two containers of black pepper, a container of rotisserie chicken seasoning, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 23 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a container of ground cinnamon, a container of mustard, a container of basil leaves, a container of garlic powder, a container of paprika, a container of oregano, an opened bag of pasta, and an opened bag of chicken gravy mix. During an interview on 8/20/24 at 1:52 p.m. with the Registered Dietitian (RD), the RD stated, Expired food items and unlabeled food items can affect resident health. During a review of the facility's policy and procedure (P&P) titled, Food: Preparation, dated 2/23, the P&P indicated, .All refrigerated, ready-to-eat TCS [temperature controlled for safety] prepared foods that are to be held for more than 24 hours at a temperature of 41F [Fahrenheit, a unit of measurement for temperature] or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by date' (Day7). During a review of the facility P&P titled, Food Storage: Dry Goods, dated 2/23, the P&P indicated, .Storage areas will be neat, arranged for easy identification, and date marked as appropriate. During a review of the US (United States) FDA 2022 Food Code (FDA FC), section 3-501.17, titled, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, dated 1/23, the FDA FC indicated, Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. 2. During the initial kitchen tour on 8/19/24 beginning at 8:18 a.m. with the DS present and confirmed findings, the following items were found expired: - In the reach in refrigerator: a container of potato salad, a container of diced tomatoes, a container of parmesan cheese, a container of mushrooms, a container of pickles, a container of mashed potatoes, a container of bacon, and a bottle of lemon juice. - In the dry storage: four bottles of lemon juice, a box of baking soda, a container of mustard, an opened bag of pasta, a container of sugar, a container of brown sugar, a container of powdered sugar, and a can of sliced peaches. - In the spice shelf: a container of baking powder, a container of salt, a container of sesame seeds, a container of ground nutmeg, and a container of ground cloves. During a review of the US FDA FC, section 3-501.17, titled, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, dated 1/23, the FDA FC indicated, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 3. During the initial kitchen tour on 8/19/24 beginning at 8:18 a.m. with the DS, single use milk cartons were found on a cart with no cooling mechanism in place. The DS stated, There should be an ice bucket to keep the milks cool. During a review of the facility's P&P titled, Food Storage: Cold Foods, dated 2/23, the P&P indicated, .All perishable foods will be maintained at a temperature of 41 F or below, except during necessary periods of preparation and service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 24 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 4. During the initial kitchen tour on 8/19/24 beginning at 8:18 a.m. with the DS present and confirmed findings, the following items were found unsealed and exposed: Level of Harm - Minimal harm or potential for actual harm - In the reach in freezers: a box of cookie dough, a box of taco shells, and a box of corn. Residents Affected - Some - In the dry storage: a container of brown sugar. The DS stated, Bags [containing food] should be tied and sealed to prevent freezer burn .Frost on food can affect quality and sanitation of food. During a review of the facility's P&P titled, Food Storage: Dry Goods, dated 2/23, the P&P indicated, .All packaged and canned food items will be kept clean, dry, and properly sealed. During a review of the US FDA FC, section 3-202.15, titled, Package Integrity, dated 1/23, the FDA FC indicated, FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants .Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. 5. During the initial kitchen tour on 8/19/24 beginning at 8:18 a.m. with the DS present and confirmed findings, a reach in freezer closest to the DS's office (freezer 1) had a temperature reading of 16 F and the reach in freezer adjacent to the first freezer (freezer 2) had a temperature reading of 8 F. The DS stated, We want 0 F so they [kitchen staff] know it's actually frozen. The reach in freezer near the kitchen exit (freezer 3) had a temperature reading of 2 F. During a concurrent observation and interview on 8/19/24 at 10:26 a.m. in the facility kitchen, with the DS and [NAME] 1 (CK 1), the freezer 1 had a temperature reading of 20 F. All ice cream, gelato, and orange sherbet containers being stored in the freezer were not frozen solid indicating the freezer was unable to maintain foods at freezing temperatures. When asked if foods stored in the freezer should be frozen solid, the DS stated, We want them frozen. CK 1 also stated, Food can get bacteria if food is not freezing correctly and affects residents. During a review of the facility's P&P titled, Food Storage: Cold Foods, dated 2/23, the P&P indicated, .Freezer temperatures will be maintained at a temperature of 0 F or below. 6. During a concurrent interview and observation on 8/19/24 at 9:34 a.m. in the kitchen, with the Dietary Aide (DA 2) and the DS, a steam table pan was found stored wet. DS and DA 2 confirmed the finding and DA 2 stated, If not air-dried [pan], the container can grow bacteria. During a review of the US FDA FC, section 4-901.11, titled, Equipment and Utensils, Air-Drying Required, dated 1/23, the food code indicated, After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining . 7. During a concurrent interview and observation on 8/20/24 at 9:48 a.m. in the kitchen food preparation area, with the District Kitchen Supervisor (DKS), the sink used to wash produce did not have an air gap. DKS confirmed the finding and indicated wastewater could wash back up and affect produce being washed in a sink without an airgap. During a review of the US FDA FC, section 5-202.13 titled Backflow Prevention, Air Gap, dated 1/23, the FDA FC indicated, During periods of extraordinary demand, drinking water systems may develop (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 25 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. During a review of the US FDA FC, section 5-203.14, titled, Backflow Prevention Device, When Required, dated 1/23, the FDA FC indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT . 8. During an observation on 8/20/24 at 12:11p.m. in the kitchen food preparation area, the kitchen can opener blade was found to have a chipping metal coating. During an interview on 8/21/24 at 10:10 a.m. with the DS, the DS confirmed the finding and stated, Chipping [of the can opener blade] can be a physical contaminant of the food. During a review of the US FDA FC, section 4-501.11, titled, Good Repair and Proper Adjustment, dated 1/23, the FDA FC indicated, The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury. 9. During a concurrent observation and interview on 8/20/24 at 9:36 a.m. in the kitchen dishwashing area, with Dietary Aide 1 (DA 1) and DS, DA 1 was not wearing a beard restraint. DA 1 and DS both confirmed DA 1 was not wearing a beard restraint. DS indicated staff should wear a beard restraint when performing kitchen duties. During a review of the US FDA FC, section 2-402, titled, Hair Restraints, dated 1/23, the FDA FC indicated, (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 26 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper infection practices were followed when: Residents Affected - Some 1. Respiratory Therapist (RT) did not perform hand hygiene during a breathing treatment for Resident 66; 2. The isolation trash can was not covered for Resident 66; 3. Oxygen tubing used by Resident 139 was not labeled and additional oxygen tubing and nebulizer facemasks were labeled with an expired date; 4. An air fan was found with black residue and lint in Resident 41's room; and 5. Three plastic trash containers were open and had no lid cover during lunch meal in the facility dining room. These failures had the potential to increase the transmission and spread of infection. Findings: 1.Resident 66 was admitted to the facility in mid-2024 with diagnoses which included chronic obstructive pulmonary disease (lung disease), atrial fibrillation (an irregular heart rate), and heart failure. During a concurrent observation and interview on [DATE] at 8:35 a.m. at Resident 66's bedside the RT was observed putting tubing into the trash can with a gloved hand and pushed the contents down into the waste bin then returned to the resident and began organizing his tubing using the same gloves. The RT confirmed that he should not have used the same pair of gloves and stated, We are supposed to hand sanitize and change our gloves. Yes, I should have done that. During an interview on [DATE] at 10:55 a.m. with the Director of Nursing (DON), the DON stated, They [RT] should always change their gloves before proceeding to the next step in treatment. 2. During a concurrent observation and interview on [DATE] at 8:37 a.m. with Licensed Nurse 6 (LN 6), in Resident 66's room, the isolation trash can was overflowing, and the lid was in the open position exposing the personal protective equipment (PPE). LN 6 confirmed the open trash can and stated, I believe it's broken and does not close .it should be covered. During an interview on [DATE] at 8:57 a.m. with the Infection Preventionist (IP), the IP stated, All the trash cans should have working lids to protect the residents . During an interview on [DATE] at 10:55 a.m. with the DON, the DON stated, I expect all trash cans to be in working order and closed, to prevent infection. 3. Resident 139 was admitted to the facility in the middle of 2022 with diagnoses which included stroke, decreased mobility, COPD, respiratory failure, and swallowing difficulty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 27 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 139's Nursing Care Plan (NCP), dated [DATE], the NCP indicated, Alteration in Respiratory status due to: DX of ACUTE AND CHRONIC RESPIRATORY FAILURE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). During a review of Resident 139's Minimum Data Set (MDS, an assessment tool), dated [DATE], the MDS indicated Resident 139 had no memory impairment. During a review of Resident 139's Order Summary Report (OSR), dated [DATE], the OSR indicated, ALBUTEROL SUL [sulfate, medication to prevent and treat wheezing and shortness of breath] .INHALE 1 VIAL VIA NEBULIZER THREE TIMES DAILY FOR COPD. During a concurrent observation and interview on [DATE] at 9:44 a.m. in Resident 139's room, Resident 139 was in bed, awake and alert and verbally responsive. Resident 139 had a nasal cannula (oxygen tubing) with no date or label, connected to an oxygen concentrator. Also, at the night stand were disconnected oxygen tubing and a nebulizer (turns liquid medicine into a mist that can be easily inhaled) facemask with labels and both dated [DATE]. During a concurrent observation and interview on [DATE] at 9:48 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 verified the oxygen tubing and nebulizer, and stated, There is no label on the tubing. The other tubing and the breathing equipment have labels and the date is [DATE]. During a concurrent observation and interview on [DATE] at 9:50 a.m. with the Director of Staff Development (DSD), the DSD verified the oxygen tubing and nebulizer facemask, and stated, The oxygen tubing should be changed every week .The oxygen tubing connected to [Resident 139] has no label or date and the other one and the nebulizer have labeled dates of [DATE]. When asked what could result if the tubes and the nebulizer were not changed every week, the DSD stated, If the tubes are not changed there is a potential for respiratory infection. During an interview on [DATE] at 9:52 a.m. with the IP, the IP stated, The oxygen tubing and the nebulizer are changed weekly and the reason is to prevent infection, especially respiratory infection. During an interview on [DATE] at 11:02 a.m. with LN 1, LN 1 stated, We change the tubing and other personal stuff weekly to prevent infections .because of bacteria, and we want to keep it down and keep it as clean as it should .it's a facility policy that we change them every week. 4. Resident 41 was admitted to the facility in early 2020 with diagnoses which included encephalopathy (brain disease that alters brain function), respiratory failure, reduced mobility, and swallowing difficulty. During a review of Resident 41's NCP, dated [DATE], the NCP indicated, Alteration in Respiratory status due to .ACUTE AND CHRONIC RESPIRATORY FAILURE .Promote adequate/effective respiration. During an observation on [DATE] at 2:21 p.m. in Resident 41's room, Resident 41 was in bed, awake and alert, but non-verbal. At the side of the bed was an electric air fan with black residue and gray lint on the front guard cover and the fan blades blowing directly towards Resident 41. During a concurrent observation and interview on [DATE] at 2:23 p.m. with CNA 10, CNA 10 verified the air fan, and stated, The air fan is dirty. That should be cleaned .The resident can get sick and will end up with respiratory illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 28 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on [DATE] at 2:27 p.m. with LN 1, LN 1 confirmed the air fan was dirty, and stated, If you see [air fans] dirty, we're always responsible to clean them .If it is not clean, the dirty air will be going to the resident and can produce respiratory illnesses. During a review of the facility's P&P titled, INFECTION PREVENTION AND CONTROL .RESPIRATORY POLICY AND PROCEDURE, undated, the P&P indicated, Assure proper equipment cleaning and maintenance .Each resident shall be supplied with tubing and .or hand held nebulizer. These items shall be disposed of and replaced every week or sooner if soiled. 5. During a concurrent observation and interview on [DATE] at 12:21 p.m. in the dining room, three plastic garbage/trash containers next to the entrance door of the dining room were opened with no lid cover while the residents were having lunch. During a concurrent observation and interview on [DATE] at 12:22 p.m. in the dining room, LN 1 verified the three containers were open and had no lid cover, and stated, I can see that .the trash containers all have to be closed. It should be covered always .it's all about infection control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 29 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain one out of three reach-in freezers in safe operating condition when the freezer was found running at unsafe temperatures. Residents Affected - Some This failure had the potential to lead to growth of bacteria and food borne illness for all 54 residents eating facility prepared meals. Findings: During a concurrent observation and interview on 8/19/24 at 8:18 a.m., in the facility kitchen, with the Dietary Supervisor (DS), the reach in freezer closest to the DS's office (freezer 1) had a temperature reading of 16 degrees Fahrenheit (F, a unit of measurement for temperature). The DM confirmed the temperature reading and stated, It should be colder. The DS stated, I think the freezer [freezer 1] was last serviced in July of this year [2024] but there is no scheduled maintenance .it might be broken. During a concurrent observation and interview on 8/19/24 at 10:26 a.m., in the facility kitchen, with the DS, freezer 1 had a temperature reading of 20 F. All ice cream, gelato, and orange sherbet containers being stored in the freezer were not frozen solid indicating the freezer was unable to maintain foods at freezing temperatures. When asked if foods stored in the freezer should be frozen solid, the DS stated, We want them frozen. During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods, dated 2/23, the P&P indicated, .Freezer temperatures will be maintained at a temperature of 0 F or below. During a review of the facility's P&P titled, Equipment, dated 9/17, the P&P indicated, .All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials .The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 30 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, clean and comfortable environment was provided for a census of 89, when: 1. Several missing slats on the window blinds, three fluorescent bulbs not functioning, and three open trash containers without lids were found in the dining room; and 2. Resident 19 had a strong odor and foul-smelling room environment. These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:42 a.m. in the facility dining room, Resident 12 stated, The place could be much better. During a concurrent observation and interview on 8/19/24 at 12:15 p.m. in the dining room, the window blinds next to the table of Resident 12 had four missing slats. Restorative Nursing Aide 3 (RNA 3) verified the missing slats, and stated, It has been a while those blinds had been missing some parts. During a concurrent observation and interview on 8/19/24 at 12:19 p.m. in the dining room, Licensed Nurse 1 (LN 1) verified the missing slats of the window blinds, and stated, Everyone should have a dignity issue on that. I mean, some people would just say like you know, if they don't want to be seen through the window . During a concurrent observation and interview on 8/19/24 at 12:21 p.m. in the dining room, three plastic garbage/trash containers next to the entrance door of the dining room were opened with no lid cover while the residents were having lunch. During a concurrent observation and interview on 8/19/24 at 12:22 p.m. in the dining room, LN 1 verified the three containers were open and had no lid cover, and stated, I can see that .the trash containers all have to be closed. It should be covered always .it's all about infection control. During a concurrent observation and interview on 8/19/24 at 12:23 p.m. in the dining room, when asked about the missing slats of the window blinds, the Activities Director (AD) stated, I am aware there are blinds missing and it has been a long time ago. Well, they got the pieces to put it together but nothing has been done .It has been for a while that we have been missing the pieces. The AD verified there were at least 17 slats missing on the window blinds in the dining room. During a concurrent observation and interview on 8/19/24 at 12:25 p.m. in the dining room, three missing fluorescent bulbs in the dining room were not lit. The AD verified the missing bulbs, and stated, I just didn't notice the bulbs are missing. The resident won't be able to see well during meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 31 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 8/20/24 at 8:35 a.m. with Maintenance (MAIN), MAIN verified the missing blinds in the dining room, and stated, If there is a problem, I go and fix it .The [missing] blinds have been more than a year already .I talked with the previous administrator, but I guess they ignored the problem. I cannot fix it if there are no parts to use. MAIN checked and verified the fluorescent bulbs in the dining room, and stated, Nobody told me about it. I am not aware of the missing bulbs. If the [bulbs] are not working, they should be replaced. 2. Resident 19 was admitted in early 2020 with diagnoses which included post-traumatic stress disorder (PTSD), blindness, and anxiety. During a review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 7/19/24, the MDS indicated Resident 19 had moderate memory impairment and did not reject ADL (activities of daily living) assistance. During a review of Resident 18's Nursing Care Plan (NCP), dated 5/9/23, the NCP indicated, ADL SELF CARE DEFICIT: [Resident 19] is at risk for self-care deficit r/t [related to] decreased/impaired mobility. During a concurrent observation and interview on 8/19/24 at 2:33 p.m. in Resident 19's room, Resident 19 was in bed, awake, alert and verbally responsive, appeared disheveled, half naked and wearing a dirty incontinence brief. Resident 19's body had a very strong-smelling pungent odor and the immediate environment had also a foul-smelling strong odor, sheets were disorganized, and the floor below the bed was dirty. When asked how he was doing, Resident 19 stated, I live like a homeless. The nurses here, they don't attend to me and they leave me filthy .From an [AGE] year-old .this is what I get, filthy and dirty .I wish they could tell me that someone will come and talk to me so I can prepare myself, not like this. These people don't know what they are doing. During an interview on 8/19/24 at 2:35 p.m. with LN 1, LN 1 entered Resident 19's room and verified Resident 19's filthy situation and strong odor and the immediate room environment's foul-smelling strong odor, and stated, I can see he is dirty right now. It's very unhealthy leaving him like that . During an interview on 8/22/24 at 9:30 a.m. with the Director of Nursing (DON), the DON stated, That is a given. The resident's immediate environment should be safe, clean and comfortable. During an interview on 8/22/24 at 12:28 p.m. with the Administrator (ADM), the ADM stated, On resident safety and cleanliness of the environment, we're just reminding staff to keep their eyes open and be aware of their surroundings .in terms of maintaining their quality of life .on the residents' immediate environment. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/09, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment .maintaining the building in good repair .maintaining light levels that are comfortable .follow established infection control precautions .inspection of building .follow established safety regulations to ensure the safety and well-being of all concerned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 32 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure the required in-service training, competency skills and techniques were provided for two out of two sampled Contracted Certified Nursing Assistants (CCNA) CCNA 15 and CCNA 16, when the facility was unable to provide documentation to demonstrate the CCNAs received no less than 12 hours of annual in-services. This failure had the potential to significantly compromise the quality of services provided to the residents. Findings: During a concurrent interview and record review on 8/20/24 at 9:40 a.m. with the Director of Staff Development (DSD), the DSD confirmed she could not find the missing documentation to support dementia management training for CCNA 15. During a concurrent interview and record review on 8/20/24 at 10:25 a.m. with the Director of Nursing (DON), the DON stated, The facility used contracted staff through a staffing agency, and the contracted nursing staffing agency is expected to provide CCNAs with mandatory training documentation. During an interview on 8/22/24 at 2:25 p.m. with the Administrator (ADM), the ADM stated, After inquiring with the contracted agency, I found out they are a scheduling agency and, therefore, there was no way to verify if the in-service training was completed. I would have to check with the specific CCNAs [CCNA 15 and CCNA 16] and get back to you. The facility should ensure that proper training is provided for proper well-being of the residents. The ADM was unable to provide verification of the requested documents. During a review of the facility's policy and procedure (P&P) titled In-Service Training Program, revised 5/19, the P&P indicated, .Annual in-services .are no less than 12 hours per employment year .address the specific skills and knowledge related to their department and job function .including .dementia management and abuse prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 33 of 33