Inspection·October 4, 2024

F 0684 pain, facial grimacing noted during removal of electrode patches . Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Progress Note, dated 9/20/24 at 1:47 a.m., indicated .Resident Son/RP/POA [Power of Attorney] called at 2338 [11:38 p.m.] rt [related to] the wounds present on scalp and forehead after EEG electrode removal on 09/19 PM [evening] shift. RP expressed he was not comfortable with his mother remaining in facility the duration of the night and requested a transfer to ED [Emergency Department]. RP was reassured by writer and RN on shift that resident's condition was stable, she is displaying her baseline indications of pain and that her wounds are being monitored closely and managed by treatments. RP maintained request. Request honored .resident sent out to [acute care hospital] . at 01:47 am . Residents Affected - Few A review of Resident 1's After Visit Summary, dated 9/20/24, indicated .You were seen for healing scalp wounds secondary to EEG electrode removal. These wounds appear to be healing well and do not show any signs of infection . A review of Resident 1's Surgical Consult, dated 9/24/24, indicated .WOUND .Right Medial [toward the center] Scalp .Etiology: Iatrogenic Injury [injury caused by medical treatment] .Wound SIGNS OF INFECTION: None .The patient has a wound located at the right medial scalp .Length (cm-centimeter) 1.0 Width (cm) 1.0 Depth (cm) 0.1 .The wound is stable and requires continued topical wound dressing therapy . During a concurrent observation and interview on 10/4/24 at 2:07 p.m. with Certified Nursing Assistant (CNA) 1 of Resident 1, observed forehead and lower scalp with multiple areas with slight discoloration and white bandage with small amount of blood stain on top of head. CNA 1 confirmed multiple areas of discoloration on Resident 1's forehead and bandage on top of head. CNA 1 stated she had noticed the patches on Resident 1 and that she has cream applied to the patches. During an interview on 10/4/24 at 2:12 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident had an EEG machine placed about two weeks ago and was supposed to return for follow up appointment. LN 1 stated EEG department did not send paperwork for follow up. If had returned with paperwork she would have notified Social Services to arrange follow up appointment. Resident 1's Family Member (FM) reported that Resident 1 was to return for follow up appointment on 9/19/24. Reviewed with LN 1, Resident 1's hard copy chart at nursing station. LN 1 acknowledged there was no documentation in chart from appointment on 9/16/24. LN 1 stated Resident 1's EEG electrodes were removed by the Director of Nursing (DON). During an interview on 10/4/24 at 2:23 p.m. with the DON, the DON stated Resident 1 had a follow up appointment on 9/19/24 to remove the EEG electrodes but Resident 1's FM did not notify the facility of the appointment. On 9/19/24, the EEG department contacted facility and requested the EEG machine be returned that day. The DON stated she asked the EEG department if they could remove the electrodes at the facility. The DON stated she was instructed on how to remove the electrodes by the EEG department. The DON stated the electrodes were on multiple sites and were red. The DON stated if the electrodes had stayed on longer could have created pressure ulcers. The DON stated that paperwork did not come back with Resident 1 on 9/16/24 after appointment to have EEG machine placed and that the FM likely had the paperwork from the appointment. The DON, when asked what would have happened if the EEG department had not contacted the facility on 9/19/24, stated, Going to figure it out after three days. Would have been more involved if in charge of appointment, not [FM]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 2 of 4 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 10/04/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/4/24 at 2:47 p.m. with the Social Services Director (SSD), the SSD stated Social Services arranged transportation for Resident 1 to EEG department appointment on 9/16/24 and FM went with her. The SSD stated usually comes back with paperwork or paperwork is faxed. If not received would follow up and request documentation. SSD stated on 9/19/24, Resident 1's family texted staff member and notified her of follow up appointment but it was not conveyed to social services to set up transportation to appointment. During a telephone interview on 10/4/24 at 3:03 p.m. with LN 3, LN 3 stated Resident 1's EEG machine was placed on 9/16/24. LN 3 stated after three or four days she observed a little drainage from electrode sites. The EEG department contacted facility on 9/19/24 to have EEG machine returned. The DON removed the electrodes on 9/19/24 and some of the skin had been peeled off. LN 3 stated Resident 1's FM was in the facility on 9/18/24 at 6:00 a.m. and reported to her that Resident 1 had an appointment on 9/18/24. The FM reported to her that he had handed paperwork to nurse on 9/16/24 but did not know the name of the nurse. LN 3 stated Resident 1's FM reported he had texted LN 5 about follow up appointment. LN 3 stated Resident 1's FM had not provided any paperwork to facility. During a telephone interview on 10/4/24 at 4:14 p.m. with LN 4, LN 4 stated Resident 1 went to appointment on 9/16/24 with FM to have EEG machine placed. LN 4 stated when Resident 1 returned, she asked FM if there was any paperwork. LN 4 stated Resident 1's FM showed her paper with instructions that said to remove in 24 to 48 hours. LN 4 stated she transcribed the information into a progress note and paperwork was returned to the FM. LN 4 stated she did not make a copy of the provided paperwork. LN 4 stated Resident 1's FM reported to her he had notified social services of follow up appointment. LN 4 stated she assumed that social services knew because FM stated he had spoken with social services. LN 4 also stated Resident 1's FM told her he had notified a nurse about the follow up as well. During an interview on 10/4/24 at 4:35 p.m. with the Administrator (ADM), the ADM stated Resident 1 had redness on the scalp and when electrodes were removed had an open area on the scalp. During a telephone interview on 10/4/24 at 4:53 p.m. with Patient Care Services (PCS) for EEG department, the PCS stated Resident 1 had appointment for EEG machine electrodes to be placed on 9/16/24. The PCS stated Resident 1 had a follow up appointment scheduled on 9/18/24 at 7:00 a.m.to remove the device. The PCS stated she spoke with Resident 1's FM on 9/18/24 who said he was still waiting for a ride at the facility and then placed multiple calls to him that day that he did not answer. The PCS stated Resident 1 did not show up for appointment on 9/18/24. The PCS stated she spoke with facility staff on 9/18/24 to reschedule but did not hear back that day. The PCS stated she called facility on 9/19/24 and spoke with staff who said they would notify the DON. The PCS stated the facility removed the electrodes on 9/19/24 on their own. The PCS stated she did not know who may have instructed the facility on how to remove the electrodes. The PCS stated on 9/16/24, paperwork with instructions on how to care for the EEG machine and follow up appointment was scheduled on 9/18/24, was sent with Resident 1. During an interview on 10/4/24 at 5:00 p.m. with the DON, the DON stated she was not aware that Resident 1's follow up was scheduled for 9/18/24 and not 9/19/24. When asked what the expectation of staff if resident does not return from appointment with instructions or any paperwork, the DON stated, [Resident 1's FM] wanted to manage the care and did not provide the information to the facility. During a telephone interview on 10/8/24 at 4:11 p.m. with LN 5, LN 5 stated Resident 1 had EEG machine placed on 9/16/24. LN 5 stated usually residents come back from appointments with paperwork. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 3 of 4 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 10/04/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's FM mentioned to LN 5 that the electrodes were supposed to be removed at the EEG department where they were placed. LN 5 stated Resident 1's FM had texted her about the initial appointment on 9/16/24 but no other texts and was not aware of any scheduled appointment on 9/18/24. When asked what should have happened if Resident 1 returned from appointment on 9/16/24 without any follow up information, LN 5 stated, Should have called the EEG department to get information about when to return. It is the SSD's job to set up transportation and arrange appointments. Should have gone through any paperwork upon return and see what the follow up is. Requested facility policy and procedures for Nursing Responsibilities, Nursing Communication, and Appointments. Policies were not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 4 of 4