Inspection·October 30, 2024

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. Based on interview and record review, the facility failed to ensure the wound care plan was updated and revised timely for one of 3 sampled residents (Resident 1) when Resident 1's moisture related skin condition deteriorated to a pressure ulcer stage 4 (pressure injuries extended to muscle, tendon, or bone) to include interventions ordered by the physician. This failure had the potential to result in an inaccurate evaluation of the progress of wound healing for Resident 1. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2022 and readmitted in January 2023 with diagnoses that included respiratory failure (not enough oxygen in the body), muscle wasting, diabetes (too much sugar in the blood), and reduced mobility. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's IDT [Interdisciplinary Team] Skin Integrity Review, dated 9/10/24, the review indicated, WEEKLY WOUND EVALUATION: 9/10/24 SITE: Sacrococcyx [tailbone] .Reclassified from shear injury [tissue layers shift in opposite direction] to Pressure injury by wound MD [medical doctor] during wound rounds. The review further indicated the Sacrococcyx pressure ulcer was Stage 4. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, WOUND ORDER: Pressure-Stage 4: WOUND VAC [uses suction to promote wound healing] .Ensure negative pressure is set at 125 mmHg [millimeters of mercury, a unit of pressure measurement] .one time a day every Tue [Tuesday], Thu [Thursday, Sat [Saturday]. During a review of Resident 1's physician order, dated 9/24/24, the order indicated, Monitor Wound Vac dressing patency and functionality. every shift. During a review of Resident 1's physician order, dated 10/5/24, the order indicated, WOUND ORDER: Sacrococcyx-Stage 4 Pressure: Cleanse area with normal saline [mixture of water and salt] and pat dry. Apply calcium alginate [absorptive, non-occlusive wound dressing] with honey and pack with AMD [antimicrobial, kills or stops growth of bacteria] gauze. Cover with foam dressing. one time a day. During a review of Resident 1's care plan, initiated on 5/20/24, the care plan indicated, The resident has a Skin shear/potential for skin tear of the sacrococcyx .Reclassified to Stage 4 Pressure (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055887 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 10/30/2024 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)