Health inspection·December 24, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some October 2022 with multiple diagnoses including respiratory failure, paraplegia (paralysis affecting the legs), pressure ulcer stage 4 (tissue damage to skin layers, exposing, muscle tendon or bone, due to prolonged pressure to the skin) and amputation of right and left leg above the knee. A review of Resident 3's Change in Condition Evaluation, dated 12/13/24, indicated .Has Sarcoptes Scabiei Examination [scabies] .Lab sent result to show positive .Start treating all rashes with permethrin 2 doses . A review of Resident 3's MAR, for 12/1/24 to 12/31/24, indicated order dated 12/13/24, .Permethrin External 5 % (Permethrin) Apply to neck to toes topically two times a day for scabies .apply neck to toe and give resident a shower 12 hours after application of this medication . Resident 3's MAR indicated treatment was completed as ordered. A review of the Rash Case/Contact Line List Form: Resident/Employees, indicated three residents were positive for scabies and 29 residents monitored for rash or exposure to scabies. A review of an email sent to facility on 12/13/24 from the Yolo County Public Health Nurse (PHN) indicated .You will need to do a thorough assessment on all residents and staff to see if there are any additional symptomatic or suspected case of scabies .You will be expected to report on this current outbreak until it is deemed over, typically 2 incubation periods, unless otherwise specified by Health Officer .Please refer to CDPH [California Department of Public Health]'s Prevention and Control of Scabies Guidance and LA [Los Angeles] County PH [Public Health] Guidance for more information and infection control measures A review of an email sent to facility on 12/17/24 from the Yolo County Public Health Officer (HO) indicated .I strongly recommend that your facility complete a second round of treatment/prophylaxis for all residents and staff. One round of permethrin treatment is approximately 90% effective in killing scabies mites. This means that if you only provide a single round of treatment/prophylaxis .there is a 10% chance that not all mites will be eradicated, leaving the door open for recurrence of cases and potentially another outbreak. I imagine that you might be thinking, We did two rounds of treatment during the last scabies outbreak, and yet here we are again.during the last outbreak you had challenges getting enough permethrin to treat everyone at the same time, and many staff were not receptive to prophylaxis .I suspect that you have an infested staff person who has not been treated and is spreading scabies in the facility .Prophylaxis is recommended for residents and staff who are not symptomatic .While facility-wide treatment and prophylaxis requires much more work than just treating symptomatic residents, treatment of only symptomatic residents is very unlikely to stop the spread of scabies in the facility . During an interview on 12/24/24 at 10:05 a.m. with the Nursing Supervisor (NS), the NS stated a scabies outbreak was identified in the facility a few weeks ago. Three resident had positive tests after skin scrapings done by the wound doctor. The NS stated that the positive cases were in two different halls. The NS stated permethrin cream was used for all residents in the facility and all staff were offered the treatment. During an interview on 12/24/24 at 10:35 a.m. and a subsequent interview at 1:15 p.m. with the Infection Preventionist (IP), the IP stated the wound doctor performed skin scrapings on 12/12/24 for three residents, Resident 1, Resident 2, and Resident 3. The IP stated she was notified on 12/13/24 that the three residents had positive scabies tests and were treated on 12/13/24. The rest of the facility was treated on 12/15/24 after obtaining enough permethrin cream for all the facility. The staff (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 12/24/2024 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 were treated also. The IP stated that the HO recommended second permethrin treatment for all residents. The IP stated not all residents received a second treatment and most staff did not receive a second treatment. The IP stated the Director of Nursing (DON) made the decision to only retreat the Line List residents, not the whole facility because it was recommended but not required per Yolo County Public Health. The IP stated, Everyone should have been retreated, but a superior higher than me decided they did not want to retreat everyone. The IP stated residents on the Line List were retreated on 12/22/24. During an interview on 12/24/24 at 12:47 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was aware of the scabies outbreak and all residents were treated initially, but not all residents were retreated. During an interview on 12/22/24 at 1:08 p.m. with Medical Doctor (MD), the MD stated that this is the second outbreak in the facility. The MD stated all residents should be treated head to toe and facility is doing constant surveillance for possible scabies. The MD stated the facility is following Yolo County Public Health recommendations. During a telephone interview on 12/27/24 at 12:28 p.m. with the DON, reviewed with the DON that HO recommended all residents be retreated to prevent another outbreak. The DON stated, Not all residents were retreated. It was just a recommendation, not mandated. The DON stated that this is the second outbreak, but not the same residents. The DON stated staff were to be treated if had rash, but no staff have reported a rash. The DON stated, Questionable residents were retreated. Everyone else was just a recommendation. If it was mandated they [Yolo County Public Health] should have stated that. During a telephone interview on 12/31/24 at 8:35 a.m. with PHN, the PHN stated the facility had a previous scabies outbreak in September or October 2024. The PHN stated the HO recommended facility- wide treatment and retreatment for all residents and staff for the current outbreak. The PHN stated the second treatment was not done due to DON push back. The PHN stated the HO made it clear to the facility what the recommendations were. The PHN stated they can only make recommendations but cannot mandate facilities. The PHN stated the facility will not retreat unless mandated. The PHN stated, If facility is not retreated, can easily spread again .Will get infestation a second time .Suspect a staff member is a carrier. A review of the facility's Policy and Procedure (P&P) titled Infection Prevention and Control Program, revised 10/18, indicated .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .:Outbreak management is a process that consists of .preventing the spread to others .reporting the information to appropriate public health authorities .The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases .Important facets of infection prevention include .instituting measures to avoid complications or dissemination .following established general and disease-specific guidelines . A review of CDPH document titled Prevention and Control of Scabies in California Healthcare Settings, dated 8/20, indicated .Controlling the Outbreak .Control of a scabies outbreak involves a choice between treating only symptomatic cases and their known contacts or facility-wide (mass) prophylaxis of all possible contacts including asymptomatic patients/residents, HCP [Healthcare Providers], volunteers, and visitors. Treatment of only symptomatic cases and their identified contacts may result in silent, continuous transmission over a sustained period of time due to delay in onset of symptoms (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 12/24/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete and delay in diagnosis and treatment. Failure to identify and treat even one contact can result in continued propagation of the outbreak. As a result, repeated prophylaxis of asymptomatic HCP and volunteers may be required .An outbreak that has likely been ongoing for a month or more is rarely controlled treating only symptomatic cases . Consultation with your local public health department is strongly recommended . A review of LA county document titled Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/19, indicated .Facility-wide (mass) prophylaxis of all patients/residents and at-risk HCW [Healthcare Worker] (HCW involved in direct patient/resident care or exposed to the patient/resident care environment) should be considered if positive skin scrapings are found in patients/residents or employees assigned to two or more areas of the facility where no direct link with an infested patient/resident or HCW can be established Event ID: Facility ID: 055887 If continuation sheet Page 4 of 4