Inspection·August 15, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and irritability. *shake well for 15 sec*. Start date 05/19/2025; 8. ENTERAL: May Crush Medications And Give Via GTube Unless Contraindicated -D/C [discontinue] Date- 08/13/2025 1714. The order was active since 10/10/24.9. ENTERAL: Flush before and after administration of medication, 30 ml, and 10 ml in between administration of each medication. Active [since] 10/10/24.10 ENTERAL: May Crush Medications And Give all together Via G-Tube Unless Contraindicated. Active 08/13/2025.During an interview on 8/14/25 at 4:47 p.m. with LN 4, LN 4 confirmed that Resident 3's chart did not have a specific order to combine and crush medications together at the time of medication pass observation on 8/13/25, but the chart did have an order to flush between each medication. LN 4 further confirmed that right after the med pass observation on 8/13/25 at 5:14 p.m. she obtained a new PO, which indicated, ENTERAL: May Crush Medications And Give all together Via G-Tube Unless Contraindicated. Active 08/13/2025. LN 4 added that the facility had a policy that allowed staff to combine, crush, and administer enteral medications together.During an interview on 8/14/25 with LN 6, LN 6 stated that facility nurses don't combine and crush medications together for enteral tube administration, and stated, Each medication is administered separately. LN 6 indicated she was not aware of the orders that would allow the practice of combining and crushing medications together for enteral administration.During an interview on 8/15/25 at 11:14 a.m. with LN 7, LN 7 stated that she administered each enteral medication separately.During a review of the facility's policy and procedure (P&P) titled, Administering Medications Through an Enteral Tube, revised November 2018, provided by the Administrator (Admin) during the facility survey prior to 8/14/25 noon time, the P&P step 3 under general guidelines indicated, Administer each medication separately and flush between medications.During a concurrent interview and P&P review on 8/14/25 at 1:15 p.m. with the Director of Nursing (DON), the DON stated that the previously provided P&P titled, Administering Medications Through an Enteral Tube, was outdated and she provided newer version with the same title and revision date as previously [ Administering Medications Through an Enteral Tube, revised November 2018]. The updated P&P step 3 under general guidelines indicated, Administer each medication separately and flush between medications, and or may administer all medications together with flush before and after administration.During an interview on 8/15/25 at 1:51 p.m. with the Admin, the Admin confirmed that he initially provided a copy of the Administering Medications Through an Enteral Tube P&P that was outdated, and DON had the most current version. Admin was not aware of the date this modified policy was implemented.During a concurrent interview and record review on 8/15/25 at 9:19 a.m. with the facility's Medical Director (MD), Resident 3's handwritten and signed order, dated 8/13/25 at 5:14 p.m. was reviewed. The order indicated, Enteral: may crush medications and give all together via G-tube [a type of enteral tube] unless contraindicated. The MD confirmed that he was the physician for Resident 3 and he wrote the order. The MD stated, It was common sense to administer each medication separately, and he did not think nurses in the facility were combining and crushing medications together.During an interview on 8/15/25 at 2:53 p.m. with the DON, the DON stated that the updated version of the P&P titled Administering Medications Through an Enteral Tube had a printed revision date of November 2018, but it was revised and modified sometime in 2023 to include language about combining and crushing medications together. The DON confirmed that she did not update the revision date on the policy at the time of revision. The P&P changes were based on consultation with the MD, and no review of professional standards or research literature was involved. The DON could not state the specific date when this policy was implemented. During a review of the National Library of Medicine, a recognized source for scientific and professional literature, the source indicated the following publication and quoted text: Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Nursing Skills [Internet]. Eau [NAME] (WI): (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 2 of 15 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 08/15/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete [NAME] Valley Technical College; 2021. Chapter 15 Administration of Enteral Medications. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593215/.Liquid medication, or appropriately crushed medication dissolved in water, is administered one medication at a time. Medication should not be mixed because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. Between each medication, the tube is flushed with 15 mL of water, keeping in mind the patient's fluid volume status. Event ID: Facility ID: 055887 If continuation sheet Page 3 of 15 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 08/15/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to meet the communication needs for three of 30 sampled residents (Resident 12, Resident 55, and Resident 60), when:1. Resident 12, non-English speaking resident, was not provided with any communication board or devices; and2. Resident 55 and Resident 60, non-verbal dependent residents, were not provided with any visual materials to express their needs. These failures had the potential to result in Resident 12, Resident 55 and Resident 60's inability to participate in daily tasks, make choices, or have their preferences and unmet needs heard. 1. During a review of Resident 12's admission Record (AR), dated 5/2025, the AR indicated Resident 12 had diagnosis of mild cognitive impairment. During a review of Resident 12's Physician's Order (PO) dated 5/28/25, the PO indicated Resident 12 had no mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/13/25 at 10:35 a.m. inside Resident 12's room with Licensed Nurse 5 (LN 5), LN 5 confirmed Resident 12 did not speak English and there were no communication board or visuals available for use in her room. During a review of Resident 12's Communication Care Plan (CCP), dated 8/14/25, the CCP indicated, Communication: First Language Mandarin.Offer communication board for translation assist when desired.During an observation on 8/14/25 at 8:54 a.m. in Resident 12's room, Resident 12 was in bed, stared back and did not answer when spoken to in English. There were no visuals, picture boards, or symbols available at the bedside for Resident 12 to communicate her understanding or needs. During a concurrent observation and interview on 8/14/25 at 2:46 p.m. in Resident 12's room with the Infection Prevention (IP) Nurse, the IPN confirmed Resident 12 did not speak English and there were no communication board or devices available at the bedside. The IPN indicated that providing communication materials in her native language (Mandarin) meant advocating for her needs and would allow Resident 12 to get engaged and feel more connected. The IPN stated Resident 12 had the right to know what services and treatment she was getting while residing at the facility. 2. During a review of Resident 55's AR, dated 2/2025, the AR indicated Resident 55 had a traumatic brain injury (TBI, injury that occurs when an external force causes damage to the brain) and aphasia (a disorder that makes it difficult to speak). During review of Resident 55's PO, dated 2/21/25, the PO indicated Resident 55 had no mental capacity to make healthcare decisions.During a review of Resident 55's Activities of Daily Living (ADL) CP, revised 6/1/25, the ADL CP indicated, ADL functioning with self-care deficit.explain procedures before performing.During an observation on 8/13/25 at 8:54 a.m. in Resident 55's room, Resident 55 was in bed, eyes opened, unable to respond verbally but was able to move his right hand and made a thumbs-up when asked to acknowledge. There were no visual materials using pictures or symbols to outline daily routines and activities, boards with images, symbols, or words that Resident 55 could point to express needs, thoughts and emotions. During a concurrent observation and interview on 8/13/25 at 11:23 a.m., in Resident 55's room with LN 9, LN 9 confirmed Resident 55 was non-verbal and there were no communication board or visual pictures available for use. When asked what method LN 9 used to communicate with Resident 55 to explain procedures, services or treatment, LN 9 could not explain how she could communicate what nursing care or treatment Resident 55 was getting. During a concurrent observation and interview on 8/14/25 at 9:23 a.m. in Resident 55's room with the IPN, the IPN stated residents with speech, language, or communication difficulties should be provided with communication visuals or materials. The IPN added having available visuals or pictures could be effective for learning and retaining new skills, especially for tasks that are difficult to explain verbally. During a review of Resident 60's AR, dated 9/2014, the AR indicated Resident 60 had TBI and aphasia. During a review of Resident 60's PO, dated 4/30/20, Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 4 of 15 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 08/15/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the PO indicated Resident 60 had no mental capacity to make healthcare decisions.During a review of Resident 60's CCP, revised 6/25, the CCP indicated, Impaired communication related to TBI, as evidenced by (AEB) sometimes understood, sometimes understands, sometimes will speak in short sentences, usually non-verbal.have communication board at bedside and use PRN [PRN-as needed]. During an observation on 8/13/25 at 10:21 a.m. in Resident 60's room, Resident 60 was in bed, unable to answer verbally but smiled and blinked his eyes when asked to respond. There were no communication visuals available at the bedside. During a concurrent observation and interview on 8/13/25 at 11:23 a.m. in Resident 60's room with LN 9, LN 9 confirmed Resident 60 was non-verbal and there were no communication visuals available at the bedside. LN 9 stated communication board for non-verbal residents should be available so they could respond back by pointing at the pictures or visuals provided. LN 9 stated not understanding the needs of our non-verbal residents could compromise safety and could potentially lead to unmet needs. During an interview on 8/15/25 at 3:58 p.m. with the Director of Nursing (DON), when asked how staff communicated with non-verbal residents or non-English speaking residents, the DON stated the facility should have a communication plan or a device that fits the residents' needs, whether communication boards, visuals, utilizing interpretation lines or get family involvement. During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, revised 11/20, the P&P indicated, The facility's language access program will ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. It is understood that in order to provide meaningful access to services provided by this facility, translation and / or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual . Competent oral translation that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means .b: a communication board.A policy and procedure specific to communication access for non-verbal residents was requested but none was provided. Event ID: Facility ID: 055887 If continuation sheet Page 5 of 15 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 08/15/2025 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, nail care and oral hygiene were provided to five of 30 sampled residents (Resident 12, Resident 22, Resident 27, Resident 60 and Resident 77) who were unable to carry out activities of daily living (ADLs), when:1. Resident 12's toenails were long, untrimmed, curled inward and discolored;2. Resident 22's left big toenail was long, jagged, untrimmed and curled outward; 3. Resident 27 toenails were long, jagged, untrimmed, discolored and curled inward;4. Resident 60's fingernails and toenails were long, jagged and untrimmed, his nostrils had yellowish-colored substance, his upper and lower eyelids and eyebrows had white-colored-crust-dried substance, his teeth were discolored, and his lips were cracked and dry, dry and scaly skin; and, 5. Resident 77's left second finger was discolored, jagged, untrimmed and curled inward, her eyebrows and the crevice of her nose had whitish-yellowish-flaky substances, and her cheeks had food residue markings. These failures resulted in Resident 12, Resident 22, Resident 27, Resident 60, and Resident 77's unkempt appearance and compromised well-being. 1. During a review of Resident 12's admission Record (AR), dated 5/2025, the AR indicated Resident 12 was admitted in mid-2025 with diagnoses of mild cognitive impairment and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 12's Physician's Order (PO), dated 5/28/25, the PO indicated Resident 12 had no mental capacity to make healthcare decisions. During an observation on 8/14/25 at 8:54 a.m., in Resident 12's room, Resident 12 was in bed, her toenails were long, jagged, untrimmed and had black substances underneath the nail beds.During a concurrent observation and interview on 8/14/25 at 2:46 p.m., in Resident 12's room with the Infection Prevention (IP) Nurse, the IPN confirmed the findings, and stated Resident 12's toenails had to be trimmed or should be referred to the podiatrist (medical specialists who help with problems that affect the feet or lower legs). The IPN indicated that toenails could harbor dirt, bacteria and fungi, leading to infections like athletes' foot and toenail fungus. The IPN stated that poor foot hygiene could increase the risk of infections, particularly residents with diabetes or weakened immune system. 2. During a review of Resident 22's AR, dated 5/2024, the AR indicated Resident 22 had diagnoses which included dementia (a progressive state of decline in mental abilities) and embolism (block in an artery caused by blood clots) of deep veins of lower left extremity (LLE).During a review of Resident 22's PO, dated 5/24/24, the PO indicated Resident 22 had mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/14/25 at 10:15 a.m., in Resident 22's room, Resident 22 was in bed, her big left toenail was long, jagged, untrimmed, mycotic (caused by a fungus), and curled outward. Resident 22 stated her big left toenail hurt when it gets pushed or touched and wanted it to be trimmed. During a concurrent observation and interview on 8/14/25 at 10:15 a.m. in Resident 22's room with the IPN, the IPN confirmed the findings, and indicated Resident 22's big left toenail had to be trimmed. The IPN stated untreated mycotic and discolored toenails could lead to nail damage or loss, could get infected and spread to surrounding tissues. 3. During a review of Resident 27's AR, dated 5/2025, the AR indicated Resident 27 had diagnoses which included diabetes and peripheral vascular disease (PVD, a slow progressive narrowing of blood flow to the arms and legs).During a review of Resident 27's PO, dated 5/7/25, the PO indicated Resident 27 had mental capacity to make healthcare decisions. During a concurrent observation and interview on 8/13/25 at 12:06 p.m. in Resident 27's room, Resident 27's toenails were long, mycotic, jagged and untrimmed. Resident 27 indicated he wanted his toenails to be trimmed and cleaned. Resident 27 stated his toenails hurt when he wore his shoes.During a concurrent observation Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 6 of 15 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 08/15/2025 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 Residents Affected - Some and interview on 8/14/25 at 9:31 a.m., in room [ROOM NUMBER]'s room with the IPN, the IPN confirmed the findings, and indicated Resident 27's long and untrimmed toenails created a warm, moist environment conducive to the growth of fungi which could eventually lead to nail infection. The IPN confirmed Resident 27's dirty, overgrown nails could cause discomfort when wearing shoes and were more prone to cause ingrown. The IPN stated regular cleaning and trimming of toenails could help maintain comfort.4. During a review of Resident 60's AR, dated 9/2014, the AR indicated Resident 60 had diagnoses which included diabetes, contracture (a stiffening/shortening at any joint, that reduces the joints range of motion) and blepharitis (an inflammation along the edges of the eyelids). During a review of Resident 60's PO, dated 4/30/20, the PO indicated Resident 60 had no mental capacity to make healthcare decisions.During an observation on 8/13/25 at 10:09 a.m. in Resident 60's room, Resident 60 was in bed, his fingernails and toenails were long, jagged and untrimmed, upper and lower eyelids and eyebrows had white-colored-crust-dried substance, nostrils had yellowish-colored substance, teeth were discolored, and the lips were cracked and dry. During a concurrent observation and interview on 8/14/25 at 2:57 p.m., in Resident 60's room, the IPN confirmed the findings for Resident 60, and stated regular cleaning of the fingernails and toenails helped prevent odors and reduced bacteria buildup which was crucial to overall fingers and feet health; by regularly cleaning the eyelids and eyelashes, it could prevent inflammation of the eyelids that could result from oil and debris buildup, by preventing infections daily eye hygiene contribute to long term health of the eyes; cleaning the nose daily is important for overall respiratory health, helps remove dust, allergens that could cause infection, regular nasal hygiene can reduce sinus infections and improve breathing. About keeping the mouth and lips moist and discolored teeth, the IPN indicated regular brush to remove food particles and bacteria that can thrive in a dry mouth, keeping the mouth and lips moist were crucial for both comfort and overall health. The IPN stated that good hygiene practices could reduce the risk of infections and illnesses and improve the overall quality of life. 5. 5. During a review of Resident 77's AR, dated 12/2024, the AR indicated Resident 77 had diagnoses which included diabetes and bed confinement status.During a review of Resident 77's PO, dated 12/23/24, the PO indicated Resident 77 had no mental capacity to make healthcare decisions.During an observation on 8/12/25 at 9:30 a.m. and 4:01 p.m., and on 8/13/25 at 8:22 a.m. in Resident 77's room, Resident 77 was in bed, her eyebrows and the crease of her nose had whitish-yellowish-crusted substances, cheeks had liquid food markings, and the left 2nd fingernail was discolored, curled inward, jagged and untrimmed.During a concurrent observation and interview on 8/14/25 at 9:09 a.m., in Resident 77's room with the IPN, the IPN confirmed the findings for Resident 77, and indicated that personal hygiene was crucial for maintaining overall health, preventing illness and enhancing social well-being; eliminates germs and bacteria, and reduces the risk of infections and good hygiene also contributed to improved self-esteem and positive social interactions. The IPN stated Resident 77's fingernail should be trimmed.During an interview on 8/15/25 at 9:18 a.m., with the Social Services Director (SSD), the SSD indicated nail care or trimming was part of the activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The SSD stated podiatry services was an additional or supplemental service and nurses were to submit to SSD the lists of residents that needed podiatry service. The SSD pointed out that nurses and nursing assistants should trim the residents' nails and toenails weekly while waiting for the podiatrist to come which was scheduled every two months.During an interview on 8/15/25 at 3:58 p.m., with the Director of Nurses (DON), the DON stated her expectations was that staff should provide the highest set of quality care to residents like showers, nail care, grooming and hygiene. During a review of the facility's policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 7 of 15 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 08/15/2025 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and procedure (P&P) titled, ACTIVITIES OF DAILY LIVING, SUPPORTING, revised 3/18, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain and improve their ability to carry their activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, FINGERNAILS/TOENAILS CARE OF, revised 2/18, the P&P indicated, The purpose of this procedure is to clean the nailbeds, to keep nails trimmed and to prevent infections. Event ID: Facility ID: 055887 If continuation sheet Page 8 of 15 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 08/15/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to ensure the resident's environment was free from accidents or hazards for one of 30 sampled residents (Resident 61), when Resident 61 had a traumatic fall with injury. This failure resulted in Resident 61's decline in physical and psychosocial well-being.During a review of Resident 61's admission Record (AR), the AR indicated Resident 61 was admitted to the facility in late 2022 with diagnoses which included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).During a review of Resident 61's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/1/25, the MDS indicated Resident was cognitively intact.During a review of Resident 61's Care Plan (CP), revised and updated 6/18/23, the CP indicated Resident 61 was at risk for falls and injury due to bilateral above the knee amputations, paraplegia and muscle wasting and interventions included frequent checks and keeping the environment free of hazards.During a review of Resident 61's eInteract Change of Condition Evaluation (eCoC) dated 1/3/25 at 9:36 a.m., the eCoC indicated, [Resident 61] had a fall from a shower bed during enter (sic) in shower room, assigned CNA [Certified Nursing Assistant] pulled shower bed from head side of shower bed because of bump before to enter shower room bed tilted down and resident fell, resident head hit floor and bump on left side of head.During a review of Resident 61's Emergency Department (ED) Provider Notes, dated 1/3/25, the ED Provided Notes indicated Resident 61 was brought in to the ED after a ground level fall when going from hospital bed and fell backward when transferring and was diagnosed with a traumatic intracerebral hemorrhage (brain bleed) and was admitted to the intensive care unit (ICU). During a review of Resident 61's eCoC dated 7/6/25 9:46 p.m., the eCoC indicated Resident 61's change of condition was reduced glenohumeral articulation with anterior glenoid rim acute fracture after Resident 61 reported pain to his left shoulder.During a concurrent observation and interview on 8/13/25 at 11:13 a.m. in Resident 61's room, Resident 61 was observed laying on his back in bed, with his left hand swollen and fingers curled into his palm, unable to make a fist. Resident 61 indicated he recently had a fracture to his left shoulder. Resident 61 stated, I had severe pain to that [left] shoulder and the x-ray showed there was a fracture. Resident 61 further stated, I was dropped on my head when I was on the shower bed going into the shower room about five months ago. The whole shower chair fell over. I don't trust going into the shower room anymore. I told the CNA [Certified Nursing Assistant] to not bring me into the shower room headfirst. I don't know if she was irritated or annoyed, or if she did it on purpose, but she pulled on the towel that was underneath me so hard I fell off and hit my head. A lot of people had to come and help me get off the floor. I was taken to the ER [emergency room] and I was diagnosed with a brain bleed. I've had a lot of problems since then that fall. During an interview on 8/14/25 at 4:58 p.m. with LN 2, LN 2 confirmed she was the LN who completed the eCoC on 7/6/25. LN 2 stated Resident 61 complained of severe pain to the left shoulder and an x-ray was ordered. LN 2 said the x-ray was done and the results showed a left shoulder fracture. LN 2 acknowledged she did not complete a full physical assessment or evaluation of Resident 61 and did not know how the left shoulder got fractured. LN 2 confirmed she did not alert the DON or Admin of the incident.During an interview on 8/15/25 at 10:18 a.m. with LN 3, LN 3 recalled the fall incident on 1/3/25. LN 3 indicated Resident 61 had a fall in the shower room and was sent to the emergency room (ER). Resident 61 was diagnosed with a brain bleed from the fall. On Resident 61's recent diagnoses of a left shoulder fracture on 7/6/25, LN 3 stated Resident 61 reported, my shoulder hurts. An x-ray was completed, and it was discovered that Resident 61 had fractured his left shoulder. During an interview on 8/15/25 at 1:51 p.m. with the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 9 of 15 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 08/15/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (ADM), the ADM confirmed he was aware of the 1/3/25 fall but was unaware of the injury. The ADM stated the DON and Assistant Director of Nursing (ADON) should discuss the incidents and residents change of conditions during the morning IDT (interdisciplinary team) meetings. When questioned about Resident 61's recent diagnosis of a left shoulder fracture on 7/6/25 the admin stated he was unaware of the recent fracture. During a concurrent interview and record review on 8/15/25 at 2:53 p.m. with the DON and Regional Consultant (RC) the DON stated she was aware Resident 61 had a fall with injury on 1/3/25. The DON stated she knew how the fall occurred but did not conduct interviews with Resident 61 or other staff members who were involved. There was no evidence to show the shower floor had been assessed. The DON confirmed she did not initiate an incident report. The DON acknowledged she was aware of Resident 61's recent fracture to his left shoulder on 7/6/25. There was no evidence an incident report had been initiated. The DON agreed an injury would be classified as an injury of unknown origin without knowledge of how an injury occurred. The DON confirmed the incident should have been reported to the ADM.During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents - Investigating and Reporting revised 7/2017, the P&P indicated, All accidents or incidents involving residents, employees.occurring on our premises shall be investigated and reported to the Administrator. 1. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data.shall be included on the Report of Incident/Accident form.c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident.k. Any corrective action taken; l. Follow-up information .5. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Event ID: Facility ID: 055887 If continuation sheet Page 10 of 15 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 08/15/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 25.81% error rate, with eight medication errors out of 31 opportunities observed during a medication pass for two of five residents (Resident 3 and Resident 76).These failures resulted in medications not being administered in accordance with the prescriber's orders and may have affected the residents' clinical conditions.During a concurrent observation and interview on 8/13/25 commencing at 4:27 p.m., a medication pass observation was conducted with Licensed Nurse (LN 4), LN 4 was observed preparing and administering seven medications for Resident 3. LN 4 combined and crushed together six medications: Aspirin 81 mg (milligram unit of measurement, blood thinning medication), docusate sodium 100 mg (a stool softener medication), Magnesium oxide 400mg (a supplement medication), Metoprolol tartrate 12.5 mg (a blood pressure medication), Risperidone 1mg (a medication used to treat psychiatric conditions), famotidine 20mg (a medication used to tread high stomach acid). LN 4 stated that Resident 3 had an order that allowed medications to be crushed and combined together. LN 4 further prepared 5ml (milliliters, unit of measurement) of Valproic Acid 250mg/5ml (milligram/milliliter unit of concentration, a medication used for seizures or psychiatric conditions). LN 4 poured Valproic Acid suspension into the measuring cup without shaking the medication prior to pouring. LN 4 came to Resident 3's room and administered 6 combined crushed medications diluted in water, followed by 5ml Valproic acid without flushing in-between administrations through PEG tube (percutaneous endoscopic gastrostomy tube, a tube inserted through a skin incision directly into the stomach) with 30ml water flushes before and after administration. After administering medications, LN 4 came out of the room and confirmed that she administered six combined and crushed medications, followed by valproic acid without flushing in-between. LN 4 also stated that she did not shake the valproic acid medication bottle prior to administration, and she showed the bottle with directions on the label to shake for 15 seconds prior to administration.During a review of Resident 3's Physician's Orders (PO), the PO indicated the following:1. Aspirin 81 Oral Tablet Chewable, give 1 tablet via PEG-Tube one time a day for Heart health. Start Date 10/10/2024;2. Docusate Sodium, oral tablet 100mg give via PEG-tube two times a day for bowel care. Start date- 05/12/2025;3. Magnesium Oxide, oral tablet 400mg, give 1 tablet via PEG-tube one time a day for supplement. Start date 10/10/2024;4. Metoprolol Tartrate tablet, give 12.5mg via PEG-Tube two times a day for Sinus Tachycardia. Start date 11/17/2024;5. Risperidone, oral tablet 1mg, give 1 tablet via PEG-Tube two times a day for continuousyelling/screaming. Start date 01/24/2025;6. Famotidine Tablet 20mg, give 1 tablet via PEG-tube every 12 hours for GI PPx (gastrointestinal prophylaxis). Start date 10/10/2024;7. Valproic Acid oral solution 250 mg/5ml, give 5 ml via PEG tube two times a day for moodswings and irritability. *shake well for 15 sec*. Start date 05/19/2025; 8. ENTERAL: May Crush Medications And Give Via GTube Unless Contraindicated -D/C [discontinue] Date08/13/2025 1714. The order was active since 10/10/24.9. ENTERAL: Flush before and after administration of medication, 30 ml, and 10 ml in between administration of each medication. Active [since] 10/10/24.During an interview on 8/14/25 at 4:47 p.m. with LN4, LN 4 confirmed that Resident 3's chart did not have a specific order to combine and crush medications together at the time of medication pass observation on 8/13/25, but it did have an order to flush between each medication.During a concurrent observation and interview on 8/14/25 commencing at 8:34 a.m., medication pass observation was conducted with LN 5, LN 5 prepared and administered ten medications for Resident 76. Preparation and administration included Polyethylene Glycol 3350 powder (a laxative medication). LN 5 measured Polyethylene glycol 3350 powder using a medication bottle cup with a white inner measurement mark. LN 5 poured powder to the top of the inner cap thread with about 1/4 of the distance to the top of the white inner cap exposed unfilled and diluted measured Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 11 of 15 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 08/15/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete powder in 4 ounces (oz) of water before providing it to Resident 76 who took the medication orally. After administering medications, LN 5 returned to the medications cart and confirmed filling the Polyethylene glycol 3350 measuring cup to the top of the cap's thread and not covering the entire white inner cup. LN 5 confirmed that engraving on the inner cap indicated 17g [17 gram, unit of mass] with an arrow pointing to the edge of the white cup and not to the thread line. LN 5 also confirmed that directions on the bottle stated, fill to top of white section in cap which is marked to indicate the correct dose (17g). During a review of Resident 76's PO, the PO indicated, Polyethylene Glycol 3350 Give 17 gram by mouth two times a day for bowel care Mix with 4-8 oz of water, juice, coffee or tea. Hold for loose stools. Start Date04/30/2024.During an interview on 8/15/25 at 3:54 p.m. with the Director of Nursing (DON), the DON indicated that nurses should follow physician orders during medication administration, including flushing between each medication as directed, measuring medications correctly, and shaking them prior to administration as directed, and stated, Not following orders could affect the therapeutic effectiveness of the medications.During a review of the facility's policy and procedure (P&P) titled, Administering Medications Through an Enteral Tube, revised 11/2018, the P&P indicated, Verify that there is a physician's medication order for this procedure. Follow g-tube administration as ordered. Event ID: Facility ID: 055887 If continuation sheet Page 12 of 15 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 08/15/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were stored securely for a census of 86, when:1. An open container of glucometer test strips was not labeled with the open date;2. One eye drop medication had no legible open date;3. Keys to the controlled substance cabinets and refrigerator were not secured.These failures had the potential for residents to receive medications or treatments that were unsafe or with reduced potency or accuracy, and increased risk of access to controlled substances by unauthorized individuals.During a concurrent observation and interview on 8/14/25 at 10:55 a.m. with Licensed Nurse (LN 6) in the hallway near room [ROOM NUMBER], the medication cart was inspected and found an open box of glucometer test strips that was not labeled with an open date. The directions on the box indicated use within 6 months after first opening. LN 6 confirmed the box should have been labeled with an open date. LN 6 was not able to state how long after opening test strips can be stored and used.During a concurrent observation and interview on 8/15/25 at 12:04 p.m. with the Assistant Director of Nursing (ADON) in Station #1 medication storage room, latanoprost (an eye drop medication) was found in the fridge labeled with open date 02/10 and refill date 3/11/25. The ADON confirmed the observation and indicated the area was used for storing active medications. The ADON confirmed the directions on the package indicated that the medication should be used within 6 weeks of opening and verified that the latanoprost had been more than 6 weeks from the opening date.During a concurrent observation and interview on 8/15/25 at 12:25 p.m. with LN 8 in Station #1's medication storage room, a set of keys was observed hanging in a plastic bag on the wall. The keys were tested and opened the drawers and the refrigerator storing the controlled substances. LN 8 confirmed the set of keys were not secured. During an interview on 8/15/25 at 3:52 p.m. with the Director of Nursing (DON), the DON confirmed that opened glucometer test strip containers should be labeled with the open date to ensure the strips are not used beyond the indicated number of days after opening for accuracy of testing. The DON stated the latanoprost eye drop medication container open date was not legible or accurate [open date predated refill date] and had to be discarded after a certain number of days. The DON stated that keeping keys unsecured to the controlled substances cabinets and the refrigerator inside the medication room increased the potential for unauthorized access. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised 11/ 2020, the P&P indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Event ID: Facility ID: 055887 If continuation sheet Page 13 of 15 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 08/15/2025 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food preparation in accordance with professional standards for food service safety were provided for a census of 86, when:1. A kitchen staff's personal food item was found in refrigerator opened and expired;2. Low temperature dishwasher logs showed documentation of 200 parts per million (ppm - a unit of concentration to measure pollutants in water) for June, July, and August 2025; and 3. Kitchen staff did not know how to calibrate thermometers to determine food time/temperature control during lunch tray line. These failures had the potential to cause food-borne illnesses in a vulnerable population.1. During a concurrent observation and interview on 8/12/25 at 8:30 a.m., in the kitchen with the Certified Dietary Manager (CDM), the CDM confirmed a seafood item in an opened plastic container found in a cardboard box labeled, Liquid Cage Free Whole Eggs, was unlabeled with expiration date of 8/8/25 in the refrigerator door. The CDM stated this food item belonged to one of the kitchen staff. The CDM indicated that expectations were that all food items were labeled with a date, expired foods were thrown out, and kitchen staff were to use the staff refrigerators on the nursing units to keep personal food. CDM acknowledged personal food in the kitchen's refrigerator was cross contamination and could make the residents sick.During a telephone interview on 8/15/25 at 8:50 a.m., with the Registered Dietician (RD), the RD stated, that is not acceptable at all. RD indicated expectations were for staff to use the refrigerators on the nursing units to store their food, all food in refrigerators should be labeled with a name, dated when opened, and expired foods should be thrown out. The RD acknowledged that these practices prevent residents from getting sick from cross contamination of old food.During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods, revision date 2/2023, the P&P stipulated, All Time/Temperature Control for Safety (TCS) foods.refrigerated, will be.stored in accordance with guidelines of the FDA Food Code.5. All foods will be stored wrapped or in covered containers, labeled and dated, and.in a manner to prevent cross contamination.2. During a concurrent observation, interview and record review on 8/13/25 at 9:30 a.m. in the kitchen with Dietary Aid 1 (DA 1), DA 2, and CDM, DA 1 was asked to demonstrate and explain the dishwasher procedure. DA 1 said the dishwasher was a low temperature washer and she did not know the cleaning chemical used. DA 1 performed a test strip at the end of the fourth cycle final rinse, and the results were 200 ppm. DA 1 presented the Dish Machine Log test strip documentation for August 2025. The documentation showed 200 parts per million (ppm) test strip results written daily for all three meals. DA 1, DA 2 and the CDM could not explain what 200 ppm meant and could not reference an instruction manual for answers. The CDM stated, I am not a dishwasher technician. During a concurrent observation and interview on 8/14/25 at 3 p.m., in kitchen with the CDM and the Dishwasher Service Technician (DST) to discuss the dishwasher sanitizing test strip results, the DST stated he did not look at the test strip results logged by the kitchen staff. The DST reviewed the documentation for August 2025 and stated the 200 ppm number was too high. The DST confirmed the ppm results should read 50-100. The CDM stated he had not provided training or in-services for kitchen staff on how to perform sanitizing test strips for the dishwasher. The CDM acknowledged residents could get sick from too much sanitizing chemical left on plates and could have created an adverse interaction with the food.During a telephone interview on 8/15/25 at 8:50 a.m., with the RD, the RD stated her spreadsheet for July 2025 showed the dishwasher's ppm was too high. The RD stated the sanitizing test results should be between 50 to 100. The RD acknowledged the dishes have to be disinfected correctly, the right concentration must be used so that residents do not get sick from possibly ingesting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055887 If continuation sheet Page 14 of 15 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 08/15/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete sanitizing solution when eating meals.During a review of the facility's policy and procedure (P&P) titled, LOW TEMP DISH MACHINE, no date, the P&P stipulated, .Step 4:.(Test sanitizer = 50-100 PPM).During a review of the facility's P&P titled, Warewashing , revised 2/2023, the P&P stipulated, 1. The Dining Services staff will be knowledgeable in the proper.handling of sanitized dishware.2. All dish machine water temperatures will be maintained in accordance with manufacturer's recommendations for.low temperature machines.3. During a concurrent observation and interview on 8/14/25 at 11:20 a.m., in the kitchen with the [NAME] and the Certified Dietary Manager (CDM), before the start of the lunch tray-line service, the [NAME] was asked to demonstrate and explain the procedure for thermometer calibration. The [NAME] grabbed a red thermometer from a cup located on the countertop at the end of the steam table area. The cup held two other thermometers, one black thermometer and one silver thermometer. The [NAME] went over to the pan of cooked lasagna positioned on stovetop and stuck his thermometer into the food. The [NAME] could not explain his actions and could not produce thermometer calibration instructions. The CDM approached [NAME] and told him to use the ice water bath. The CDM grabbed an approximate 2L (liter - a unit of measurement) clear plastic square shaped container, added cubed ice, and filled the container with 3/4 water from the sink. The CDM told the [NAME] to place his thermometer in the iced water to do the calibration. The [NAME] and the surveyor synchronized insertion of the digital thermometers into the same cubed iced plastic container of water. The thermometers were held in water. The surveyor's thermometer read 32 degrees after 10 seconds. After approximately 45 seconds, the [NAME] was asked to verbalized his thermometer reading, he said 32.5. The [NAME] stated he did not know about an ice water bath, and indicated he used a thermometer after foods were cooked. The CDM stated she performed the thermometer calibrations and documented the results on the log sheet. The CDM acknowledged that the [NAME] was not properly trained on how to perform thermometer calibration.During a concurrent interview and record review on 8/15/25 at 1:15 p.m. in CDM's office, the CDM presented the thermometer calibration instructions, found on the bottom of the calibration log sheet dated [DATE]. The CDM confirmed that per instructions, the crushed ice was not used during the thermometer calibration, timed 30 seconds were not identified by the Cook, or herself, during the calibration, and the [NAME] used a red thermometer instead of the black thermometer that is being calibrated and logged by the CDM. The CDM stated she had not provided training or in-services for kitchen staff on how to calibrate thermometers. The CDM acknowledged the importance to have accurate temperature food checks to prevent food borne illnesses in a vulnerable population related to undercooked foods.During a telephone interview on 8/15/25 at 8:50 a.m. with the RD, the RD stated the CDM provided all training for kitchen staff. The RD acknowledged the importance to have thermometers met food code regulations to avoid compromised residents from getting sick.During a review of the facility's P&P titled, Thermometer Calibration Log INSTRUCTIONS, dated 2/2025, the P&P stipulated, All thermometers in use should be tested.for accuracy and calibrated.Ice Point Method: 1.with crushed ice.2.Wait 30 seconds.3. If the temperature is at 32 *F, remove the thermometer. It is now ready for use.During a review of the facility's P&P titled, Food: Preparation, revised 2/2025, the P&P stipulated, .4. The .Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 *F and/or less than 135 *F.10. Thermometers in use should be tested and calibrated. Event ID: Facility ID: 055887 If continuation sheet Page 15 of 15