Inspection·August 21, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure physician orders and consistent monitoring were followed in accordance with professional standards for Resident 1, when Resident 1's side effects were not consistently monitored and treatments not done as ordered by the physician.This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being.Resident 1 was originally admitted to the facility in May 2024 with multiple diagnoses which included sepsis (extreme response to infection) due to methicillin resistant staphylococcus aureus (type of bacteria), urinary tract infection (infection in the urinary system), type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin), cellulitis (skin infection) of left lower limb, pain in right hip, and dysphagia (difficulty swallowing foods or liquids). A review of Minimum Data Set (MDS, an assessment tool), dated 2/5/25, indicated Resident 1 had impaired cognition.A review of Resident 1's Order Summary Report, with start date 2/3/25, indicated, Preparation H [medication used to relieve the symptoms of hemorrhoids, such as itching, swelling, and discomfort] Rectal Ointment 0.25-14-74.9 % (Phenylephrine-Mineral Oil-Petrolatum) Insert 1 application rectally every day and night shift for skin maintenance.A review of Resident 1's Medication Administration Record (MAR-a legal document used to record medications given to the residents), for the month of February 2025, indicated ointment for skin maintenance was not applied on 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25 and 2/9/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 2/5/25, indicated, MIDLINE [midline catheter is a thin, soft tube that is placed into a vein, usually in the arm]: Flush before and after administration of medications with 10ml [milliliters-unit of measurement] NS [normal saline] every shift.A review of Resident 1's MAR for the month of February 2025, indicated midline flushing was not done on 2/7/25, 2/8/25, 2/9/25, 2/12/25, and 2/15/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 2/5/25, indicated, MIDLINE: Monitor every shift for s/s [signs and symptoms] of infection every shift.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for midline infection was not done on 2/7/25, 2/8/25, 2/9/25, and 2/15/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, monitor for s/s of constipation, delirium, over sedation, changes in mental status, and reduced respirations. every shift for OPIOID [drug used to reduce moderate to severe pain] use.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for s/s of opioid use was not done on 2/3/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, monitor for s/s of dehydration, electrolytes [minerals that help regulate the body's fluid balance], AKI [acute kidney injury], edema [swelling], weight changes, and congestion. every shift for diuretic [medication that increases urine production] use.A review of Resident 1's MAR for the month of February 2025, indicated monitoring for s/s of diuretic use was not done on 2/3/25 as physician ordered. A review of Resident 1's Order Summary Report, with start date Residents Affected - Few (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 3 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 08/21/2025 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)