Health inspection·February 25, 2026

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 the needs of residents were accommodated for five of nine sampled residents (Resident 3, Resident 4, Resident 5, Resident 6 and Resident 7) when:Resident 3 and Resident 4 did not have a call light system that accommodated their special needs; and, 2. Resident 5, Resident 6, and Resident 7 did not have their call lights within reach.These failures had the potential to result in residents being unable to ask for needed assistance and not attaining their highest practicable physical, psychosocial, and emotional well-being.Findings:1.During a review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 3 was admitted to the facility November 2023 with multiple diagnosis including contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left and right hand.During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/5/26, the MDS indicated Resident 3 was dependent with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 4's face sheet, indicated Resident 4 was admitted to the facility February 2023 with multiple diagnosis including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury).During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was dependent with ADLs.During a concurrent observation and interview on 2/25/26 at 12:07 p.m. with Licensed Nurse (LN) 1 in Resident 3's and Resident 4's room, Resident 3 and Resident 4 had their call lights placed on their chest. LN 1 confirmed Resident 3 and Resident 4 had mobility issues that prevented them from using their call light. LN 1 further stated she did not know how Resident 3 and Resident 4 would be able to use their call light if they needed help.During an interview on 2/25/26 at 12:38 p.m. with Director of Nursing (DON), DON confirmed Resident 3 and Resident 4 were not given accessible call lights. DON stated, Why would I give him (resident) an accessible call light if he can't move? We don't do assessments for accessible call lights. They can't press them anyways.During a review of the facility's policy and procedure (P&P) titled, Resident Rights revised December 2016, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity.these rights include.a dignified existence.The facility did not provide a policy and procedure for Call Light accessibility upon request. 2.During a review of Resident 5's face sheet, the face sheet indicated Resident 5 was admitted to the facility December 2022 with multiple diagnosis including respiratory failure.During a review of Resident 6's face sheet, the face sheet indicated Resident 6 was admitted to the facility October 2022 with multiple diagnosis including anoxic (when the brain receives no oxygen at all) brain injury.During a review of Resident 7's face sheet, the face sheet indicated Resident 7 was admitted to the facility February 2026 with multiple diagnosis including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a concurrent Residents Affected - Some Page 1 of 2 055887 055887 02/25/2026 River Bend Nursing Center 2215 Oakmont Way West Sacramento, CA 95691

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observation and interview on 2/25/26 at 12:17 p.m., with LN 2 in Resident 5's and Resident 6's room, Resident 5 and Resident 6 were lying in bed, and their call lights were on the floor. LN 2 confirmed the call lights were not within the residents' reach. LN 2 acknowledged call lights on the floor were a safety issue.During a concurrent observation and interview on 2/25/26 at 12:21 p.m., with Respiratory Therapist (RT) in Resident 7's room, Resident 7 was lying in bed and her call light was on the floor. RT confirmed the call light was out of the resident's reach. RT acknowledged resident would not be able to use call light to get help.During a review of the P&P titled, Answering the Call Light, revised September 2022, the P&P indicated, .Ensure that the call light is accessible to the resident when in bed. 055887 Page 2 of 2