Other·February 25, 2020

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00651253. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 41197 Health Facilities Evaluator Nurse, 33361 Health Facilities Evaluator Nurse, 29108 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 01/17/2020 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 1 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on staff interview, clinical record and policy review, the facility failed to develop a baseline plan of care to meet the immediate needs for one of ten sampled residents (Resident 6) within 48 hours of admission. This facility failure caused Resident 6 to be at risk of a delay in necessary treatment and nursing care interventions to meet the resident's immediate needs. Review of Resident 6's clinical record revealed an "Admission Record," which indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 2 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident was readmitted to the facility in July of 2019, with diagnoses of paraplegia (paralysis of the legs), chronic respiratory failure, a tracheostomy (an incision made in the neck for a person to breathe through) with dependence on a ventilator (a machine that breathes for a person), and a feeding tube. Review of Resident 6's clinical record revealed the presence of the following documents: A plan of care created by a licensed nurse, dated 7/9/19, related to the resident being prescribed a medication to "aid in sleep." A plan of care created by an occupational therapist, dated 7/10/19, related to the resident requiring occupational therapy to address the presence of bilateral (right and left) arm contractures (a condition of shortening and hardening of muscles, tendons and other tissue often leading to deformity and rigidity of joints). Review of Resident 6's clinical record contained no documented evidence of additional nursing care plans initiated on or before 7/10/19 to address immediate care needs related to the multiple admission diagnoses. A concurrent interview and record review was conducted with the Director of Nurses (DON), on 11/21/19 at 5:08 p.m. The DON provided a document titled, "Baseline Care Plan (DBTPA) - V 3.0," effective date 7/19/19. The DON confirmed the document's effective date as 7/19/19. The DON also indicated the document contained both the resident's initial admission date and readmission date to the facility. The DON was unable to provide additional documented evidence of a baseline care plan initiated within 48 hours of the resident's readmission to the facility related to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 3 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admission diagnoses such as tracheostomy or ventilator care. Review of a facility policy entitled "Care Plans Baseline," undated, indicated, "A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The policy further indicated, "The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs..."

F657 SS=E Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 01/17/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 4 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on staff interview, record review, and policy review, the facility failed to review and revise a person-centered comprehensive care plan with individualized approaches for three of ten sampled residents (Resident's 6, 7, and 8) when: 1. Resident 6: a) Was admitted to the facility with bilateral arm contractures (a condition of shortening and hardening of muscles, tendons and other tissue often leading to deformity and rigidity of joints) identified by staff as interfering with wound healing. b) Exhibited refusal of care behaviors. c) Had a sacral (tail bone area) wound worsen and require a wound vac (negative pressure wound therapy - a device placed over a wound to create suction in the wound bed used to promote wound healing). 2. Resident 7: a) Had a Foley catheter (a tube inserted into the bladder to drain urine) present throughout admission. b) Was readmitted to the facility with a nephrostomy tube (a surgically inserted tube into the kidney used to drain urine when the normal flow of urine is obstructed). c) Exhibited hypothermia (body temperatures below 95 degrees, where normal is 98.6 degrees) in the month of August. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 5 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE d) Exhibited signs of bleeding and had medications held as a result. 3. Resident 8: a) Presented with abnormally high blood glucose levels over a period of two weeks. These facility failures had the potential to result in inconsistent and delayed care and treatment for Resident's 6, 7, and 8. 1. Resident 6: Review of Resident 6's clinical document titled, "Admission Record," indicated the resident was originally admitted to the facility in June of 2019, and readmitted to the facility in July of 2019. Resident 6 was admitted with diagnoses of paraplegia (paralysis of the legs), chronic respiratory failure, a tracheostomy (a surgical incision made into the windpipe for a person to breathe through) with dependence on a ventilator (a machine used to breathe for a person), and a feeding tube. a) Contractures: Review of a "History and Physical," dated 6/12/19, indicated Resident 6 was admitted to the facility with bilateral arm contractures. In an interview with the facility Wound Care Physician (WCP) on 9/10/19 at 12:52 p.m., the WCP reported Resident 6 had significant contractures to both arms that prevented the resident from being fully off loaded of wounds. The WCP further stated the primary way to promote wound healing is to turn or "offload" residents off of their wounds. In an interview with the DON on 9/11/19 at 3:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 6 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., the DON confirmed Resident 6 was unable to be fully offloaded of her wounds due to the contractures in her arms. A review was conducted of the plans of care present in Resident 6's clinical record. One care plan was present to address the resident's contractures related to splint wearing and application, and was initiated by the occupational therapy department. The plan of care had no identified focus or problem of contractures interfering with wound healing. Further, the plan of care had no interventions implemented by nursing staff or any other facility discipline. The Care Plan had an initiated date of 7/10/19 and a goal target date of 7/25/19. In an interview with LN 3 on 11/1/19 at 10:06 a.m., LN 3 indicated plans of care for Resident 6's wounds were initiated. LN 3 further stated she could not remember if any specific interventions were included in the wound care plans such as problems with repositioning or contractures. Review of a facility policy titled "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed the comprehensive person-centered care plan will, "Incorporate risk factors associated with identified problems." b) Refusal Behaviors: Review of Resident 6's clinical record indicated a "Skin/Wound Note," dated 7/11/19 at 9:49 a.m. The note indicated Resident 6 was "noncompliant with turning," and the plan was to educate the resident in the importance of turning and repositioning as tolerated every two hours "to offload wound and promote wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 7 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE healing." An additional "Skin/Wound Note," dated 7/12/19 at 4:39 p.m., was reviewed. The note reported the resident continued to be "noncompliant with off-loading, turning and repositioning." The note further indicated Resident 6 was educated on the importance of off-loading wounds to promote healing. Further review of Resident 6's clinical record revealed a "Skin/Wound Note," dated 7/18/19 at 7 p.m., which indicated Resident 6 was turned side to side and "refuses at times." A July admission MDS (Minimum Data Set, an assessment tool), dated 7/19/19, was present in the clinical record. The MDS indicated the "resident rejected evaluation or care that is necessary to achieve the resident's goals for health and well-being." Resident 6's clinical record contained a "Skin/Wound Note," dated 7/29/19 at 2:41 p.m. The note indicated the resident continued to be non-compliant with turning "at times." An additional "Skin/Wound" nurse progress note, dated 8/8/19 at 3:01 p.m., reported Resident 6 "refused scheduled wound treatments at this time." In an interview with Licensed Nurse (LN) 3 on 9/11/19 at 11:35 a.m., LN 3 stated Resident 6 did refuse repositioning at times. LN 3 further reported attempts to educate the resident in the importance of turning were conducted. In an interview with the Director of Nurses (DON) on 9/11/19 at 3:30 p.m., the DON was asked what interventions were implemented to address Resident 6's refusal behaviors. The DON did not refer to the resident's care plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 8 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but indicated that information should have been obtained through staff interview. A review of Resident 6's initiated care plans were conducted. The four following plans of care, dated 7/24/19 were present: "The resident has pressure ulcer on Sacrum/coccyx [tailbone area] ...," "The resident has pressure ulcer on right ischium [the curved bony area at the base of the buttock] ...," "The resident has pressure ulcer Right posterior [back] shoulder ...," and "The resident has pressure ulcer on left ischium ..." Each of these four care plans had the following identical intervention listed: "If The resident refuses treatment, confer with the resident, IDT [Interdisciplinary Team] and family to determine why and try alternative methods to gain compliance. Document alternative methods." No documented evidence was present in Resident 6's care plans to solely address refusal of care behaviors. Further, the existing plans of care contained no documented evidence to indicate what, if any, interventions were provided to determine why Resident 1 was refusing care or any other alternatives tried by facility staff to gain compliance. Additionally, the four wound care plans all had an initiated date of 7/24/19, a revision date of 7/24/19, and a goal target date of 7/25/19. Review of a facility policy titled, "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed the comprehensive person-centered care plan will, "Describe services that would otherwise be provided ...but are not provided due to the resident exercising ...the right to refuse treatment." c) Sacral Wound Requiring Negative Pressure Therapy: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 9 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 6's clinical record contained an "Admit/Readmit Assessment," dated 7/8/19. The assessment indicated Resident 6 had a pressure wound on the coccyx/sacral area at the time of readmission to the facility. Further review of Resident 6's record indicated Wound Care Physician (WCP) "Surgical Consult" notes for dates 7/9/19, 7/16/19, 7/23/19, 7/30/19, and 8/6/19. All referenced notes contained a description of a sacral wound. A review of Resident 6's "Medication Review Report," dated 8/1/19-8/31/19, was conducted. The report listed changes to physician orders for wound care of the sacrum with a start date of 8/4/19. The report further indicated additional new physician orders with a start date of 8/9/19, to apply a negative pressure wound vac to the existing sacral wound. A plan of care with a focus on a Sacrum/coccyx wound was reviewed. The plan of care was initiated on 7/24/19 and had a revision date of 7/24/19. The plan of care contained no documented evidence to indicate treatment orders were changed in the month of August for the wound. Further, the care plan contained no interventions related to the placement of a wound vac to treat the sacral wound. In an interview with LN 3 on 11/1/19 at 10:06 a.m., LN 3 indicated care plans were initiated to address Resident 6's wounds. LN 3 further stated she could not remember if any specific interventions were included in the care plans related to a wound vac. Review of a facility policy titled, "Care Plans, Comprehensive Person-Centered," revised December 2016, was conducted. The policy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 10 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE directed, "Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change." 2. Resident 7 Resident 7's clinical "Admission Record," indicated Resident 7 was originally admitted to the facility in 2016 with diagnoses of traumatic brain injury, persistent vegetative state, diabetes, chronic kidney disease, and frequent urinary tract infections. a) Foley Catheter: A review of Resident 7's facility provided care plan related to a Foley catheter was completed. The document was dated 11/2/18 and listed a problem area of "Potential for infection related to use of Foley catheter to gravity drain AEB [as evidenced by] inability to pass urine with retention of urine. The care plan goal listed specified "Will be free of signs and symptoms of UTI [urinary tract infection] daily x 3 months." No goal date was listed, and according to the document, the care plan was last reviewed on 2/14/19. Review of Resident 7's MDS, dated 5/17/19, indicated the Resident had a Foley catheter in place. Additional document review indicated the presence of three documents titled, "Weekly Summary Assessment," dated 7/10/19, 7/16/19, and 8/5/19. The documents each indicated the resident continued to have a Foley catheter present. An "SBAR [Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 11 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE appropriate communication] GENERAL" note was reviewed, dated 8/8/19 at 10:04 p.m. The note reported " ...patient has a history of recurring UTI's...," and further indicated Resident 7 had just completed antibiotic (a medication to treat infection) therapy for a urinary tract infection on the morning of 8/8/19. In a concurrent interview and record review with the DON on 11/21/19 at 5:08 p.m., the DON confirmed the review date of 2/14/19 on the care plan related to a Foley catheter. The DON further stated there was "nothing newer than what is on paper," related to care plan review dates. Review of a facility policy titled, "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed, "The Interdisciplinary Team must review and update the care plan ...When the desired outcome is not met;...and...At least quarterly..." b) Nephrostomy Tube: Review of a "History and Physical" report, dated 7/2/19, indicated Resident 7 was readmitted to the facility with a nephrostomy tube. Further review of Resident 7's clinical record indicated no plan of care was implemented or revised related to nephrostomy tube care with nursing interventions. In a concurrent interview and record review with the DON on 11/21/19 at 5:08 p.m., the DON confirmed the record contained no care plan related to a nephrostomy tube. A facility provided policy titled, "Nephrostomy Tube, Care of," Revised October 2010, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 12 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reviewed. The policy directed to, "Review the resident's care plan to assess for any special needs of the resident." Review of a facility policy titled, "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed, "The Interdisciplinary Team must review and update the care plan ...When the resident has been readmitted to the facility from a hospital stay ..." c) Hypothermia: Review of Resident 7's clinical record indicated a plan of care with a focus of "Presents with change in condition AEB [As Evidenced By] Hypothermia." The care plan revealed a date initiated of 4/25/19. The hypothermia care plan contained no revision dates, but a target date of 7/20/19. A "Nurse's Note," dated 8/8/19 at 10:22 a.m., reported, "Pt [patient] hypo-thermic, warming measures provided. Will continue to monitor." Resident 7's clinical record contained no documented evidence of a body temperature recorded at this time. A "Nurse's Note," dated 8/8/19 at 2:25 p.m., indicated, "Pt remains hypothermic; warming measures continued. Will continue to monitor..." and the nurse would report to the next shift. Review of a document titled, "Weights and Vitals Summary," indicated on 8/8/19 at 2:37 p.m., Resident 7 had a body temperature of 92 degrees (where normal body temperature is 98.6 degrees and anything below 95 degrees is considered a medical emergency). Further review of Resident 7's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 13 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE revealed a "Nurse's Note," dated 8/8/19 at 3:58 p.m. The note indicated, "patient is hypothermic," at 94.2 degrees and "warming measures applied, will recheck temperature." An interview was conducted with LN 6 on 11/21/19 at 4:50 p.m. regarding Resident 7. LN 6 indicated he remembered the resident being hypothermic, and applying warming measures, such as putting warm blankets on the resident. Review of a facility policy titled "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed, "The Interdisciplinary Team must review and update the care plan ...When there has been a significant change in the resident's condition ..." d) Bleeding: According to an 8/8/19 1:41 a.m. "Nurse's Note," Resident 7 was noted to have bleeding to the " ...bilateral [both sides] inner thighs, abdominal folds, inferior [below] aspect [view from a particular direction] to the anal cavity and bilateral gluteal area..." An "Incident/SBAR" note, dated 8/8/19 at 4:51 a.m., was present in the clinical record. The note indicated cleaning the resident during incontinence care "produces blood." The note further reported, "It takes time for the bleeding to stop." Review of an "Order Note," dated 8/8/19 at 8:27 a.m., indicated blood was noted to Resident 7's nephrostomy tube and Foley catheter. Blood was also noted to be seeping through the skin on the resident's back and buttocks, and the note indicated the physician had been notified and an order to hold the resident's aspirin was obtained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 14 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A facility provided care plan related to "Anticoagulant Therapy" for Resident 7 was reviewed. The plan of care was dated 11/2/18 and indicated the goals were to be reevaluated quarterly and as needed. The plan further indicated to observe the resident for abnormal bleeding. The document had a listed review date of 2/14/19. In a concurrent interview and record review with the DON on 11/21/19 at 5:08 p.m., the DON confirmed the review date on the care plan of 2/14/19. The DON further stated there was "nothing newer than what is on paper," related to care plan review dates. Review of a facility policy titled "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed "The Interdisciplinary Team must review and update the care plan ...When there has been a significant change in the resident's condition..." 3. Resident 8: Review of a facility document, titled "Admission Record," indicated Resident 8 was originally admitted to the facility in March of 2013. Resident 8 was admitted with diabetes, respiratory failure, a tracheostomy, and a severe pressure wound. a) Elevated blood glucose levels: Review of a facility provided "Diabetes Resident Care Plan" was conducted. The plan of care was dated 8/2/18 and indicated the resident had the potential for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to Diabetes. A listed goal was to reevaluate in three months. The last FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 15 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review date listed on the care plan was 11/15/18. Review of Resident 8's clinical record revealed a plan of care, dated 7/26/19, addressing a nutritional risk related to the presence of a pressure ulcer and diabetes. The care plan was created by a dietician and had a listed goal for the resident to have "...no signs/symptoms of hyper/hypoglycemia daily." The goal had a listed target date of 6/20/13, and contained no nursing interventions. Review of Resident 8's clinical record indicated a medication administration record, dated 8/1/19-8/31/19, exhibiting blood sugar levels checked every day at midnight, 6 a.m., 12 p.m., and at 6 p.m. Of the over 70 blood sugar levels documented, only three were considered within normal limits (70-150) and did not require insulin (a medication to help lower blood sugar) to be administered. The remaining documented blood sugar values documented were greater than 150, with the highest value being 512. In a concurrent interview and record review with the DON on 11/21/19 at 5:08 p.m., the DON confirmed the review date on the care plan as 11/15/18. The DON further stated there was "nothing newer than what is on paper," related to care plan review dates. Review of a facility policy titled, "Care Plans, Comprehensive Person-Centered," Revised December 2016, was conducted. The policy directed "The Interdisciplinary Team must review and update the care plan...When the desired outcome is not met ..."

F684 SS=H Quality of Care CFR(s): 483.25

F684 01/17/2020 § 483.25 Quality of care Quality of care is a fundamental principle that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 16 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and clinical record review, the facility failed to completely assess and/or intervene timely with changes of condition for three of ten sampled residents (Resident 6, Resident 7, and Resident 8) when: 1. Resident 6 presented with signs and symptoms of infected and worsening wounds, low blood pressure, and fluctuating changes in behavior with altered levels of consciousness over a seven-day period before being sent to the hospital with a critically low blood pressure and oxygen level. 2. Resident 7 presented with bleeding, hypothermia (a medical emergency consisting of a dangerously low body temperature below 95 degrees) and low blood pressure for approximately 12 hours before being sent to the hospital. 3. Resident 8 presented with an elevated blood sugar followed by a progressive worsening altered level of consciousness over an approximate period of 36 hours, became unresponsive and was sent to the hospital. These failures resulted in residents' continued deterioration and a delay in needed medical attention, placing the residents at increased risk for death, and resulted in the death of one resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 17 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Resident 6: Review of Resident 6's clinical document titled, "Admission Record," indicated the resident was readmitted to the facility in July of 2019. Resident 6 was admitted with diagnoses of paraplegia (paralysis of the legs), chronic respiratory failure, a tracheostomy (a surgical incision made into the windpipe for a person to breathe through) with dependence on a ventilator (a machine used to breathe for a person), and a feeding tube. A "Nurse's Note," dated 7/8/19 at 10:59 p.m., was reviewed. The note indicated Resident 6 had arrived to the facility earlier in the day and was alert and oriented to person, place, time and situation. The note reported Resident 6 was able to, "mouth words and make head gestures to make needs known." The note also indicated Resident 6 had eyes with regular, equal pupils and they were reactive to light. Resident 6 was also noted to have, "adequate sight and hearing." A Minimum Data Set (MDS, an assessment tool) admission assessment, dated 7/19/19, was reviewed. The MDS indicated the resident was cognitively intact and required complete dependence on staff for bed mobility, toileting and bathing. A "Surgical Consult" note from the Wound Care Physician (WCP), dated 7/23/19, was present in the medical record. The report detailed wounds with signs of infection on Resident 6's body. The note described a right ischial (the curved bony area at the base of the buttock) wound with the following signs of infection: inflammation and yellow drainage. A sacral (tailbone area) wound was described as being bigger in size compared to a previous assessment on 7/16/19, having "infected FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 18 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tissue," dead tissue, and delayed healing. A review of Resident 6's "Medication Review Report," dated 7/1/19-7/31/19, indicated a physician's order to start antibiotics (a medication to treat infection) on 7/23/19. The order further indicated to administer the antibiotics, "every 12 hours for wound healing for 10 days." An additional "Surgical Consult" note from the WCP, dated 7/30/19, was reviewed. The report detailed several wounds with continued signs of infection. The note described the surrounding area of a left ischial wound as unhealthy, inflamed and bigger in size, as compared to a previous assessment on 7/23/19. A right ischial wound was noted to contain the following signs of infection: heavy drainage, delayed healing, and necrotic (dead) tissue. A sacral wound was described as being bigger in size compared to a previous assessment on 7/23/19, having infected tissue, dead tissue, and having an unhealthy, inflamed and unstable surrounding area. A review of Resident 6's "Medication Administration Record," dated 8/1/19-8/31/19, was conducted. The record indicated the resident received the last dose of antibiotics "for wound healing" on 8/2/19 at 6 a.m. An additional "Surgical Consult" note from the WCP, dated 8/6/19 (four days after antibiotics were completed), was reviewed. The note detailed the same wounds with continued signs of infection as compared to the previous assessment conducted on 7/30/19. The note described the left ischial wound with the following signs of infection: inflammation, heavy drainage, necrotic (dead) tissue, and induration (localized hardening of the tissue from excess fluid). The wound was also documented as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 19 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE being larger in size as compared to the previous assessment on 7/30/19. A right ischium wound was noted to also be bigger in size as compared to the previous assessment, have moderate purulent (consisting of pus) drainage, and have an inflamed surrounding area. The sacral (tailbone area) wound was described as being bigger in size and having "infected tissue," dead tissue, redness and inflammation, and heavy drainage. A "Diagnostic Laboratories [lab] & Radiology" report, dated 8/6/19, was reviewed. The lab report indicated the resident had blood work completed and many results were abnormal. The white blood cell count (indicates the number of white blood cells per microliter (a unit of measurement) of blood), where an elevated value can indicate the presence of infection, was higher than normal range (normal white blood cell range is considered 4,000 to 10,000) at 13,400. The report further indicated the resident's platelet count was nearly twice the previous report on 7/27/19 at 406 (normal platelet range is 150-400, where an elevated number can indicate inflammation). A "Weights and Vitals Summary," with blood pressures listed for dates 8/1/19 through 8/13/19 was reviewed. The document indicated Resident 6's blood pressure documented on 8/7/19 at 9:56 a.m., and 9:58 a.m., was 88/40 (normal range is considered 90/60-120/80). According to the document, 88/40 was the lowest value recorded compared to the previously recorded values. An "Orders - Administration" note, dated 8/7/19 at 9:56 a.m., indicated a prescribed blood pressure medication was not given to the resident because the blood pressure was too low. The note contained no documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 20 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE evidence other measures were taken to intervene with the low blood pressure, other assessments had been conducted, or a physician had been notified. In an interview with Licensed Nurse (LN) 11 on 11/21/19 at 1:50 p.m., LN 11 indicated a call was placed to the physician to notify of the low blood pressure and medication held. LN 11 confirmed no documentation existed regarding the phone call. LN 11 further stated if a Resident's blood pressure was low, it would be rechecked an hour later to see if it had improved and this would also be documented in the record. LN 11 was unable to indicate where the resident's blood pressure had been rechecked. A "Nurse's Note," dated 8/7/19 at 4 p.m., was reviewed. The note reported Resident 6 was, "awake but unaware, eyes open but no tracking. pt [patient] is unaware." The note contained no documented evidence a physician was notified of the resident's change in consciousness, or further assessments and interventions were completed. In an interview with LN 6 on 11/21/19 at 4:32 p.m., LN 6 indicated he remembered Resident 6 was normally alert and oriented and was able to make her needs known to staff. LN 6 further reported the resident would have episodes of being awake with eyes open, but nonresponsive. LN 6 stated this generally happened related to infection, and "she did get frequent UTI's [urinary tract infections] and had multiple stage four wounds [wounds categorized as having full-thickness skin and tissue loss where muscle, ligaments, and bone are exposed]." The same "Weights and Vitals Summary," report for August was reviewed. The report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 21 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated the resident's next recorded blood pressure was not until 8/7/19 at 5:05 p.m., approximately seven hours later than the previously recorded blood pressure. An "Orders - Administration" note, dated 8/7/19 at 5:05 p.m. was reviewed. The note indicated Resident 6 had medication held again for a low blood pressure. The note contained no documented evidence a physician was notified of the now combined low blood pressure and altered level of consciousness. In the same interview with LN 6 on 11/21/19 at 4:32 p.m., LN 6 confirmed there was no documentation to support a physician was notified of both the resident's low blood pressure and change in mentation. LN 6 indicated "I did intervene and let the doctor know," but was unable to indicate what the interventions were and when the physician was notified in the resident's medical record. An "Orders - Administration" note, dated 8/8/19 at 9:27 a.m., was reviewed. The note indicated Resident 6 had medication held again for a low blood pressure. The note contained no documented evidence a physician was notified of the resident's blood pressure medications being held for a second day in a row due to low blood pressure. An additional "Orders - Administration" note, dated 8/8/19 at 5:06 p.m., was present in the clinical record. The note indicated Resident 6's blood pressure was again below the prescribed parameters to administer blood pressure medication. The note contained no documented evidence related to a physician being notified of the persistent withholding of the resident's blood pressure medications. In an interview with Resident 6's medical doctor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 22 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (MD), on 11/14/19 at 7:45 a.m., the MD indicated he was sure he was notified of the resident's two consecutive days of blood pressure medication being held. The MD further indicated it would be documented in the record if he was aware. Resident 6's clinical record contained a "Physician's Progress Note," signed by a Physician's Assistant (PA) and dated 8/8/19. The note documented the resident's blood pressure as "92/48," and to continue "acute care." The note contained no further documented evidence of changes made to the resident's plan of care, changes to medications, or additional diagnostics ordered to determine the cause of the resident's low blood pressure combined with an altered level of consciousness. Additionally, the note contained no documentation related to the resident's wounds which were exhibiting signs and symptoms of infection. A "Nurse's Note," dated 8/8/19 at 10:51 p.m., was present in the clinical record and indicated Resident 6 had verbalized more than once "im [sic] going to die. God is coming to get me," and was pleading for someone to "stop him." The note further indicated the nurse, "will continue to monitor." An additional "Nurse's Note," dated 8/8/19 at 11:57 p.m., further indicated Resident 6 was continuing to verbalize "God is coming to get me, he wants me to die, I think am going to die." The note contained no documented evidence any other care provider was made aware of the continued change in Resident 6's behavior, or a plan of care was implemented to assist Resident 6 with a new onset of feelings of imminent death. Two additional "Nurse's Note," dated 8/9/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 23 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1:13 a.m. and 3:48 a.m., were present in the clinical record. The notes indicated Resident 6 was now hallucinating. The first note detailed Resident 6 was seeing "a Mexican guy in the room who ran away ...call the cops to get the guy." The second note reported Resident 6 was "seeing six kids in the room who were causing trouble and an old lady who was impatient with the kids." Both notes indicated the nurse oriented the resident to the environment. The notes contained no documented evidence other interventions were taken, assessments were conducted, or a physician was notified of the progressive changes in Resident 6's mentation. In an interview with Resident 6's medical doctor (MD), on 11/14/19 at 7:45 a.m., the MD indicated he was sure he was notified of the resident's combined low blood pressure and altered level of consciousness. The MD further indicated he had felt the resident had "recovered." A "Social Service Note," dated 8/9/19 at 3:34 p.m., was present in the clinical record. The note indicated Resident 6 was found to be "rather somulant[sic] and somewhat confused." The note reported the social worker would try to go back later in the day to talk with the resident. The note contained no documented evidence any other care provider was notified of the change in the resident's level of consciousness or other interventions were taken to determine why Resident 6 was somnolent (sleepy or drowsy) and confused. An interview was conducted with the Social Services Director (SSD) on 11/14/19 at 9:52 a.m. The SSD indicated all care conference notes were entered electronically in each resident's record. The SSD stated she could not remember if she spoke with staff regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 24 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the change in Resident 6's level of consciousness. The SSD further indicated she could not remember if she did in fact follow up with Resident 6 later in the day. In a concurrent interview and record review with the Director of Nurses (DON), on 11/14/19 at 10 a.m., the DON indicated there were no additional notes found in the record that were entered by the social services department for the months of July and August. Resident 6's clinical record contained no documented evidence a plan of care was implemented, revised and/or updated to address the resident's fluctuating low blood pressure, changes in level of consciousness, hallucinations, progressively larger and infected wounds, throughout the month of August. Resident 6's clinical record contained no documented evidence any existing care plan was revised or had a target (or goal) date after 8/1/19. Resident 6's clinical record contained a "Physician's Progress Note," written by the PA dated 8/11/19. The note indicated urine test results were pending and the resident had a history of urinary tract infections. The note contained no documented evidence of the recent hallucinations or altered level of consciousness exhibited by the resident. In an interview with the facility administrator on 11/14/19 at 10:25 a.m., the administrator indicated there were no physician orders present in Resident 6's clinical record for a urine test for the month of August. The administrator further indicated there were no urine test results present in Resident 6's clinical record for the month of August, and the PA "must have been thinking of a different patient when he wrote that." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 25 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Further review of Resident 6's physician progress notes indicated no documented evidence existed related to repeated low blood pressures with two consecutive days of nursing staff holding blood pressure medications, or altered mentation with hallucinations. No new physician orders such as labs or medications were entered in the clinical record related to Resident 6's acute changes on or after 8/7/19. Resident 6's clinical record review indicated an additional "Orders - Administration Note," dated 8/12/19 at 9:24 a.m. The note indicated the resident's blood pressure was again too low to administer blood pressure medication. Again, the note contained no documented evidence of a physician being notified of the low blood pressure, or other interventions taken or assessments completed to address a low blood pressure. In an interview with LN 8 on 11/21/19 at 12:24 p.m., LN 8 indicated Resident 6 was anxious at times but not confused and was overall "a pleasant lady." LN 8 further stated the physician was not notified regarding the incidence of low blood pressure on 8/12/19 at 9:24 a.m., because it was already in the physician orders to hold blood pressure medication if the resident's blood pressure was too low. Review of Resident 6's clinical record indicated a "Weights and Vitals Summary," with documented blood pressure values for the month of August. The summary indicated the following documented blood pressures: 95/53 on 8/12/19 at 11:48 p.m., 82/56 on 8/13/19 at 8:01 a.m., and 80/44 on 8/13/19 at 9:41 a.m. Review of Resident 6's clinical record indicated a "Orders - Administration Note," dated 8/13/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 26 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at 9:42 a.m., in which it was noted blood pressure medication was held due to a low blood pressure of 80/44 and a heart rate of 115 (normal heart rate range is 60-100). The note contained no documented evidence a physician was notified of the resident's combined low blood pressure and elevated heart rate. In an interview with LN 11 on 11/21/19 at 1:50 p.m., LN 11 reported a low blood pressure and an elevated heart rate would be concerning. LN 11 confirmed there was no documented evidence in Resident 6's clinical record to support a doctor was notified or other interventions were conducted by nursing staff. Resident 6's clinical record contained a note titled, "*SBAR (Situation Background Assessment Recommendation) General," dated 8/13/19 at 11:13 a.m. The note indicated Resident 6's blood pressure was 82/56 at the "beginning of shift," was noted to have a low oxygen level of 70% (normal is 90-100%) at 9:20 a.m., and the administered oxygen flow rate was increased from 4L (Liters - a unit of measurement) to 5L. At 10:52 a.m., the resident was noted to be cyanotic (blue in color due to a low oxygen level) and at 11:08 a.m., the blood pressure was 52/28. The note further indicated it was recommended for Resident 6 to be sent to the hospital for further evaluation. Resident 6's clinical record contained a "Nurse's Note," dated 8/13/19 at 12:23 p.m. The note indicated the resident was awake and alert "with some confusion" and sent to the hospital. The blood pressure documented in the note was 64/48. Review of Resident 6's general acute care hospital records revealed an "Emergency Medicine - Provider Note," dated 8/13/19 at 1:05 p.m. The note indicated Resident 6 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 27 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted with severe sepsis (a potentially lifethreatening condition caused by the body's response to an infection associated with at least one new organ dysfunction). A facility policy titled "Blood Pressure, Measuring," Revised September 2010, indicated, "Hypotension [low blood pressure] is defined as blood pressure less than 100/60 mm/Hg [millimeters of mercury, a unit of measurement]. The policy further indicated, "Hypotension should be reported to the physician. Staff should record several readings throughout the day ..." In an interview with the MD on 11/14/19 at 7:45 a.m., the MD indicated he was aware of the resident's low blood pressure and altered level of consciousness but could not speak to the severity of, or signs of infection identified in, Resident 6's wounds. MD further indicated he was not made aware of the signs and symptoms of Resident 6's wound infection, and that he did not recall any communication with WCP regarding the residents wounds. MD also indicated that he was not notified of all Resident 6's changes in condition (blood pressure, mental status, and wound infection) at one time, that each time the low blood pressure was reported, it was reported as a single occurrence and that he was not made aware of the sequential low blood pressure readings. During an interview with WCP on 11/21/19 at 1:10 p.m. with WCP, he stated that he had no recollection of Resident 6 having signs of a wound infection. WCP stated that he probably would not use the term "infection" to document a wound description, if the wound did not have infection. WCP indicated that he had no recollection of speaking to MD about Resident 6, and that if he would have made a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 28 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recommendation for an antibiotic for an infected wound, that he would have communicated through the treatment nurse. WCP stated that low blood pressure and a change in level of consciousness along with a wound infection would indicate that a patient had a systemic (in blood stream) infection and indicate that the patient required transfer. WCP stated he was not aware of Resident 6's low blood pressure or her alteration in her mental status. 2. Resident 7: Review of Resident 7's clinical "Admission Record," indicated Resident 7 was originally admitted to the facility in 2016 with diagnoses of traumatic brain injury (injury to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions), persistent vegetative state (a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness), diabetes, and chronic kidney disease. A physician history and physical, dated 7/2/19, was reviewed. The document indicated the resident had returned from a hospital stay after exhibiting blood in the urine and was readmitted to the facility with a nephrostomy tube (a surgically inserted tube into the kidney used to drain urine when the normal flow of urine is obstructed). The note further indicated the resident had a tracheostomy and a feeding tube. A "Physician's Progress Note," dated 8/4/19, was present in the clinical record. The note indicated the resident was examined by the Registered Nurse. The resident was noted to be obtunded (a state of lethargy), skin was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 29 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documented as "Normal," and the body temperature was documented as 97.2 degrees. Review of a "Weights and Vitals Summary," indicated documented body temperatures every shift from 8/1/19 through 8/8/19. All documented body temperatures prior to 8/8/19 at 2:37 p.m. were as low as 96.6 degrees F (Fahrenheit, a temperature scale where normal body temperature is around 98.6 degrees F), and as high as 98.6 degrees F. A "Nurse's Note," dated 8/8/19 at 1:41 a.m., was reviewed. The note revealed, "Noted some bleeding from the resident's bilateral [right and left] inner thighs, abdominal folds, inferior [below] aspect to the anal cavity and bilateral gluteal [buttock] area ...MD [Medical Doctor] to be notified." A progress note titled, "Incident/SBAR," dated 8/8/19 at 4:51 a.m., was present in the record. The note indicated Resident 7 had bleeding between the inner thighs, abdominal fold, and area below the anus. The note further indicated Resident 7 had been having, "extremely raw and sensitive skin" and wiping the resident produced blood. Also in the note was "it takes time for the bleeding to stop." The note further indicated a recommendation was made to "Notify MD if condition worsens." An "Orders - Administration Note," dated 8/8/19 at 5:49 a.m., was reviewed. The note indicated a blood pressure medication was held due to a low blood pressure "92/55; MD [Medical Doctor] is notified." Review of a document titled "Blood Pressure Summary," indicated documented blood pressures every shift throughout the month of August. The document indicated the 92/55 blood pressure dated 8/8/19 at 5:49 a.m. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 30 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE summary report further indicated the next blood pressure was not documented until 8/8/19 at 2:37 p.m. (almost nine hours later), and the value was 86/40. An additional "Nurse's Note," dated 8/8/19 at 7:21 a.m., indicated, "awaiting response from MD regarding the bleeding episode ..." The note contained no documented evidence a physician was made aware of the resident's bleeding episode combined with a low blood pressure. An "Order Note," dated 8/8/19 at 8:27 a.m., indicated blood was noted to Resident 7's nephrostomy tube and Foley catheter (a tube inserted into the bladder through the urethra to drain urine). Blood was also noted to be seeping through the skin on the resident's back and buttocks, and the note indicated the physician had been notified and an order to hold the resident's aspirin was obtained. The note contained no documented evidence of notification made to Resident 7's family or responsible party for the changes to the resident's condition and medication orders. A "Nurse's Note," dated 8/8/19 at 10:22 a.m., was reviewed. The note reported blood was still present in the nephrostomy and Foley catheter. Also noted was "Pt [patient] hypo-thermic, warming measures provided. Will continue to monitor." Resident 7's clinical record contained no documented evidence of a body temperature recorded at this time, and no documented evidence a physician or family member was notified the resident was hypothermic. In an interview with LN 11 on 11/21/19 at 2:15 p.m., LN 11 indicated she was familiar with Resident 7 and remembered the bleeding episode. LN 11 reported she could not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 31 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remember if the physician was notified of both the combined bleeding and hypothermia the resident was exhibiting and confirmed the absence of documentation in the record to support the physician was notified. LN 11 further indicated the resident's family is supposed to be called for any changes, and did not remember speaking with the family. A "Nurse's Note," dated 8/8/19 at 2:25 p.m. (approximately four hours later than the previous note which documented the resident was hypothermic), indicated "Pt remains hypothermic; warming measures continued. Will continue to monitor ..." and the nurse would report to the next shift. Resident 7's clinical record contained no documented evidence of a body temperature recorded at this time. In an interview with LN 11 on 11/21/19 at 2:15 p.m., LN 11 indicated she would have rechecked the resident's temperature in 30 minutes to an hour to see if there was any improvement. LN 11 further stated if the resident's temperature had come up to 94 degrees, for example, she would just continue "warming measures". Warming measures were described as placing warm blankets on the resident. LN 11 confirmed there were no other body temperatures documented for the resident noted in the clinical record on the 8/8/19 day shift prior to 8/8/19 at 2:37 p.m. to indicate the temperature was continuously monitored. Further review of the documents titled, "Blood Pressure Summary" and "Weights and Vitals Summary," indicated on 8/8/19 at 2:37 p.m., Resident 7 had a body temperature of 92 degrees (where normal body temperature is 98.6 degrees and anything below 95 degrees is considered a medical emergency), a heart rate of 54 (normal heart rate range is 60-100), and a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 32 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE blood pressure of 86/40. An interview was conducted with LN 6 on 9/11/19 at 4:36 p.m. LN 6 reported if a resident had a low body temperature, the staff would first attempt "warming measures," and recheck the temperature. If the temperature had not come up in one hour, the resident would be sent out to the hospital. LN 6 further indicated staff do not need to wait for permission from the physician to send a resident to the hospital. LN 6 stated the date and time a physician was notifed of the resident's status would be documented in the clinical progress notes. Review of Resident 7's clinical record indicated an interdisciplinary team (IDT) note was entered by the Assistant Director of Nursing (ADON) on 8/8/19 at 2:57 p.m., and indicated the resident was "checked and assessed this am [morning]," and no bleeding was noted to the inner thighs. The note contained no documented evidence of the resident being hypothermic or having a low blood pressure. In an interview with the facility's medical director on 11/14/19 at 8:00 a.m., the medical director indicated he was made aware of Resident 7's bleeding episode and hypothermia. The medical director further indicated he believed the resident had a "short episode of hypothermia," warming measures applied to the resident were effective, and the body temperature had returned to normal. Further review of Resident 7's clinical record revealed a "Nurse's Note," dated 8/8/19 at 3:58 p.m. The note indicated, "patient is hypothermic," at 94.2 degrees and "warming measures applied, will recheck temperature." The note further indicated the resident continued to have blood present in the Foley catheter and nephrostomy tube. Additionally, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 33 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the note dictated the PA would assess the resident "later this evening." An additional interview was conducted with LN 6 on 11/21/19 at 4:50 p.m. regarding Resident 7. LN 6 indicated he remembered the resident being hypothermic, but did not recall the bleeding episode at the same time. An "Orders - Administration Note," dated 8/8/19 at 5:47 p.m., indicated Resident 7 had an additional medication held due to a low blood pressure. A "Nurse's Note," dated 8/8/19 at 6:45 p.m. revealed a physician's assistant had ordered labs related to resident's blood in the urine. The note made no indication the physician's assistant was aware the resident had been hypothermic as last documented by a nurse at 10:22 that morning. An additional progress "Nurse's Note," dated 8/8/19 at 9:50 p.m., was reviewed. The note indicated the resident had continued moderate blood tinged urine in the foley catheter and nephrostomy tube. A progress note titled, "SBAR GENERAL," dated 8/8/19 at 10:04 p.m., indicated Resident 7 was sent to the hospital "after discussing with family members ...for further evaluation." The note further indicated the resident's blood pressure was 86/40, and the body temperature was 92.4 degrees. In an interview with the facility's medical director on 11/14/19 at 8:00 a.m., the medical director indicated the delay in ordering diagnostics and sending the resident to the hospital was due to the belief the resident's family was not going to pursue any further treatment and nursing staff were working with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 34 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the family to determine what their wishes were. In an interview with the Director of Nursing (DON) on 11/14/19 at 8:30 a.m., the DON indicated there should be documentation in the resident's record related to communication between nursing staff and family members. In the interview with LN 6 conducted on 11/21/19 at 4:50 p.m., LN 6 indicated the family of Resident 7 was difficult to deal with because they wanted to pursue aggressive treatment and were resistive to comfort only measures. In an interview with LN 11 on 11/21/19 at 2:15 p.m., LN 11 confirmed there was no documentation in the clinical record to support family notification of Resident 7's change of condition prior to the note entered at 10:04 p.m. on 8/8/19. LN 11 further indicated if there were any changes in a resident's condition, the family would be notified and it should be documented in the record. LN 11 reported she did not remember speaking with Resident 7's family, and would have specifically noted in the record if the family had requested no further treatment or if they did not want to send the resident to the hospital for any reason. Review of Resident 7's general acute care hospital record indicated a "History and Physical," dated 8/9/19 at 12:42 a.m. The document indicated the resident's "Principal Problem" was "Severe sepsis with septic shock." Further review of Resident 7's general acute care record contained a "Clinical Social Work Progress Note," dated 8/9/19 at 10:20 a.m. The note indicated the resident's family "has been very clear regarding their decision to keep the patient Full Code [permission to use any and all interventions should the heart stop beating] and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 35 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE continue with full, aggressive care." A facility policy titled, "Temperature, Axillary (Digital Thermometer)," Revised September 2013, indicated "Temperatures below 97°F and above 99°F must be rechecked with another thermometer and must be reported to the nurse supervisor." 3. Resident 8: Review of Resident 8's clinical record contained an "History and Physical" document, dated 7/26/19, which indicated the resident was readmitted to the facility in July of 2019 with diagnoses of chronic respiratory failure, tracheostomy, Bipolar depression (a mental health condition characterized by severe mood swings), a feeding tube and diabetes. Further review of Resident 8's clinical record revealed an MDS, dated 8/5/19, which showed the resident had a Brief Interview for Mental Status (BIMS) conducted and scored at the highest level (15) meaning the resident was cognitively intact. In an interview with LN 10 on 11/21/19 at 12:51 p.m., LN 10 indicated she remembered Resident 8 was "always alert and oriented and able to make her needs known to staff." A "Nurse's Note," dated 8/18/19 at 1:38 a.m., was reviewed. The note indicated Resident 8 was alert and oriented and was able to mouth words to make needs known. The note further indicated Resident 8 had anxiety "noted on the start of the shift," and was unable to relax. An "Orders - Administration Note," dated 8/18/19 at 6:16 a.m., was reviewed. The note indicated the resident was anxious the whole night and medication administered was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 36 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Ineffective." A Medication Administration Record (MAR), for the month of August, indicated the resident was to be monitored for the number of episodes and behaviors, such as repetitive calling after needs met or frequent anxious complaints, for each shift. From 8/1/19 through 8/16/19, the number of behaviors documented ranged from 0 (no behaviors noted) to at the most, 8 behaviors noted in one shift. For the night shift starting on 8/17/19, the total number of behaviors was documented as 10. Resident 8's clinical record contained no documented evidence a physician was notified of the sudden and increased number of anxious behaviors at this time. Additionally, the record contained no documented evidence a physician was notified the medication administered for anxiety was ineffective. In an interview with the facility's Medical Director (MD) on 11/14/19 at 8:41 a.m., the medical director reported it was normal for Resident 8 to be anxious and for medications to not be effective in relieving anxiety. A Medication Administration Record (MAR), for the month of August, indicated a physician's order to give Alprazolam (a medication for anxiety) every 12 hours if needed for anxiety and restlessness. The record further indicated the resident only received this medication a total of four different times for the month of August on dates 8/2/19, 8/6/19, 8/11/19, and 8/18/19. Only one administration of the antianxiety medication (the one given on 8/18/19) was documented as "ineffective." Further review of Resident 8's clinical record revealed the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 37 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A "Nurse's Note," dated 8/18/19 at 11 a.m. The noted indicated the resident had "a decreased LOC [level of consciousness]" with an "increased" blood sugar, and the nurse would "continue to monitor." A "Nurse's Note," dated 8/18/19 at 11:05 a.m., indicating the nurse "attempted to call" the physician for the resident's increased blood sugar, and was left a voicemail message to return the call. A medication administration record, dated August 2019, indicated Resident 8 had fluctuating elevated blood sugars (a normal blood sugar level is considered to be between 70 to 100; and as high as 140 after eating) throughout the month of August, with the highest being 400 documented on 8/15/19. On 8/18/19 at 12 p.m., the blood sugar level was documented as 512. In an interview with the MD on 11/14/19 at 8:41 a.m., the MD indicated he likely would have been notified of the Resident's elevated blood sugar and altered level of consciousness. The MD further indicated it would not be unexpected for an elevated blood sugar to cause a change in mentation. He further stated the resident would have been drowsy if she did not sleep well the night before. An "Orders - Administration Note," dated 8/18/19 at 1:13 p.m., was reviewed. The note indicated Resident 8 had a medication held due to a decreased level of consciousness and the resident was "drowsy." The record contained no documented evidence what specific medication was held and a physician was notified of the continued change in the resident's level of consciousness. In a concurrent record review and interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 38 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with LN 10 and the DON on 11/21/19 at 12:51 p.m., LN 10 confirmed the resident was drowsy. Both the DON and LN 10 were unable to indicate which medication was held after reviewing the Resident's record, nor could they locate documentation to support the physician was notified the resident was too drowsy to receive medications. A "Nurse's Note," dated 8/18/19 at 2:11 p.m., was present in the clinical record. The note indicated Resident 8 had an elevated blood sugar of 460 and the physician was called and notified. It was further documented the physician gave a new order for additional insulin (a medication to lower blood sugar levels) to be administered. The note contained no documented evidence the physician was notified of the continued change in the resident's mentation. In the same interview with LN 10 on 11/21/19 at 12:51 p.m., LN 10 indicated she remembered being "very concerned" about the change in Resident 8's mental status. LN 10 reported Resident 8 seemed to wake up a little bit "after a while," but was still not herself. Resident 8 also appeared to be "flushed." LN 10 was unable to locate documented evidence the physician was notified of the LN's concerns in Resident 8's mentation. An additional "Nurse's Note," dated 8/19/19 at 2:16 a.m., reported resident 8 had a change in level of consciousness and the physician was made aware "at the start of the shift around 2324 PM [11:24 p.m.]." The note further indicated the resident was noted to have "Occasional gasping ...Use of accessory muscles [additional rib cage muscles used when breathing becomes labored] noted." The note contained no documented evidence the physician was made aware of the changes in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 39 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident's breathing. An interview with the MD on 11/14/19 at 8:41 a.m., was conducted. The MD indicated the staff did notify him of the changes in the resident's breathing and he felt "it was transient." Review of Resident 8's clinical record revealed a "Nurse's Note," dated 8/19/19 at 3:32 a.m., approximately 14 hours after the initial decreased level of consciousness was documented. The note indicated Resident 8 "Remains to be confused at this time." An additional "Nurse's Note," dated 8/19/19 at 6:45 a.m., indicated the resident was noted as "still not coherent at this time," and the physician was aware "about patient's condition." Further review of Resident 8's clinical record revealed a "Nurse's Note," dated 8/19/19 at 10:59 a.m. (approximately 24 hours after the first documented note where the resident was noted to have a decreased level of consciousness). The note indicated Resident 8 was lying in bed with both eyes closed and only "Reactive to painful stimuli ...Decreased movement to," arms and legs. The note contained no documented evidence a physician was notified of the resident's persistent and worsening level of consciousness, or a family was notified of the resident's worsening condition. In an interview with LN 7 on 9/11/19 at 4:40 p.m., LN 7 reported if a change in level of consciousness was noted in a resident, vital signs and a neuro (neurological) assessment would be done. LN 7 further indicated, the doctor and family would be notified of the change, and if the resident did not improve FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 40 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE within an hour, they would be sent to the hospital. An additional "Nurse's Note," dated 8/19/19 at 4:14 p.m., was present in Resident 8's clinical record. The note indicated Resident 8 had a slow response "to stimuli," and the pupils had a slow reaction to light. The note contained no documented evidence the physician was made aware of the resident's further decline. In an interview with the facility medical director on 11/14/19 at 8:41 a.m., the medical director indicated he did not recall if staff notified him of the additional changes in the resident's level of consciousness and the pupils eventually being slowly reactive. When asked if staff should have conducted a thorough neurological assessment at this time, the medical director indicated, "Only if they felt alarmed." Further review of Resident 8's clinical record revealed a "Nurse's Note," (documented more than seven hours after the previous assessment) dated 8/19/19 at 11:40 p.m., which indicated Resident 8's eyes were closed and swollen, the tongue was swollen, and the resident was non-reactive to touch, cold, or painful stimuli. The note further indicated the resident's pupils also had a slow reaction to light and the resident had no purposeful movements. The note also indicated the "RN [Registered Nurse] made aware," and the blood pressure was 87/38. An additional "Nurse's Note," dated 8/20/19 at 12:40 a.m., indicated at 12:06 a.m., an ambulance arrived to take Resident 8 to the hospital and when resident's blood sugar was checked, it was too high for the glucometer to give a numerical reading and resulted as "high." The note further indicated at 12:22 a.m., the resident left the facility for the hospital. At FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 41 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12:33 a.m., the emergency room nurse informed the facility the ambulance was still in route to the hospital and was now being given chest compressions. At 12:35 a.m., a family member had been informed of the situation and was told to call the hospital for further information. Review of Resident 8's acute care hospital record revealed an emergency medicine provider note, dated 8/20/19 at 12:37 a.m. The note indicated Resident 8 had arrived to the emergency room unresponsive and pulseless and CPR (cardiopulmonary resuscitation) was being given. The note further indicated the resident did not respond to any medications/interventions provided by the medical team and at 12:58 a.m., time of death was called. Review of Resident 8's clinical record revealed an additional "Nurse's Note," dated 8/20/19 at 7:36 a.m. The note indicated the resident's sister had called the facility asking for information. The note further indicated the phone number to the hospital was provided and the sister was informed to "call the hospital for further information." A facility policy titled "Neurological Assessment," Revised October 2010, indicated, "Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately." A facility policy titled, "Change in a Residents Condition or Status," Revised May 2017, indicated the "facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 42 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/17/2020 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record review, and facility policy review, the facility failed to implement, monitor and modify interventions consistent with professional standards of practice to prevent worsening of existing pressure wounds for one of ten sampled residents (Resident 6) when: 1. Wounds and skin areas of concern were not assessed, and staged (a classification system performed to indicate the characteristics and extent of tissue injury) in a timeframe and manner consistent with facility policy and procedure, throughout the course of Resident 6's facility stay. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 43 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Risk factors identified as interfering with wound healing, such as contractures [a condition of shortening and hardening of muscles, tendons and other tissue often leading to deformity and rigidity of joints] that restricted repositioning, resident refusal, and pain, were not addressed in the resident's plan of care. 3. Treatment interventions were not modified or implemented in response to ongoing resident assessments to prevent worsening of wounds when nursing staff and the wound care physician (WCP) identified that wounds were showing signs and symptoms of infection and continually worsening. These failures caused Resident 6's existing wounds to progressively worsen to the point of bones being visible in the wound beds (base of the wound) and resulted in Resident 6 requiring hospitalization for a severe infection, which placed the resident at a high risk for death. Findings: Review of Resident 6's clinical record revealed an "Admission Record," which indicated the resident was originally admitted to the facility in June of 2019, with diagnoses of paraplegia (paralysis of the legs), chronic respiratory failure, tracheostomy (an incision made in the neck for a person to breathe through) with dependence on a ventilator (a machine that breathes for a person), and a feeding tube. 1. Wounds and skin areas of concern were not regularly or consistently assessed or staged. In an interview with the Director of Nursing (DON) on 9/10/19 at 1:04 p.m., the DON indicated he believed Resident 6 was initially FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 44 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE admitted to the facility with about 12 different areas of skin issues. Review of Resident 6's clinical record contained the following documents: A "Skin/Wound Note," dated 6/11/19 at 6:47 p.m., which included documentation of the following: 1. "Wound to left lateral [side] neck-measuring 7.0 cm (centimeter, a unit of measurement) x 3.5 cm x 0.1 cm, 100% granulated tissue [pinkred moist tissue that fills a wound when it starts to heal], scant [small amount] serous [clear, watery, or slightly yellow] exudate [drainage], 0 odor, 0 s/sx [signs or symptoms] of infections, periwound [area surrounding the wound] stable, wound edges erythematous [redness]." 2. "Redness to bilateral inner thigh" 3. "Redness to PEG [Percutaneous Endoscopic Gastrostomy Tube] [a tube surgically inserted into the stomach generally used for feeding] tube site with crusty exudate [drainage]" 4. "Dry scab/eschar (a dry, dark scab or falling away of dead skin) to left elbow 1.0 cm x 0.5 cm" 5. "BLE [Bilateral Lower Extremities] - dry scaly skin" 6. "Right ischium [the curved bony area at the base of the buttock] open wound measuring 2.6 cm x 2.1 cm x 1.2 cm. 100% granulated tissue, 0 odor, 0 s/sx of infections, periwound erythematous, wound edges erythematous. Scan[sic] serous exudate." 7. "Non blanchable [color does not change/return to normal when pressing on the skin] redness to coccyx [tailbone] area." 8. "Pink scar tissue to right scapula [shoulder blade] and shoulder area." 9. "non-blanchable redness to bilateral heels" 10. "open area to left hip/ischium area measuring 4.0 cm x 3.1 cm x 0.1 cm, 100% FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 45 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE granulated, periwound stable, wound edges defined. 0 (zero - none) odor, 0 s/sx of infections." 11. "Redness underneath trach ties area [bands that go around the neck to hold a tracheostomy tube in place]." A "History and Physical" note, dated 6/12/19 described skin as: "unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed)" right and left ischium. The note contained no further documentation related to other wounds or skin areas of concern on the resident's body. A "Skin/Wound" note, dated 6/12/19 at 2:05 p.m., which documented assessments or descriptions for three wounds on the resident's body. The wounds were described as located on the right ischium, left ischium, and left neck. No documented evidence of the other skin related areas of concern described in the admission "Skin/Wound Note" from the previous day were present in the note. Two plans of care addressing existing wounds were also present in Resident 6's clinical record. They were listed as "The resident has pressure ulcer (an observable pressure-related alteration of intact skin) left HIP ...," initiated on 6/13/19, and "The resident has pressure ulcer to right ischium ...," initiated on 6/13/19. The clinical record contained no further plan of care to address skin areas of concern or specific wounds until 6/22/19. In a concurrent interview and record review with Licensed Nurse (LN) 3 on 11/1/19 at 10:06 a.m., LN 3 confirmed the next detailed "Skin/Wound" note was not entered in Resident 6's clinical record until 6/16/19 at 3:45 p.m. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 46 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE note documented assessments and/or descriptions for three wounds on the resident's body located to the "bilateral buttocks" and left neck. No documented evidence of other skin related areas of concern were present in the note. An additional "Skin/Wound" note, dated 6/17/19 at 3:19 p.m., was present in Resident 6's clinical record. The note again documented assessments or descriptions for three wounds on the resident's body located on the right ischium, left ischium, and left neck. No documented evidence of any other skin related areas of concern were present in the note. Further review of Resident 6's clinical record contained the following documents: A "Surgical Consult" note, dated 6/18/19 (approximately seven days after admission to the facility), documented by the facility Wound Care Physician (WCP). The note included descriptions of the previously indicated three wounds: a left ischium wound, a right ischium wound, and a left lateral neck wound. The report also described a fourth wound, located at the sacrum (tailbone area). The sacral wound was described as "Sacrum [tailbone area] ...Pressure injury/ulcer ...EXUDATE: None ...PERIWOUND: Erythematous ...WOUND EDGE: Purple ..." and the size of the wound was documented as 4.0cm x 7.0cm x 0cm. The note also stated, "A comprehensive, 14-point skin exam showed no significant abnormalities except those noted ...," and the plan was to continue the dressings as discussed, work with respiratory therapy to find less abrasive way to secure tracheal tube to neck, and "continue offloading (not bear weight) - turn per facility protocol." A "Skin/Wound Note," dated 6/19/19 at 6:23 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 47 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m. The note again described the initial left ischium, right ischium, and left neck wound. The note also addressed the new sacrum wound as described by the wound care physician in the previous report. The note contained no other identified skin areas of concern. An additional "Skin/Wound Note," for dates 6/20/19, 6/22/19, and 6/23/19 continued to only include descriptions of the following four wounds: a sacral (tailbone area) wound, a left neck wound, and a right and left ischial (the curved bony area at the base of the buttock) wound. An admission Minimum Data Set (MDS - an assessment tool), dated 6/21/19 indicated Resident 6 was identified as at risk for developing pressure ulcers, and was noted to have the following six existing pressure wounds defined as: two Stage 1 pressure injuries (intact skin with nonblanchable redness of a localized area, usually over a bony prominence), one Stage 2 pressure injury (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed), two unstageable pressure ulcers (due to the presence of slough [dead tissue yellow, tan, gray, green or brown in color] or eschar [dead tissue usually brown or black in color and may appear scab-like] in the wound bed), and one deep tissue injury (intact skin with an area of persistent red, maroon, or purple discoloration due to damage of underlying soft tissue). A plan of care, initiated on 6/22/19 (approximately ten days after the resident was admitted to the facility), with a focus "The resident has non-blanchable/DTI to sacrum/coccyx area ..." Two additional "Nurse's Note," dated 6/24/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 48 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9:05 p.m., and 6/24/19 at 9:21 p.m. reflected Resident 6 was noticed to be unresponsive and was transported to the hospital. A "Skin/Wound Note," dated 6/28/19, four days after Resident 6 was sent to the hospital from the facility referenced a "wound eval (evaluation) report" from the WCP completed on 6/24/19. The report described the same four wounds to the "left ischium - measuring 1.8 cm x 1.5 cm x 0 ...," "right ischium - measuring 2.0 cm x 2.5 cm x 0 ...," "left lateral Neck measuring 8.0 cm x 2.5 cm x 0 ...," and "Sacrum - measuring 7.0 cm x 4.0 cm x 0 ..." The report also included a description of a new additional fifth wound to the "right posterior shoulder" wound measuring 3.0 cm x 2.5 cm x 0 cm. Wound edges to the shoulder wound were noted as "erythematous" and "purple." Further review of Resident 6's clinical record indicated no plans of care were initiated to address the left neck wound or the right shoulder wound, or to address a general risk of further skin breakdown for the month of June. Additionally, none of the "Skin/Wound Note" documented by nursing staff, or the wound care physician reports consistently staged the resident's wounds. In an interview with LN 3 on 11/1/19 at 10:06 a.m., the WCN indicated wounds were not typically staged in assessments. LN 3 further reported a wound could only be staged if confirmed by the doctor. Review of Resident 6's general acute care hospital (GACH) records revealed a "WOCN [Wound, Ostomy and Continence] Wound Consult Note," dated 6/25/19. The note indicated a problem list of a "Sacral/coccyx [tailbone area], L ischial, R scapula [shoulder blade] DTI [Deep Tissue Injury] ...R ischial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 49 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stage 3 pressure injury ...L neck partial thickness wound ..." The sizes of these wounds were documented as left ischial (4cmx6cm), right ischial (4cmx6cmx0.5cm), left neck (9cmx6cmx0.1cm), coccyx/sacral spine [sacrum] (9cmx12cm), and right upper back/scapula (3cmx4cm). All wound sizes recorded were larger than those documented in the facility "Skin/Wound" note one day earlier. According to Resident 6's "Admission Record," the resident was readmitted to the facility on 7/8/19, with the same diagnoses of paraplegia (paralysis of the legs), chronic respiratory failure, tracheostomy (an incision made in the neck for a person to breathe through) with dependence on a ventilator (a machine that breathes for a person), and a feeding tube. Further review of Resident 6's clinical record contained the following documents: A Physician History and Physical, dated 7/8/19, which documented the resident's skin as warm and dry and contained no documentation regarding existing pressure wounds. A "Skin/Wound Note," dated 7/8/19 at 7:06 p.m., included documentation of the wounds and skin areas of concern which contained no documented evidence of a left ischial wound or staging of any of the following wounds: 1. Wound to left neck with pink wound bed, with a size of 5.75 cm x 3 cm. 2. Wound to sacrum with pink wound bed, 80% slough, and a size of 6 cm x 8.25 cm. 3. Wound to right ischial tuberosity with pink wound bed, 60% slough, and a size of 4 cm x 2 cm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 50 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. Multiple wounds to upper right rear shoulder. Wound to upper rear back with pink wound bed with 80% slough, and a size of 2.5 cm x 2.5 cm. Wound to upper rear back with red wound bed "2 cm x cm." Intact healing wounds to upper rear back. 5. Ecchymosis (bruising) to lower abdomen noted. 6. Redness to lower posterior (back) thigh noted. Physician orders entered on 7/8/19 indicated for treatments to "Coccyx/sacrum DTI [Deep Tissue Injury] wound," "DTI pressure wound on Left ischial tuberosity," "Left neck wound," "Right upper back/scapula," and "Stage III right ischial tuberosity pressure wound." A Surgical Consult note entered by the wound care physician, dated 7/9/19 (one day after Resident 6 returned to the facility), indicated the consult was to "manage wounds." The wounds were documented with sizes of: left ischium 3cm x 2cm x 0cm (smaller than GACH measurements recorded on 6/25/19); right ischium 2.5 cm x 3.0 cm x 1 cm (smaller than GACH measurements recorded on 6/25/19); left lateral neck 7.0 cm x 1.2cm x 0cm (smaller then GACH measurements recorded on 6/25/19); sacrum 5.5 cm x 6.5 cm x 0.2 cm (smaller than GACH measurements recorded on 6/25/19); and the right posterior shoulder was 2.0 cm x 6.5 cm x 0 cm (smaller than GACH measurements recorded on 6/25/19). All documented wound dimensions were notably different compared to the "Skin/Wound Note" from the previous day (7/8/19). An admission MDS, dated 7/19/19, indicated the resident was cognitively intact, and required complete dependence on staff for bed mobility, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 51 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE toileting and bathing. The admission assessment also indicated Resident 6 was again identified as at risk for developing pressure ulcers, and had the same described six existing pressure wounds on readmission. These wounds were again defined as two stage 1 pressure injuries, 1 Stage 2 pressure injury, 2 unstageable pressure ulcers due to the presence of slough or eschar in the wound bed, and one deep tissue injury. The MDS did not include a Stage III pressure wound. In a concurrent interview and record review with the MDS Coordinator (MDSC) on 11/1/19 at 11:52 a.m., the MDSC indicated the wound staging entered in the MDS assessments came from looking at the patient and the clinical record "as a whole" in correlation with the Resident Assessment Instrument (RAI) Manual. The MDSC confirmed no Stage III wound was present in the MDS assessment as indicated by the physician orders (to the right ischium), dated 7/8/19, and only one DTI wound was noted in the MDS assessment where the physician orders, also dated 7/8/19, indicate to treat two separate DTI wounds (the coccyx and left ischial wounds). Additional surgical consults from the wound care physician, dated 7/16/19, 7/23/19, and 7/30/19 were present in Resident 6's clinical record. The reports contained no wound staging in any of the physician assessments to demonstrate progression or changes in wound characteristics. Resident 6's clinical record contained a "Skin/Wound Note," dated 8/12/19 at 5:25 p.m. The note indicated the wound to the right ischium had "necrotic (a form of cell injury which resulted in the premature death of cells in living tissue) tissue hanging out," and "moderate serous/purulent exudate" but there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 52 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were no signs and symptoms of infection. The assessment also indicated the nurse was "able to palpate bone" in the resident's shoulder wound. The note contained no documented evidence of wound measurements or wound staging. Resident 6 was admitted to an acute care hospital on 8/13/19 and review of the GACH records indicated Resident 6 had a wound care consult on 8/15/19. The wound care nurse documented a problem list consisting of: left/right ischial wound unstageable pressure injuries, sacrococcygeal (tailbone area) Stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) , right posterior scapula Stage 4 pressure injury, left neck full thickness wound." A facility policy titled, "Pressure Ulcers/Skin Breakdown - Clinical Protocol," revised April 2018, indicated " ...the nurse shall describe and document/report the following ...Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue ..." A facility policy titled, "Prevention of Pressure Ulcers/Injuries," revised July 2017, indicated, "Inspect the skin on a daily basis ...identify any signs of developing pressure injuries ...inspect pressure points." A facility policy titled, "Pressure Ulcers/Injuries Overview," revised July 2017, indicated if the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned, and the pressure ulcer does not have to be completely debrided (surgical removal of lacerated, devitalized, or contaminated tissue) or free of all slough or eschar for the reclassification of stage to occur. In reference to deep tissue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 53 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure injuries, the policy indicated once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. In reference to a medical device related pressure injury, the policy indicates the injury should be staged using the staging system. 2. Risk factors identified by the WCP during an interview on 9/10/19 at 12 p.m. as interfering with Resident 6 wound healing included patient complaint of pain, difficulty with repositioning due to contractures (a permanent shortening (as of muscle, tendon, or scar tissue producing deformity or distortion), and difficulty offloading. During a subsequent interview with LN 3 on 9/11/19 at 11:35 a.m., she stated Resident 6 was always in pain, required a lot of pain meds with dressing changes, refused care and required a lot of education, and could only tolerate turning for a short time during dressing changes. In an interview with the DON on 9/11/19 at 3:30 p.m., he stated that Resident 6 had "refusal behaviors" and that she could not be offloaded due to contractures. In a follow up interview with LN 3 on 11/1/19 at 10:10 a.m. regarding Resident 6, LN 3 stated that the resident had refused turning and did not tolerate having the head of her bed lowered due to anxiety and dyspnea (difficulty breathing). LN 3 further stated that Resident 6 had difficulty with position changes due to respiratory distress and decreased oxygen saturation. LN 3 stated that Resident 6 had no sensation or pain below her shoulders. LN 3 stated that she did not recall participating in an IDT (Interdisciplinary Team Meeting) for Resident 6. LN 3 stated she was not aware of any strategies or interventions used by nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 54 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to address these problems, she stated she had her own strategies. Review of Resident 6's clinical record revealed the following documents: A physician's order, dated 6/11/19, to "Turn and reposition every 2 hours and as needed every shift." Nurse "Progress Notes" entered daily for dates 6/12/19 through 6/18/19, where at least one daily note was present indicating Resident 6 was turned and repositioned every two hours and as needed. The clinical record contained no documented evidence related to the specific times Resident 6 was repositioned in two hour increments, or the position in which the resident was placed. A WCP "Surgical Consult" note, dated 6/18/19 indicated to "continue offloading - turn per facility protocol." A "Skin/Wound Note," dated 6/19/19 at 6:23 p.m. indicated Resident 6 was a "quadriplegic (affected by or relating to paralysis of all four limbs), hard to fully off-load wounds d/t [due to] her BUE (bilateral [both sides] upper extremities [arms]) contracture out ways ..." Daily nurse progress notes entered on 6/20/19 through 6/23/19, which indicated Resident 6 was either turned and repositioned every two hours or advised/encouraged to turn side to side. The nurse progress notes entered in this time frame contained no documented evidence the resident was unable to be turned due to contractures or any other reason. A nurse "Skin/Wound Note," dated 6/28/19 at 2:34 p.m., which indicated a wound care physician note from 6/24/19 was reviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 55 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE note indicated the resident had "difficulty positioning side to side," due to restricted mobility from contractures. Review of Resident 6's clinical record contained no documented evidence physician orders were present for a turning protocol or how frequently Resident 6 should be repositioned when readmitted to the facility in July. Review of Resident 6's clinical record indicated a WCP note, dated 7/9/19, directing to "Continue offloading - turn per facility protocol." Further review of Resident 6's clinical record revealed the following documents: A nurse progress "Skin/Wound Note," dated 7/11/19 at 9:49 a.m. The note indicated Resident 6 was non-compliant with the turning protocol of every two hours, and the resident required education in the importance of turning and repositioning as tolerated every two hours "to offload wound and promote wound healing." The note contained no documented evidence to indicate why the resident was noncompliant with turning or that mobility may have been restricted. Further, there was no documented evidence in the note the physician was notified of the resident's noncompliance with the "turning protocol." Additional "Nurse's Note" progress notes entered from dates 7/12/19 through 8/11/19, where there was at least one mention Resident 6 was turned and repositioned every 2 hours. A wound care physician note, dated 7/16/19, indicated, "Continue offloading - turn per facility protocol." A "Skin/Wound Note," dated 7/19/19 at 1:43 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 56 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m. indicated Resident 6 was hard to turn completely "due to bilateral [both right and left] hands bent and extending out wards from elbow." The note contained no documented evidence a physician was notified Resident 6 was unable to fully comply with the previous wound care physician's noted recommendation to "Continue offloading." A wound care physician note, dated 7/23/19, which revealed Resident 6 was "exhibiting factors that can retard wound healing which are: difficulty offloading ulcer [wound] ...." The note then indicated for offloading, to "Continue offloading - turn per facility protocol." An additional wound care physician note, dated 7/30/19, approximately three weeks after readmission to the facility. The note again indicated Resident 6 was exhibiting conditions that could hinder wound healing such as "inability to offload a pressure site." The note also indicated a plan to consider using a specialty bed "for this patient whose wounds have deteriorated and because of her upper extremity contractures is almost impossible to offload." Finally, the note further indicated to "Continue offloading - turn per facility protocol." Facility documents included an invoice from a mattress rental company. The invoice indicated an "Alternating pressure therapy with airflow ...." Mattress was delivered to the facility on 8/5/19, approximately 28 days after Resident 6 was admitted to the facility. An interview was conducted with the WCP on 9/10/19 at 12:52 p.m. The WCP reported "at first glance" of the resident, significant contractures were present to both arms. The WCP stated the only thing that was going to help heal Resident 6's wounds was to be fully FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 57 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE offloaded, or repositioned off of the compromised areas where wounds already existed, and the resident was unable to because of the way both arms were contracted. WCP stated one of the only other interventions that could have been implemented was to place the resident on a specialty bed. Review of an untitled care plan dated 6/13/2019 included the following: "Focus...The resident has pressure ucler left HIP r/t [related to] disease process Quadriplegic, Hx [history] of ulcers, Immobility, chronic edema...Interventions...If the resident refuses treatment, confer with the IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods...Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes...The resident needs (SPECIFY: encouragement, assistance, supervision) with use of bedrails, trapeze bar, etc for resident assist with turning..." Review of an additional untitled care plan dated 6/13/19 the following was noted: "Focus...The resident has pressure ulcer to right ischium or [sic] r/t disease process quadraplegic, Immobility, Chronic edema BUE, BLE [bilateral upper extremities and bilateral lower extremities...Interventions...The resident needs (SPECIFY: monitoring/reminding/assistance) to turn/reposition as least every two hours, more often as needed or requested." A facility policy titled "Repositioning," revised May of 2013, indicated, "For residents with a Stage 1 or above pressure ulcer, an every two hour (q 2 hour) repositioning schedule is inadequate." The policy also indicated to document in the resident's clinical record, "The position in which the resident is placed ...Any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 58 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE problems or complaints made by the resident related to the procedure ... if the resident refused the care and the reason(s) why." The policy further indicated, "If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated." 3. Treatment interventions were not continually modified when nursing staff identified worsening of wounds, and additional treatments were not implemented in a timely manner when Resident 6's showed signs and symptoms of worsening infection. Review of Resident 6's clinical record revealed the following documents: An admission "Skin/Wound Note," dated 6/11/19 at 6:47 p.m., which included documentation of the following: 1."Wound to left lateral neck-measuring 7.0 cm x 3.5 cm x 0.1 cm, 100% granulated tissue, scant serous exudate, 0 odor, 0 s/sx of infections, periwound stable, wound edges erythematous." 2. "Redness to bilateral inner thigh" 3. "Redness to PEG tube site with crusty exudate" 4. "Dry scab/eschar to left elbow 1.0 cm x 0.5 cm" 5. "BLE - dray scaly skin" 6. "Right ischium open wound measuring 2.6 cm x 2.1 cm x 1.2 cm. 100% granulated tissue, 0 odor, 0s/sx of infections, periwound erythematous, wound edges erythematous. Scan (sic) serous exudate." 7. "Non blanchable redness to coccyx area." 8. "Pink scar tissue to right scapula and shoulder area." 9. "non-blanchable redness to bilateral heels" 10. "open area to left hip/ischium area FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 59 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE measuring 4.0 cm x 3.1 cm x 0.1 cm, 100% granulated, periwound stable, wound edges defined.0 odor, 0 s/sx of infections." 11. "Redness underneath trach ties area." Physician's orders for wound care to the left neck, left ischium, right ischium and coccyx/sacrum area, dated 6/11/19. A "Skin/Wound Note," dated 6/12/19 at 2:05 p.m. The note reported the right ischium wound now had necrotic tissue along the wound margins present, as compared to the previous day's assessment and a moderate amount of drainage. The note contained no documented evidence a physician was notified of changes to the wound. A "Surgical Consult" note from the wound care physician, dated 6/18/19. The note reported signs and symptoms of infection to the: right ischium (yellow drainage, delayed healing) and the wound was debrided; and left neck (inflammation, delayed healing). The recommendation was to "use Bactroban [an antibiotic ointment] or AMD [Antimicrobial Dressing, used for fending off bacteria in a wound] gauze for neck wound that has aspect of possible infection." Physician orders indicated changes to wound care were entered for the left neck on 6/19/19, the left ischium on 6/19/19, and the right ischium on 6/19/19. Wound care orders for the coccyx/sacrum area were not changed throughout Resident's stay in June. The record contained no further documented evidence to indicate wound care was ordered in June for the right shoulder area, or the five other skin issues noted in the admission skin assessment. Resident 6 was transferred to an acute care hospital on 6/24/19, and was readmitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 60 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility on 7/8/19. Review of Resident 6's clinical record contained the following documents: A "Skin/Wound Note," dated 7/8/19, which included documentation of the following wounds: 1. Wound to left neck with pink wound bed 5.75 cm x 3 cm. 2. Wound to sacrum with pink wound bed with 80% slough 6 cm x 8.25 cm. 3. Wound to right ischial tuberosity with pink wound bed 60% slough 4cm x 2cm. 4. Multiple wounds to upper right rear shoulder. Wound to upper rear back with pink wound bed with 80% slough 2.5 cm x 2.5 cm. Wound to upper rear back with red wound bed "2 cm x cm." Intact healing wounds to upper rear back. 5. Ecchymosis to lower abdomen noted. 6. Redness to lower posterior thigh noted. Physician orders, dated 7/8/19, for treatments to "Coccyx/sacrum DTI [Deep Tissue Injury] wound," "DTI pressure wound on Left ischial tuberosity," "Left neck wound," "Right upper back/scapula," and "Stage III right ischial tuberosity pressure wound." A wound care physician note, dated 7/16/19, indicated the wounds were exhibiting signs of infection. The right ischium wound was exhibiting "Delayed Healing," and the sacrum wound exhibited "Significant Devitalized Infected Tissue," and delayed healing. The note further indicated both wounds required debridement by the wound care physician. A wound care physician note, dated 7/23/19, indicated the right ischium and sacrum were again showing signs of infection, where the right ischium had "Poor Healing," and "Slough," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 61 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and the sacrum had "Infected Tissue, Delayed Healing," and "Necrotic Tissue." The note further indicated the right ischium had a subcutaneous tissue debridement performed by the wound care doctor, and the sacrum had a "Muscle tissue debridement performed by surgical excision of devitalized subcutaneous, muscle, fascia [a band of connective tissue that attaches, stabilizes, encloses, and separates muscles and other internal organs]. A physician's order for antibiotics for wound healing every 12 hours for 10 days, dated 7/23/19. A "Skin/Wound Note," dated 7/24/19 at 4:20 p.m., which described the sacrum wound as inflamed, having copious amounts of drainage, the wound bed being covered with dead tissue and a "mild odor noted." An additional "Skin/Wound Note," dated 7/25/19 at 1:44 p.m., which noted the sacrum wound as having undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket or tunneling beneath the skin at the wound's edge). An "Infection Note," dated 7/26/19 at 1:01 p.m. indicated the resident continued on antibiotic therapy for "wound infection," and described the coccyx wound as having slough, dead tissue, bleeding and odor. The note further indicated the physician would be called if "changes occur." Resident 6's clinical record contained a "Skin/Wound Note," dated 7/28/19 at 12:01 p.m., approximately six days after the resident was started on antibiotics for wound healing. The note indicated the sacrum wound was noted with an "increase in size and unhealthy," and "Right ischium wound bed" with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 62 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE undermining and moderate amount of drainage. The note further indicated "will continue to monitor for s/s [signs and symptoms] of infection ..." The note contained no documented evidence a physician was notified for changes noted to the wounds. An additional "Skin/Wound Note" was present in Resident 6's clinical record, dated 7/29/19 at 2:41 p.m. The note indicated the sacrum wound was inflamed and the nurse was "able to palpate bone." The right posterior shoulder wound had a moderate amount of drainage and the wound edges were red. The note further indicated the wounds would continue to be monitored. The note contained no documented evidence a physician was notified for the worsening noted to the wounds, or the continued signs and symptoms of infection present. Review of Resident 6's clinical record indicated a physician wound care note, dated 7/30/19, seven days after the resident was started on antibiotics for wound healing. The left ischium wound was noted to have increased in size and presented with delayed healing. The right ischium wound was noted with signs of infection such as "Drainage, Heavy Drainage, Delayed Healing, Necrotic Tissue." The sacrum wound was also noted to be exhibiting signs of infection such as, "Infected Tissue, Necrotic Tissue, Delayed Healing, Significant Devitalized Infected Tissue," and was debrided. The right posterior shoulder wound was also documented as exhibiting signs and symptoms of infection such as "Delayed Healing, Yellow Drainage, Necrotic Tissue," and was debrided by the wound care physician. The note suggested Resident 6's "wounds have deteriorated ..." Review of Resident 6's clinical record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 63 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a physician's order, dated 8/3/19, to "Monitor open wound to Sacrum and notify MD [Medical Doctor] if condition worsens." No indication of how frequently the wound was to be monitored was present in the order. Resident 6's clinical record contained a wound care physician note, dated 8/6/19. The note indicated the left ischium wound had increased in size and was showing signs of infection such as "Inflammation, Heavy Drainage, Necrotic Tissue, Induration [Abnormal hardening of the tissue caused by swelling, which may be a sign of underlying infection]." The right ischium wound was also described as larger in size and showing signs of infection such as "Inflammation, Delayed Healing, Necrotic Tissue." The sacrum wound was described as having multiple signs of infection such as, "Delayed Healing, Necrotic Tissue, Yellow Drainage, Erythema, Inflammation, Infected Tissue, Heavy Drainage," and "increased in size." The right posterior shoulder wound was described as "decreased in size," a mild amount of drainage, and "0% slough ...0% necrotic tissue ..." The note further indicated, "Sacrum and ischial wounds getting progressively worse," and recommended adding AMD gauze to wound beds to all wounds except the neck wound. The note further indicated a recommendation for a wound vac (a device applied to a wound to create suction against the wound bed and promote healing) for the sacrum wound, "as this is much worse as there is more necrotic tissue." Review of Resident 6's clinical record indicated physician orders for wound care were not changed or amended to add AMD gauze to wounds as recommended by the wound care physician after 8/6/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 64 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE An interview with was conducted on 8/21/19 at 8:56 a.m. with LN 4. LN 4 reported each resident's wound care is dictated by reviewing the physician orders prior to dressing changes. In an interview with LN 3 on 8/21/19 at 10:37 a.m., LN 3 stated if a wound was worsening or showing signs of infection, there would be redness and discharge from the wound, and the wound care doctor or the resident's primary care doctor would be notified. Further review of Resident 6's clinical record revealed the following documents: A "Skin/Wound Note," dated 8/7/19 at 2:32 p.m., described the right posterior shoulder wound "with undermining ...loose yellow slough ...and necrotic." The shoulder wound was also described as having a moderate amount of drainage. The note contained no documented evidence a physician was notified of changes to the wound. A physician's order, dated 8/9/19, to clean the sacrum wound with normal saline, pat dry and apply a "Negative pressure wound vac." A "Skin/Wound Note," dated 8/9/19 at 4:53 p.m., which described the application of the physician ordered wound vac to the sacrum wound. The sacrum wound was described as having "copious" amounts of purulent yellow drainage, inflamed, unstable, and red with necrotic wound edges. The left ischium wound was also described as having a moderate amount of yellow drainage, an unhealthy surrounding area and inflamed. The right ischium wound had "yellow purulent" drainage and inflamed. The right posterior shoulder wound contained no description of undermining compared to the skin/wound note entered on 8/7/19. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 65 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A "Skin/Wound Note," dated 8/10/19 at 1:02 p.m., which described the right ischium wound as having no signs or symptoms of infection, but also having a moderate amount of "yellow purulent drainage." The note further indicated the wound vac applied to the sacrum wound had been dislodged, and was replaced. A "Skin/Wound Note," dated 8/11/19 at 1:51 p.m., which again described the right ischium wound as having no signs and symptoms of infection, but also having a moderate amount of purulent drainage. The left ischium wound was described as having "80% necrotic tissue," and the right posterior shoulder wound " ...able to palpate bone." The note further reported, " ...educated pt [patient] on wound conditions, made pt aware that no improvement is noted on wounds ..." The note ended with, "will cont [continue] to monitor." An additional "Skin/Wound Note," dated 8/12/19 at 5:25 p.m., which indicated "no changes noted from previous days eval [evaluation]," further described the right ischium wound as having "necrotic tissue hanging out," moderate purulent drainage; the right shoulder wound "able to palpate bone," and "will cont [continue] to monitor." Resident 6's clinical record contained no documented evidence changes were made to treat progressively worsening wounds or treatment of possible infection after the wound vac was placed to the resident's sacrum wound on 8/9/19. Review of Resident 6's general acute care hospital records revealed an "Emergency Medicine - Provider Note," dated 8/13/19 at 1:05 p.m. The note indicated Resident 6 presented to the emergency room with severe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 66 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sepsis (a potentially life-threatening condition caused by the body's response to an infection associated with at least one new organ dysfunction). In an interview with the WCP on 9/10/19 at 1:04 p.m., the WCP reported there were no other alternatives to treat Resident 6's wounds and further indicated the wounds would continue to worsen. In an interview with LN 3 on 11/1/19 at 10:06 a.m., LN 3 stated signs and symptoms of an infected wound are redness, drainage, warmth, pain and odor. LN 3 further stated a wound presenting with signs and symptoms of infection would be reported to either the primary care physician or the wound care physician, and the notification would be documented in the resident's clinical record. LN 3 indicated treatments for infected wounds consist of wound cultures, changes in dressings and medications such as antibiotics. In an interview with the Assistant Director of Nursing (ADON) on 11/1/19 at 11:16 a.m., the ADON reported a physician should be notified as soon as possible when changes to a resident's skin or worsening of wounds is noted. The ADON further stated, documenting in the clinical record "will continue to monitor," is not acceptable. During an in an interview with the Medical Director (MD) on 11/14/19 at 7:45 a.m., the MD indicated he was not made aware of the signs and symptoms of Resident 6's wound infection, and had that he did not recall any communication with WCP regarding the residents wounds. MD stated that he could not speak to the severity of, or signs of infection identified in, Resident 6's wounds. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 67 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with WCP on 11/21/19, he stated that he had no recollection of Resident 6 having signs of a wound infection. WCP stated that he probably would not use the term "infection" to document a wound description, if the wound did not have infection. WCP indicated that he had no recollection of speaking to MD about Resident 6, and that if he would have made a recommendation for an antibiotic for an infected wound, that he would have communicated through the treatment nurse. WCP stated that low blood pressure and a change in level of consciousness along with a wound infection would indicate that a patient had a systemic (in blood stream) infection and indicate that the patient required transfer. WCP stated he was not aware of Resident 6's low blood pressure or her alteration in her mental status.

F693 SS=E Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 01/17/2020 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 68 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, medical record and document review, the facility failed to provide appropriate treatment and services by enteral means (tube feeding; TF) in accordance with facility policies and professional standards when: 1. Tube feeding dietary recommendations and physician orders were miscalculated and/or not clarified timely for 3 out of 8 sampled residents (Residents 3, 6, 8); 2. Interdisciplinary team (IDT) for 5 out of 5 sampled residents (Resident 1, 2, 3, 4, and 5) receiving enteral nutrition did not include the required and appropriate (as determined by each resident's needs) professionals. This deficient practice violated each resident's right to comprehensive and individualized nutrition care and; 3. Resident 1's bottle of Jevity 1.5 kcal (a brand of enteral nutrition; 1.5 kilocalories/milliliters=1.5 calories/ml) was unlabeled. The cumulative effect of these failures put these vulnerable residents at further risk of inadequate nutrition, hydration and tube feeding complications. Findings: 1. Tube Feeding Miscalculations and Lack of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 69 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Clarification According to a review of a November 2018 facility policy titled, "Enteral Nutrition", "The dietician, with input from the provider and nurse: a. estimates calorie, protein, nutrient and fluid needs; b. determines whether the resident's current intake is adequate to meet his or her nutritional needs; c. recommends special food formulas; and d. calculates fluids to be provided...Enteral nutrition is ordered by the provider based on the recommendations of the dietician....The nurse confirms that the orders for enteral nutrition are complete. Complete orders include...[the] administration method (continuous, bolus or intermittent), the volume and rate of administration [and] the volume/rate goals and recommendations for advancement toward these..." Resident 3 1.a.I. According to a review of the Admission Record, Resident 3 was admitted to the facility on 7/30/19 with multiple diagnoses including ventilator (breathing machine) dependence due to acute respiratory failure, tube feeding dependence and gastrostomy (opening into the stomach from the abdominal wall, made surgically for the introduction of food), pancreatic insufficiency (malfunctioning organ of the digestive system) and type II diabetes. An unsigned admission Dietary Profile (generally completed by the Food and Nutrition Service Director per 2018 facility policy), effective date 8/1/19, was reviewed. Under Section A., "Diet Order", the following was documented: "TF order: Glucerna 1.2 (a brand of enteral nutrition; 1.2 kcal/ml) @ (at) 75 cc/hour (hr) x 20 hrs. Provides 1206 cc/1800 kcal (cc=cubic centimeters=ml) in 24 hours..." The total volume of tube feeding intended, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 70 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE specified in Resident 3's Dietary Profile, was miscalculated. Glucerna 1.2 running at a rate of 75 cc/hr x 20 hrs yielded a total volume of 1500 ml/1800 kcal delivered in 24 hours, not 1206 ml/1447 kcal. In a concurrent review with Registered Dietician 3 (RD 3) on 1/6/20 at 10 a.m., RD 3 confirmed total volume and calories were miscalculated. During a review of Resident 3's August 2019 physician orders, an Enteral Feed Order, initiated 8/2/19, specified: "one time a day [Enteral] Glucerna 1.2 @ 75 cc/hr x 20 hours. 1500 ml total fluids, 1800 kcal, 90 g (grams), [sic], 1206 ml free water." As evidenced by the August 2019 Medication Administration Record (MAR), from 8/2/19 to 8/9/19, Resident 3 was administered 1200 cc/1440 kcal, instead of the correct amount 1500 ml/1800 kcal, of Glucerna 1.2 every day for 8 days. Resident received 300 ml, or 360 kcal less daily, during this time period. In a concurrent review of the MAR with RD 3 on 1/6/20 at 10 a.m., RD 3 acknowledged Resident 3 received the incorrect tube feeding volume according to the MAR. Further review of the record revealed a Nutritional Risk Assessment of Resident 3 was completed by RD 1 on 8/1/19. On this date, RD 1 recommended the following: "Nutritional Intervention: 1. [Discontinue] current [tube feeding] and flush order. 2. Glucerna 1.2 via pump @ 75 ml x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1500 ml total fluids, 1800 kcal..." Despite this recommendation, it wasn't until 8/9/19, (8 days later) that a physician's order for Resident 3's tube feeding was modified ensuring the correct volume was administered. 1.a.II. Further review of Resident 3's medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 71 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record revealed a tube feeding recommendation, documented in the 9/27/19 Nutritional Risk Assessment. The recommendation read: "Glucerna 1.2 via pump @ 85 ml [sic] x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1700 ml total fluids, 2040 kcal, 102 g pro (protein), 1369 ml free H2O." During a review of Resident 3's September 2019 physician orders, an Enteral Feed Order, initiated 9/28/19, read, "Every shift [Enteral] Glucerna 1.2 via pump @ 85 ml x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1600 ml total fluids, 1920 kcal, 96 g grams pro and 1288 ml free H2O." The tube feed infusion rate was again miscalculated; Glucerna 1.2 running at a rate of 85 ml/hr x 20 hrs equaled a total volume of 1700 ml/2040 kcal, not 1600 ml/1920 kcal. As evidenced by the Resident 3's September 2019 MAR, from 9/29/10 to 10/1/19, nursing staff administered 1600 cc or 1920 kcal of Glucerna 1.2 every day for 3 days. Resident 3 received 100 ml or 120 kcal less daily during this time period. During an interview on 1/6/20 at 10 a.m., RD 3 confirmed the 9/28/19 Enteral Feed Order and corresponding MAR were reflective of the miscalculation, resulting in Resident 3 receiving less nutrition. Resident 6 1.b.I. According to a review of the Admission Record, Resident 6 was originally admitted to the facility on 6/11/19, with conditions including, ventilator dependence due to chronic respiratory failure, a gastrostomy for enteral nutrition, nutritional anemia (low blood count) and hyperglycemia (high blood sugar). The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 72 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/11/19 "Patient Discharge Summary Report" from the transferring facility was noted to have the following "Diet Instructions": "Jevity 1.2 cal at 65 ml/hr continuous via PEG (a type of gastrostomy tube). TF provides 1872 kcal, 87 gm protein, 1264 ml water." Next to these typed instructions was a handwritten note that read, "Jevity 1.5 65/hr x 20 [sic]." Resident 6's June physician orders were reviewed. An Enteral Feed Order, dated 6/11/19, the day of admission, specified, "Every shift [Enteral] Jevity 1.5 (1.5 calories/ml) @ 65 ml/hr x 24 hours ON @ 1200 and OFF @ 0800 or until completed to provide 1560 ml/1872 kcal." Jevity 1.5 running at 65 ml/hr x 24 yielded a total volume of 1560 ml, however, a HIGHER calorie yield of 2340 kcal. In contrast, Jevity 1.5 running at 65 ml/hr x 20 hrs, taking into account the four hour period the tube feeding was NOT infusing, yielded 1300 ml or 1950 kcal. Resident 6's June Enteral Feed Order for Resident 6 included two different and conflicting durations for the Jevity 1.5 infusion, AS WELL AS, a caloric intake miscalculation. Alternatively, had Jevity 1.2 (1.2 calories/ml; less calories than Jevity 1.5) been used, Jevity 1.2 via pump at 65 ml/hr for 24 hours would explain the calculation of 1872 kcal in 1560 ml. During a concurrent interview on 1/6/20 at 10:30 a.m., RD 3 acknowledged the conflicting tube feeding order and the miscalculation. Review of the unsigned 6/13/19 admission Dietary Profile of Resident 6 revealed a "Diet Order" that read, "TF order: Jevity 1.5 @ 65 ml/hr. Provides 1560 ml/1872 kcal." Jevity 1.2 at the same rate and duration would yield 1872 kcal, not Jevity 1.5. As evidenced by Resident 6's June MAR, between 6/13/19 and 6/24/19, nurses documented they administered "1500 ml"of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 73 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Jevity 1.5 every day AND turned the tube feeding pump off from 8 a.m. to 12 p.m. There was documented evidence Jevity 1.5 was administered via pump at 65 ml/hr x 20 HRS, since the tube feeding was charted as "ON" at "1200" and "OFF" at "0800." This meant 1300 ml or 1950 kcal was administered daily for 12 days, not 1560 ml or 2340 kcal. In a concurrent interview on 1/6/20 at 10:30 a.m., RD 3 stated, "if the pump was turned ON and OFF [for 4 hrs], then it had to be going for 20 hrs, it mathematically doesn't work," referring to the administration volume of 1500 ml. During a group interview with RD 2 and RD 3 on 1/6/20 at 10:30 a.m., RD 3 explained that "9 out of 10 times" the transferring hospital sends residents to the facility with orders for continuous 24 hour tube feeding administration. Based on the facility's practice, the Enteral Feeding Protocol, and their discretion, RD 2 stated, the tube feedings were changed on admission to run 20 hours/day, to give each resident a four hour window disconnected from the tube feeding for activities, bathing, etc. RD 2 said the resident would remain on the hospital's tube feeding regimen until a new Enteral Feed Order was written. The admission Nutritional Risk Assessment of Resident 6 was completed 4 days post admission by RD 1 on 6/14/19. RD 1 documented the following: "Current TF regimen: Jevity 1.5 @ 65 ml x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1300 ml total fluids, 1950 kcal." Review of the medical record revealed Resident 6 required transfer to the hospital on 6/24/19 and returned to the facility on 7/8/19. 1.b.II. Upon Resident 6's return on 7/8/19, the hospital advised the facility of its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 74 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Recommended Orders" upon transfer. The following tube feeding was recommended for Resident 6 at the facility: "Jevity 1.2 Cal...65 ml/hr." A review of Resident 6 's July physician orders revealed an Enteral Feed Order, started 7/9/19, with the following instructions: "Every shift Jevity 1.2 (1.2 calories/ml; less calories than Jevity 1.5) @ 65 ml/hr x 20 hours ON @ 1200 OFF @ 0800 or until final volume delivered provide [sic] 1300 ml/1560 kcal in 24 hrs." Upon admission, facility staff did not consider Resident 6 had been given Jevity 1.5, NOT Jevity 1.2, prior to her hospitalization on 6/24/19. As evidenced by the July MAR, from 7/10/19 to 7/18/19, a total of 9 days, Resident 6 received "1300 ml" or 1560 kcal of Jevity 1.2 daily. In a concurrent interview, RD 2 acknowledged it would have been prudent for the facility to have evaluated the tube feeding formula and instructions used prior. A [Re]-admission Nutritional Risk Assessment was completed on 7/18/19, 10 days after Resident 6's readmission to the facility on 7/8/19. RD 1 noted, "Current TF regimen: Jevity 1.2 via pump @ 65 ml x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1300 total fluids, 1560 kcals....Current regimen is NOT adequate to meet needs for wound healing." The Nutritional Risk Assessment further indicated RD 1 made the following recommendations for Resident 6's tube feeding: "1) [Discontinue] current TF and flush order 2) Jevity 1.5 via pump @ 80 ml x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1300 ml total fluids, 1950 kcals, 83 g protein, 988 ml free H2O..." The tube feeding was miscalculated; Jevity 1.5 administered at a rate of 80 ml/hr for 20 hours yielded a total volume of 1600 ml or 2400 kcal, not 1300 ml or 1950 kcal in 24 hrs. In a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 75 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concurrent interview, RD 3 on 1/6/20 at 10:45 a.m., RD 3 acknowledged the total volume was miscalculated. A review of Resident 6's physician orders revealed an Enteral Feed Order, initiated 7/19/19, consistent with RD 1's 7/18/19 recommendations, including the miscalculation. Fortunately, although the July 2019 MAR erroneously indicated: "Jevity 1.5 @ 80 ml/hr x 20 hours...This provides 1300 ml total fluids/1950 cal...," there was documented evidence that from 7/19/19 to 8/1/19 Resident 6 received "1600 ml" or 2400 kcal of Jevity 1.5 daily. Resident 8 1.c. According to a review of the Admission Record, Resident 8 was admitted to the facility on 7/23/19 with diagnoses including amyotrophic lateral sclerosis (ALS; Lou Gerhig's, a progressive neuromuscular disease), respiratory failure and sacral pressure ulcer (bed sore). During a review of Resident 8's Enteral Feed Order, initiated 7/24/19, read, "every shift [Enteral] Glucerna 1.2 @ 60 cc/hour x 24 hours. ON @ 1200 OFF @ 0800 or until final volume delivered, provide [sic] 1440 cc total fluids, 1728 cal in 24 hours." This Enteral Feed Order initiated upon Resident 8's admission prescribed two conflicting tube feed durations. Glucerna 1.2 running for 24 hours continuously (without a 4 hr break) at a rate of 60 cc/hr, would yield a total volume of 1440 ml/1728 kcal, however the tube feeding infusion, having been turned off at 0800 and back on at 1200 noon would yield only 1200 ml/1440 kcal total volume delivered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 76 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE As evidenced by the July MAR, from 7/24/19 to 7/26/19, nursing staff documented Resident 8 was administered "1440 cc" of Glucerna 1.2 every day for 3 days, IN ADDITION to stopping the tube feeding daily between 8 a.m. and 12 p.m. In a concurrent interview with RD 3 on 1/6/20 at 10:45 a.m., RD 3 acknowledged the ambiguous and conflicting tube feeding order, contributing to probable administration errors. Between the order and the MAR, "It doesn't add up," RD 3 said. An admission Nutritional Risk Assessment of Resident 8, completed 7/26/19, was reviewed. At this time, Resident 8's current tube feeding regimen consisted of "Glucerna 1.2 via pump @ 60 ml x 24 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1440 ml total fluids, 1728 kcal." RD 1 further documented, "Current TF is not adequate to meet the needs for wound healing" and made the following nutritional interventions, "1. [Discontinue]current TF and flush order. 2. Glucerna 1.2 via pump @ 85 ml/hr x 20 hrs. On at 1200 and off at 0800 or until dose limit is met. This provides 1700 ml total fluids, 2040 kcal, 102 g pro, 1366 ml free H2O..." A review of Resident 8's physician orders revealed an Enteral Feed Order, initiated 7/27/19, consistent with RD 1's 7/26/19 recommendations. In an interview with RD 1 on 9/10/19 at 4:20 p.m., RD 1 stated it was the physician's responsibility to review the enteral nutrition order recommendations and notes made by the registered dietician prior to signing the tube feeding order. RD 1 explained the physician ultimately makes the decision about the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 77 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE appropriateness and accuracy of the tube feeding when he/she orders it. In a group interview with RD 2 and RD 3 on 1/6/20 at 10 a.m., RD 2 acknowledged the sooner the registered dietician evaluated a new or returning resident the better. RD 3 acknowledged it was unacceptable for a registered dietician to evaluate a resident 10 days after he/she was admitted to the facility. RD 2 explained that upon admission, a nutrition risk assessment was completed and, if applicable, make recommendations for tube feeding and water flushes. These recommendations were documented on a standardized form and passed on to "the Administrator, the Director of Nursing", and the licensed nurse directly responsible for the resident. The licensed nurse generally communicated the RD recommendations to the physician. RD 2 said she expected the physician be notified of her recommendations without delay. When asked if the physician and nurses reviewed her recommendations and notes, RD 2 said, "I hope so." RD 3 continued saying that ambiguous, inconsistent or miscalculated enteral nutrition orders should always be clarified to prevent administration errors. "The numbers need to match," RD 3 added. During an interview with RD 3 on 1/6/20 at 10:30 a.m., RD 3 stated, "I expect [the RDs] to do the math correctly." In an interview on 1/6/20 at 11 a.m., RD 3 recognized there were multiple opportunities for improvement; both the facility and the dietary consultants needed to make some changes to ensure appropriate and accurate enteral nutrition was provided to residents at the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 78 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In a concluding interview with the Administrator (ADM) and the Director of Nursing (DON) on 1/6/20 at 11:15 p.m., when asked if the nurses were expected to review the tube feeding orders were appropriate and accurate, the DON said, "[The] nurses don't calculate." Both the ADM and DON referred to the conflicting tube feeding recommendations, orders and miscalculations as, "clerical errors." 2. The Interdisciplinary Team 2.a. According to a review of the medical record, Resident 1 was diagnosed with chronic respiratory failure (ventilator dependent), unspecified anemia (low red blood cells or hemoglobin), hypothyroidism, and dysphagia (difficulty swallowing). It was evident from a review of a 3/28/19 Nutrition/Dietary Note/Quarterly Review and 6/17/19 Quarterly Nutritional Risk Assessment, Resident 1 was seen by a registered dietician for nutritional risk factors. Resident 1 received enteral nutrition through a gastrostomy tube. Resident 1's Custom IDT Care Conference Form, dated 6/21/19 and IDT Notes, dated 6/24/19, 7/9/19 and 7/15/19, were reviewed. Neither the attending physician, non-physician practitioner (NPP) nor registered dietician were listed as having participated in any of the four IDT meetings. Review of an undated tube feeding Care Plan, without goal time frames,discipline(s) responsible, or revisions, indicated Resident 1 had the "Potential for complication from use of a gastrostomy tube..." The "Interventions" list included, "Dietary Consult as ordered." 2.b. According to a review of the medical record, Resident 2 was admitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 79 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with diagnoses including chronic respiratory failure (ventilator dependent) and anoxic brain damage (total loss of oxygen to the brain). A review of a 3/4/19 Nutrition/Dietary Note and the 5/3/19 (Quarterly), 6/14/19 (Admission) and 8/13/19 (Quarterly) Nutritional Risk Assessments revealed Resident 2 was being seen by a registered dietician for weight loss and enteral nutrition. Resident 2's IDT Notes, dated 6/5/19, 6/11/19 and 6/17/19, and Custom IDT Care Conference Forms, dated 5/20/19 and 8/9/19, were reviewed. Neither the attending physician, NPP, nor registered dietician were listed as having participated in any of the IDT meetings. Review of an undated tube feeding Care Plan, without goal time frames, discipline(s) responsible, or revisions, indicated Resident 2 had the "Potential for complication from use of a gastrostomy tube..." The "Interventions" list included, "Dietary Consult as ordered." 2.c. According to a review of the medical record, Resident 3 was admitted to the facility with diagnoses including respiratory failure (ventilator dependent), insulin dependent Type 2 diabetes mellitus (disease resulting in elevated blood sugar in the blood and urine), and exocrine pancreatic insufficiency (the inability to properly digest food due to a lack of enzymes made by the pancreas). A review of a 8/1/19 Admission Nutritional Risk Assessment and 8/13/19 Nutrition/Dietary Note revealed Resident 3 was seen by Registered Dietician 1 (RD 1) for many nutritional risk factors including abnormal labs, tube feedings, skin breakdown and a Body Mass Index (BMI) of 15.8, or underweight. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 80 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 3's IDT Notes, dated 8/15/19 and 8/23/19, and Custom IDT Care Conference Form, dated 8/15/19, were reviewed. Neither the attending physician, NPP, nor registered dietician were listed as having participated in either IDT conference. Review of an undated tube feeding Care Plan, without goal time frames, discipline(s) responsible, or revisions, indicated Resident 3 had the "Potential for complication from use of a gastrostomy tube..." The "Interventions" list included, "Dietary Consult as ordered." 2.d. According to a review of the medical record, Resident 4 was admitted to the facility with diagnoses including, chronic respiratory failure, type II diabetes mellitus, and dependence on enteral nutrition via gastrostomy. A review of Resident 4's 7/16/19 Admission Nutritional Risk Assessment indicated RD 1 recommended modifying Resident 4's tube feedings and lab draws. Resident 4's 7/15/19, 7/22/19 and 9/12/19 IDT Notes were reviewed. Neither the attending physician, NPP, nor registered dietician were listed as having participated in any of the three IDT conferences. Review of an undated tube feeding Care Plan, without goal time frames, discipline(s) responsible, or revisions, indicated Resident 4 had the "Potential for complication from use of a gastrostomy tube..." The "Interventions" list included, "Dietary Consult as ordered." 2. e. According to a review of the medical record, Resident 5 was admitted to the facility in a persistent vegetative state (wakeful unconsciousness lasting longer than a few FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 81 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE weeks) after an anoxic brain injury. Resident 5 was ventilator dependent. A review of Resident 5's 6/17/19 Quarterly Nutritional Risk Assessment revealed Resident 5 was seen by RD 1 for enteral nutrition and hydration. Resident 5's 7/8/19 IDT Notes were reviewed. Neither the attending physician, NPP, nor registered dietician were listed as having participated in the 7/8/19 IDT meeting. Review of an undated tube feeding Care Plan, without goal time frames, discipline(s) responsible, or revisions, indicated Resident 5 had the "Potential for alteration in comfort related to use of G-tube (gastrostomy tube)." The list of "Interventions" included, "Dietary Consult as ordered." During an interview with RD 1 on 9/10/19 at 1:45 p.m., RD 1 stated she did not attend or participate in IDT meetings or care conferences. In a group interview with the Medical Director/Attending Physician (MD 1), the Director of Nursing (DON) and the Administrator (ADM) on 11/14/19 at 7:45 a.m., the DON stated it was difficult to have all appropriate members of the IDT "sit down at the same time." MD 1 acknowledged he did not attend formalized IDT meetings either onsite or remotely. MD 1 continued saying he had attended IDT meetings at other facilities. The Minimum Data Set Coordinator (MDSC) was interviewed 11/14/19 at 9:30 a.m. when asked if either a physician, physician's assistant or registered dietician attended the IDT meetings, she stated, "No." MDSC acknowledged tube feedings, weights and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 82 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident nutrition was reviewed during IDT meetings. According to the 2013 facility policy titled, "Care Planning-Interdisciplinary Team", "Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident...The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but it not necessarily limited to the following personnel:...f. Consultants (as appropriate)..." The policy did not specify that the attending physician (or NPP) participate as a member of the IDT, as required by regulation (refer to F 657 ). A review of the 2016 facility policy titled, "Care Plans, Comprehensive Person-Centered" revealed the following: "The Interdisciplinary Team (IDT), "The IDT includes: a. the attending physician...and f. other appropriate staff or professionals as determined by the resident's needs...Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process...the resident's physician (or primary healthcare provider) is integral to this process." According to the 11/18 facility policy titled, "Enteral Nutrition", "The interdisciplinary team, including the dietician, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings....The dietician, with input from the provider and nurse: a) estimates calorie, protein, nutrients and fluid needs; b) determines whether the resident's current intake is adequate to meet their needs; and c) recommends special food formulations...The dietician monitors residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 83 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings." 3. Unlabeled bottle of Enteral Nutrition During an initial tour of the facility on 9/10/19 at 12:30 p.m., Resident 1 was observed sitting up in bed. A full bottle of Jevity 1.5 CAL was observed infusing through an administration set (tubing) via an enteral feeding pump. The tubing was connected to Resident 1's gastrostomy tube (GT). The manufacturer's label on the bottle of Jevity was missing the following information: the resident's name or initials, the date and time the bottle was hung and administration started, the infusion rate and staff initials. During a concurrent observation and interview with Licensed Nurse 3 (LN 3) on 11/14/19 at 10 a.m., LN 3 explained that the nurses write the patient's name, the date, and time each enteral nutrition bottle was "hung" or started. LN 3 was observed removing a new, unopened bottle of enteral nutrition from a nutrition closet. LN 3 indicated the location on the bottle where the following information was required on the manufacturer's label: the resident's name, room number, the date and time a new bottle was started and the rate of infusion. According to a 2018 facility policy titled, "Enteral Tube Feeding via Continuous Pump," "On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6E2X11 Facility ID: CA030000027 If continuation sheet 84 of 85 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055887 (X3) DATE SURVEY COMPLETED 01/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER BEND NURSING CENTER 2215 Oakmont Way West Sacramento, CA 95691 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 6E2X11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000027 (X5) COMPLETE DATE If continuation sheet 85 of 85