River Bend Nursing Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

2/19/25, indicated, MIDLINE: Cap Change every shift every shift.A review of Resident 1's MAR for the month of February 2025, indicated midline cap change was not done on 2/27/25 and 2/28/25 as physician ordered. During an interview on 8/20/25, at 2:05 p.m., with the Director of Nursing (DON), the DON confirmed the expectation was for nursing staff to follow physician's orders. During a concurrent interview and record review on 8/21/25, at 1:20 p.m., with Licensed Nurse 3 (LN 3), LN 3 reviewed Resident 1's February 2025 MAR and confirmed Resident 1 had missing dates for Preparation H treatment order, midline monitoring and flushing, monitoring s/s for opioid use, monitoring s/s for diuretic use and changing midline cap changes as physician ordered. LN 3 also reviewed Resident 1's medical chart and confirmed

the physician was not notified on those dates and stated the physician was supposed to be notified when a medication or treatment was not given or if monitoring was not done. LN 3 further stated Resident 1 potentially could have had a change of condition or possible infection if monitoring and treatment was not done or documented. LN 3 stated, Anything could happen.could be change of condition. A review of the facility's document titled, Registered Nurse (RN), undated, indicated, Provide nursing services to residents

in accordance with scope of practice, facility policies and professional standards of care.Monitor residents for development of acute changes of condition.conduct assessments and notify the provider as needed.Monitor the chronic health conditions of residents.Maintain documentation of all nursing care and services provided to the residents.Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors.A review of the facility's policies and procedures (P&P) titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescribed orders, including any required time frame.If a dosage is believed to be inappropriate.the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.A review of the facility's P&P titled, Charting and Documentation, revised 7/2017, indicated, Documentation of procedures and treatments will include care-specific details, including:.e. Whether the resident refused the procedure/treatment.f.

Notification of family, physician.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

River Bend Nursing Center

2215 Oakmont Way West Sacramento, CA 95691

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to ensure Resident 1 was free from significant medication error when Resident 1 did not receive prescribed antihypotensive medication (used to increase low blood pressure) in accordance with the physician's order.This failure had the potential to result in Resident 1 experiencing low blood pressure and other unnecessary side effects which could have negatively affected Resident 1's health.Resident 1 was originally admitted to the facility in May 2024 with multiple diagnoses which included hypotension (low blood pressure, means that the pressure of blood circulating around the body is lower than normal). A review of Minimum Data Set (MDS, an assessment tool), dated 2/5/25, indicated Resident 1 had impaired cognition. A review of Resident 1's Order Summary Report, with start date 1/31/25, indicated, Midodrine HCl [medication to treat low blood pressure (hypotension)] Oral Tablet 5 MG [milligrams-unit of measurement] (Midodrine HCl) Give 1 tablet by mouth two times a day for hypotension *HOLD for SBP [systolic blood pressure, the top number and refers to the amount of pressure experienced by the arteries while the heart is beating] GREATER THAN 120*.A review of Resident 1's Medication Administration Record (MAR, a legal document used to record medications given to the residents), for the month of February 2025, indicated Resident 1 did not receive the physician prescribed Midodrine medication on 2/1/25, 2/2/15, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/11/25, 2/12/25, 2/17/25, and 2/20/25 as ordered. During an interview on 8/20/25, at 2:05 p.m., with the Director of Nursing (DON), the DON confirmed the expectation was for nursing staff to follow physician's orders. During a concurrent interview and record review on 8/20/25, at 3:43 p.m., with Licensed Nurse 2 (LN 2), LN 2 reviewed Resident 1's February 2025 MAR and confirmed Resident 1's SPB was lower than 120 and should have received prescribed antihypotensive medication on 2/1/25, 2/2/15, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/11/25, 2/12/25, 2/17/25, and 2/20/25 as ordered. LN 2 also reviewed Resident 1's medical chart and confirmed the physician was not notified on those dates and stated the physician was supposed to be notified if a medication was not given. LN 2 further stated Resident 1's blood pressure could have continued to keep dropping and result in Resident 1 having a change of mentation and change in condition. A review of the facility's document titled, Registered Nurse (RN), undated, indicated, Administer medications according to practitioner orders and report adverse consequences, side effects or any medication errors.A

review of the facility's policies and procedures (P&P) titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescribed orders, including any required time frame.If a dosage is believed to be inappropriate.the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet