River Bend Nursing Center
River Bend Nursing Center in West Sacramento, CA — inspection on March 30, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
administer a prescribed antibiotic (a medication used to kill or stop the growth of bacteria) medication
and worsening symptoms for Resident 1.Findings:Resident 1 was originally admitted to the facility in March 2026 with diagnoses that included nonˆtraumatic intracerebral hemorrhage (bleeding inside the brain) and H. pylori gastritis (a stomach infection caused by Helicobacter pylori bacteria).A review of Resident 1's Hospital After Visit Summary (AVS), dated 3/17/26, the AVS indicated that the metronidazole (medication used to treat infections caused by bacteria or parasites) 500 mg (milligram, unit of measurement) every 6 hours was last given on 3/17/26 at 12:12 p.m.A review of Resident 1's Order Summary Report, with a start date of 3/17/26, indicated, Metronidazole Oral Tablet 500 mg.
Give 1 tablet via PEGˆtube [a small tube that helps deliver food and medicine directly to the stomach when eating by mouth is not safe] every 6 hours for H.
Pylori Gastritis.A review of Resident 1's Medication Administration Record (MAR) for March 2026, the MAR indicated that Resident 1 did not receive the prescribed metronidazole doses scheduled for 3/17/26 at 6 p.m. and 3/18/26 at 12 a.m.During a concurrent interview and record review on 3/30/26 at 3:45 p.m. with the Infection Preventionist (IP), the IP stated that the medication had not been given as indicated in Resident 1's Administration Notes dated 3/17/26 at 7:45 p.m. and 3/18/26 at 12:32 a.m.
The Administration Notes indicated that the medication was pending pharmacy delivery.During a concurrent observation and interview on 3/30/26 at 4 p.m. with the Infection Preventionist (IP) Nurse in the medication room, the IP was observed checking the contents of the medication emergency kit (eˆkit), which contained metronidazole.
The IP stated the nurse should have utilized the medication e-kit to administer the scheduled antibiotic if it was available.
The IP further stated that if antibiotics were not administered appropriately, bacteria could become resistant to the medication.During an interview on 3/30/26 at 4:22 p.m. with the Director of Nursing (DON), the DON stated that if an antibiotic was not administered, it could delay the healing process, and an acute situation might occur.
The DON stated the nurse should have used the ordered medication from the eˆkit.A review of the facility's policies and procedures titled Administering Medications (undated) 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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in West Sacramento, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from River Bend Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.