B+
80/100River Bend Nursing Center Inspection Report, Violations & Safety Grade (West Sacramento, California)
2215 Oakmont Way, West Sacramento, California 95691
Phone: 9163711890
CMS Overall:4/5
Overview & Bed Count
Certified Beds
99
Avg Residents/Day
90.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Yolo
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | California Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.06 | 0.68 | +0.38 |
| Total Nurse Hours per Resident per Day | 4.87 | 4.54 | +0.32 |
| CMS Staffing Rating | 3/5 | 3.3/5 | - |
| Nursing Staff Turnover | 43.4% | 36.6% | - |
Health Citation History
40 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-30 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-07-30 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-07-30 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2026-07-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-07-30 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2026-03-30 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2026-02-25 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2025-08-21 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-08-21 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2025-08-15 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-08-15 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2025-08-15 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | E – Moderate Harm Potential |
| 2025-08-15 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2025-08-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-08-15 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-08-15 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2024-12-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-10-30 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-10-04 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-09-17 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-08-22 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | E – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | E – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | E – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-08-22 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-08-22 | Environmental Deficiencies | Keep all essential equipment working safely. | E – Moderate Harm Potential |
| 2024-08-22 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2024-08-22 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E – Moderate Harm Potential |
| 2024-08-22 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-08-22 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-08-22 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-08-22 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-08-22 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2024-08-22 | Quality of Life and Care Deficiencies | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D – Moderate Harm Potential |
| 2024-08-22 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2024-08-22 | Nutrition and Dietary Deficiencies | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D – Moderate Harm Potential |
| 2023-12-14 | Quality of Life and Care Deficiencies | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | G – Actual Harm |
| 2023-10-03 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
Fire Safety Citation History
29 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-07-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2026-07-30 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2026-07-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | E – Moderate Harm Potential |
| 2026-07-30 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2026-07-30 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2026-07-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2026-07-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-08-15 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | F – Moderate Harm Potential |
| 2025-08-15 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | D – Moderate Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | D – Moderate Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-08-15 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | C – Minimal Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | C – Minimal Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | C – Minimal Harm Potential |
| 2025-08-15 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | C – Minimal Harm Potential |
| 2024-08-22 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | F – Moderate Harm Potential |
| 2024-08-22 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2024-08-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-08-22 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2024-08-22 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2024-08-22 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2024-08-22 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2024-08-22 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | C – Minimal Harm Potential |
| 2024-08-22 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2024-08-22 | Smoke Deficiencies | Provide properly protected cooking facilities. | C – Minimal Harm Potential |
| 2024-08-22 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | C – Minimal Harm Potential |
Total Penalties & Fines
$21,879
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2023-12-14 | Fine | $21,879 | - |
| 2023-12-14 | Payment Denial | - | 2 days starting 2024-01-03 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the West Sacramento area at no cost.
Find Safe, Vetted Facilities Near West Sacramento
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.