River Bend Nursing Center
2215 Oakmont Way, West Sacramento, CA 95691 · Yolo County · 99 certified beds · avg 90 residents/day · certified since Feb 8, 1968
Part of chain: BVHC, LLC (12 facilities, chain avg rating 3.3★)
3/5
Health inspection rating (on-site)
2
Serious findings on record
$21,879
Fines, last 3 years
3.15
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 14, 2023 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 5, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 30, 2021 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 3, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (47)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 30, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 25, 2026 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 21, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 15, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 15, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 15, 2025 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Aug 15, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 15, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 15, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 15, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Dec 24, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 30, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Oct 4, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 17, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Aug 22, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Dec 14, 2023 | ▲ G · Actual harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Jul 30, 2021 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 30, 2021 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Jul 30, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 30, 2021 | E · Potential for harm, repeated | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Jul 30, 2021 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 30, 2021 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (18 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 12 | 1 | G ▲ |
| 2023 | 2 | 1 | G ▲ |
| 2024 | 22 | 0 | E |
| 2025 | 9 | 0 | F |
| 2026 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $21,879, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Dec 14, 2023 | Fine | $21,879 |
| Dec 14, 2023 | Payment Denial | 2 days from Jan 3, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.15 | 4.31 | 3.95 | bottom 2% in California; bottom 19% in the U.S. |
| Registered Nurse hours | 0.66 | 0.61 | 0.69 | top 28% in California; top 41% in the U.S. |
| Weekend total nurse staffing | 3.00 | 3.90 | 3.50 | bottom 4% in California; bottom 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.85 | 0.51 | 0.48 | top 10% in California; top 10% in the U.S. |
| Total nursing staff turnover (%) | 43.4 | 36.7 | 45.8 | bottom 29% in California; top 46% in the U.S. |
| RN turnover (%) | 36.8 | 38.1 | 42.9 | top 50% in California; top 41% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.90, RN 1.02, weekend 4.66. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Brazier, Suzanne | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/12/2022 |
| Brazier, Suzanne | Individual | ADP of the SNF | NOT APPLICABLE | 12/12/2022 |
| Calabazaron, Redentor | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/14/2022 |
| Calabazaron, Redentor | Individual | ADP of the SNF | NOT APPLICABLE | 02/14/2022 |
| Chinthakindi, Ravi | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/30/2024 |
| Chinthakindi, Ravi | Individual | ADP of the SNF | NOT APPLICABLE | 01/30/2024 |
| Mays, Darlene | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/18/2022 |
| Mays, Darlene | Individual | ADP of the SNF | NOT APPLICABLE | 04/18/2022 |
| Thapa, Nischal | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/06/2024 |
| Thapa, Nischal | Individual | ADP of the SNF | NOT APPLICABLE | 08/06/2024 |
| Van Wagenen, Sean | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/19/2024 |
| Van Wagenen, Sean | Individual | ADP of the SNF | NOT APPLICABLE | 08/19/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Pioneer House | 2.2 mi | Sacramento, CA | ★★★☆☆ | 2/5 | abuse |
| Cedarwood Post Acute | 3.2 mi | Sacramento, CA | ★★★☆☆ | 3/5 | |
| Mid-Town Oaks Post-Acute | 3.8 mi | Sacramento, CA | ★★★☆☆ | 2/5 | |
| McKinley Park Care Center | 4.3 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| Saylor Lane Healthcare Center | 4.4 mi | Sacramento, CA | ★★★★☆ | 3/5 | |
| University Post-Acute Rehab | 4.5 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Advanced Health Care of Sacramento | 4.6 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Greenhaven Healthcare Center | 4.9 mi | Sacramento, CA | ★★★☆☆ | 2/5 | abuse |
| Sherwood Healthcare Center | 5.4 mi | Sacramento, CA | ★★★★★ | 4/5 | |
| Capital Post Acute | 6.0 mi | Sacramento, CA | ★★☆☆☆ | 2/5 | abuse |
| Acc Care Center | 6.4 mi | Sacramento, CA | ★★★★★ | 3/5 | |
| North Pointe Care Center | 6.7 mi | Sacramento, CA | ★★☆☆☆ | 1/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 055887.