River Bend Nursing Center
2215 Oakmont Way · West Sacramento, CA · 95691 · 9163711890
99 certified beds For profit - Limited Liability company Chain: Bvhc, LLC
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 3 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 4.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.88 | 0.55–0.75 |
| Weekend hours / resident-day | 4.67 | ≈ weekday level |
| Nursing turnover / year | 45% | median 45% |
| Fines (3-yr window) | 1 · $21,879 |
Inspection citations (48 in the current record)
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Potential for harm · D March 30, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 10, 2026 · Resident Assessment and Care Planning
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Potential for harm · E February 25, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected February 26, 2026 · Resident Rights
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Potential for harm · D August 21, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 21, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 12, 2025 · Pharmacy Service
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Potential for harm · E August 15, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected September 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 15, 2025
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · E August 15, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · D August 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · D August 15, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected September 10, 2025 · Pharmacy Service
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Potential for harm · D August 15, 2025
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.
Corrected September 10, 2025 · Pharmacy Service
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Potential for harm · F August 15, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 10, 2025 · Nutrition and Dietary
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Potential for harm · E December 24, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 23, 2025 · Infection Control
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Potential for harm · D October 30, 2024 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected November 12, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 4, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 12, 2024 · Quality of Life and Care
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Potential for harm · D September 17, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 23, 2024 · Pharmacy Service
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Potential for harm · D August 22, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 18, 2024 · Resident Rights
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Potential for harm · E August 22, 2024
Keep residents' personal and medical records private and confidential.
Corrected September 18, 2024 · Resident Rights
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Potential for harm · D August 22, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 18, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 22, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected September 18, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 22, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 18, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
Provide activities to meet all resident's needs.
Corrected September 18, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
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.
Corrected September 18, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 18, 2024 · Pharmacy Service
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Potential for harm · E August 22, 2024
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected September 18, 2024 · Nutrition and Dietary
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Potential for harm · E August 22, 2024
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.
Corrected September 18, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 14, 2023 | Fine | $21,879 |
| December 14, 2023 | Payment Denial | 2 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055887 · certified since February 8, 1968. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.