American River Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the professional standards of food service safety for a census of 98 residents, when: 1. Two thermometers, one manual and one digital, were not in good working condition; and 2. Weekly thermometer calibration was not done and not documented in the thermometer log binder. These failures had the potential for inaccurate thermometer readings and the time/temperature control for food safety not accurately monitored and increased the risks of food-borne illnesses. During a concurrent observation, interview, and record review on 4/8/26 at 9:30 a.m., the kitchen thermometers used for food preparation were inspected. [NAME] 1 (CK 1) demonstrated how to calibrate the thermometers. CK 1 indicated, two thermometers, one manual and one digital were not in good working conditions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 24 sampled residents (Residents 22 and 72), when: 1. Resident 72 was not observed during the entire medication pass to ensure medications were completely administered; and 2. Nursing staff did not use multiple strategies to administer Humalog KwikPen (a fast-acting insulin to treat diabetes) for Resident 22. These failures resulted in Resident 22 and Resident 72's not receiving their medications and had the potential to result in worsening of their clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications for disposal were not rendered unusable, irretrievable, and were not securely stored when red sharps containers with open lids were used to dispose of medication in 2 of 2 medication carts inspected; and medications with discontinued orders were not removed from facility drug supply and destroyed in a timely manner. These failures had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 50 and 76) were free of significant medication errors when: Resident 50 received dorzolamide (a medication to treat high eye pressure in glaucoma, a group of eye diseases that causes high fluid pressure inside the eye, leading to permanent vision loss or blindness if untreated) ophthalmic (eye) solution 18 times (doses) and latanoprost (a medication to treat high eye pressure) six times, past the expiration date; andResident 76 received fluticasone/salmeterol (a medication to chronic obstructive pulmonary disease (COPD), a progressive, long-term lung disease that makes it hard to breathe) 37 times, past the expiration date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date, expired medications were not available for resident use, medications were stored according to manufacturer's labeling, and prescription medications were appropriately labeled with a pharmacy label. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications from being stored outside of manufacturer's specifications.

Inspectors wroteBased on interview, record review, the facility failed to ensure one out of 24 sampled residents (Resident 2) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors), when Resident 2's fluoxetine (a medication to treat depression) dose was increased without adequate documented clinical rationale and without target behavior monitoring for efficacy. This failure had the potential to result in the unnecessary use of psychotropic medication and increased the risk of exposure to side effects such as nausea, headache, insomnia, diarrhea, dry mouth, and fatigue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) wound care treatment was followed as ordered, when the Treatment Nurse (TN) wrapped Resident 3's right lateral heel diabetic (chronic condition caused by increased blood sugar level and can delay wound healing) wound with a bandage (stretchable, reusable compression bandage made of cotton, polyester, and synthetic rubber, to support inured muscle and joint, reduce swelling) which was not ordered or indicated. This failure had the potential to delay the wound healing process and develop complications to Resident 3's right lateral heel diabetic wound. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a safe and sanitary manner for 96 residents who received food from the kitchen when: 1. Opened and prepared foods stored without used by dates labeled; 2. foods with opened packages not covered tightly; and 3. spoiled food available to be served. These failures had the potential to result in foodborne illnesses among the vulnerable residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. A visitor was observed accessing and obtaining ice from the nursing unit's ice chest unsupervised; 2. Ice scoop was stored uncovered; and 3. Certified Nursing Assistant (CNA) was observed not performing hand hygiene after handling garbage. These failures had the potential to result in the spread of infections for a facility census of 97 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 71) urinary tract infection (UTI, an infection in the bladder/urinary tract) person-centered care plan was developed. This failure had the potential to negatively impact Resident 71's quality of treatment, care and services received.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 51) had compression stocking (stockings that apply gentle pressure to the legs and ankles to improve blood flow) applied everyday to Resident 51's left lower extremity (LLE) as ordered. This failure had the potential to compromise Resident 51's blood circulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 1) had hearing aids (HA) applied everyday as ordered. This failure decreased the facility's ability to provide treatment and assistive devices to maintain Resident 1's hearing acuity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1), needs and preferences were accommodated, when Resident 1 was left on a patio outside of the facility and unable to contact staff. This failure reduced the facility's potential to provide services to Resident 1 with reasonable accommodation of her needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge home for one resident (Resident 1) of three sampled residents when Resident 1 was discharged home without verified home health service arrangements. This failure resulted in Resident 1 not receiving the necessary continuity of care for his wound.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an injury of unknown origin for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to protect Resident 1 from a possible allegation of abuse and ensure a safe environment during the investigation of the cause of the injury.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of four sampled residents (Resident 2) when Resident 2 had repeated falls. This failure resulted in Resident 2 to have unmet care needs for falls and could have contributed to the thigh bone fracture during her stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for one of four sampled residents (Resident 1) when two Certified Nursing Assistants (CNA) had an argument regarding a staffing assignment while providing a shower to Resident 1. This failure resulted in Resident 1 crying and feeling afraid and decreased the facility's potential to protect residents' dignity.

Inspectors wroteBased on interview and record review the facility failed to follow its own policy for readmission when one of 3 sampled residents (Resident 1) was not permitted to return to the facility. This failure resulted in the violation of Resident 1's rights for readmission to resume residence at the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Ice machine was not clean, 2. The food storage racks were not well maintained in the walk-in refrigerator and walk-in freezer, and 3. The temperature of the freezer sections of the resident's food refrigerators located in nurse station one (1) and two (2) were not monitored. These failures had potential to cause food-borne illness in a highly susceptible population of 97 out of 98 residents who consumed meals or food in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was being followed for the therapeutic diet for lunch on 3/20/24 when: 1. Seven residents (Resident 2, 4, 6, 16, 20, 41, and 408) were on modified texture diets Dysphagia mechanical soft (a diet for people with mild to moderate chewing and/or swallowing difficulty) and Dysphagia advance (a diet for people with mild chewing and/or swallowing difficulty and usually more soft and moist for food tolerance) who received no gravy for the meat entrée instead of receiving gravy as indicated on the menu; 2. [...]

Inspectors wroteBased on interview and record review the facility failed to provide documentation for current COVID-19 (a contagious viral disease that can cause severe respiratory distress) immunizations for three of seven sampled residents (Resident 7, Resident 61, and Resident 73) when there was no documentation of the vaccine being offered, given or refused. These failures decreased the facility's potential to prevent prevent or reduce the severity of COVID-19 .

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control standards of practice for two of 24 sampled residents (Resident 204 and Resident 7) when: 1. Resident 204's indwelling catheter (tube placed into the bladder to collect urine) bag was lying on the floor and, 2. EBP/ESP (Enhanced Barrier Precautions/Enhanced Standard Precautions- infection control interventions designed to reduce transmission of multi drug organism [MDRO] which involve gown and glove use during high contact resident care activities) were not followed for Resident 7. These failures decreased the facility's potential to prevent the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medical records were kept private for a census of 98, when the computer containing resident medical records was exposed to the public. This failure violated the residents' medical records confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored locked and secured for a census of 98, when a medication cart was unlocked and keys were left unattended. This failure had the potential for medication misuse and drug diversion.