Health inspection·July 29, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff answered call lights (device used by residents to signal his or her need for assistance from staff) in a timely manner for three of 4 sampled residents (Resident 3, Resident 4, and Resident 1).These failures had the potential to result in resident's care needs not being met and placed residents' safety at risk. Findings: 1a. A review of the admission Record indicated Resident 3 was admitted last week of July 2025 with diagnoses including acute respiratory failure with hypoxia (lungs unable to get enough oxygen into the blood) and protein calorie malnutrition (the body does not get enough protein and energy to function properly).A review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/30/25 indicated Resident 3 was cognitively intact.A review of Resident 3's physician order dated 7/26/25 indicated Resident 3 had the capacity to make healthcare decisions.In a concurrent observation and interview on 7/29/25 at 12:29 p.m., Resident 3 was lying in bed with the head of the bed elevated and had ongoing oxygen via nasal cannula (a small plastic tube, which fits into the person's nostrils providing supplemental oxygen). Resident 3 stated she needed oxygen all the time. Resident 3 further stated she cannot walk, she had incontinent briefs and when she pressed the call light, she had to wait a long time to be changed. Resident 3 was asked to elaborate the specific time when she had to wait for assistance, resident stated whenever I go [opened bowels or urinated].1b. A review of the admission Record indicated Resident 4 was admitted [DATE] with diagnoses including encephalopathy (a condition where the brain is not working properly due to some damage or disease), and cerebrovascular disease (conditions that affect blood flow to the brain).A review of Resident 4's MDS dated [DATE] indicated Resident 4 was cognitively intact, dependent on staff for toileting, personal hygiene, dressing, and bed mobility.A review of Resident 4's physician order dated 7/3/25 indicated Resident 4 had the capacity to make healthcare decisions.In a concurrent observation and interview on 7/29/25 at 12:43 p.m., Resident 4 was awake and lying in bed. Resident 4 stated sometimes it took 30 minutes for her call light to be answered. Resident 4 further stated it depends on how busy they are out there.1c. A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including fracture of upper of right humerus (upper arm bone), dislocation of right shoulder joint (the head of the upper arm bone comes out of the shoulder socket), and fall.A review of Resident 1's MDS dated [DATE] indicated Resident 1 was cognitively intact, dependent on staff for bed mobility, and required substantial/maximal assistance [staff does more than half of the effort] for toileting, upper and lower body dressing, and personal hygiene.In an interview on 7/29/25 at 2:12 p.m., Resident 1 stated at around 11:30 p.m. last night, she held and pressed the call light for assistance. Resident 1 further stated the staff ignored her call light, and somebody finally came at 11:45 p.m.In an observation conducted on 7/29/25 at 1:47 p.m., there were multiple call lights unanswered in Hall 6.An interview was conducted on 7/29/25 at 3:27 p.m. with the Director of Staff Development (DSD). The DSD stated her Residents Affected - Few (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055402 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055402 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River City Post Acute 2540 Carmichael Way Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)