Health inspection·November 20, 2025

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 12/2021, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .m. exercise rights not delegated to a legal representative; . o. be notified of his or her medical condition and of any changes in his or her condition; p. be informed of, and participate in, his or her care planning and treatment; .A review of the facility's P&P titled, Health Care Decision Making, dated 2/1/23, indicated, Centers must: .Inquire with the individual's patient representative if the patient is incapacitated at the time of admission as to whether an advance directive has been completed/executed in accordance with state law.A review of the facility's P&P titled, admission Agreement, revised 2/2025, indicated, 1. At the time of admission, the resident (or his/her representative) must sign an admission agreement (contract). Event ID: Facility ID: 055402 If continuation sheet Page 2 of 4 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 11/20/2025 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1) was free from significant medication error when Resident 1 did not receive his prescribed antiseizure medications (used to treat epilepsy and other seizure disorders by altering electrical activity in the brain) in accordance with the physician's order and standards of practice.This failure had the potential for Resident 1 to experience seizure activity (a sudden, uncontrolled electrical disturbance in the brain that can cause a range of symptoms, such as muscle stiffening, shaking, or altered sensations) and other seizure related complications which could negatively affect the resident's health.Findings:A review of Resident 1's clinical record indicated Resident 1 was admitted January of 2025 and had diagnoses that included cerebral infarction (damage to a part in the brain due to a disrupted blood flow), cerebrovascular disease (a group of conditions that affects the blood flow and the blood vessels in the brain), hemiplegia (complete loss of the ability to move one side of the body) affecting right dominant side, and aphasia (a language disorder that affects a person's ability to understand and express written and spoken language).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 10/3/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 1 had an intact cognition (mental process of acquiring knowledge and understanding).During an interview on 11/20/25 at 12:09 p.m. with Resident 1, in Resident 1's room, Resident 1 gestured he was not receiving his antiseizure medication regularly.During a phone interview on 11/20/25 at 12:16 p.m. with Resident 1's sister, in Resident 1's room, Resident 1's sister stated a facility staff called her yesterday and told her that Resident 1 had not received his antiseizure medication since November 13th. A review of Resident 1's active physician's order, dated 7/2/25, indicated, levetiracetam (a medication used to prevent and control seizures in individuals with epilepsy) Oral Tablet 1000 MG (milligrams- unit of measurement) .Give 1 tablet by mouth three times a day for Seizures.A review of Resident 1's medication administration record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of November 2025 indicated Resident 1 did not receive levetiracetam on the following times:11/13/25 at 10 p.m.11/14/25 at 9 a.m.11/14/25 at 1 p.m.11/15/25 at 9 a.m.11/15/25 at 1 p.m.11/15/25 at 10 p.m.11/16/25 at 9 a.m.11/16/25 at 1 p.m.11/18/25 at 9 a.m.11/18/25 at 1 p.m.During an interview on 11/20/25 at 12:42 p.m. with Licensed Nurse (LN) 2, LN 2 stated nurses should make sure that residents with antiseizure medication should be given their medications properly and timely. LN 2 also stated staff should always re-order the antiseizure medication seven days ahead before it ran out. LN 2 further stated there would be a risk for the resident to have a seizure if he was not getting his medications regularly. A review of Resident 1's Physician Progress Note, dated 11/13/25, indicated, .Plan .3. Seizure Disorder*** Continue **levetiracetam 1000 mg TID [three times a day** A review of a facility documented titled, PROVIDER COMMUNICATION LOG, NON-URGENT MATTERES ONLY, dated 11/13/25, indicated, . [Name of Resident 1] .Levetiracetam oral tablet 1000 MG give 1 tab [tablet] by mouth three times a day for seizures. Patient is fine and stable. Called pharmacy to order medication, awaiting delivery. The column indicating that the doctor noted the issue was blank. A review of a facility document titled, URGENT: NOTICE OF NON-COVERED/HIGH-COST DRUG, for Resident 1's levetiracetam indicated the Director of Nursing (DON) signed the notice on 11/14/25.A review of Resident 1's Progress Note, dated 11/18/25, indicated, Resident has not received his levetiracetam for > [more than] 3 days. Resident has not had any seizures [on] AM shift. Continuing to monitor for any seizures.A review of the delivery Manifest [receipt] for Resident 1's levetiracetam indicated the facility received the medication on Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055402 If continuation sheet Page 3 of 4 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 11/20/2025 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 11/18/25 at 5:29 p.m.During a concurrent interview and record review on 11/20/25 at 3:09 p.m. with the Assistant Director of Nursing (ADON), Resident 1's clinical records were reviewed. The ADON confirmed that Resident 1 did not receive his prescribed antiseizure medications in accordance with the physician's order for 10 occasions. The ADON also confirmed that there was no documented evidence in Resident 1's clinical records that his doctor was notified with the issue and the medication re-order was followed up to the pharmacy between 11/13/25 to 11/18/25. The ADON stated Resident 1 should have received his antiseizure medications on those 10 occasions because there would be a risk for Resident 1 to have a seizure if he was not getting his medications regularly.During a concurrent phone interview and record review on 11/20/25 at 3:41 p.m. with the Pharmacist from the Facility's Pharmacy (PP), Resident 1's medication orders were reviewed. The PP stated they only received Resident 1's medication order for levetiracetam on 11/18/25 through a phone call and had filled and sent it on the next scheduled delivery time. The facility then received a 30-day supply of levetiracetam on for Resident 1 on 11/18/25 at 5:29 p.m.During an interview on 11/20/25 at 4:26 p.m. with the Director of Nursing (DON), the DON stated she would expect staff to re-order medications before it ran out. The DON further stated that the doctors' order should always be followed and that the doctor should always be notified if they don't have the medication.A review of the facility's policies and procedures (P&P) titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated 10/2017, indicated, B. Administration .2) Medications are administered in accordance with written orders of the attending physician.A review of the facility's P&P titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated 4/2008, indicated, A. Ordering Medications from the Dispensing Pharmacy .2) If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication five days in advance of need to assure an adequate supply is on hand .A review of the facility's P&P titled, Pharmacy Services - Role of the Provider Pharmacy, revised 4/2019, indicated, 3. The provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including (but not limited to), the following: a. Supply the facility with approved medications, biologicals, and supplies, as well as any compounded medications or investigational drugs that are needed; .e. Provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week; .h. Establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medications and prescriptions; . Event ID: Facility ID: 055402 If continuation sheet Page 4 of 4