Health inspection·March 22, 2024

F 0803 receive gravy for the pork chop. Level of Harm - Minimal harm or potential for actual harm 3. Residents 14, 303, and 553 were on Renal diet and CCD/Renal diets who received cake for dessert. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, showed that Renal and CCD/Renal diets should receive cookie as dessert. Residents Affected - Some 4. Residents 65 and 402 were on CCD diet who received sweet potato. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, show that CCD diet should receive mashed potato. During an interview with the Regional Registered Dietitian (RRD) on 3/20/24, at 1:33 p.m., she acknowledged and the residents who were on therapeutic and/or modified texture diets received the incorrect food items and stated the staff needed to pay attention and the staff needed to follow the menu/spreadsheet when they prepared meals for the residents. During an interview with the Registered Dietitian (RD) on 3/21/24, at 9:10 a.m., she stated the staff should have followed the menu or spreadsheet during preparing meals which may make the meal under- or overnutrition and affect the nutrition needs for the residents. A review of facility document, titled Job Description: Cook, showed .The [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu .adhere to menus and portion control stands, including those for special diets when preparing and serving meals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 2 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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: Residents Affected - Many 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. Findings: 1. During an initial kitchen tour on 3/19/24, at 9:30 a.m., a concurrent interview and observation of the ice machine was conducted. The Maintenance Supervisor (MS) stated he was responsible for the cleaning and sanitizing the ice machine. He stated he would take the parts out from the machinery part of the ice machine to clean and sanitize weekly. The MS stated he did the deep cleaning monthly and quarterly which included cleaning and sanitizing the machinery parts, running the chemical cycles, and the ice storage bin. Upon the ice machine dissemble, there were significant black and brown stains with scratches observed on the bottom of the evaporator unit (the part where conducts the heat exchange with water and freezes the water into ice cubes). The MS confirmed and he stated he scrubbed the bottom of the evaporator unit every time when he cleaned the machinery part of the ice machine, but the stains did not come off. He stated the scratches were old and the surface was not smooth, and the machinery part of the ice machine was old which might need to replace. During an interview with the Registered Dietitian (RD) on 3/21/24, at 9:10 a.m., she stated the scratches on the bottom of the evaporator unit surface could be easily harbor microorganisms which could contaminate the ice. The RD added the food contact surface should be smooth and could be cleaned easily. A review of departmental policy and procedure, titled, Equipment, dated 9/2017, it stated, .all foodservice equipment will be clean, sanitary, and in proper working order . A review of departmental policy and procedure, titled, Ice, dated 9/2017, it stated, .Ice will be prepared and distributed in a safe and sanitary manner . According to FDA (Food and Drug Administration) Food Code 2022, Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 3 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0812 Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits . Level of Harm - Minimal harm or potential for actual harm 2. During an observation in the walk-in freezer and walk-in refrigerator on 3/19/24, at 9:12 a.m. and 9:16 a.m., observed there were two food storage metal racks in the walk-in freezer and two racks in walk-in refrigerator with brown substances. A concurrent interview with the Food and Nutrition Service Director (FNSD), she confirmed the brown substance was rust on the food storage metal racks. The FNSD stated she was aware of the rust and was working on the replacements. Residents Affected - Many A review of departmental document, titled Kitchen Sanitation Checklist, completed on 1/2024 by the Regional Registered Dietitian (RRD), it indicated the RRD commented the walk-in refrigerator food storage metal racks showed signs of rust. A review of departmental policy and procedure, titled, Equipment, dated 9/2017, it showed, .all non-food contact equipment will be clean and free of debris . According to FDA Food Code 2022, on Section 4-101.19 Nonfood-Contact Surfaces, it showed, .Nonfood-Contact Surfaces of equipment .shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material . On Section 4-101.11 Characteristics, .Smooth means .a nonfood-contact surface of equipment having a surface equal to that of commercial grade hot-rolled steel free of visible scale . 3. During an observation of the resident's food refrigeration units (unit with combination of refrigerator and freezer) located at nurse station 1 and 2 on 3/19/24, at 12:29 p.m. and 12:42 p.m., there was a concurrent interview with the Assistance Director of Nurses (ADON) regarding the freezers' temperature monitor logs. She stated the refrigerators and freezers usually monitor temperature by the Director of Staff Developer (DSD). The ADON stated they did not have any monitor logs for both freezers when she reviewed the temperature monitor log folders for nurse station 1 and 2. During a follow up interview with the ADON on 3/19/24, at 2:29 p.m., she confirmed and stated she could not locate any records for the freezers' temperature monitor logs. The ADON stated the nurses did not monitor the temperature for both freezers of the resident's food refrigerators in nurse station 1 and 2. During an interview with the DSD on 3/20/24, at 9:45 a.m., she was aware that the policy and procedure said monitor refrigerator and freezer temperature for the resident's food refrigerator daily. The DSD stated she did not monitor the freezer temperatures and she would start to monitor as of now. A review of facility policy and procedure, titled, Safe Handling of Foods from Visitor, dated 8/25/21, it indicated, .b. have temperature monitored daily for refrigeration .and freezer . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 4 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0880 Provide and implement an infection prevention and control program. 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 follow infection control standards of practice for two of 24 sampled residents (Resident 204 and Resident 7) when: Residents Affected - Few 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. Findings: 1. Resident 204 was admitted to the facility early 2024 with diagnoses which included benign prostatic hyperplasia (BPH, enlargement of the prostate gland ), and history of urinary tract infections. Minimum Data Set, (MDS, an assessment tool) dated 3/20/24 indicated Resident 204 had an indwelling catheter. During a review of Resident 204's Order Summary Report [OSR], dated 3/22/24, the OSR indicated, [brand name of indwelling catheter] catheter .to drainage bag . During a review of Resident 204's Care Plan Detail [CP], undated, the CP indicated, Resident requires indwelling catheter .Resident will have no signs and symptoms of urinary tract infection .Keep catheter off floor . During a concurrent observation and interview on 3/19/24 at 9:23 a.m. with Certified Nursing Assistant (CNA 1) in Resident 204's bedroom, the urinary catheter bag was lying directly on the floor under his bed. CNA 1 confirmed the urinary catheter bag was on the floor and stated, They are not supposed to be like that, they should be hanging and not on the floor . During an interview on 3/21/24 at 3:10 p.m. with the Director of Nursing (DON), the DON was shown a picture of the indwelling catheter bag for Resident 204 lying on the floor. DON confirmed the findings and stated, .catheter bags should never be on the ground and should be on the bed hanging . The DON stated the catheter bag on the floor increased the risk for infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, undated, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Be sure the catheter tubing and drainage bags are kept off the floor . 2. Resident 7 admitted to the facility mid 2019 with diagnoses which included persistent vegetative state (when a person shows no sign of awareness). MDS, dated [DATE], indicated Resident 7 had a feeding tube (tube placed in to the stomach to give nutrition). During a review of Resident 7's OSR dated, 3/22/24, the OSR indicated, NPO [nothing by mouth] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 5 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0880 .Enteral Feed Order . Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/20/24 at 9:54 a.m. of Resident 7's care, two certified nursing assistants (CNA 2 and CNA 3) entered his room wearing gloves, mask, but no gown. There was a sign outside Resident 7's door, directly above the name plate which indicated, Enhanced Standard Precautions ANYONE PARTICIPATING IN ANY OF THESE SIX MOMENTS MUST ALSO: [NAME] gown and gloves .Toileting & changing incontinence briefs . The CNA's changed the incontinence brief of Resident 7 without wearing gowns. CNA 2's shirt touched the bed during care. CNA 2 exited the room and when shown the sign, confirmed she was not wearing a gown during the brief change, and stated they did not need to wear a gown during care. Residents Affected - Few During an interview on 3/21/24 at 2:42 p.m. with the Assistant Director of Nursing (ADON), when asked the procedure for ESP care, the ADON stated, If they provide contact .expect they wear gown and gloves. When asked why it was important to wear gown during care of a patient on ESP the ADON stated, .you want to make sure you protect yourself and the residents .don't want to transmit infection. During a review of the facility's P&P titled, Enhanced Standard/Barrier Precautions, dated 8/22, the P&P indicated, Enhanced standard/barrier precautions [ESP/EBPs] are utilized to prevent the spread of multi-drug resistant organisms [MDROs] to residents .ESP/EBP employ targeted gown and glove use during high contact resident care activities .ESP/EBP are indicated . for resident with wounds and/or indwelling medical devices regardless of MDRO colonization . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 6 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based 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 . Findings: Resident 7 admitted to the facility mid 2019 with diagnoses which included persistent vegetative state (when a person shows no sign of awareness), history of pneumonia, and history of COVID-19. During a review of Resident 7's Immunization Report [IR], dated 3/2024, the IR indicated, Covid-19 Vaccination Dose 3 .consented .administered 11/09/2021. Resident 61 admitted to the facility mid 2019 with diagnoses which included cerebral infarct (lack of adequate blood supply to the brain). During a review of Resident 61's IR dated 3/2024, the IR indicated, Covid-19 Vaccination Dose 3 .consented .administered 11/16/2021. Resident 73 was initially admitted to the facility late 2020 with diagnoses which included history of COVID-19. During a review of Resident 73's IR, dated 3/2024, the IR indicated, Covid-19 Vaccination Dose 3 .consented .administered 11/16/2021. During a concurrent interview and record review on 3/21/24 at 3:48 p.m. with the Director of Nursing (DON), Resident 7, Resident 61, and Resident 73's, vaccination records were reviewed. The DON confirmed there were no documented current 2023-2024 COVID vaccines, consents, or refusals. When asked the process for offering vaccinations the DON stated, The previous IP [Infection Preventionist] sent out a mass text to families when vaccines were available for the residents .if they agree they can come in and sign the consents . When asked if there was any follow up after the text was sent to families, the DON stated, I don't see any . When asked the expectations for how COVID -19 vaccinations were tracked, the DON stated, My expectation is like any other vaccine. There should be a consent that says yes or no . During a phone interview on 3/22/24 at 10:19 a.m. with Resident 61's Family Member (FM 1), FM 1 was asked if she had received any messages which offered COVID-19 vaccination and stated she had not received any text or email. During a phone interview on 3/22/24 at 10:29 a.m. with Resident 73's FM 2, FM 2 was asked if she had received any message which offered COVID-19 vaccination and stated, Not recently, but they did send out a text. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 7 of 8 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 555450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE American River Center 3900 Garfield Avenue 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, SNF CLINIC Coronavirus Disease [COVID-19]- Vaccination of Residents, dated 6/22, the P&P indicated, Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated .Booster vaccine doses are provided in accordance with current CDC guidance .The resident's medical record includes documentation that indicates, at minimum, the following .That the resident or resident representative was provided education .signed consent .Each dose of COVID-19 vaccine that was administered to the resident .If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record . During a review of the cdc.gov website page titled, Vaccines & Immunizations, the website indicated, COVID-19 vaccine recommendations have been updated as of February 28, 2024, to recommend adults ages 65 years and over receive an additional updated 2023-2024 COVID-19 vaccine dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555450 If continuation sheet Page 8 of 8