Health inspection·June 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: Resident 1 was a [AGE] year-old female, re-admitted to the facility on [DATE]. She had multiple diagnoses, which included Unspecified dementia (impaired ability to remember) without behavior disturbance, Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), unspecified site of disorders of bone density and structure (osteoporosis), history of falls, and muscle weakness. A review of Resident 1's Practitioner's Progress Notes (PPN), dated 5/14/24 at 4:05 p.m. indicated, [Resident 1] seen in [the] room after nursing report she is c/o [complaining of] left forearm pain. [Resident 1] with significant tenderness to palpation [touch]. She yelps and pulls [her] arm away during the exam. Will obtain xray of left forearm. A review of Resident 1's Radiology Results Report (x-ray), dated 5/15/24 at 3:52 a.m., indicated, .LEFT FOREARM .There is evidence of an acute [sudden onset] or possibly subacute fracture [break] of the distal radial diaphysis [both bones of the forearm] .There is [a] deformity of the distal ulna consistent with [a] distal diaphyseal fracture [wrist fracture] . A review of Resident 1's Daily Documentation (DD), dated 5/15/24 at 8:35 a.m., indicated at 5:29 a.m., Resident 1 was complaining of pain with a pain level of 6 over 10 (between moderate and severe level). A review of Resident 1's DD dated 5/16/24 at 2:50 a.m., indicated, Resident noted with pain [8/10] to left arm due to recent fracture . A review of Resident 1's Interdisiplinary Team (IDT) progress notes, dated 5/16/24 at 1:33 p.m. indicated, .IDT to review [Resident 1's] fx. [fracture] of [the] distal end of the L [left] radius. [Resident 1] c/o pain to left arm . was evaluated by NP [Nurse Practitioner] with rec. [recommendation] for [an] x-ray. X-ray ordered and results indicate fracture to left arm . (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 2 Event ID: 555450 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 06/11/2024 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)