Health inspection·January 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based 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. Findings: During a review of Resident 71's admission Record (AR), the AR indicated, Resident 71 had diagnoses which included urinary tract infection and bacteremia (the presence of bacteria in the blood). During a review of Resident 71's Physician's Orders (PO) dated 1/6/25, the PO indicated, Nitrofurantoin Macrocystal (used to treat bladder infection) 50 mg (milligrams-metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth one time a day for UTI. During a review Resident 71's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 1 through 10, 2025, Nitrofurantoin Macrocystal 50 mg was administered daily. During a record review of Resident 71's plan of care, the record did not indicate a care plan for UTI was developed. During a concurrent interview and record review on 1/10/25 at 8:59 a.m., with the Director of Nursing (DON) together with the Assistant Director of Nursing (ADON), Resident 71's clinical record was reviewed. The DON and the ADON confirmed there was no UTI care plan developed for Resident 71. The DON stated nursing care could be compromised when care plan was not put in placed. During a review of the facility's policy and procedure (P/P) titled, Care Plan Comprehensive, dated 8/25/21, the P/P indicated, .an individualized comprehensive care plan that includes measureable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident . 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 7 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 01/10/2025 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)