Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at American River Center during CMS and state inspections, most recent first.
Kitchen thermometers were not maintained in good working condition, and weekly calibration was not documented in the log binder. A kitchen staff member, the CDM, and the RD all confirmed that one manual and one digital thermometer were not working properly and that calibration records were missing, despite facility policy requiring weekly testing and calibration for accuracy.
A nurse did not remain with a resident until a ClearLax mixture was fully consumed, leaving part of the dose unfinished, and did not ensure complete ingestion after giving other scheduled meds. In a separate event, an LPN prepared Humalog for a resident with a language barrier, but after the resident pushed his hand away, he treated it as a refusal and made no further attempts, despite staff expectations to use a translation device and try additional strategies.
Improper disposal of medications and retention of discontinued controlled drug: Whole tablets were found in open red sharps containers on 2 med carts, and nursing staff used those containers for dropped or refused non-narcotic doses even though the meds were still retrievable. A discontinued clonazepam bubble pack for a resident with anxiety and insomnia remained in the locked narcotics compartment after the order had been stopped, and the ADON and CP confirmed discontinued meds should not have remained in the cart.
Expired medications were administered to two residents. One resident received expired glaucoma eye drops, including dorzolamide and latanoprost, from a med cart after the discard date, and another resident received an expired fluticasone/salmeterol inhaler for COPD after the manufacturer’s discard date. The LN confirmed the doses were given, and the ADON and CP stated staff were expected to check medication expiration dates.
Medication labeling and storage practices were not followed consistently. Surveyors found expired suppositories, eye drops, and inhalers in stock and on med carts, an Infuvite vial stored on a countertop instead of refrigerated, an insulin pen without a pharmacy label, and multiple inhalers and nebulized solutions opened without open dates or kept outside required foil pouches. The DON, LNs, and CP confirmed the findings and stated staff were expected to label opened meds, follow manufacturer storage directions, and remove expired meds from use.
A resident with bipolar disorder, anxiety, and major depressive disorder had fluoxetine increased from 40 mg to 60 mg for depression manifested by sadness and anger without adequate documented clinical rationale or target behavior monitoring for efficacy. The ADON stated behavior monitoring should have shown increased target behaviors before the psychotropic dose was raised, but the record contained only limited notes of irritability and an overly nonspecific MAR behavior order that only required yes/no documentation.
Unordered bandage wrap used on heel wound. A resident with PVD and a chronic right heel ulcer had a physician order for triad, medi-honey, calcium alginate, and a foam dressing, but no bandage wrap was ordered. During observation, an RN/TN was seen removing and then reapplying the same bandage wrap to the wound. The TN confirmed the wrap was not in the order and said she did not clarify whether it should be used; the ADON stated orders should be clarified to ensure accuracy.
A resident with dementia and a traumatic brain injury, identified as being at risk for elopement, was able to leave the facility unsupervised and undetected for about an hour. The resident's care plan and assessments documented the need for supervision due to cognitive impairment and a history of wandering, but staff did not implement the required supervision as outlined.
The facility failed to store food safely, affecting 96 residents. Observations revealed unlabeled and uncovered food items, including desserts and cheeses, and spoiled tomatoes in the refrigerator. The CDM confirmed these practices were against the facility's policy, posing a risk of foodborne illness.
The facility failed to maintain infection control practices, as a visitor accessed ice unsupervised, and an ice scoop was stored uncovered. Additionally, a CNA did not perform hand hygiene after handling garbage. The Infection Preventionist and Administrator confirmed that only staff should distribute ice, and hand hygiene is crucial to prevent infections.
A facility failed to develop a person-centered care plan for a resident with a UTI and bacteremia. Despite the resident receiving daily Nitrofurantoin Macrocystal as prescribed, there was no care plan in place. The DON and ADON confirmed this oversight, acknowledging potential compromises in nursing care. The facility's policy mandates individualized care plans, which was not followed.
A resident with hemiplegia and thrombosis was not provided with compression stockings as ordered, despite physician instructions for daily use to manage edema. Observations showed the resident's left leg was swollen, and staff confirmed the stockings were not applied. The DON and ADON acknowledged the oversight, which could affect the resident's circulation.
A resident with dementia and a need for personal care assistance did not have her hearing aids applied daily as ordered, despite a physician's order and care plan specifying their use. Observations confirmed the resident was not wearing the aids, and staff interviews revealed non-compliance with the order. The facility's policy on hearing aid care was not followed, resulting in a deficiency.
A resident with multiple sclerosis and quadriplegia was left outside the facility past the agreed time on multiple occasions, unable to contact staff for assistance. Despite having an arrangement to be outside from 9:00 a.m. to 11:00 a.m., the resident was left alone and felt frightened when unable to reach staff. Staff interviews confirmed the arrangement and acknowledged the issue, while the facility's policy emphasized the resident's right to self-determination and communication.
A resident was discharged from the facility without verified home health service arrangements, despite having a disrupted surgical wound requiring specific care. The discharge plan included home health services, but there was no evidence that these were confirmed with the agency. Post-discharge follow-up showed the resident had not been contacted by the home health agency, leading to a lack of necessary wound care. Facility staff confirmed the expectation for social services to ensure these arrangements, which was not met.
A resident with multiple diagnoses, including dementia and osteoporosis, suffered a fracture of unknown origin. Despite the injury being identified, the facility failed to report it to state agencies as required by their policy. The DON confirmed the injury was not reported and acknowledged it could have been a pathological fracture, but no fall was reported.
A resident with multiple diagnoses was left crying and afraid after receiving a cold shower due to an argument between two CNAs about a staffing assignment. The incident highlighted the inappropriate behavior of the CNAs and the impact on the resident's dignity.
A resident with vascular dementia and moderate protein-calorie malnutrition was not readmitted to the facility after hospitalization, despite being eligible for a 7-day bed hold. The facility's Interdisciplinary Team decided against readmission due to unresolved conflicts with the resident's family, violating the resident's rights for readmission.
The facility failed to maintain food safety standards by not properly cleaning the ice machine, allowing rust on food storage racks, and not monitoring freezer temperatures in resident food refrigerators. These deficiencies could lead to food-borne illnesses among residents.
The facility failed to follow therapeutic diets for 14 residents, including those on modified texture, TLC, Renal, and CCD diets, during a lunch meal. The staff did not adhere to the menu, resulting in residents receiving incorrect food items, which could potentially affect their nutritional needs.
The facility failed to document the offering, administration, or refusal of the COVID-19 vaccine for three residents, despite their medical histories and the facility's policy requiring such documentation. The DON confirmed the absence of proper records, and family members reported not receiving recent vaccine offers.
The facility failed to follow infection control standards for two residents. A resident's catheter bag was found lying on the floor, and two CNAs did not wear gowns while providing high-contact care to another resident, contrary to Enhanced Barrier Precautions.
Kitchen Thermometers Not Calibrated Weekly and Not in Working Condition
Penalty
Summary
The facility failed to follow professional standards of food service safety when two kitchen thermometers, one manual and one digital, were not in good working condition. During a concurrent observation, interview, and record review, a kitchen staff member demonstrated how to calibrate the thermometers and identified that the two thermometers were not working properly. The thermometer log binder did not show that the thermometers had been calibrated weekly. During the same review, the Certified Dietary Manager confirmed that weekly thermometer calibration was not documented and that the two thermometers were not in good working condition. The CDM stated that thermometer calibration was important to ensure accurate temperature readings and prevent food borne illness caused by undercooked food. The Registered Dietician stated that kitchen staff were expected to calibrate thermometers weekly and record the readings, and that all thermometers should be in good working condition. The facility policy titled Food Preparation stated that thermometers in use should be tested and calibrated at least once a week for accuracy.
Medication Administration Not Completed or Fully Attempted
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for two residents. For one resident, a medication pass observation showed the nurse prepared eleven medications, including ClearLax mixed in lemonade, and gave the resident the pills and the cup with the mixture. The resident took the pills with sips of the ClearLax mixture, but about half of the solution remained in the cup when the nurse left the room before the resident finished consuming it, leaving the medication in the resident’s hand. The nurse later stated he did not recall leaving the resident with the ClearLax solution half drunk, and the facility policy stated the resident is always observed after administration to ensure the dose was completely ingested. For another resident, the nurse prepared Humalog KwikPen after checking the resident’s blood sugar and entered the room to administer 10 units. When the nurse attempted to lift the resident’s sweater to give the insulin in the abdomen, the resident pushed the nurse’s hand away. The nurse then stated the resident had refused the medication and made no further attempts to administer the insulin. The ADON stated staff were expected to use a translation device when there was a language barrier, that the resident pushing the nurse’s hand away was not considered a refusal, and that the nurse should have made additional attempts using other staff or other strategies. The nurse acknowledged he did not use the translation device and did not make any additional attempts to give the insulin.
Improper Disposal of Medications and Retention of Discontinued Controlled Drug
Penalty
Summary
The facility failed to ensure medications for disposal were rendered unusable and irretrievable when red sharps containers with open lids were used in 2 medication carts to dispose of dropped or refused non-narcotic tablets. During inspection, whole tablets were observed in the sharps containers on Station 1 Medication Cart 2 and Station 2 Medication Cart 2, and nursing staff stated these containers were used for disposal of dropped or refused doses. The Assistant DON confirmed the medications were not non-retrievable using that method, and the Consultant Pharmacist stated non-controlled medications should be disposed of in a designated container with a substance such as coffee grounds, hand sanitizer, or soap so they could not be easily poured out in their original form. The facility also failed to remove discontinued medications from the drug supply in a timely manner when a bubble pack of clonazepam for a resident remained in the locked narcotics compartment after the order had been discontinued in December 2025. The resident’s record showed clonazepam 0.5 mg at bedtime for anxiety manifested by inability to sleep, and the ADON confirmed the order had been discontinued and that discontinued medications should not have remained in the medication cart. The Consultant Pharmacist stated discontinued controlled medications were expected to be given to the DON at the end of the shift, and the facility policy stated medication is destroyed within 90 days from the date it was discontinued.
Expired Medications Administered to Two Residents
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors when expired medications were administered. For Resident 50, the record showed physician orders for dorzolamide 2% ophthalmic solution and latanoprost 0.005% ophthalmic solution for ocular hypertension and glaucoma. During medication cart inspection, both eye drop bottles were found labeled to discard on 4/1/26, yet the MAR showed Resident 50 received 18 doses of expired dorzolamide and 6 doses of expired latanoprost after that date. The LN confirmed the expired doses were given and stated staff were expected to check expiration dates when preparing medications. For Resident 76, the medication cart contained an opened fluticasone/salmeterol 250/50 mcg inhaler that the manufacturer’s labeling indicated should be discarded one month after opening the foil container. The LN confirmed the inhaler had expired on 3/20/26 and that this was the inhaler used for administration to the resident. The MAR showed Resident 76 received the expired fluticasone/salmeterol twice daily for a total of 37 doses after expiration. The ADON and CP stated staff were expected to check expiration dates, and the CP noted medications may not be fully efficacious beyond their expiration date.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled and stored according to accepted professional principles and manufacturer instructions. During inspection of the medication storage room and medication carts, surveyors found multiple expired hemorrhoidal suppositories, including boxes and loose suppositories with expiration dates of 11/2025 and 2/2025, available in facility stock. A vial of Infuvite with a pharmacy label indicating refrigeration was found on the countertop instead of in the refrigerator. The DON and nursing staff confirmed the expired and improperly stored medications should not have been present in stock or on the cart. Surveyors also found several medications on the carts that were expired, opened without required dates, or not stored in the manufacturer’s protective packaging. These included expired dorzolamide and latanoprost eye drops, an expired fluticasone/salmeterol inhaler, an opened Trelegy Ellipta inhaler with an open date that showed it had passed the discard timeframe, two Anoro Ellipta inhalers and two Trelegy Ellipta inhalers that were opened but unlabeled with an open date, and an opened Advair Diskus inhaler without an open date. LN 1 and LN 2 confirmed these findings and reviewed the manufacturer labeling during the inspection. Additional storage and labeling issues were identified with prescription medications and nebulized solutions. A Humalog KwikPen was found in a clear plastic bag without a pharmacy label. Four arformoterol vials and two ipratropium/albuterol vials were stored outside their foil pouches without dates showing when they were removed from the pouch or brought to room temperature, and a box of dorzolamide/timolol single-use vials had one vial outside the foil pouch. LN 1 confirmed the storage did not match manufacturer instructions. The DON and CP stated staff were expected to label opened medications with open dates, keep bottles clean, follow manufacturer storage directions, and remove expired medications from stock.
Unnecessary Psychotropic Medication Dose Increase Without Adequate Behavior Monitoring
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication when fluoxetine was increased from 40 mg to 60 mg without adequate documented clinical rationale and without target behavior monitoring for efficacy. The resident was admitted with diagnoses including bipolar disorder, anxiety, and major depressive disorder, and the physician’s orders showed fluoxetine prescribed for depression manifested by verbalizations of sadness and anger. During interview and record review, the ADON stated she expected an increase in target behaviors to be documented before a psychotherapeutic medication dose was increased. Review of the resident’s progress notes for the 6 weeks before the dose increase showed only two notes indicating the resident was irritable and irate, both on the same date. The MARs for the prior two months showed the behavior monitoring order was nonspecific and directed staff only to document yes or no, and the ADON stated this made it difficult to monitor and document the resident’s behavior. The MARs indicated the resident exhibited behavior twice on evening shifts during the monitoring period.
Unordered bandage wrap used on heel wound
Penalty
Summary
The facility failed to ensure that one resident’s right lateral heel diabetic wound was treated as ordered when the Treatment Nurse wrapped the wound with a bandage wrap that was not included in the physician’s order. The resident was admitted with peripheral vascular disease and a chronic ulcer of the right heel and midfoot. The physician’s order for the right lateral heel eschar diabetic ulcer directed staff to apply triad to the peri-wound, medi-honey to the immediate wound, calcium alginate, and a foam dressing, but it did not include any bandage wrap. The resident’s revised care plan identified the resident as at risk for skin breakdown related to PVD and the right lateral heel diabetic ulcer and directed staff to provide wound treatment as ordered. Wound surgical consults dated 3/13/26, 3/20/26, 3/27/26, and 4/3/26 described the goal as preventing wound decline and creating a wound healing bed, with treatment including calcium alginate with honey and collagen, and they did not indicate wrapping the wound with a bandage wrap. During observation, the resident was in bed with the right lateral heel wound wrapped with bandage wrap. The Treatment Nurse removed the wrap, cleansed the wound, applied the ordered treatments, and then wrapped the wound again with the same bandage wrap. The Treatment Nurse confirmed the order did not indicate the wound should be wrapped and stated she did not clarify whether to use a bandage wrap after every treatment. The ADON also stated nurses should always clarify physician orders to ensure the treatment was accurate, including the use of bandage wrap.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a traumatic brain injury from eloping from the facility. The resident was identified as being at risk for elopement based on an Elopement Evaluation and had a care plan in place that addressed this risk, including a history of wandering and previous elopement at a hospital. The resident's Minimum Data Set assessment indicated impaired cognitive status, and the care plan specifically noted the need for supervision due to alcohol/drug-seeking behavior and elopement risk. Despite these documented risks and care plan interventions, the resident was able to leave the facility unsupervised and undetected. Staff became aware of the resident's absence after being informed by another staff member, and the resident was missing for approximately one hour before being located. Facility policy required adequate supervision for residents at risk of elopement, but this was not implemented as indicated in the resident's care plan. Interviews with facility staff and the administrator confirmed the resident's high risk for elopement and acknowledged that closer supervision should have been provided.
Plan Of Correction
The preparation and/or the execution of this plan of correction do not constitute admission of agreement by the provider of true facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because the provisions of the Federal and State law require it. This Plan of Correction constitutes the facility's credible allegation of compliance. Corrective action accomplished for identified resident(s) affected by the deficient practice: Resident 1 was found and brought back into the facility without incident or injury. Resident placed on 1 on 1 supervision until the wanderguard system for the front door was adjusted with an additional reader on 10/3/2025. How other residents having potential to be affected by the same deficient practice will be identified and what corrective action will be taken: On 10/2/2025, an audit of all residents that triggered at risk for elopement was completed by the Medical Records Director to ensure that they all have appropriate interventions in place. Updates made as identified. Immediate measures and systemic changes put in place to ensure that the deficient practice does not recur: On 10/1/2025 and 10/2/2025, the Director of Staff Development in-serviced CNAs and Licensed Nurses on the elopement policy and procedure and wanderguard devices. A description of the plans and persons responsible for monitoring ongoing performance, and ensuring that the corrective actions are achieved and sustained: The Medical Records Director or designee will conduct an audit for residents triggering as elopement risks weekly to confirm interventions are in place. The results of the audits will be reported to the QAPI Committee meeting monthly for 3 months and then re-evaluated thereafter. Completion Date: 11/4/2025
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, affecting 96 residents who received food from the kitchen. During observations and interviews with the Certified Dietary Manager (CDM), it was confirmed that opened and prepared foods were stored without labeled use-by dates. Specifically, a pan of cinnamon brown sugar blondie dessert and opened packages of processed yellow cheese and sliced cheese were found without any date labels. The CDM acknowledged the importance of labeling food items to track when they were prepared and when they should be used by. Additionally, the facility did not adequately cover or seal opened food packages, which could lead to foodborne illnesses. Observations revealed a pan of prepared dessert and several peanut butter and jelly sandwiches in unsealed bags, as well as a package of hot dogs that were not tightly wrapped. Furthermore, spoiled food was found in the walk-in refrigerator, including two mushy and rotten tomatoes. The CDM confirmed that these practices were not in line with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated to ensure safe food handling.
Infection Control Deficiencies in Ice Distribution and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations. A visitor was seen accessing and obtaining ice from the nursing unit's ice chest without supervision, which was confirmed by a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD). The Infection Preventionist (IP) and the Administrator (ADM) both stated that only facility staff should distribute ice, and there was no specific policy written for the usage and distribution of ice from the nursing station ice chest. Additionally, the ice scoop was observed to be stored uncovered on a cart, which was confirmed by both the CNA and the DSD. The IP stated that the ice scoop must be stored covered to prevent exposure to dust or other contaminants. Furthermore, a CNA was observed handling garbage and then handling plastic wrist bands for residents without performing hand hygiene. The ADM confirmed that staff are expected to perform hand hygiene immediately before and after patient care activities. The facility's policy on hand hygiene emphasizes its importance in preventing the spread of infections.
Failure to Develop UTI Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with a urinary tract infection (UTI) and bacteremia. The resident's Admission Record indicated these diagnoses, and the Physician's Orders dated January 6, 2025, prescribed Nitrofurantoin Macrocystal 50 mg to be administered daily for the UTI. The Medication Administration Record confirmed that the medication was administered daily from January 1 through January 10, 2025. However, upon review, it was found that there was no care plan developed specifically for the UTI. During an interview and record review on January 10, 2025, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the absence of a UTI care plan for the resident. The DON acknowledged that nursing care could be compromised without a proper care plan in place. The facility's policy and procedure on comprehensive care plans, dated August 25, 2021, requires an individualized care plan with measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with hemiplegia affecting the left side and acute embolism and thrombosis of the left lower extremity, had compression stockings applied daily as ordered by the physician. The physician's order specified that the compression stockings should be worn during the day and removed at night to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings, and the left lower extremity appeared larger than the right, indicating swelling. Interviews with the resident and staff confirmed that the compression stockings were not offered or applied as required. A Certified Nurse Assistant admitted to not applying the stockings on the observed day. The Director of Nursing and Assistant Director of Nursing reviewed the resident's clinical record and confirmed the physician's order for daily use of compression stockings, acknowledging that failure to comply could compromise the resident's blood circulation. The facility's policy mandates that licensed nurses are responsible for implementing and documenting physician orders, which was not adhered to in this case.
Failure to Apply Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who required hearing aids, had them applied daily as ordered. The resident, who had diagnoses including dementia and a need for assistance with personal care, had a physician's order to apply both hearing aids in the morning and remove them at night. The care plan also specified the need for the resident to wear bilateral hearing aids every morning and remove them every evening. However, during multiple observations over several days, the resident was not wearing her hearing aids as required. Interviews with facility staff, including a Certified Nursing Assistant and a Licensed Nurse, confirmed that the hearing aids were not applied as ordered, and they were not stored in the medication cart as per the physician's order. The Director of Nursing and the Assistant Director of Nursing acknowledged that the order should have been followed and emphasized the importance of the hearing aids for the resident's communication. The facility's policy on hearing aid care, which aims to maintain the resident's hearing at the highest attainable level, was not adhered to, leading to a deficiency in care.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with multiple sclerosis, quadriplegia, and anxiety, who was dependent on staff for self-care and mobility. The resident had an arrangement with the staff to be taken outside daily from 9:00 a.m. to 11:00 a.m. However, on multiple occasions, the resident was left outside past the agreed time and was unable to contact staff for assistance. On one occasion, the resident attempted to call the facility's front desk but received no response, and on another occasion, the resident was left outside until 11:30 a.m. without being able to contact staff, causing the resident to feel frightened. Interviews with staff confirmed the arrangement for the resident to be outside and acknowledged the issue of the resident being unable to contact staff when needed. The Recreations Assistant confirmed that the resident was left alone and unable to contact a CNA for assistance. The Director of Nursing stated that the resident was able to communicate her needs and preferences, including the times she wanted to be outside and return inside. The facility's policy on Resident's Rights emphasized the resident's right to self-determination and communication with people and services, which was not upheld in this instance.
Failure to Ensure Safe Discharge and Continuity of Care
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was discharged home without verified home health service arrangements. The resident, who had been admitted with cellulitis, a disrupted surgical wound, and required nonsurgical wound dressing changes, was discharged with a plan for home health services including physical therapy, occupational therapy, and skilled nursing services. However, there was no documented evidence that the facility's social services or nursing staff confirmed these arrangements with the home health agency prior to the resident's discharge. The resident's discharge plan indicated that home health services were to start shortly after discharge, with specific instructions for wound care, including the use of a wound vac to be changed every 72 hours. Despite these plans, the resident's post-discharge follow-up revealed that the home health agency had not been in contact, and the resident had left several voicemails without response. This lack of coordination resulted in the resident not receiving the necessary continuity of care for his wound. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, Unit Manager, and Administrator, confirmed that there was an expectation for social services to follow up with the home health agency to ensure services were scheduled to start prior to discharge. The facility's policies required social services to coordinate resident referrals with outside agencies, but this was not done in this case, leading to a failure in ensuring the resident's continuity of care upon discharge.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for a resident, which decreased the potential to protect the resident from a possible allegation of abuse and ensure a safe environment during the investigation. The resident, a female with multiple diagnoses including unspecified dementia, Alzheimer's Disease, osteoporosis, a history of falls, and muscle weakness, was readmitted to the facility. On a specific date, the resident complained of left forearm pain, and an x-ray revealed an acute or possibly subacute fracture of the distal radial diaphysis and a deformity of the distal ulna consistent with a wrist fracture. Despite the injury being identified, the Director of Nursing (DON) confirmed that the fracture was an injury of unknown origin as no fall was reported. The DON acknowledged that the fracture could have been a pathological fracture and conducted an investigation to determine the cause. However, the facility did not report the injury to the appropriate state agencies as required by their policy, which mandates that all injuries of unknown source be promptly reported. The facility's policy also requires a written report of the findings of the investigation to be provided to the appropriate agencies within five working days of the incident.
Failure to Maintain Resident Dignity During Shower
Penalty
Summary
The facility failed to maintain dignity for a resident when two CNAs had an argument regarding a staffing assignment while providing a shower to the resident. The resident, who had multiple diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, dysarthria, aphasia, muscle weakness, and major depressive disorder, was left crying and feeling afraid after receiving a cold shower. The incident occurred when CNA 1 placed the resident in the shower chair and turned on the water to warm up. CNA 1 was then approached by CNA 2, who stated that the assignment had changed. While the CNAs argued about the assignment, the resident was left in the shower with cold water, leading to the resident crying and feeling afraid. The incident was documented in a Report of Suspected Dependent Adult/Elder Abuse and an Investigative Summary Report. During interviews, the resident confirmed that he cried because the water was cold and expressed fear that it might happen again. The Director of Nursing, Social Services Director, and Administrator acknowledged the inappropriate behavior of the CNAs and the impact on the resident. The facility's policies on Resident Rights and Dignity were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that staff should communicate professionally and outside the hearing range of residents.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to follow its own policy for readmission when a resident was not permitted to return after hospitalization, despite being eligible for a 7-day bed hold. The resident, who had vascular dementia and moderate protein-calorie malnutrition, was transferred to a General Acute Care Hospital (GACH) at the request of his daughter due to concerns about worsening oral candidiasis and poor care at the facility. Despite multiple attempts by the hospital's Case Manager to readmit the resident, the facility repeatedly responded that they were unable to accept the patient. Interviews with the Admissions Director, Director of Nursing (DON), and Administrator confirmed that the resident was eligible for readmission under the facility's bed hold policy. However, the Interdisciplinary Team (IDT) decided not to readmit the resident due to unresolved conflicts between the family and facility staff. This decision was made despite the facility's policy, which prioritizes readmission for residents discharged to the hospital or on therapeutic leave. The facility's actions resulted in a violation of the resident's rights for readmission.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an initial kitchen tour, the ice machine was found to have significant black and brown stains with scratches on the bottom of the evaporator unit. The Maintenance Supervisor confirmed that despite regular cleaning, the stains did not come off, and the scratches were old. The Registered Dietitian noted that the scratches could harbor microorganisms, potentially contaminating the ice. Additionally, the walk-in freezer and refrigerator had food storage metal racks with rust, which was confirmed by the Food and Nutrition Service Director. The rust was noted in a previous inspection but had not been addressed yet. The FDA Food Code requires food-contact surfaces to be smooth and free of imperfections to prevent microorganism attachment and biofilm formation, which can release pathogens to food. Furthermore, the temperature of the freezer sections of the resident's food refrigerators located in nurse stations one and two were not monitored. The Assistant Director of Nurses confirmed that there were no temperature monitor logs for these freezers, and the Director of Staff Developer admitted to not monitoring the freezer temperatures despite being aware of the policy requiring daily monitoring. This lack of monitoring could lead to improper food storage temperatures, increasing the risk of food-borne illnesses among the residents.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to ensure that the menu was being followed for therapeutic diets during lunch on 3/20/24. Seven residents on modified texture diets (Dysphagia mechanical soft and Dysphagia advance) did not receive the required gravy for their meat entree, contrary to the facility's diet guide sheet. Additionally, two residents on a Therapeutic Lifestyle Change (TLC) diet received gravy on their pork chop, which was not in accordance with their dietary requirements. Furthermore, three residents on Renal and CCD/Renal diets received cake instead of the prescribed cookie for dessert and gravy on their pork chop, which was not compliant with their dietary needs. Lastly, two residents on a CCD diet received sweet potato instead of mashed potato as indicated on the menu. During interviews, the Regional Registered Dietitian and the Registered Dietitian acknowledged that the staff did not follow the menu or spreadsheet when preparing meals, which could potentially affect the nutritional needs of the residents. The facility's job description for the cook emphasizes the importance of adhering to menus and portion control standards, including those for special diets, when preparing and serving meals. The failure to follow these guidelines had the potential to compromise the medical and nutritional status of the 14 residents involved.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documentation for current COVID-19 immunizations for three residents, specifically regarding the offering, administration, or refusal of the vaccine. Resident 7, who has a persistent vegetative state and a history of pneumonia and COVID-19, had no documented current 2023-2024 COVID vaccine information. Similarly, Resident 61, with a diagnosis of cerebral infarct, and Resident 73, with a history of COVID-19, also lacked documentation for the current COVID-19 vaccine. The Director of Nursing (DON) confirmed the absence of documented consents or refusals for these residents during a review of their vaccination records. The DON explained that the previous Infection Preventionist had sent out mass texts to families when vaccines were available, but there was no follow-up to ensure consents were signed. Family members of Residents 61 and 73 confirmed they had not received recent messages offering the COVID-19 vaccine. The facility's policy required that each resident be offered the vaccine and that documentation of education, consent, and administration be maintained in the resident's medical record. The lack of proper documentation and follow-up decreased the facility's potential to prevent or reduce the severity of COVID-19 among its residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards for two residents. Resident 204's indwelling catheter bag was observed lying on the floor, contrary to the care plan and facility policy, which stated that catheter bags should be kept off the floor to prevent infection. This was confirmed by a CNA and the DON, who acknowledged that the catheter bag on the floor increased the risk of infection. The facility's policy on catheter care explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. For Resident 7, the facility did not adhere to Enhanced Barrier Precautions (EBP) during high-contact care activities. Two CNAs were observed changing the resident's incontinence brief without wearing gowns, despite a sign indicating that gowns and gloves were required for such activities. One CNA's shirt came into contact with the bed during care. The ADON confirmed that gowns and gloves should be worn during high-contact care to prevent the transmission of infections. The facility's policy on Enhanced Standard/Barrier Precautions emphasized the importance of gown and glove use to prevent the spread of multi-drug resistant organisms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 722 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eskaton Village Care Center | 0.5 mi | ★★★★★ | 13 | 0 |
| Whitney Oaks Care Center | 0.7 mi | ★★★★★ | 6 | 0 |
| College Oak Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 14 | 1 |
| Mission Carmichael Healthcare Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Mountain Manor Senior Residence | 1.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.