American River Center

In the surveyor’s words

From the most serious findings on record at American River Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to follow the professional standards of food service safety for a census of 98 residents, when: 1. Two thermometers, one manual and one digital, were not in good working condition; and 2. Weekly thermometer calibration was not done and not documented in the thermometer log binder. These failures had the potential for inaccurate thermometer readings and the time/temperature control for food safety not accurately monitored and increased the risks of food-borne illnesses. During a concurrent observation, interview, and record review on 4/8/26 at 9:30 a.m., the kitchen thermometers used for food preparation were inspected. [NAME] 1 (CK 1) demonstrated how to calibrate the thermometers. […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2024

  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: 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. […]

• No harm, potential for more than minimal, patternF658Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 24 sampled residents (Residents 22 and 72), when: 1. Resident 72 was not observed during the entire medication pass to ensure medications were completely administered; and 2. Nursing staff did not use multiple strategies to administer Humalog KwikPen (a fast-acting insulin to treat diabetes) for Resident 22. These failures resulted in Resident 22 and Resident 72's not receiving their medications and had the potential to result in worsening of their clinical conditions.Findings: 1. During a medication pass observation on 4/7/26 at 8:41 a.m. […]

• No harm, potential for more than minimal, patternF755Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications for disposal were not rendered unusable, irretrievable, and were not securely stored when red sharps containers with open lids were used to dispose of medication in 2 of 2 medication carts inspected; and medications with discontinued orders were not removed from facility drug supply and destroyed in a timely manner. These failures had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of timely.Findings: 1. During an inspection on 4/7/26 at 10:27 a.m. […]

• No harm, potential for more than minimal, patternF760Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 50 and 76) were free of significant medication errors when: Resident 50 received dorzolamide (a medication to treat high eye pressure in glaucoma, a group of eye diseases that causes high fluid pressure inside the eye, leading to permanent vision loss or blindness if untreated) ophthalmic (eye) solution 18 times (doses) and latanoprost (a medication to treat high eye pressure) six times, past the expiration date; andResident 76 received fluticasone/salmeterol (a medication to chronic obstructive pulmonary disease (COPD), a progressive, long-term lung disease that makes it hard to breathe) 37 times, past the expiration date. […]