Advanced Health Care of Sacramento

Inspectors wroteBased on interviews and record review, the facility failed to follow professional standards of quality for one of six sampled residents (Resident 1) when staff did not ensure that Resident 1, who received nasojejunal tube (NJT, a feeding tube that goes through the nose, passes the stomach, and ends in the jejunum [part of the small intestine]) feedings also received the required water flushes. This failure placed Resident 1 at risk for her NJT becoming clogged and increased her risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preparation in accordance with professional standards for food service safety were provided for a census of 40, when kitchen staff did not know how to calibrate thermometers to determine food time/temperature control during lunch tray line. This failure had the potential to cause food-borne illnesses in a vulnerable population. During a concurrent observation and interview on 7/24/25 at 12 p.m., in kitchen with Lead [NAME] 1 (LC 1), before the start of lunch tray line service, LC 1 was asked to demonstrate and explain the procedure for thermometer calibration. LC 1 placed a coffee cup, three-fourths full of water with cubed ice, on countertop. LC 1 was not able to verbalize the procedure for thermometer calibration and could not provide a policy for reference. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication administration were followed in accordance with professional standards of practice for one of 13 sampled residents (Resident 24), when hold parameters were not added to the lispro insulin (a high-risk medication that affects blood sugar levels) administration order. This failure resulted in the medication not administered several times and had the potential to result in unstable blood sugar levels affecting the resident's highest practicable well-being. During a review of Resident 24's Face Sheet, dated 7/25/25 (print date), the Face Sheet indicated, Resident 24 was admitted to the facility in May of 2025 with diagnoses which included femur (thigh bone) fracture and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 31) was free of unnecessary medications when an antidepressant (a medication to improve mood) was administered without corresponding medical diagnosis or documented behavioral symptoms to justify its use. This failure had the potential to result in adverse reactions, functional decline, and chemical restraint for Resident 31. Resident 31 was admitted to the facility in the middle of 2025 with diagnoses which included anxiety disorder. During a review of Resident 31's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 6/11/25, the MDS indicated Resident 31had no diagnosis of depression, and had no symptoms and no behavioral symptoms of depression exhibited. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored securely for a census of 40, when:1. The refrigerator used for storing controlled substances in the medication storage room was found unlocked and unattended; and 2. Medication cart #1 was found unlocked and unattended. These failures had the potential for unauthorized personnel to access medications, biologicals and controlled substances. 1. During a concurrent observation and interview on 7/22/25 at 6:33 a.m. with the Director of Staff Development (DSD), a medication storage room was inspected. The DSD opened the locked door to the storage room and no licensed staff was inside the room. The medication refrigerator was observed not locked and contained lorazepam (a controlled substance sedative medication). [...]

Inspectors wroteBased on observation and interview, the facility failed ensure sanitary condition of the environment was maintained for a census of 40, when the kitchen waste fat in the indoor and outdoor refuse receptacles were not properly covered. This failure had the potential risk for the spread and transmission of diseases from pest or rodent activity in the kitchen and nearby outside dumpsters to a vulnerable population. During the initial kitchen tour observation on 7/22/25 at 6:20 a.m., in the Receiving Room, an approximately one-gallon uncovered silver pot, half-filled with a thick yellow liquid, was found on the floor near a garbage can. During the initial kitchen tour observation on 7/22/25 at 7 a.m. of the outside dumpsters, the dumpster doors were opened, and one moderately sized green, rigid plastic receptacle bin was found with lid open. [...]

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to ensure safety when Resident 1 from eloped from the facility for a census of 37. This failure had the potential to result in serious injury or death for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store food for two of five sampled residents (Resident 2 and Resident 5) when food was stored in resident room refrigerators labeled coolers and were not monitored for food safe temperatures. This failure had the potential to place residents at risk for food- borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold at the time of transfer was provided for 1 of 3 sampled residents (Resident 1) or her responsible party (RP, a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action). This failure resulted in Resident 1 and her responsible party not being fully informed about bed-hold options and rights. A review of a Resident Face sheet indicated Resident 1 was admitted to the facility in early 2024 with admitting diagnoses which included hypertensive heart disease with failure (heart failure) and generalized weakness. Resident 1's facesheet indicated she was not her own RP. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/5/24 indicated, moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan was developed for 5 sampled Residents (Resident 22, Resident 32, Resident 186, Resident 189, and Resident 191) and was not updated for one resident (Resident 1) for a census of 39. These failures decreased the facility's ability to meet the goals and address the medical, physical, mental and psychosocial needs of the residents.

Inspectors wroteBased on observation, interview, and record review, nursing staff failed to meet professional standards of quality for four of 17 sampled residents (Residents 22, 26, 392, and 537) when: 1. Nursing staff failed to administer digoxin (a medication to control heart rate) and midodrine (a medication to improve the heart's ability to pump and support low blood pressure) to Resident 26 based on the parameters (a fixed limit) set in the physician's order; 2. Nursing staff failed to follow manufacturer's specifications to rotate injection sites when administering Lovenox (a medication to prevent blood clots) to Resident 392; 3. Nursing staff failed to monitor the intravenous (I.V., catheter in the vein that delivers medication or fluids) site or obtain a physician order to change the dressing for the I.V. site for Resident 22; and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled substance medications (those with high potential for abuse or addiction) were accurately accounted for on the medication administration records (MARs) and controlled drug record (CDR) for one of six randomly selected residents (Resident 3). This failure resulted in the facility not having accurate accountability of controlled medications, and the potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a 18.18% error rate when six medication errors out of 33 opportunities were observed during a medication pass for two of three Residents (Residents 26 and 392). These failures resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which resulted in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 15) was free of a significant medication errors when he received seven doses insulin lispro (a rapid-acting insulin, medication to lower blood sugar level) and four doses insulin glargine (a long-acting insulin) past their expiration dates. This deficient practice had the potential for ineffective use of insulin, resulting in uncontrolled high blood sugar for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: - Medication was stored at temperatures specified by manufacturer; - An inhaler was labeled properly with a pharmacy label to ensure it was used for the right resident; - Five opened biologicals, multi-dose eye medications, and inhalers were dated with an open and discard date, to make sure they were not used beyond the discard date; and - Six expired medications, including insulin vials (a medication used to lower elevated blood sugar levels) were not available for resident use. These deficient practices had a potential for residents to have inaccurate tuberculosis (a contagious disease affecting the lungs) or blood glucose testing results, and to receive medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe and sanitary environment to prevent the spread of infection when: 1. Licensed Nurse 1 (LN 1) did not perform hand hygiene (cleansing hands with soap and water or hand sanitizer) during medication preparation and administration in accordance with facility policy and procedure. 2. The pill cutter was not sanitized and disinfected after use. These failures placed 39 residents at increased risk of infections and had the potential to spread infection to other residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure care was provided in accordance with professional standards for one of three sampled residents (Resident 1) when Resident 1 did not receive a medication as prescribed. This failure resulted in Resident 1 having had a burning sensation all over her back, neck, and shoulders and resulted in her shoulders appearing red, irritated, and very sensitive to touch.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of three sampled residents (Resident 1) when wound care was not provided, as ordered. This failure had the potential to result in worsening of Resident 1's wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were accurate for one of three sampled residents (Resident 1) when a Licensed Nurse (LN 1) falsely documented that she completed ordered wound care. This failure had the potential to result in worsening of Resident 1's wounds.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secure for a census of 38, when a medication cart was found unlocked and unattended with multiple people walking by. The facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards of care were met for one of five sampled residents (Resident 1), when the physician's order for fluid restriction was not followed. This failure had the potential to result in Resident 1 not attaining his highest practicable well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food storage and preparation, as well as maintain equipment and food contact surfaces in accordance with professional standards for food safety for a census of 40, when: 1. One large pan was found with a worn-out coating. 2. Three out of three small pans were found dirty with visible food residue/build-up. 3. Two expired food products were stored in the reach-in refrigerator. 4. One expired food product was stored in the baking room. 5. Three expired food products were stored on the spice shelf. These failures increased the potential for food-borne illnesses among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical standards of nursing were practiced for four residents (Resident 294, Resident 95, Resident 22, and Resident 295) when: 1) Licensed Nurse 1 (LN 1) and LN 2 did not identify Resident 295 and Resident 22 prior to medication administration; 2) LN 1 did not assess Resident 294 for the presence and level of pain prior to medication administration; 3) LN 1 did not affix a medication direction change sticker on Resident 294's medication bottle when there was a dosage change; and, 4) LN 3 did not follow-up with the physician when Resident 95's blood sugar level was high. These failures increased residents' risk for unsafe medication administration, unmonitored pain, and uncontrolled blood glucose level.

Inspectors wroteBased on interview and record review, the facility failed to schedule a urologist (a medical doctor specializing in conditions that affect the urinary tract) appointment as ordered for one resident (Resident 143) of 13 sampled residents. This failure increased Resident 143's risk for bladder complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Nurse (LN) administered pain medication as prescribed for one resident (Resident 294) of 12 sampled residents. This failure increased Resident 294's risk of discomfort due to pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was observed by Licensed Nurse 2 (LN 2) during medication pass administration. This failure increased the risk for infection to spread for a facility census of 40.