Citrus Heights Health Center

Inspectors wroteBased on interviews and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of one sampled resident (Resident 1) who was at high risk for falls by failing to:Ensure Certified Nursing Assistant (CNA 1) provided two-person physical assistance (help from two persons) while providing personal care (hands-on assistance with everyday tasks) to Resident 1 as indicated in Resident 1's care plan (CP), titled, [activities of daily living (ADL's - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)]/Functional Status/Rehab [rehabilitation], dated 7/3/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were not allowed to keep medications at bedside without a physician's order and/or without being assessed to determine if the residents were capable of self-administering medications, for two of two sampled residents (Residents 26 and 38). These deficient practices had the potential for Residents 26 and 38 to self-medicate resulting in unsafe medication administration and adverse (harmful) consequences for Residents 26 and 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities identified from the Monthly Drug Regimen Review (MDRR), reported by the facility's pharmacist were acted upon for three of five sampled residents (Resident 2, Resident 16 and Resident 39). For Resident 2, the resident's physician was not informed regarding a GDR (tapering of medication overtime) for the antipsychotic (manage psychosis, including delusions, hallucinations, and disorganized thinking) medications. For Resident 16, the resident's physician was not informed regarding the GDR for Remeron (mirtazapine, a prescription antidepressant used to treat major depressive disorder). For Resident 39, the facility failed to obtain a lipid panel (a blood test that measures the levels of fats/lipids in the blood). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 16) was free from chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom of movement of a resident) by failing to ensure Resident's 16's consent for Mirtazapine (antidepressant medication to treat major depressive disorders) was signed by the physician. This failure had the potential to negatively impact Resident 16's care and for Resident 16 to experience adverse side effects (unexpected or harmful consequences) from taking Mirtazapine.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for the 3/16/2026 admission was completed within the required time frame for one of one sampled resident (Resident 7). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of Resident 10's Minimum Data Set (MDS, a resident assessment tool) assessment when bipolar disorder was coded as an active diagnosis when bipolar disorder was a historical diagnosis during the assessment's reference period. This deficient practice resulted in an inaccurate reflection of Resident 10's clinical status and the potential to result in improper treatment to Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding was maintained for one of one sampled resident (Residents 40) as indicated in Resident 40's Care Plan (CP, a structured, personalized roadmap that outlines an individual's health conditions, care needs, and specific goals) and Physician's Order (PO). This deficient practice had the potential for Resident 40 to receive over and/or lack of feeding other than what was ordered by Resident 40's Physician. During a review of Resident 40's Profile Face Sheet, the Profile Face Sheet indicated the resident was re-admitted to the facility on [DATE] with diagnosis that included hemiplegia (paralysis of one side of the body) following cerebral infarction (Stroke) and gastrotomy. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the screening result for the Preadmission Screening and Resident Review (PASRR) for one of two sampled residents (Resident 31). Resident 31 had a mental illnesses including schizophrenia (a brain disorder that disrupts how a person interprets reality), bipolar (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and depression (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and was receiving psychotropic medication, but the PASRR indicated No under diagnoses of mental disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a call light within reach for one of ten randomly selected residents (Resident 39). This deficient practice had the potential to result in staff delay in meeting Resident 39's needs for hydration, toileting, and activities of daily living. During a review of Resident 39's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with a diagnosis of personal history of other diseases of the circulatory system. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and maintain a copy of the Advance Directive (AD - legal document indicating resident preference on end-of-life treatment decisions) in the same section of the resident's medical record readily retrievable by any facility staff for two of two sampled residents (Resident 3 and Resident 13) who had executed an AD.This failure had the potential for Resident 3 and Resident 13 to receive inappropriate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate care and services were provided for three of three sampled residents (Resident 8, Resident 3, and Resident 32) by failing to ensure:a. Resident 8, who was on anticoagulant (medication that thins the blood) therapy, was monitored for bleeding in the months of May, June, and July 2025 and Resident 32 who was on anticoagulant therapy was monitored for bleeding in July and August 2025.b. Resident 3's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) physician orders were followed and/or clarified.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when five cups of orange colored ice or cream were observed unlabeled and undated in the facility's walk-in freezer. These deficient practices had the potential to result in improper food storage, which could lead to foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required direct care staffing (employees and contract staff who, through interpersonal contact with residents or resident care management, provided care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being) information based on payroll data for one of two quarters (Quarter 2) was submitted in the Payroll-Based Journal (PBJ - a system implemented by the Centers for Medicare & Medicaid Services [CMS] that requires nursing homes and long-term care facilities to electronically submit auditable and verifiable staffing and payroll data) on the schedule specified by CMS, but no less frequently than quarterly. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the initial minimum data set (MDS, a standardized assessment and care-screening tool) assessment in a timely manner for one of one sampled residents (Resident 29) as indicated in the Centers for Medicare & Medicaid Services (CMS is a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents) manualThis deficient practice resulted in a late completion and transmission of MDS assessment to Centers of Medicare and Medicaid (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. This had the potential to affect the facility's quality monitoring data.

Inspectors wroteBased on interview and record review, the facility failed to screen one of one of sampled resident (Resident 4) for Preadmission Screening and Resident Review (PASARR). Resident 98 has a mental illnesses including schizophrenia (a mental disorder effecting how a person thinks and feels), bipolar (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and depression (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and was receiving psychotropic medication. This deficient practice had the potential to result in Resident 4 to not receive special services for treatment of mental illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of nursing practice were followed during a blood draw by venipuncture (a medical procedure that involves inserting a needle into a vein to draw blood) for one of one sampled resident (Resident 1) who had a Peripheral (situated on the edge) Central Catheter (PICC - a type of central venous catheter [CVC, thin flexible tube inserted into a large vein [vessel] typically in the neck, chest, or groin, and threaded into a central vein near the heart to access the bloodstream for administering medications) line for long-term central venous access. This deficient practice had the potential to result in catheter malfunction, an infection, or physical decline to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 3), who was unable to carry out activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain personal and oral hygiene (refers to the maintenance of a healthy mouth, which includes not only teeth, but the lips, gums, and supporting tissues.) This failure had the potential for Resident 3 to develop mildly uncomfortable to severely painful discomfort, pain and/or bleeding from cracked lips.

Inspectors wroteBased on interview and record review, the facility failed to ensure a follow-up for needed services from a Home Health (HH - medical and supportive services provided in a patient's home to help them manage their health conditions, recover from illness or injury) Agency was completed and the service was confirmed prior to discharge home for one of one sampled resident (Resident 32) who required continuity of care at home by HH services for Diabetes management (a variety of strategies to control blood glucose [sugar] levels and minimize the risk of complications associated with Diabetes [a disease that results in elevated levels of glucose in the blood]). [...]

Inspectors wroteBased on interview and record review the facility failed to identify a potential chemical restraint for one of one resident (Resident 204) by having a physician order that indicated to give Ativan (used commonly as a sedative and to relieve anxiety) if Resident 204 attempted to get out of bed unassisted. This deficiency had the potential to restrict Resident 204's movement for staff convenience or discipline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive plan of care for one of two sampled residents (Resident 153) with a limited Range of Motion (ROM - the degree of movement a joint can make). This deficient practice had the potential for a decline in ROM for Resident 153.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to provide services to prevent a further decrease in range of motion (ROM, full movement potential of a joint) that included performing an assessment of joint mobility for one of two sampled residents (Resident 153) as a baseline for monitoring decline or improvement in ROM for Resident 153 as indicated in the facility's Policy and Procedure (P&P) titled Resident Mobility and Range of Motion. This deficient practice had the potential to result in a decline to Resident 153's ROM.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 153) was assessed for the use of Buspirone (medication used to treat anxiety [a feeling of fear, dread, and uneasiness]) and Clonazepam (medication used to treat seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness), panic disorders [reoccurring unexpected panic attacks: persistent worry, intense fear, sweating, shaking, and shortness of breath], and anxiety) to treat a behavior of persistent blowing. Additionally, the facility failed to ensure Buspirone was not increased unless the behavior was clinically significant. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rates of 5 percent or greater for one of three sampled residents. There were 4 medication errors out of 25 medications observed during Medication Administration Observation on 9/10/24 and on 9/12/24. The facility's medication error rate was 16 percent. 1. Licensed Vocational Nurse 1 (LVN 1) did not check Resident 152's blood pressure (BP, pressure inside the blood vessels) and heart rate (HR, the number of times the heart beats in a minute, also known as the pulse rate ) immediately before LVN 1 administered (gave) amlodipine (medication used to treat high blood pressure and/or chest pain) 10 milligrams (mg, unit of measure) to Resident 152. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four garbage dumpster's lids were not left open as indicated in the facility's Policy and Procedure (P&P) titled, Non-medical Waste Disposal. This deficient practice had the potential to result in pests and the spread of infectious diseases throughout the facility.

Inspectors wroteBased on observation, interview, and record review, Certified Nursing Assistant 3 (CNA 3) and Director of Nursing (DON) failed to wear the needed personal protective equipment (PPE) for one of one resident (Resident 203) at indicated by Resident 203's physician orders, the signage posted outside of Resident 203's room and the facility's policy for Enhanced Barrier Precaution. This failure put Resident 203's risk of acquiring an infection through the indwelling foley catheter (device that drains urine from the bladder into a collection bag outside one's body).