Citrus Heights Post Acute

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for three of 34 sampled residents (Resident 3, Resident 30 and Resident 129) when blood pressure medications were given outside of ordered parameters for Resident 30 and Resident 129 and pulse was not taken prior to medication administration for Resident 3. These failures had the potential to cause adverse medication outcomes such as low blood pressure and dizziness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of 34 sampled residents (Resident 35 and Resident 12) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when;1. Resident 35's order for the use and monitoring of for Jackson Pratt (JP) drain bulb (closed-suction device used after surgery to remove fluids-like blood or serum-from the wound site, reducing infection risk and aiding healing) was not followed; and,2. Resident 12's elevated blood sugar (BS-the main sugar in body that gives you energy) was not monitored according to physician's order and plan of care. These failures had the potential for Resident 35 and Resident 12's medical condition to get worse, and for the residents to not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and storage practices in accordance with professional standards for food service safety when:1a. One steam table pan had food residue in the pan, one pot had food residue on the bottom of the pan.b. One steam table pan was stored wet.2a. The dry storage area floor had an unopened bag of rice on the floor.b. The dry storage area had debris on the floor. These failures had the potential to lead to food borne illness for the 150 Residents out of 158 Residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for one out of 34 sampled residents (Resident 11) when Resident 11's call light button was not within reach. This failure placed the resident at risk for unmet needs and compromised safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 34 sampled residents (Resident 12) received adequate supervision to prevent accidents. This lack of supervision and assistance resulted in Resident 12 sustaining a fall that caused a fracture (break in a bone), severe pain, and a decline in functional ability.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 34 sampled residents (Resident 24) received dialysis care services consistent with professional standards of practice, facility's policy and procedure (P&P) when Resident 24 had an inaccurate dialysis medical record. This failure had the potential for Resident 24 to not receive safe and appropriate dialysis care treatment and services and to not achieve her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 34 sampled residents (Resident 35 and Resident 9) were free from significant medication error when:1. Resident 35 did not receive prescribed insulin (medication used to manage blood sugar level) in accordance with the standards of practice; and,2. Resident 9's insulin was not administered as prescribed. These failures had the potential to result in Resident 35 and Resident 9 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect Resident 35's health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely dental services to two of 34 sampled resident (Resident 16 and Resident 52) when the facility did not carry out recommended tooth extractions. This failure had the potential to cause tooth pain and infection. Resident 16 was admitted to the facility in late 2018 with diagnoses that included a stroke with left side weakness. During an interview on 4/21/26 at 9:35 a.m. with Resident 16 in her room, Resident 16 stated she had a bad tooth and was waiting for the dentist to fix her mouth. During a review of Resident 16's dental exam notes, dated 10/2/25, the dental note indicated Resident 16 had tooth pain in the top left side of her mouth and that the tooth is mobile [loose] and needs EXT [extraction, removal]. During a concurrent interview and record review on 4/22/26 at 9:33 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the prepared menu and meet the nutritional needs for one out of 34 sampled residents (Resident 155) when Resident 155 was not served with a regular portion of protein during the 4/20/26 lunch meal. This failure had the potential to result in Resident 155 not being able to meet and maintain her nutritional needs and achieve her highest practicable wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate assistive eating and drinking utensils to one out of five sampled residents (Resident 2) when Resident 2 was not provided a specialized drinking cup and plate guard (a curved, removable rim that snaps onto the edge of a dinner plate to prevent food from being pushed off, assisting with independent dining) during the 4/14/26 lunch meal. This failure had the potential to result in Resident 2 not being able to properly and safely eat and drink and had the potential for nutrition and hydration problems.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 1) was treated with dignity and respect, when Restorative Nursing Assistant (RNA 1) spoke inappropriately to Resident 1. This failure caused Resident 1 to feel upset, humiliated, and disrespected and had the potential to negatively impact Resident 1's psychosocial well-being. A review of the facility's 'Resident Rights' policy dated 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. A review of the admission Record indicated the facility admitted Resident 1 in the spring of 2025 with multiple diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure required documentation for discharge was present in the medical record for one of four sampled residents (Resident 1), when there was no physician order indicating the basis of Resident 1 ' s discharge, there was no discharge summary, and there was no notice of discharge in Resident 1 ' s medical record. This failure had the potential for delay in Resident 1 ' s care after discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of 35 sampled residents (Resident 68 and Resident 77) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 68 and Resident 77's wound treatment orders were not consistently done. This failure had the potential for Resident 68 and Resident 77's wounds to get worse and not achieve healing, and for the residents to not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 35 sampled residents (Resident 78) Resident when, Resident 78 was provided with oxygen therapy without a physician's order. This failure had the potential to result in unsafe delivery of oxygen to Resident 78 and for Resident 78 to not achieve her highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 35 sampled residents (Resident 77 and Resident 141) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 77 and Resident 141 pain medication orders were not consistently followed. This failure had the potential for Resident 77 and Resident 141 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services according to policy and procedures to meet the needs of residents for a census of 158 when: 1. The facility failed to accurately document and secure emergency medications (E-kit, a sealed container of essential medications and supplies designed for immediate use in emergency situations); 2. Dispose of expired E-Kit insulin (medication used to control blood sugar) and 3. Ensure the narcotic (substance used to treat moderate to severe pain) count was correct for Resident 37. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and potential for diversion of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1a. Three steam table pans were stored wet, and one had food residue in the pan, b. The food processor and blender were both stored wet with food residue in them, with the lids on, 2. The dry storage area floor had debris on it. These failures had the potential to lead to food borne illness for the 152 Residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices and procedures were followed for three of 35 sampled residents (Residents 48, 55, and 78) when: 1. Resident 48's Incentive Spirometer (a device used to exercise the lungs) was left unlabeled and not covered. 2. Resident 55's Enhanced Barrier Precautions (EBP) were not followed. 3. Resident 78's Nasal Cannula (a device used to deliver oxygen through the nose) was left uncovered. These failures had the potential to result in the spread of infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 35 sampled Residents (Resident 110 and Resident 80) were assisted with nail care as part of their Activities of Daily Living (ADLs - normal daily functions required to meet basic needs) when; 1. Resident 110 had long toenails; and, 2. Resident 80 had long fingernails with grayish substance underneath them. These failures had the potential for Resident 110 and Resident 80 to have sustained a skin injury, and to possibly acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure for the proper storage of drugs and biologicals for a census of 158 when: 1. Loose pills were found in a medication cart, and; 2. A bottle of Drug Buster (medication disposal system) was observed with brown substance on the outside of the bottle and on the bottle of the drawer. These failures had the potential for drug diversion and medication at risk of degradation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 35 sampled residents (Resident 141) when Resident 141 who was on No Added Salt diet (NAS- a dietary restriction that limits the intake of salt) received a packet of salt during the 4/21/25 lunch meal. This failure had the potential to negatively affect Resident 141's medical condition and for Resident 141 not to achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system was accessible for two out of 35 sampled residents (Resident 120 and Resident 85) when Resident 120 and Resident 85's call light buttons were observed not within reach. This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices for one (Resident 1) of three sampled residents, when Licensed Nurse (LN) 1 did not don a gown and did not perform hand hygiene (process of cleaning ones ' hands using soap or alcohol-based hand rub) during Resident 1 ' s dressing change. These failures had the potential to increase the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of food safety for a census of 154 when: 1. Four large cuts of pork loin were not thawed to standards, and 2. Foods past their expiration and use-by date were not discarded. These failures had the potential to increase the risk of foodborne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food safety for a census of 151 when: 1) The kitchen was not maintained under sanitary conditions; 2) The bleach concentration was out of range; and 3) Undated snacks were available for use in the nourishment room refrigerator. These failures placed the residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with the facility policy and procedure for two of 30 sampled residents (Resident 113 and Resident 82) when: 1. Resident 113's nebulizer mask (a device used to change liquid medication into a mist form that is inhaled through a mask) was left in an opened drawer of the bedside table, uncovered and unlabeled. 2. Resident 82's nebulizer mask was hung on the wall uncovered and unlabeled. These failures placed Resident 113 and Resident 82 at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals properly for a census of 151 when: 1. Insulin pens were not labeled with an open date, 2. Loose pills were found in medication carts, and; 3. A flush (used to keep a feeding tube from getting clogged by flushing it with warm water after each feeding and before and after giving medicines) that was ready to use was not labeled or dated. These failures had the potential for drug diversion, residents to receive expired medications, and for Resident 1 to receive an unknown fluid flush.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals properly for a census of 151 when: 1. Insulin pens were not labeled with an open date, 2. Loose pills were found in medication carts, and; 3. A flush (used to keep a feeding tube from getting clogged by flushing it with warm water after each feeding and before and after giving medicines) that was ready to use was not labeled or dated. These failures had the potential for drug diversion, residents to receive expired medications, and for Resident 1 to receive an unknown fluid flush.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control guidelines to provide a safe and sanitary environment for a census of 151 residents when, 1. two clean white linens (sheets) touched the floor as the Laundry Aide (LA) folded the sheets; and 2. clean shirt and pants placed on top of the table touched the LA's uniform as she leaned over to reach for linens, 3. the facility failed to properly label residents' personal belongings in a shared room. These deficient practices had the potential to spread infection and disease among residents and staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were secure for a census of 149, when a medication/treatment cart was found unlocked and unattended with the key laying across the top. This failure had the potential to expose residents, staff and visitors to unauthorized access to medications, resulting in possible injury or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention program for a census of 136 residents when: 1. Staff entered rooms of Coronavirus disease 2019 (COVID-19, viral respiratory illness that causes fever, coughing, and shortness of breath) patients without full personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards); 2. Doors to COVID-19 positive residents' rooms were not closed 3. Double gloves were used without handwashing, scissors were not cleaned prior to cutting dressings, dirty scissors were placed on residents bedside table, dressings for wound care were placed on a resident bed, contaminated dressings were placed into resident wounds 4. Hand washing was not performed between glove changes, and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received treatments as ordered for her pressure ulcer ( PU- injury to the skin and underlying tissue from prolonged pressure on the skin). This failure had the potential for the worsening of Resident 1's wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the treatment nurse (TX 1)1 had the competencies to provide wound care for one of six sampled residents (Resident 2) when: 1. Scissors were not cleaned prior to cutting dressings; 2. Uncleaned scissors were placed on resident's bedside table; 3. Dressings for wound care were placed on resident's bed; 4. Double gloves were used without handwashing, and 5. Contaminated dressings were placed into resident's wound. These failures increased the potential for infection and/or physical harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secured storage of prescribed medication for a census of 136 when a medication cart was left unattended and unlocked. This failure had the potential for unauthorized personnel to access the medication cart.