Citrus Heights Respiratory and Rehabilitation

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that three residents (Residents #4, #50, and #60) medications were administered per physician's orders of three residents sampled. The universe was 113. The deficient practice could result in unnecessary use of opioids.

Inspectors wroteBased on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure the presence of complete and readily accessible medical records for 17 out of 23 residents sampled residents (#22, #26, #43, #124, #125, #136 #137, #138, #143, #144, #146, #148, #149, #151, #154, #155, #157). The deficient practice could lead to a lack of historical data for the residents impacting their care.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy regarding conducting thorough investigations of abuse and neglect allegations and protecting residents from further abuse for 2 out of 67 sampled residents (#148 and #149). This deficient practice had the potential to result in continued abuse and/or neglect that was not prevented. Findings Included:Resident #148Review of the SA records revealed that Resident #148 reported that a nurse aide at the facility was involved with loss of personal property on August 23, 2024. It was reported that the facility conducted an internal investigation immediately following the incident. A request for the facility's investigation report was made on March 11, 2026, at 9:20 a.m.; [...]

Inspectors wroteBased on interviews, review of clinical records, and review of facility policies and procedures, the facility failed to ensure that allegations of abuse were reported to the state agency for 2 out of 67 sampled residents (#148 and #149). The deficient practice could have led to allegations of abuse not being investigated thoroughly and in a timely manner. Findings Included:Resident #148 Resident #148 was involved in an altercation with a nurse aide at the facility regarding the loss of personal property on August 23, 2024. It was reported that the facility conducted an internal investigation immediately following the incident. A request for the facility's investigation report was made on March 11, 2026, at 9:20 a.m.; however, the facility indicated that it was not in possession of the requested records. [...]

Inspectors wroteBased on clinical record review, facility documentation, State Agency (SA) database review, staff interviews, and facility policies and procedures, the facility failed to ensure that 11 allegations of abuse and neglect 2 out of 67 sampled residents (#148 and #149) were thoroughly investigated in accordance with established policy. The facility's failure to conduct and maintain complete investigations had the potential to result in allegations of abuse and neglect not being fully evaluated, thereby increasing the risk that abuse and/or neglect could occur and remain unaddressed within the facility. Findings Included:Resident #148Review of SA records revealed that Resident #148 allegedly accused a nurse aide at the facility of loss of personal property on August 23, 2024. Facility staff reported that an internal investigation had been conducted immediately following the incident. [...]

Inspectors wroteBased on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were administered and stored according to policy for one resident (#36), out of 23 sampled. The universe was 113. The deficient practice could result in overdose, negative medication interactions and other residents having unrestricted access to medications.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure food items in the kitchen and the nourishment refrigerator were labeled, dated, and stored correctly. The deficient practice could result in possible food-borne illnesses.

Inspectors wroteBased on observations, interviews, and review of facility policy and procedures, the facility failed to ensure that appropriate infection prevention and control practices were followed regarding hand hygiene, and the use of proper personal protective equipment (PPE) when entering and cleaning a contact isolation room for 1(resident #84) of 2 sampled residents. The universe was 113. The deficient practice could result in the spread of infection.

Inspectors wroteBased on staff interview, and review of the clinical record and facility policy, the facility failed to ensure that one resident (resident #90)was provided a pneumococcal vaccination. The deficient practice could result in a higher likelihood of developing pneumonia.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that medical records were maintained for the regulated timeframe for one of three residents (#37). The deficient practice could result in incomplete documentation in resident medical records.

Inspectors wroteBased on clinical record review, staff interviews, facility policy review, and observation of current practice, the facility failed to ensure one resident's medications were obtained and administered as ordered by the physician. The deficient practice led to one resident not receiving prescribed antibiotics for eight days, delaying treatment of infection.

Inspectors wroteBased on review of clinical records and policy, observations, and staff interviews the facility failed to ensure enhanced barrier precaution (EBP) policies, notably use of personal protective equipment (PPE) during wound care, were up-to-date with professional standards of practice. The deficient practice may result in development or transmission of infections within the facility.

Inspectors wroteBased on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure a baseline care plan was developed for two residents (#98 and #393). The deficient practice could result in resident's not receiving basic care and services to meet their needs.

Inspectors wrote-Resident #33 was readmitted on [DATE] with diagnoses that included cellulitis of chest wall, hypotension, and chronic kidney disease. A physician order dated October 26, 2022 revealed an order for midodrine hydrochloride (vasoconstrictor) 10 milligrams (mg) one tablet by mouth three times a day for hypotension; and, to hold for systolic blood pressure (SBP) greater than 105. The MDS (minimum data set) dated December 20, 2022 revealed resident had a BIMS (brief interview for mental status) score of 15. indicating intact cognition. Active diagnosis included orthostatic hypotension. The care plan dated December 28, 2022 revealed resident had a diagnosis of hypotension. Intervention included to give medications as ordered. Another care plan dated December 28, 2022 revealed resident was alert, makes own decisions and was non-compliant with medication management. [...]

Inspectors wroteBased on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure on resident (#143) received necessary care and services in a timely manner after a fall. The deficient practice could result in negative resident outcomes.

Inspectors wrote-Resident #76 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, muscle weakness and hypertension. A care plan initiated on May 9, 2022 revealed the resident was at risk for falls related to history of falls, injury from falls, and poor safety awareness and impulsiveness. Interventions included resident chooses at times to roll off the bed to the floor, mattress placed on the floor related to resident rolling off bed to the floor. The Minimum Data Set, dated [DATE] coded that resident had one fall with no injury since admission. A care plan initiated on May 17, 2022 revealed the resident had potential disturbance in behavior as evidenced by yelling out, places self on floor frequently. Intervention included to anticipate resident's needs. The Minimum Data Set, dated [DATE] revealed resident had 2 falls with no injury since admission or re-entry. [...]

Inspectors wroteBased on resident and staff interviews, facility assessment, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in residents' needs not being met. The census was 92.

Inspectors wroteBased on observations, staff interviews, facility documentation, policies and procedures, the facility failed to ensure expired medications were appropriately disposed and available for resident use; and, failed to ensure medications were stored in accordance with professional standards. The deficient practice could result in residents receiving expired medications and that medications are stored safely.

Inspectors wroteBased on resident and staff interviews, observations, review of the clinical record, and policy and procedure, the facility failed to honor preference to use an adult brief and to provide a low air loss (LAL) mattress as requested for one resident (#94). The deficient practice may result in preferences and needs essential to the resident not being accommodated.

Inspectors wroteBased on review of clinical records, staff interviews, facility investigations, and facility policy and procedures, the facility failed to ensure one resident (#44) was free from neglect. The deficient practice could result in other residents being neglected.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of facility policy/procedure, the facility failed to ensure one resident (#245) was free from misappropriation of personal funds. The deficient practice could result in residents having personal funds misappropriated by staff members.

Inspectors wroteBased on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure a comprehensive care plan related to fall was developed with interventions for one resident (#95). The deficient practice could result in care needs not being met.

Inspectors wroteBased on resident and staff interviews, review of clinical records and facility policies and procedure, the facility failed to ensure one resident (#98) was served and provided with food that the resident was not allergic to. The deficient practice could result in residents at risk for allergic reaction.