Sacramento Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:Several kitchenware found not in sanitary manners and stored away in the clean and ready-to-use storage areas;The arrangement of the raw meat stored in the walk-in refrigerator were not in a food safety manner;The ice machine was not clean; andOne microwave designated for residents' food was not clean and not well maintained. These failures had the potential to result in food contamination which could cause illness for 71 medically [NAME] residents who received food prepared from the facility kitchen. The census was 89.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control and prevention practices for a census of 89. when:Two certified nursing assistants (CNAs) did not follow the Enhanced Barrier Precautions (EBP-infection control measures that require staff to wear gowns and gloves during high-contact care, such as dressing, transferring, or changing linen) required during resident's care;Five packs of adult briefs and three elongated packs of vinyl plank flooring covered with whitish-to-brownish substances were inside the dusty floor of the linen storage room [ROOM NUMBER]; A resident's indwelling urinary catheter (IUC, flexible tube inserted through the urethra into the bladder to continually drain urine into an external collection bag) urine drainage bag was sagging and touching the floor; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was below 5% for two of 23 sampled residents (Resident 76 and Resident 11) when:1. Licensed Nurse (LN) 5 applied a medication patch not in accordance with the Physician's Orders (POs) for Resident 76;2. A medication was not available for timely administration for Resident 76 by LN 5; and3. LN 5 administered the wrong dose of a medication to Resident 11. These failures resulted to three errors identified out of 29 opportunities for error during the observation of medication administration with the facility's medication error rate of 10.34%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that prescription medications were labeled and that expired medications were not available for a census of 89, when:1. Multiple unlabeled prescription medications were found in the medication room and the treatment cart; and2. Expired wound dressings containing silver were found inside the treatment cart. These failures had the potential to compromise resident safety by increasing the risk of medication errors and the use of ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors for a census of 89, when one of one garbage dumpster, located outside the facility, was not closed securely with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of 23 sampled residents (Resident 38), when Resident 38's Bowel and Bladder Toileting Program (B&BTP) was not implemented with focused measurable objectives. This failure had the potential to negatively impact Resident 38's quality of life, and the care and services received. A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility in early 2026, as his own responsible party, with a diagnosis of benign prostatic hyperplasia (BPH, prostate enlargement which causes bladder dysfunction occurring in men), and a stool incontinence. A review of Resident 38's Order Summary Report, indicated physician orders on 1/27/26 for a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of the 23 sampled residents (Resident 76) received treatment and care in accordance with professional standards of practice, when Licensed Nurse 5 (LN 5) did not notify the physician about the unavailability of Resident 76's blood pressure medication. This failure prevented the physician from providing alternative orders and placed the resident at risk for uncontrolled blood pressure, which had the potential to cause stroke or other adverse effects such as headaches, dizziness, and fatigue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve his or her ability to carry out the activities of daily living for one of 23 sampled residents (Resident 61), when the eye patch (specialized, often concave, devices used to cover, protect, or treat an eye abnormality) was not worn during lunch time as ordered by the physician. This failure had the potential to result in the decline of Resident 61's functional independence during meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care and dignity to maintain good grooming for one of 23 sampled Residents (Resident 65), when Resident 65 had sweaty smell and scattered white flakes on his scalp, strands of his hair, ears, face and neck. This failure resulted to Resident 65's with unkempt appearance and not attaining his highest practicable physical, mental and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and quality care services were provided for two of twenty-three sampled residents (Resident 67 and Resident 1) when:Resident 67 indwelling urinary catheter (IUC, a flexible tube inserted into the bladder to continuously drain urine, typically used when a patient cannot urinate on their own) smelled foul odor of urine and the tubing had creamy-white-brownish encrustation (forms when minerals and other debris accumulate inside the catheter or drainage bag) The physician was not notified of creamy-white encrustation in Resident 1's IUC. These failures had the potential for Resident 67 and Resident 1 to develop complications including blockage of urine flow, urine leakage, bladder pain, and recurrent urinary tract infections (UTIs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Mince and Moist level 5 (MM5) texture (the food texture is designed for residents who experience biting, chewing, or swallowing limitations. All food must be soft, moist and minced to size [no larger than 4 millimeters (mm) x 15 mm]. The food item size and texture must pass testing requirements, fork test and spoon tilt test) food items prepared properly for one of 23 sampled residents (Resident 9). This deficient practice had the potential to increase risk for Resident 9 with swallowing and chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway).

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate, sufficient supervision to each resident to prevent an avoidable accident for one of two sampled residents (Resident 1) and failed to investigate an accident thoroughly when:Resident 1 fell to the floor while being transferred from her bed to a shower chair, and the facility failed to provide documentation of a fall investigation for Resident 1. These failures had the potential for Resident 1 to sustain a major injury, be exposed to physical pain, increased anxiety from her history of falls, and placed Resident 1 at risk for an unidentified injury from the failure to investigate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 62 residents who received food prepared from the kitchen, when: 1. Expired food items were found on the kitchen shelf; 2. An unclean appliance attachment cap was on the steam table and an unclean oven top and mesh rack for storage of water pitchers were found in the kitchen; 3. Pans with hard black residue were available for use in the kitchen; 4. The dry storage room had no documented evidence of temperature monitoring; 5. The freezer section of the refrigerator used for storage of resident foods had no thermometer and no documented temperature monitoring evidence; and, 6. the ice dispensing mechanism of the ice maker had dark residue. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the reach-in meat freezer in safe operating condition when door seals were observed with tears/cracks, and the top of the freezer had ice buildup on the inside. This failure decreased the facility's potential to ensure food safety and quality for 62 residents who ate facility prepared meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing care provided met professional standards for three residents (Resident 63, Resident 36, and Resident 53) of 23 sampled residents when licensed nursing staff did not: 1. Perform Resident 63's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen, just above the pubic bone) care and coccyx (also known as the tailbone which is the triangular bony structure found at the bottom of the spine) skin care as ordered; 2. Ensure Resident 36's medical record indicated the physician was notified as ordered; and, 3. Ensure Restorative Nurse Assistant (RNA, a program which provides exercise and a range of motion activities to the residents) services were provided to Resident 53 without active prescriber orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. Resident 37's nephrostomy bag (a bag that collects urine from a nephrostomy tube, which is a thin, flexible tube placed into the kidney) was observed touching the floor and the antimicrobial bag used as a privacy bag was not labeled with a placement date; and, 2. The Continuous Air Mist (CAM) respiratory equipment was not labeled with placement dates for Resident 14 and Resident 59. These failures had the potential to result in infection among a facility census of 85 residents.

Inspectors wroteBased on interviews and record review, the facility failed to report an incident of alleged abuse for one of three sampled residents (Resident 1), when Resident 1 verbalized he was treated roughly and handled like a rag doll. This failure had the potential to place the resident at risk for further harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policy and procedure (P&P) to investigate an allegation of abuse for one of three sampled residents (Resident 1), when on [DATE] Resident 1 was noted to have a degloving (avulsion-a traumatic injury that occurs when the top layers of skin and tissue are torn away from the underlying muscle, connective tissue, or bone) injury to right forearm and finger point areas to posterior right forearm and right wrist', and claimed it was from rough treatment from the Certified Nursing Assistant. This failure had the potential to place the resident at risk for further harm.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician promptly or implement monitoring timely for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure resulted in Resident 2 not being monitored for an allergic reaction for approximately 20 hours, which increased the risk for unmet health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure person centered care plans were developed which included specific goals and interventions for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure had the potential for Resident 2 to experience unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of four sampled residents (Resident 2) when Resident 2 was administered Norco (a narcotic mediation that contained hydrocodone and acetaminophen) when hydrocodone was listed as an allergy. This failure had the potential for adverse systemic effects and jeopardized Resident 2's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's communication within the facility for one of three sampled residents (Resident 1) when Resident 1's call light was not within reach. This failure had the potential to increase the residents' fear of not being able to get assistance from staff when needed.

Inspectors wroteBased on interviews, clinical record review, and facility documents review, the facility failed to readmit one of one resident (Resident 1) to return to the facility after hospitalization when Resident 1 was ready to be readmitted to the facility. This failure resulted in the denial of Resident 1's right to return to the facility and had the potential to negatively affect Resident 1's wellbeing.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication administration error rate was less than 5 percent (%), when two medication errors occurred out of 25 opportunities during medication administration for two residents (Resident 46 and Resident 7) of 21 sampled residents. As a result of these failures, the facility's medication administration error rate was 8%.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Supervisor (DS) completed one of the seven pathways required to manage a skilled nursing facility in California. This failure had the potential for unsafe food handling and food borne illness in a highly susceptible population of 88 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were performed for four residents (Resident 46, Resident 102, Resident 7, and Resident 86) of 21 sampled residents when: 1. The Licensed Nurse 1 (LN 1) and LN 3 did not perform hand hygiene between glove changes; 2. The LN 1 did not disinfect a stethoscope (an equipment used in listening to sounds produced within the body) prior to its use; 3. The LN 2 brought a container of glucometer strips (test strips used in a glucometer machine to check blood sugar level) and a glucometer to Resident 102's bedside without disinfecting them prior to use; 4. The LN 3 dropped a packet of powdered medication on the floor and continued to use the dropped medication to administer to Resident 7; and, 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one resident (Resident 51) of 21 sampled residents upon re-admission to the facility. This failure reduced the facility's potential to meet Resident 51's care needs for a urinary catheter (a tube used to drain urine from the bladder to a collection bag).

Inspectors wroteBased on observation, interview, and record review, the facility failed to update care plans for two residents (Resident 24 and Resident 65) of 21 sampled residents when: 1. A care plan was not created on the precautions and safe usage for Resident 24's new medication enoxaparin (an injected medication that prevents blood clots); and, 2. A care plan was not created for the Resident 65's new diagnosis of septicemia (sepsis, an infection in the blood). These failures decreased the facility's potential to meet residents' needs upon a change in their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards for one resident (Resident 65) of 21 sampled residents when: 1. Staff did not immediately notify the physician of Resident 65's change in condition; and, 2. Staff carried out an intervention for Resident 65 but did not evaluate the effectiveness of the intervention per protocol. These failures reduced the facility's potential to provide safe and effective care to Resident 65.

Inspectors wroteBased on interview and record review, the facility failed to maintain an acceptable parameter of nutritional status when one resident (Resident 62) of four sampled residents lost 9.9% of his body weight over a 12-day period. This failure placed Resident 62 at risk for potential muscle loss increasing his susceptibility to infection and delayed wound healing for a census of 88.