Advanced Health Care of Sacramento

In the surveyor’s words

From the most serious findings on record at Advanced Health Care of Sacramento, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 13, 2023

  Based on observation, interview and record review, the facility failed to provide an environment free of accident hazards, for one resident (Resident 1) of three sampled residents, when Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 to a wheelchair (WC) while still wet from a shower. This failure resulted in Resident 1 sliding out of the wheelchair and sustaining a fracture to the left hip. Findings: A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated 5/13/23, indicated Resident 1: was an [AGE] year-old male, admitted on [DATE], with diagnoses of Parkinson's disease (a brain disorder that causes shaking, stiffness, and difficulty with balance and coordination) and osteoporosis (a condition in which the bones become fragile), had intact cognitive… […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Dec 31, 2024

  Based 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. Findings: A review of Resident 2's Resident Face Sheet indicated Resident 2 was admitted to the facility in December 2024 with multiple diagnoses including metabolic encephalopathy (brain dysfunction due to imbalance of chemicals in the blood), surgical aftercare following thrombectomy (surgical procedure that removes a blood clot from an artery or vein) and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one… […]

• No harm, potential for more than minimal, patternF656Aug 9, 2024

  Based 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. Findings: During a record review of Resident 32's Face Sheet (FS), the FS indicated, Resident 32 had diagnoses which included urinary tract infection (UTI, an infection in any part of the urinary system). […]

• No harm, potential for more than minimal, patternF658Aug 9, 2024

  Based 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. […]