Citrus Heights Health Center

In the surveyor’s words

From the most serious findings on record at Citrus Heights Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF554Jun 24, 2026

  Based 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.Findings: a. […]

• No harm, potential for more than minimal, patternF756Jun 24, 2026

  Based 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). […]

• No harm, potential for more than minimal, patternF578Aug 6, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF684Aug 6, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Aug 6, 2025

  Based 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. Findings:During an initial tour of Kitchen 1 on 8/4/2025 at 8:42 am, with the Dietary Supervisor (DS), five cups of orange colored ice or cream was observed without a label to indicate what type of food was contained within the cups and a used by or expiration date indicating when the orange substance would expire.During an interview with the DS, on 8/4/25 at 8:43 am, the DS stated the DS was… […]