Citrus Heights Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Dec 28, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF658Apr 23, 2026

  Based 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.Findings:Resident 3 was admitted to the facility in early 2025 with diagnoses that included atrial fibrillation (condition when the heart beats irregularly), heart failure (heart muscles are weak and do not effectively pump blood), and hypertension (HTN, high blood pressure).During a review of Resident 3's Order Summary Report [OSR], dated… […]

• No harm, potential for more than minimal, patternF684Apr 23, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Apr 23, 2026

  Based 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.Findings:1a. […]

• No harm, potential for more than minimal, patternF684Apr 24, 2025

  Based 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. Findings: 1a. […]