Citrus Heights Respiratory and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Citrus Heights Respiratory and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF658Jul 3, 2023

  Based on observations, resident, resident representative, and staff interviews, and facility documentation, the facility failed to ensure that one resident's (#8) was free from sustaining injuries of unknown origin. Findings include: Resident #8 initially admitted on [DATE] with a reentry on 4/4/22 with diagnoses that included dementia, major depressive disorder, hemiplegia, and polyneuropathy. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident's mental status was unable to be assessed by an interview with her, due to both short term and long-term memory problems. Staff assessment showed severely impaired cognition. The resident had no recorded skin conditions. […]

• No harm, potential for more than minimal, patternF760Mar 12, 2026

  Based 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. Findings include: Regarding Resident #4 Resident #4 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subdural hemorrhage, unspecified, extradural and subdural abscess, and cognitive communication deficit. Review of the baseline care plan initiated on February 12, 2026 revealed a focus indicating Resident #4 was prescribed an opioid medication with interventions that included to administer the opioid medication as prescribed. […]

• No harm, potential for more than minimal, patternF842Mar 12, 2026

  Based 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. Findings included: On review of the residents' records in the facility's electronic health system, significant discrepancies were identified, as resident records dated prior to March 1, 2025, were not available. […]

• No harm, potential for more than minimal, patternF880Jun 14, 2024

  Based 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. Findings include: An observation of wound care was conducted on June 13, 2024 at 08:40 AM with Certified Wound Nurse/Licensed Practical Nurse (LPN/Staff # 65) after verbal consent of approval by Resident # 89. Staff # 65 entered the room, drew curtain for privacy, and donned gloves. Staff # 65 did not wear a protective gown at this time. […]

• No harm, potential for more than minimal, patternF600Aug 17, 2023

  Based on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#407) was not abused by staff (#33) and one resident (#54) was not neglected by staff (#13). The deficient practice could result in residents being physically and emotionally harmed and not receiving the services that are needed. Findings include: Resident #407 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, delusional disorders, and respiratory failure. Review of the self-care deficit care plan, revealed that resident #407 required extensive assistance with ADIS related to dementia and respiratory failure dated January 3, 2023. […]