Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citrus Heights Post Acute during CMS and state inspections, most recent first.
Failure to Follow Medication Orders and Vital Sign Parameters: Staff did not follow physician orders for three residents when a pulse was not checked before amiodarone was given to one resident with atrial fibrillation, and amlodipine and carvedilol were administered to two residents despite SBP being below the ordered hold parameters. The UM confirmed the medication administration errors, and the DON stated nurses were expected to check vital signs and follow physician orders.
A resident with a JP drain order was observed with a drainage bag instead of the ordered JP drain bulb, and staff confirmed the ordered bulb monitoring was not being followed. Another resident with DM had very high blood sugar readings, but the record did not show the ordered recheck, insulin administration, or supporting nursing documentation for the elevated glucose events. The DON and other staff confirmed the documentation and care did not match the physician orders.
Food Service Sanitation and Storage Deficiencies: During a kitchen tour, an AKS found a steam table pan and a pot with food residue in the ready-to-use rack, and another steam table pan stored wet. The AKS also found an unopened 50-lb bag of rice on the dry storage floor, along with forks, cardboard, and plastic wrap on the floor. The RD confirmed residue and wet stacking may harbor bacteria, and the AKS stated these items should not have been stored that way.
Call Light Not Within Reach for A Resident: A resident with myasthenia gravis, dementia, CHF, and muscle weakness had a severely impaired BIMS score and needed assistance with toileting, oral care, eating, bed mobility, and transfers. Staff observed the resident in bed without the call light within reach; it was found on the floor behind the bedside drawer, and CNA confirmed it was not accessible even though the care plan directed staff to keep the call light within reach.
Failure to provide adequate supervision led to a resident’s fall with a patella fracture, severe pain, and a skin tear. The resident had muscle weakness, reduced mobility, moderately impaired cognition, and was assessed as a moderate fall risk. Staff records showed the fall was witnessed and the bed was elevated above waist level; the DON stated staff would have been expected to use two people if needed or keep one hand on the resident to help prevent the fall. After the injury, the resident’s functional status declined to mostly dependent for most ADLs.
Inaccurate dialysis record led to conflicting ESA orders. A resident with ESRD on hemodialysis had an active order for epoetin alfa in the chart, while the dialysis communication sheet showed Mircera was being given at the dialysis center. The dialysis AA confirmed the resident had been receiving Mircera for years and stated epoetin alfa had been discontinued and should not be given because it would be double dosing of ESA medication. The DSD confirmed the record was not accurate and that nursing staff were supposed to check and reconcile the dialysis communication sheet.
Insulin Administration Errors: Two residents experienced insulin-related medication errors. One resident with DM2 received rapid-acting insulin before lunch, but the meal was delayed well beyond the 10 to 15 minute window described by nursing staff and the DSD. Another resident with diabetes and CKD received lispro even though the MAR showed blood sugars below the ordered hold parameter of less than 150, and the DON confirmed the insulin should have been held.
The facility failed to provide timely dental follow-up for two residents whose dental notes documented a need for extractions. One resident with a hx of stroke and left-sided weakness had a loose, blackened tooth and reported pain, while another resident with memory loss and muscle weakness had broken, jagged teeth with dark areas along the gumline and wanted to see a dentist. The SSD confirmed there had been no follow-up to schedule the recommended dental care, and later dental notes described decayed teeth and antibiotic treatment for likely infection.
Failure to Serve Ordered Protein Portion: A resident with dementia, DM, severe PCM, and muscle weakness was served only a half portion of hamburger patty at lunch instead of the regular protein portion listed on the meal ticket and menu. The resident said this had been happening recently without her request, and both the CRN and RD confirmed she should have received a regular portion of protein to match her ordered CCHO diet with regular texture and small starch portions.
A resident with Parkinson’s disease, polyneuropathy, muscle weakness, and documented weight loss was care planned and ordered via diet tickets to receive adaptive equipment, including a divided plate, plate guard, and sippy cup, to support self-feeding. During a lunch meal observation, the resident, who had shaky hands and required supervision/touching assistance with eating per MDS, was given regular drinking cups and a divided plate without a plate guard, contrary to the meal ticket and nutritional risk reviews. The resident reported being unable to hold the regular cups, and staff (a CNA, an LN, the RD, and the Administrator) acknowledged that the adaptive devices should have been provided in accordance with the meal ticket, care plan, and facility policy on self-feeding devices.
A resident with paraplegia and a skin infection was transferred due to a conflict of interest with an NP, but the facility failed to obtain a physician order, complete a discharge summary, or provide a notice of discharge as required. Staff interviews confirmed the absence of these documents in the medical record, despite facility policy mandating their completion for all discharges.
Two residents with chronic wounds and skin conditions did not consistently receive prescribed wound care treatments, including hydrocortisone cream, Aquaphor ointment, and zinc oxide paste, as documented in treatment administration records. Staff interviews confirmed that wound care orders were not followed as directed and that required documentation was lacking when treatments were missed.
A resident with COPD, CHF, and sleep apnea received oxygen therapy multiple times without an active physician's order, as documented in clinical records and confirmed by staff interviews. Facility policy requires a physician's order for oxygen administration, but staff provided oxygen when the resident experienced breathing difficulties, resulting in care that did not follow established procedures.
Two residents with chronic pain conditions did not receive pain medications as ordered by their physicians, with staff administering medications intended for different pain levels than those documented. Medication administration records and staff interviews confirmed that pain management orders were not consistently followed, contrary to facility policy and professional standards.
Surveyors identified failures in emergency medication documentation and controlled substance management, including missing entries in the E-Kit log after medications were removed, retention of expired insulin from a previous pharmacy, and a discrepancy in the narcotic count for a resident's pain medication. The ADON and LNs confirmed that these actions did not follow facility policy for medication tracking and reconciliation.
Surveyors found that food service equipment, including steam table pans, a food processor, and a blender, were stored wet and with food residue, contrary to facility policy and FDA Food Code. Additionally, the dry storage area floor was observed to have food packets and debris, with the Dietary Supervisor confirming the need for cleaning. These failures demonstrate noncompliance with professional standards for food storage and preparation.
Surveyors identified infection control deficiencies involving three residents: an incentive spirometer was left unlabeled and uncovered, enhanced barrier precautions were not followed during personal care for a resident with a chronic wound, and a nasal cannula used for oxygen therapy was left uncovered when not in use. Staff interviews and facility policies confirmed these lapses in required infection prevention practices.
Two residents who were dependent on staff for ADLs did not receive necessary nail care, resulting in one having long, curling toenails and another with long fingernails containing debris. Both residents expressed discomfort and a desire for nail care, but staff either deferred care to the podiatrist or did not initiate referrals, despite facility policy requiring assistance with hygiene and grooming for residents unable to perform these tasks independently.
Surveyors found that drugs and biologicals were not stored properly, with loose pills present in a medication cart and a Drug Buster bottle observed with a brown substance on its exterior and in the drawer. A nurse confirmed these findings, and facility policy requires medication storage areas to be kept clean and safe.
A resident with chronic kidney disease and hypertension, who was prescribed a No Added Salt (NAS) diet, was served a salt packet with her meal despite clear dietary orders and care plan instructions. Staff interviews and policy reviews confirmed that the NAS diet should have excluded extra salt, and the error was acknowledged by both dietary and nursing staff.
Two residents with cognitive and mobility impairments were found without accessible call light buttons, as the devices were placed out of reach in their rooms. Staff and facility leadership confirmed that call lights should be within reach, and facility policy requires this practice.
A licensed nurse did not wear a gown or perform hand hygiene during a G-tube dressing change for a resident on Enhanced Barrier Precautions, contrary to facility policy requiring these infection control measures for high-contact care activities.
The facility failed to follow food safety standards by improperly thawing pork loin without running water and storing expired food items in the refrigerator. The Kitchen Supervisor confirmed these practices, which were against the facility's policy and the FDA Food Code, posing a risk of foodborne illness.
Failure to Follow Medication Orders and Vital Sign Parameters
Penalty
Summary
The facility failed to follow physician orders for three sampled residents when medications were administered outside ordered parameters or without required vital sign checks. Resident 3 was admitted with diagnoses including atrial fibrillation, heart failure, and hypertension. The resident’s order for amiodarone 200 mg daily directed staff to hold the medication for heart rate less than 60, but the Medication Administration Record did not document a heart rate with amiodarone administration from 4/1/26 through 4/15/26, and the medication was marked as administered. Resident 30 was admitted with hypertension and had an order for amlodipine besylate 10 mg daily with instructions to hold if systolic blood pressure was less than 110. The MAR showed amlodipine was given on 4/7/26 when the systolic blood pressure was 107 and on 4/12/26 when it was 106. Resident 129 was admitted with atrial fibrillation and hypertension and had an order for carvedilol 12.5 mg, 2 tablets twice daily, to be held if systolic blood pressure was less than 110. The MAR showed carvedilol was given on 4/6/26 when the systolic blood pressure was 103. During interview and record review, the Unit Manager confirmed the heart rate was not checked before amiodarone was administered to Resident 3 and that amlodipine and carvedilol were given outside the ordered parameters. The DON stated nurses were expected to check vital signs before administering medications and follow physician orders.
Failure to Follow Drain and Blood Sugar Orders
Penalty
Summary
Resident 35 had diagnoses that included postprocedural complications and disorders of the digestive system, infection following a procedure, diabetes mellitus, and muscle weakness. The resident’s record showed a JP drain order requiring monitoring for decreased or absent output, sudden increase in output, or changes in color every shift, and another order requiring the bulb to remain compressed to maintain suction and for the drain to be emptied, measured, and recorded as needed. During observation, the resident had a drainage tube from the right side of the abdomen connected to a drainage bag that was draining dark yellow fluid and was placed on the bed at the same level as the drainage site. The resident stated staff would sometimes drain the fluids from the bag but did not know whether the drainage bag was changed. During interview and record review, LN 5 stated the resident always had a drainage bag and never had a JP drain bulb, even though the record contained an order for JP drain bulb monitoring. LN 5 also stated the order should have been followed because the JP drain bulb provides suction that helps prevent complications and supports faster healing. The DSD likewise stated the order for the drainage bulb should have been followed, and that if a drainage bag was being used it should be placed below the drainage site to promote drainage. The facility’s JP drain policy described emptying the JP drain bulb, squeezing the bulb flat, and replugging it so suction could restart. Resident 12 had diagnoses including diabetes mellitus and adult failure to thrive. The resident had physician orders for Humalog sliding-scale insulin before meals and at bedtime, with instructions to notify the MD for blood sugar values above 400. On one occasion, the resident’s blood sugar was documented as 502, and the nurse recorded that the NP was informed and to give the scheduled sliding-scale insulin and recheck, but the resident refused a recheck and no new order was documented. The MAR showed an entry for Humalog at that time, but the Resource Nurse stated there was no progress note documenting a recheck or that insulin was administered as prescribed. Later that same day, the resident’s blood sugar was documented as 401 at bedtime, with another MAR entry for Humalog, but again there was no note documenting the nurse’s actions. The DON stated she would expect the nurse to have re-checked the resident’s blood sugar and administered insulin as prescribed.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
The facility failed to follow proper sanitation and storage practices for food service equipment and dry goods. During an initial kitchen tour, the Assistant Dietary Supervisor observed one steam table pan with food residue in it and one pot with food residue on the bottom while both were in the ready-to-use storage rack. The Assistant Dietary Supervisor removed both items to the washing area and stated they were supposed to be checked for debris before being placed back on the ready-to-use storage rack. In a continued observation, a steam table pan was also found stored wet in the ready-to-use rack, and the Assistant Dietary Supervisor removed it to the washing area, stating the pans are expected to be air dried before storage. The Registered Dietician later confirmed that food residue left on pans and pans stacked away wet may harbor bacteria. The dry storage area was also observed to have an unopened 50-pound bag of rice stored on the floor by the door, and the Assistant Dietary Supervisor moved it to a rack and confirmed it should not be stored on the floor. In the same area, two forks, a piece of cardboard, and a piece of plastic wrap with brown paper were found on the floor, and the Assistant Dietary Supervisor confirmed there should not be any items on the floor. The report cited facility policies requiring pots and pans to be properly sanitized and air-dried, and cited FDA Food Code requirements that food-contact surfaces be free of soil accumulations and food be stored in a clean, dry location at least 6 inches above the floor.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to provide reasonable accommodation of Resident 11’s needs when the resident’s call light button was not within reach. Resident 11 was admitted in February 2026 and had diagnoses including myasthenia gravis, dementia, congestive heart failure, and muscle weakness. The resident’s MDS dated 4/7/26 showed a BIMS score of 7 out of 15, indicating severely impaired cognition, and documented the need for substantial/maximal assistance with toileting hygiene, supervision or touching assistance with oral hygiene, setup or clean-up assistance with eating, and supervision or touching assistance with bed mobility and transfers. Resident 11’s care plan dated 2/23/26 identified the resident as at risk for falls and directed staff to keep the call light within reach. During observation on 4/20/26, Resident 11 was lying in bed and stated she did not know where her call light button was; it was found on the floor behind the bedside drawer, about 3 to 4 feet away. Later that day, the call button was again not within reach while the resident was in bed, and CNA 2 confirmed it was not accessible and found it in the same location. LN 6, the DSD, and the ADM each stated that call lights should be placed within residents’ reach when they are in bed so they can call for help when needed.
Failure to Provide Adequate Supervision During a Fall
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for one sampled resident who had multiple diagnoses including muscle weakness and reduced mobility, and whose annual MDS indicated moderately impaired cognition and need for assistance with several ADLs. The resident’s fall risk assessment identified the resident as a moderate fall risk. After the resident was sent to the hospital following a fall, the facility documented that the resident returned with a right patella fracture, a new order for a knee brace, a skin tear on the right elbow, and severe pain on arrival back to the facility. Record review and staff interviews showed the fall was documented as a witnessed fall, and the LN note indicated the resident’s bed was elevated above waist level. The Resource Nurse confirmed the resident sustained a right knee fracture and elbow skin tear from the fall. The DON stated staff would have been expected to use two people if needed or keep one hand on the resident to help prevent a fall. The MDS Coordinator later stated the resident experienced a significant change in functional abilities after the fall and fracture, with most ADLs declining to mostly dependent.
Inaccurate dialysis record led to conflicting ESA orders
Penalty
Summary
The facility failed to ensure safe and appropriate dialysis care/services for one resident with end stage renal disease who required hemodialysis three times per week. Resident 24 was admitted with diagnoses including ESRD, dependence on renal dialysis, and muscle weakness. Her care plan and physician orders identified hemodialysis on Tuesday, Thursday, and Saturday, and an order also listed Epoetin Alfa (Retacrit) to be given in the dialysis clinic. A weekly summary note documented that she was on dialysis and alert and oriented, and the MDS indicated she was on hemodialysis on admission and while residing in the facility. The resident’s dialysis communication sheet dated 3/31/26 documented that Mircera was administered at the dialysis center. During interview and record review with the dialysis center AA, it was confirmed that Resident 24 was receiving Mircera 50 mcg IV push every 2 weeks and had been receiving it since March 2024. The AA stated the center had discontinued epoetin alfa long ago and that Resident 24 should not be receiving epoetin alfa because it would be double dosing of ESA medication. The DSD confirmed the resident’s active order still indicated Epoetin Alfa at the dialysis center, while the hemodialysis communication sheet indicated Epoetin Beta (Mircera), and confirmed the medical record was not accurate. The DSD stated nurses were supposed to check and reconcile the dialysis communication sheet, and that residents should have an accurate medical record so they could safely receive dialysis treatments.
Insulin Administration Errors
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication error related to insulin administration. Resident 35 had diagnoses including DM2, respiratory failure, and muscle weakness, and his MDS indicated moderately impaired cognition and a need for set-up or clean-up assistance with eating. He had active orders for scheduled insulin lispro 5 units subcutaneously three times daily and additional lispro per sliding scale based on blood sugar readings. During a concurrent interview and record review, Licensed Nurse 5 stated Resident 35 had a blood sugar reading of 155 and received a total of 6 units of insulin before 1:00 p.m. The nurse stated the lunch meal should have been given within 15 minutes of the insulin administration and was not sure why lunch was late. Resident 35 stated at 1:45 p.m. that he was still waiting for lunch and was hungry. At 1:56 p.m., a CNA was observed delivering the lunch tray to Resident 35. The DSD stated lispro is rapid acting and meals should be given within 10 to 15 minutes of administration, and that a one-hour gap was a big gap between lispro administration and receiving the meal. Resident 9 had diagnoses including diabetes and stage 3 chronic kidney disease and had an order for insulin lispro 4 units subcutaneously three times daily, to be held for blood sugar less than 150 or when the patient does not eat, and to be administered with meals. Review of the April 2026 MAR showed insulin was documented as given on 4/4/26 when the blood sugar was 119 and on 4/20/26 when the blood sugar was 148. The DON confirmed the check marks and stated the insulin should not have been given per the parameter and should have been held for blood sugar less than 150.
Failure to Provide Timely Dental Follow-Up for Needed Extractions
Penalty
Summary
The facility failed to provide timely dental services for two residents when recommended tooth extractions were not completed. One resident, admitted in late 2018 with a history of stroke and left-sided weakness, told staff she had a bad tooth and was waiting for the dentist to fix her mouth. Her dental exam note from 10/2/25 documented tooth pain in the upper left side of her mouth, a loose tooth, and a need for extraction, but the Social Service Director confirmed there had been no follow-up on her dental needs since September 2025. During observation, the resident had a blackened tooth loosely hanging from the back left upper side of her mouth and stated that it hurt. A later dental visit note described the tooth as mobile and decayed, and the resident was prescribed antibiotics for likely infection. The second resident, admitted in late 2024 with diagnoses including memory loss and muscle weakness, stated she had broken teeth and wanted to see a dentist; observation showed several broken jagged teeth with dark blackened areas along the gumline. Her dental note from 5/15/25 indicated she needed extractions on the next visit, and the Social Service Director confirmed the facility had not completed any follow-up to schedule them. A later dental note described two teeth that appeared decayed, and the resident was prescribed antibiotics for likely dental infection.
Failure to Serve Ordered Protein Portion
Penalty
Summary
The facility failed to follow the prepared menu and meet the nutritional needs of one sampled resident, Resident 155, when she was not served a regular portion of protein during the lunch meal. Resident 155 had been admitted in November 2023 and had diagnoses including dementia, diabetes mellitus, severe protein-calorie malnutrition, and muscle weakness. Her MDS indicated a BIMS score of 11, showing moderately impaired cognition, and that she needed set-up or clean-up assistance with eating. Her active physician order specified a CCHO diet, regular texture, and small starch portions, and her care plan and nutritional risk review identified her as being at nutritional risk with severe PCM and poor oral intake. The facility's menu for the lunch meal listed baked hamburger with sauce, diced fried potatoes, Capri blend vegetables, wheat roll, and spring fruit crisp. During observation, Resident 155 was served only a half slice of hamburger patty with brown sauce, and her meal ticket did not indicate a half portion of meat. The resident stated she had recently been given half portions of meat without requesting them and said she ended up eating more cookies and extra sweets because of it. The CRN confirmed she received only a half slice of hamburger patty and stated the meal ticket did not call for a half portion of meat, so she should have received a regular portion. The RD also stated Resident 155 should receive a regular portion of protein and should not be getting only a half portion. The facility's tray identification policy stated trays should be checked for correct diets before serving residents.
Failure to Provide Prescribed Adaptive Eating and Drinking Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive eating and drinking equipment to a resident during a lunch meal. The resident had diagnoses including Parkinson’s disease, polyneuropathy, and muscle weakness, and an MDS indicating moderately impaired cognition and a need for supervision or touching assistance with eating. The resident’s care plan and nutritional risk reviews documented a history of weight loss, weakness in hands and arms, and the ongoing need for a divided plate, plate guard, and sippy cup at meals. During an observation of a lunch meal in the resident’s room, the resident was seen with shaky hands and had not touched the lunch meal on the bedside table. The meal tray contained two full cups of reddish beverages in regular 8 fl oz cups and a small can of ginger ale with a straw. The resident had been provided a divided plate but was not provided a plate guard or sippy cups, despite the lunch meal ticket specifying adaptive equipment including a plate guard and sippy cup. In interviews conducted at the time of the observation, the resident stated she could not hold the regular cups because of her shaky hands and expressed a desire for a better cup to hold drinks more steadily without spilling. A CNA confirmed that the resident had not been provided a plate guard or sippy cups and acknowledged that, due to the resident’s shaky hands, these items should have been provided so she could eat and drink safely and properly. An LN stated that the meal ticket should have been followed and that the resident should have received the plate guard and sippy cups, noting that nurses normally check trays for completeness. The RD confirmed the resident’s weight loss and need for assistive utensils, stated there were no refusals or functional changes documented, and indicated the resident should continue to receive the plate guard and sippy cups with each meal. The Administrator stated an expectation that assistive utensils be provided when indicated on meal tickets, and facility policy specified that self-feeding devices such as plate guards are to be stored by Food & Nutrition Services and provided on meal trays for residents needing them. This failure had the potential to result in the resident not being able to properly and safely eat and drink and had the potential for nutrition and hydration problems.
Missing Required Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure that required documentation for discharge was present in the medical record for one resident. The resident, who had paraplegia and a local skin infection, was admitted with intact cognition. During the resident's stay, a conflict of interest arose when the nurse practitioner (NP) recognized the resident as being involved in a lawsuit with the NP. The resident agreed to be transferred to another facility due to this conflict. Upon review, it was found that there was no physician or provider order indicating the basis for the resident's discharge, no discharge summary, and no notice of discharge in the resident's medical record. Multiple staff interviews confirmed that these required documents were missing. The case manager, social services director, assistant director of nursing, medical records director, and administrator all acknowledged the absence of the necessary discharge documentation. Facility policy required that a physician or provider's order be obtained for all discharges, that a discharge summary be completed, and that a notice of proposed discharge be provided to the resident and documented in the medical record. Despite these requirements, none of these steps were completed for the resident in question, resulting in a lack of proper documentation and communication regarding the discharge.
Failure to Consistently Administer Wound Care Treatments as Ordered
Penalty
Summary
Two residents did not receive wound care treatments as ordered by their physicians, in accordance with professional standards of practice and the facility's policies and procedures. One resident, with diagnoses including peripheral vascular disease, venous insufficiency, and major depressive disorder, had physician orders for hydrocortisone cream and Aquaphor ointment to be applied to chronic ulcers on both lower legs. Review of treatment administration records showed that these treatments were frequently missed or not administered at the prescribed frequency over a period of nearly two months. The resident reported not receiving treatments consistently, and staff confirmed that the wound care orders were not followed as directed. Another resident, with diagnoses including vascular parkinsonism, adult failure to thrive, morbid obesity, and overactive bladder, was at risk for skin breakdown and had open sores on the back. This resident had physician orders for zinc oxide paste to be applied to the rear thighs and right buttock twice daily for moisture-associated skin damage (MASD). Treatment administration records indicated that these treatments were also missed or not performed at the required frequency. The resident reported that staff were not properly caring for the sores, and staff interviews confirmed the inconsistency in following wound care orders. Interviews with nursing staff, the Director of Staff Development, and the Director of Nursing confirmed that wound treatments were not consistently performed as ordered and that documentation was lacking when treatments were not administered. Facility policy required that wound care be provided according to physician orders and that the care plan be reviewed for special needs, but these procedures were not followed for the two residents identified.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sleep apnea was provided with oxygen therapy without an active physician's order. The resident's care plan indicated the need for oxygen as ordered, and multiple clinical records, including vital summaries and progress notes, documented the use of oxygen via nasal cannula on several occasions. During interviews, both the licensed nurse and the Director of Staff Development confirmed that oxygen was administered to the resident when she experienced difficulty breathing, despite the absence of a current physician's order for this treatment. Facility policy and procedures for oxygen administration require verification of a physician's order prior to providing oxygen therapy. Both the Director of Staff Development and the Director of Nursing stated that an active physician's order is necessary to safely administer oxygen to residents. The failure to obtain and verify a physician's order before administering oxygen resulted in the delivery of respiratory care that was not consistent with facility policy and standard practice.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to ensure that two residents received appropriate pain management services in accordance with professional standards of practice, facility policy, and physician orders. For one resident with vascular parkinsonism and osteoarthritis, pain medication orders specified different medications for mild, moderate, and severe pain levels. However, medication administration records showed that this resident was given acetaminophen, intended for mild pain, when experiencing moderate pain, and was also administered hydrocodone-acetaminophen, intended for severe pain, during episodes of moderate pain. These discrepancies were confirmed by the nurse supervisor during record review. Another resident with multiple fractures and osteoarthritis had physician orders for acetaminophen for mild pain and varying doses of Norco for moderate and severe pain. Medication administration records indicated that this resident received 1 tablet of Norco, intended for moderate pain, during episodes of severe pain, and 2 tablets of Norco, intended for severe pain, during episodes of moderate pain on multiple occasions. The nurse supervisor confirmed that the pain medication orders were not consistently followed for this resident as well. Interviews with staff, including the Director of Staff Development, Consultant Pharmacist, and Director of Nursing, all confirmed that pain medications should be administered according to physician orders. The facility's policies and procedures also require that pain medications be administered as ordered and in accordance with the resident's care plan. The failure to follow these orders was observed in the medication administration records and confirmed by staff interviews.
Deficiencies in Emergency Medication Documentation and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its policies and procedures, as evidenced by several deficiencies related to emergency medication management and controlled substance documentation. During inspections of the medication rooms and carts, it was observed that emergency kits (E-Kits) had been opened and resealed with red color-coded locks, but there was no documentation in the Emergency Kit Log regarding which medications were removed or the dates of removal. Multiple white slips in the narcotic E-Kit indicated repeated access, yet the required log entries were missing. The Assistant Director of Nursing (ADON) confirmed that licensed nurses were expected to record all medication removals in the log and notify the pharmacy for kit replacement, as outlined in the facility's policy. Additionally, an expired insulin E-Kit from a previous pharmacy provider was found in the refrigerator, and the ADON acknowledged it should have been removed or destroyed after the pharmacy change, in accordance with policy requirements for handling discontinued or outdated medications. Further, a discrepancy was identified in the controlled drug record for a resident receiving narcotic pain medication. The on-hand count of Percocet tablets did not match the documented record, with one less tablet present than recorded. The licensed nurse attributed the discrepancy to a missed documentation by the night nurse, who had administered the medication but failed to record it. The ADON stated that both outgoing and incoming staff were expected to reconcile and sign off on narcotic counts at each shift change, as per facility policy. These findings demonstrate lapses in medication documentation, storage, and accountability.
Improper Food Storage and Equipment Cleaning in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations. Three steam table pans were found stored while still wet, with one pan containing food residue, in the ready-to-use area. Additionally, both a food processor and a blender were stored with their lids on, wet, and with food residue inside. The Dietary Supervisor confirmed during interviews that these items were expected to be clean and air-dried before storage, and acknowledged that improper washing and drying could lead to foodborne illness. Review of the facility's dishwashing policy and the FDA Food Code confirmed that all dishes and equipment should be properly sanitized, free of food residue, and air-dried before storage. Further observations revealed that the dry storage area floor contained food packets, a piece of plastic wrap, and paper debris. The Dietary Supervisor confirmed that the floor needed to be swept. According to the FDA Food Code, food must be stored in a clean, dry location, protected from contamination. These findings demonstrate that the facility did not consistently follow professional standards for food storage, preparation, and cleanliness, as required by both facility policy and federal regulations.
Infection Control Lapses in Device Labeling, PPE Use, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices for three residents. For one resident with chronic respiratory failure, an incentive spirometer was observed on a shared shelf, unlabeled and not contained in a protective covering. Both the resident and a licensed nurse confirmed that the device was not labeled or bagged, despite facility policy requiring labeling and storage in a bag. The resident had a physician's order for use of the spirometer multiple times per week. Another resident with a history of cellulitis of the lower limb was on enhanced barrier precautions (EBP) due to a chronic wound. During personal care, a certified nursing assistant provided direct care without wearing the required personal protective equipment (PPE), even though signage at the room entrance indicated EBP and the care plan specified the use of gown and gloves for high-contact activities. The CNA acknowledged not wearing PPE, and the infection preventionist confirmed that PPE was required for such care. A third resident, admitted with chronic obstructive pulmonary disease, congestive heart failure, and sleep apnea, was observed with an oxygen concentrator and nasal cannula. The nasal cannula was left uncovered on top of the concentrator when not in use. Both the resident and a CNA confirmed the cannula was not bagged, and the director of staff development stated that respiratory tubing should be placed in an antimicrobial bag when not in use to prevent contamination. Facility policy also required safe storage of oxygen administration equipment.
Failure to Provide Nail Care Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents who were unable to perform this activity of daily living independently. One resident, with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, dermatophytosis, and varicose veins with ulcer, was dependent on staff for bathing, personal hygiene, and required assistance with dressing and footwear. Observations revealed that this resident had thick, long, and curling toenails. The resident expressed a desire to have her toenails trimmed, but staff indicated that due to her diabetes diagnosis, only the podiatrist could perform this care, and she was not currently on the podiatrist's list. The podiatrist only visited every two months, and the resident was at risk for ingrown toenails and skin injury if her nails were not trimmed. Another resident, with a history of stroke, muscle wasting, diabetes, and major depressive disorder, required substantial to maximal assistance with personal hygiene and was dependent on staff for several ADLs. During observation, this resident was found to have long fingernails with a grayish substance underneath. The resident stated discomfort and a desire for nail care. A CNA confirmed the condition of the nails and stated that they should be trimmed and cleaned to prevent infection. The resident had not been referred for podiatry care, and staff interviews revealed that nail care was considered an implied daily task for nurses, with referrals to the podiatrist as needed for complex cases. Review of facility policy indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including hygiene and grooming. Despite this, both residents did not receive necessary nail care, as observed and confirmed by staff and record review. The lack of timely nail care for these dependent residents constituted a failure to meet their basic hygiene needs as outlined in their care plans and facility policy.
Improper Storage and Handling of Medications and Disposal System
Penalty
Summary
Surveyors observed that drugs and biologicals were not properly stored according to facility policy and accepted professional standards. During an inspection of a medication cart, multiple loose pills were found inside the cart, and a bottle of Drug Buster, used for medication disposal, was noted to have a brown substance on its exterior and on the bottom of the drawer where it was stored. The licensed nurse present confirmed the presence of the loose pills and the brown substance. The Assistant Director of Nursing later stated that the expectation was for loose pills to be destroyed and for any Drug Buster bottle with spilled contents to be discarded. The facility's policy requires nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Follow Physician-Ordered No Added Salt Diet
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered No Added Salt (NAS) diet was served a packet of iodized salt with her lunch meal. The resident, who had a history of multiple fractures, chronic kidney disease, and hypertension, was admitted in February 2025 and had a care plan and physician's order specifying the NAS diet. Despite these orders, the resident received a salt packet on her meal tray, which she did not request. Observations and interviews confirmed that the meal ticket indicated the NAS diet, and both the Certified Nurse Assistant and Registered Dietician acknowledged that the resident should not have received extra salt. The Registered Dietician stated that nursing staff are expected to check meal trays before serving them to residents, and the Director of Nursing confirmed that prescribed diets should be followed. Facility policies also required that therapeutic diets be provided as ordered by the physician.
Call Light System Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for two residents. For one resident with dementia, gait abnormalities, and muscle weakness, the call light button was found on the floor, approximately three feet away from the bed, and the resident was unaware of its location. This resident required substantial to maximal assistance with daily activities and had a care plan intervention to reinforce the need to call for assistance. A certified nurse assistant confirmed the call light was not within reach and acknowledged it should have been accessible to the resident. For another resident with Alzheimer's disease, dementia, muscle weakness, and difficulty walking, the call light button was placed inside a bedside drawer about four feet from the bed. This resident was dependent on staff for most activities of daily living and had a care plan intervention to keep the call light within reach. A certified nurse assistant confirmed the call light was not accessible and stated it should have been within the resident's reach. Both the Director of Staff Development and the Director of Nursing confirmed that call light buttons should be accessible to residents, as outlined in the facility's policy.
Failure to Follow Enhanced Barrier Precautions During G-Tube Dressing Change
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow proper infection control practices during a dressing change for a resident with a G-tube. The resident, who had a history of dysphagia and cerebral infarction, was on Enhanced Barrier Precautions (EBP) as indicated in their care plan. The facility's policy required staff to don a gown and gloves for high-contact care activities, such as G-tube care, and to perform hand hygiene after glove removal and after contact with potentially contaminated surfaces. During the observed dressing change, the nurse did not wear a gown and did not perform hand hygiene after removing the old dressing or after removing gloves. The nurse confirmed these lapses during the interview. The infection preventionist also confirmed that these actions were not in accordance with facility policy and increased the risk of spreading infectious organisms.
Improper Food Storage and Thawing Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety in two significant instances. Firstly, four large cuts of pork loin were observed thawing improperly in a sink without running water. The Kitchen Supervisor confirmed this method of thawing, which did not comply with the facility's policy that requires meat to be thawed under running cold water. The Registered Dietitian emphasized the importance of proper thawing to prevent the growth of bacteria that could lead to foodborne illnesses. Secondly, during the same observation, expired food items, including a container of plain low-fat yogurt and a pre-cooked ham, were found in the walk-in refrigerator. The Kitchen Supervisor acknowledged that these items were past their expiration and use-by dates and should have been discarded. The Registered Dietitian reiterated that expired foods pose a risk of foodborne illness, aligning with the US Food and Drug Administration Food Code, which mandates that time/temperature control for safety refrigerated foods must be consumed, sold, or discarded by their expiration date.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 683 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Citrus Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Healthcare Center | 1.3 mi | ★★★★★ | 23 | 0 |
| Manzanita Healthcare Center | 2.7 mi | ★★★★★ | 17 | 0 |
| Sacramento Post-acute | 3.2 mi | ★★★★★ | 16 | 0 |
| American River Center | 3.9 mi | ★★★★★ | 12 | 0 |
| College Oak Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 14 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.