Health inspection·February 5, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two out of six sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2's room was cluttered with multiple medium sized brown boxes, an empty soda can, two white towels, overripe bananas, and multiple personal items of their roommate. This failure had the potential to result in an unsafe and unsanitary environment for Resident 1 and Resident 2 to receive care and services and risk for the residents not to achieve their highest practicable well-being.Findings: 1a. A review of Resident 1's clinical record indicated Resident 1 was initially admitted January of 2026 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebrovascular disease (a group of conditions that affects the blood flow and the blood vessels in the brain) affecting right dominant side, need for assistance with personal care, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 1's MDS Mood Status, dated [DATE], indicated Resident 1 experienced several days of Feeling down, depressed, or hopeless. A review of Resident 1's care plan, dated [DATE], indicated, [Resident 1] is at risk for falls/injury. Impaired mobility .Maintain a clutter-free environment in the resident's room . During a phone interview on [DATE] at 11:56 a.m. with Resident 1's daughter, Resident 1's daughter stated she visited her mother on [DATE] and her room was cluttered with multiple boxes and was very unsanitary. Resident 1's daughter further stated they requested her mother to be moved to a different room because the room was so cluttered and unsanitary. Resident 1's daughter sent multiple photos and a video of Resident 1's room she took on [DATE]. A review of the photos and a video of Resident 1's room taken on [DATE] showed the room had multiple brown boxes which were stacked in front of the residents' beds, on the way to the room's bathroom. There were multiple personal items placed on top of the boxes. There was an empty brown box placed on top of a wheelchair. There were two white towels, and an empty can of soda placed in front of the television, next to a power cord. There were multiple personal items placed in front of one bed and there were overripe bananas on top of it. A review of Resident 1's social services progress note, dated [DATE], indicated, [Resident 1] is expected to transfer rooms on Reason for transfer: Family request [DATE] . During an interview on [DATE] at 12:05 p.m. with Housekeeping Staff (HKS), the photos and video of Resident 1's room taken on [DATE] were viewed. HKS stated staff should tidy and clean the room because it was not safe for residents to have a cluttered room. HKS further stated the clutter in Page 1 of 2 055308 055308 02/05/2026 Elk Grove Post Acute 9461 Batey Avenue Elk Grove, CA 95624

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's room could cause an accident. 1b. A review of Resident 2's clinical record indicated Resident 2 was admitted November of 2025 and had diagnoses that included congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), need for assistance with personal care, muscle weakness, and difficulty walking. A review of Resident 2's MDS cognitive Patterns, dated [DATE], indicated Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 had an intact cognition. A review of Resident 2's MDS Mood Status, dated [DATE], indicated Resident 2 experienced several days of Feeling down, depressed, or hopeless. A review of Resident 2's care plan, dated [DATE], indicated, [Resident 2] is at risk for falls/injury r/t [related to] Impaired mobility .Maintain a clutter-free environment in the resident's room . During an interview on [DATE] at 12:37 p.m. with Resident 2, Resident 2 stated she remembered her room was cluttered with a lot of boxes and was not clean sometime last week and they did not talk to her about what the boxes were for. Resident 2 also stated she did not like it when her room was cluttered with boxes and was not clean. Resident 2 further stated staff should have tidied and cleaned the room up so it would be safe for them in the room. During an interview on [DATE] at 12:53 p.m. with Licensed Nurse (LN) 1, the photos and video of Resident 1's room taken on [DATE] were viewed. LN 1 explained the resident in bed C was moving out of the facility and was packing her personal items, that was why there were a lot of boxes in the room. LN 1 stated the room should not have been left cluttered and unsanitary because of resident safety concerns and infection control issues. LN 1 also stated the room should be kept clutter free for the residents in bed A and bed B so they could move around and be free from any accident. LN 1 further stated it was not a homelike environment for the residents in bed A and bed B. During an interview on [DATE] at 1 p.m. with Certified Nurse Assistant (CNA) 1, the photos and video of Resident 1's room taken on [DATE] were viewed. CNA 1 stated residents in bed A and bed B have the right to a clean and nice environment just like their home. CNA 1 further stated if she saw the room cluttered and unsanitary, she would say something because personally, she does not want any clutter in her own space too. During an interview on [DATE] at 1:08 p.m. with LN 2, the photos and video of Resident 1's room taken on [DATE] were viewed. LN 2 stated it was okay for the resident in bed C to have her personal items but not to the point that it compromises other residents' personal space and things. LN 2 also stated it was not good, and it was not right for the other residents in the room to have a cluttered and unsanitary room. LN 2 further stated having a cluttered and unsanitary room could cause infection control issues and safety concerns- especially in emergency situations. During an interview on [DATE] at 2:51 p.m. with LN 3, LN 3 stated she worked last [DATE] and saw Resident 1 and Resident 2's room cluttered with boxes and personal items and was left unsanitary. LN 3 further stated it was not safe for the residents, it could be a fire hazard, and it was not a homelike environment for the residents in the room. During an interview on [DATE] at 3:15 p.m. with the Administrator, (ADM), the ADM stated Resident 1's family requested Resident 1 to be moved to another room because her room was cluttered and unsanitary. The ADM further stated that all residents have the right to have a safe, clean, and homelike environment. A review of the facility's policy and procedures titled, Homelike Environment, revised 2/2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment . 055308 Page 2 of 2