Health inspection·February 17, 2026

F 0656 Level of Harm - Potential for minimal harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's risk for fall interventions for bilateral floor mats were implemented. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident.Findings: Review of the P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the comprehensive, person-centered care plan describes the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being. Medical record review for Resident 1 was initiated on 2/11/26. Resident was readmitted to the facility on [DATE]. Review of Resident 1's SBAR for falls dated 1/28/26, showed Resident 1 had an unwitnessed fall and was found lying face down on the side of the bed. Review of Resident 1's care plan for risk for falls dated 1/28/26, showed interventions including bilateral floor mats to minimize injury in case of falls. Review of Resident 1's Morse Fall assessment dated [DATE], showed a score of 65. Further review showed a score of 45 and above indicated a high fall risk. On 2/17/26 at 0849 hours, during an observation of Resident 1, Resident 1 was noted with a round hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, often causing a painful, raised, and bruised lump) on her forehead, dark purple bruising on both cheeks, chin, and the front of her neck. There were no floor mats seen in the room or on the floor next to the resident's bed. On 2/17/26 at 1113 hours, during an interview with Resident 1, Resident 1 stated the bump on her forehead was from the fall she had at the facility. On 2/17/26 at 1242 hours, an observation of Resident 1 and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 1 did not have floor mats in place and stated there should be floor mats due to her being a fall risk. On 2/17/26 at 1539 hours, the Administrator and the DON acknowledged the above findings. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555093 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Post-Acute 1929 N. Fairview Street Santa Ana, CA 92706 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)