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. Page 1 of 2 555093 555093 02/17/2026 Citrus Post-Acute 1929 N. Fairview Street Santa Ana, CA 92706

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Potential for minimal harm **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 necessary care and services were provided to prevent the development and worsening of pressure ulcer for one of five sampled residents (Resident 5). * The facility failed to update the physician's order for Resident 5's low air-loss mattress setting to the resident's current weight. This failure had the potential for the resident to develop pressure ulcers or worsening of existing pressure ulcer(s).Findings: Review of the facility's P&P titled Support Surface Guidelines revised 9/2013 showed redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Medical record review for Resident 5 was initiated on 2/13/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's Order Summary Report dated 9/19/25, showed a physician's order to implement a low air-loss mattress for wound care and management. The setting was set for 99 lbs. every shift. Review of Resident 5's Weights and Vitals Summary dated 2/1/26, showed the resident weighed 115 lbs. Review of Resident 5's Skin assessment dated [DATE], showed Resident 5 had surgical wound on her left buttock. Further review showed the resident was on a low air-loss mattress that was functioning properly. On 2/13/26 at 0958 hours, during an observation in Resident 5's room, Resident 5's low air-loss mattress setting was set at 120 lbs. On 2/17/26 at 1440 hours, an observation and concurrent medical record review for Resident 5 was conducted with the ADON. The ADON verified Resident 5's low air-loss mattress was set at 120 lbs. The ADON verified the physician's order and low air-loss mattress setting were not updated to reflect Resident 5's current weight of 115 lbs. On 2/17/26 at 1539 hours, the Administrator and the DON acknowledged the above findings. Residents Affected - Some 555093 Page 2 of 2