Health inspection·December 28, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure the treatment nurse (TX 1)1 had the competencies to provide wound care for one of six sampled residents (Resident 2) when: Residents Affected - Few 1. Scissors were not cleaned prior to cutting dressings; 2. Uncleaned scissors were placed on resident's bedside table; 3. Dressings for wound care were placed on resident's bed; 4. Double gloves were used without handwashing, and 5. Contaminated dressings were placed into resident's wound. These failures increased the potential for infection and/or physical harm to the resident. Findings: Resident 2 was admitted to the facility late 2023 with diagnoses which included chronic ulcer (open sore) of his right heel, diabetes (a chronic condition that affects the way the body processes blood sugar). During a review of Resident 2's, electronic treatment administration record (ETAR), dated 12/1-12/31/23, the ETAR indicated, Rt [right] heel Wound Vac [ Negative Pressure Wound Therapy, NPWT vacuum assisted wound care device, removes excess drainage] .Cleanse with NS [normal saline] .Apply Foam .cut to fitting size and shape of wound. Apply transparent Drape [clear adhesive film] to cover foam, then connect the port to the drape then to canister then to machine, then secure with Kerlix [gauze type dressing] . Change .every .Mon, Wed, Fri . During an interview on 12/27/23 at 11:22 a.m., with TX 1, TX1 was asked if the facility provided any in-service for NPWT trouble shooting. TX 1 stated, Sorry, I'm a traveler [traveling nurse], so I'm not aware if they did any in-service . TX 1 was asked if the facility had any policy on NPWT use, TX 1 stated, I'm just not sure if they have a policy . TX 1 was asked if the facility had provided any policy on how wound care is done in the facility, TX 1 stated, Usually they don't train us because we are travelers, they know that most of us are already capable and know what we're doing . During a concurrent observation and interview on 12/27/23 at 1:24 p.m., with TX 1, of Resident 2's right heel wound dressing change. TX 1 entered the room wearing blue gloves and placed a pair of scissors directly on Resident 2's bedside table. TX 1 used the scissors to cut the gauze wrap off Resident 2's ankle, then placed the scissors directly on the bedside table. Without changing gloves, TX 1 unhooked a drain from the cannister that was sitting on the floor, removed the transparent dressing from the wound, poured normal saline onto gauze and cleaned the wound. TX 1 then removed the blue gloves revealing a second pair of gloves underneath. TX 1 did not remove the second pair of gloves or sanitize her hands. The new drape and wound dressings had been placed directly on the resident's mattress. Without cleaning the scissors, TX 1 used the scissors to cut the foam dressing then placed the contaminated dressing directly into Resident 2's open wound. TX 1 placed the transparent dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 2 of 7 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 555337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few over the foam. This surveyor found it necessary for patient safety to stop the treatment process. TX 1 acknowledged she did not clean the scissors after cutting the used bandage and before cutting the clean foam bandage. During an interview on 12/27/23 at 1:52 p.m., with the Infection Preventionist (IP, professional responsible to educate healthcare workers on preventing infections). When asked if the practice of wearing double gloves was acceptable, the IP stated, There should be no double gloving .They all have to come off if you are going from dirty to clean . When asked if using dirty scissors to cut a clean dressing was acceptable, the IP stated, .no ., if you are using those scissors on a clean dressing, they need to be disinfected . When asked if it was acceptable to place wound care supplies on a resident bed the IP stated, If it's opened, no. Don't put stuff on patient's bed because you don't know what's on it. When asked the purpose of having a clean surface to place items, the IP stated, To not cross contaminate wounds, to not introduce new bacteria . During an interview on 12/27/23 at 2:15 p.m., with TX 1, TX1 confirmed she was wearing two pairs of gloves and did not wash or sanitize her hands. TX 1 stated, I do it to take off the dirty dressing, so then I'll have the next one one .but you are not supposed to do the two gloves. When asked the importance of cleaning scissors, TX 1 stated, If you cut the dirty bandage then you are just reintroducing what you just removed. When asked what outcome could occur TX 1 stated, Infection and the wound worsening. During an interview on 12/28/23 at 1:25 p.m., with the Director of Nursing (DON), the DON was asked if the facility had a designated treatment nurse, the DON stated, [TX 1] is our treatment nurse, she is a traveler .been here a long time. During a review of the undated facility's policy and procedure (P&P) titled, Dressing Change: Non-Sterile [Clean], the P&P indicated, .Set up area .Disinfect overbed table using an .approved disinfectant .If dressing need to be cut to size, clean scissors [disinfect with .approved disinfectant before and after using] . During a review of the P&P titled, NEGATIVE PRESSURE WOUND THERAPY, dated 1/11, the P&P indicated, Procedure .perform hand hygiene, apply latex free non-sterile gloves .remove dressing .remove gloves and perform hand hygiene .apply second pair of latex free non-sterile gloves .cleanse wound with normal saline .remove gloves, perform hand hygiene .open kit on clean dry surface . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 3 of 7 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 555337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure safe and secured storage of prescribed medication for a census of 136 when a medication cart was left unattended and unlocked. This failure had the potential for unauthorized personnel to access the medication cart. Findings: During a concurrent observation and interview on 12/27/23 at 12:25 p.m., with Registered Nurse (RN 1), RN 1 walked by an unlocked, unattended medication cart in the 500 hallway. RN 1 confirmed the cart was unlocked and unattended. During an interview on 12/27/23 at 12:26 a.m., with Licensed Nurse (LN 1) 1, confirmed the medication cart was unlocked and unattended. LN 1 stated medication carts are supposed to be locked when not in use. When asked a potential outcome for leaving a medication cart unlocked, LN 1 stated, A patient could get into it, especially a confused patient and take medications . During an interview on 12/28/23 at 3:59 p.m., with the Director of Nursing (DON), the DON was asked the expectation of staff when leaving the medication cart. The DON stated, They [medication carts] are supposed to be locked anytime they are not in use. During a review of undated facility's policy and procedure (P&P) titled, Medication and Treatment Administration Guidelines, Long Term Care, the P&P indicated, Medication Storage and Security .Medications and biologicals are securely stored in a locked cabinet, cart, or medication room, accessible to only licensed nursing staff .and maintained under lock system when not actively utilized and attended to by nursing staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 4 of 7 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 555337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention program for a census of 136 residents when: Residents Affected - Many 1. Staff entered rooms of Coronavirus disease 2019 (COVID-19, viral respiratory illness that causes fever, coughing, and shortness of breath) patients without full personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards); 2. Doors to COVID-19 positive residents' rooms were not closed 3. Double gloves were used without handwashing, scissors were not cleaned prior to cutting dressings, dirty scissors were placed on residents bedside table, dressings for wound care were placed on a resident bed, contaminated dressings were placed into resident wounds 4. Hand washing was not performed between glove changes, and 5. Multi-use house supply tubes of ointments were brought into a resident room. These failures increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential for exposure of germs, and infection among residents, staff, and visitors. Findings: 1. During an interview on 12/28/23, at 10:20 a.m., with the Infection Preventionist (IP, professional responsible to educate healthcare workers on preventing infections), the IP stated all staff entering the rooms of Coronavirus disease 2019 positive residents are required to wear full personal protective equipment (PPE-equipment worn to minimize exposure to a variety of hazards) including N95 mask (type of mask that filters up to 95% of particles in the air), gloves, gown, and face shield or goggles. The IP confirmed all staff are to wear full PPE even if not giving direct resident care. During a concurrent observation and interview on 12/28/23, at 10:30 a.m., with Certified Nursing Assistant (CNA 1) 1, CNA 1 entered rooms [ROOM NUMBERS] wearing an N95 mask. CNA 1 confirmed residents in room [ROOM NUMBER] and 608 had COVID-19 and that the only PPE she wore was an N95 mask. CNA 1 stated she was not aware she had to wear full PPE. During a concurrent observation and interview on 12/28/23, at 10:55 a.m., with the IP, a staff member from the physical therapy department was observed in a resident's room working with a COVID-19 positive resident without wearing proper PPE. IP stated the staff member was not wearing the required face shield or goggles and that staff members are educated on the proper PPE when working with COVID-19 positive patients. A review of the facility document titled, DROPLET PRECAUTIONS, indicated, EVERYONE MUST .Make sure their eyes, nose and mouth are fully covered before room entry. A review of the facility document titled, COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel, indicated, Goggles or disposable full-face shield .N95 .gown .nonsterile gloves . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 5 of 7 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 555337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. During an interview on 12/28/23, at 11:01 a.m., with the Infection Preventionist (IP), IP stated the rooms for Coronavirus disease 2019 positive patients should have Droplet Precaution signage and the doors be closed at all times. During a concurrent observation and interview on 12/28/23, at 11:20 a.m., with Licensed Nurse (LN 2) 2, LN 2 confirmed the doors to rooms [ROOM NUMBERS] were open. rooms [ROOM NUMBERS] had a red STOP sign posted below the room number sign which indicated, DROPLET PRECAUTIONS. LN 2 confirmed residents in rooms [ROOM NUMBERS] were positive with COVID-19 and both doors were to remain closed at all times. A review of Centers for Disease Control and Prevention website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/23, indicated, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed . https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#:~:text=Place%20a%20pati 3. Resident 2 was admitted to the facility late 2023 with diagnoses which included chronic ulcer (open sore) of his right heel, diabetes (a chronic condition that affects the way the body processes blood sugar). During a concurrent observation and interview on 12/27/23 at 1:24 p.m., with Treatment Nurse (TX 1) 1, of Resident 2's right heel wound bandage change. TX 1 entered the room wearing blue gloves and placed a pair of scissors directly on Resident 2's bedside table. TX 1 used the scissors to cut the gauze wrap off Resident 2's ankle, then placed the scissors directly on the bedside table. Without changing gloves, TX 1 unhooked a drain from the cannister that was sitting on the floor, removed the transparent dressing from the wound, poured normal saline onto gauze and cleaned the wound. Tx 1 then removed the blue gloves revealing a second pair underneath. TX 1 did not remove the second pair of gloves or sanitize her hands. The new drape and wound dressings had been placed directly on the resident ' s mattress. Without cleaning the scissors, TX 1 used the scissors to cut the foam dressing then placed the contaminated dressing into Resident 2's open wound. TX 1 placed the transparent dressing over the foam. This surveyor found it necessary for patient safety to stop the treatment process. TX 1 acknowledged she did not clean the scissors after cutting the used bandage and before cutting the clean foam bandage. During an interview on 12/27/23 at 1:52 p.m., with the IP, the IP was asked if the practice of wearing double gloves was acceptable, the IP stated, There should be no double gloving .They all have to come off if you are going from dirty to clean . When asked if using dirty scissors to cut a clean dressing was acceptable, the IP stated, .no ., if you are using those scissors on a clean dressing, they need to be disinfected . When asked if it was acceptable to place wound care supplies on a resident bed the IP stated, If it's opened, no. Don't put stuff on patient ' s bed because you don't know what's on it. When asked the purpose of having a clean surface to place items, the IP stated, To not cross contaminate wounds, to not introduce new bacteria . During an interview on 12/27/23 at 2:15 p.m., with TX 1, TX1 confirmed she was wearing two pairs of gloves and did not wash or sanitize her hands. TX 1 stated, I do it to take off the dirty dressing, so then I'll have the next one one .but you are not supposed to do the two gloves. When asked the importance of cleaning scissors, TX 1 stated, If you cut the dirty bandage then you are just (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 6 of 7 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 555337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many reintroducing what you just removed. When asked what outcome could occur TX 1 stated, Infection and the wound worsening. 4. Resident 1 was admitted to the facility mid 2021 with diagnoses which included dementia (memory problems), muscle weakness, and diabetes (chronic condition that affects the way the body processes blood sugar). During a concurrent observation and interview on 12/28/23 at 11:45 a.m., with Registered Nurse (RN 3) 3 of Resident 1's pressure injury (injury caused by pressure) dressing change. RN 3 removed a pair of scissors from her pocket and cut a piece of the dressing before placing it directly on Resident 1's wound. RN 3 confirmed she did not clean the scissors before using them to cut the dressing. 5.Resident 6 was admitted to the facility late 2023 with diagnoses which included abscess of left leg. During a concurrent observation and interview on 12/28/23 at 12:12 p.m., with RN 4 of Resident 6's wound dressing change. RN 4 brought multi-use tubes of ointment into the room of Resident 6. RN 4 did not sanitize hands between glove changes. RN 4 confirmed she took the entire tube into the resident room and stated, .I think I made a mistake; I should have put it in a cup . During an interview on 12/28/23 at 1:16 p.m., with the IP, the IP was asked if bringing multi-use tubes of ointments into a resident's room was acceptable. The IP stated No, it would be considered contaminated if it was open in the room. When asked if hands should be sanitized between glove changed the IP stated, Always. During a review of the undated facility's policy and procedure (P&P) titled, Dressing Change: Non-Sterile [Clean], the P&P indicated, .Set up area .Disinfect overbed table using an .approved disinfectant .If dressing need to be cut to size, clean scissors [disinfect with .approved disinfectant before and after using] . During a review of the P&P titled, NEGATIVE PRESSURE WOUND THERAPY, dated 1/11, the P&P indicated, Procedure .perform hand hygiene, apply latex free non-sterile gloves .remove dressing .remove gloves and perform hand hygiene .apply second pair of latex free non-sterile gloves .cleanse wound with normal saline .remove gloves, perform hand hygiene .open kit on clean dry surface . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 7 of 7