Health inspection·March 7, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with the facility policy and procedure for two of 30 sampled residents (Resident 113 and Resident 82) when: Residents Affected - Few 1. Resident 113's nebulizer mask (a device used to change liquid medication into a mist form that is inhaled through a mask) was left in an opened drawer of the bedside table, uncovered and unlabeled. 2. Resident 82's nebulizer mask was hung on the wall uncovered and unlabeled. These failures placed Resident 113 and Resident 82 at risk for respiratory infections. Findings: 1. Resident 113 was admitted to the facility in 2024 with diagnoses that included, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). A review of the Medication Administration Record for Resident 113 indicated, a physician's order, dated 2/12/24 for, Ipratropium-Albuterol (a medication used to prevent wheezing and shortness of breath caused by ongoing lung disease) 3 milliliters (ml, a unit of measurement) inhale orally via nebulizer every 6 hours for shortness of breath/wheezing . During an observation on 2/6/24 at 11 a.m., Resident 113's nebulizer mask was left in an opened drawer of the bedside table, uncovered and unlabeled. During a concurrent observation and interview with the Nurse Consultant (NC) on 2/6/24 at 11:10 a.m., the NC verified the nebulizer mask had been left out, uncovered, and unlabeled. The NC stated, When the nebulizer mask is not in use it should be stored in a labeled bag with the resident's name and room number. During an interview with the Director of Nursing (DON) on 2/6/24 at 11:30 a.m., the DON stated it was her, Expectation for resident's nebulizer masks when not in use, to be stored in a labeled bag with the residents' name and room number. 2. During a concurrent observation and interview on 3/4/24 at 11:20 a.m., with Licensed Nurse 7, (LN 7) in resident's room, LN 7 confirmed the handheld mask nebulizer was hung on the wall unlabeled and uncovered. LN 7 stated, The nebulizer mask should be labeled, dated and kept in a bag to keep it clean. (continued on next page) 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 10 Event ID: 555337 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 03/07/2024 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)