Health inspection·June 4, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/4/25 at 12:32 p.m. with the Social Services Director (SSD), the SSD stated, .For all discharges, there has to be an order before they go, otherwise it ' s against medical advice (AMA – when a resident leaves before the medical team recommends discharge) .The doctor also write the discharge summary .Notice of proposed transfer or discharge should also be completed for planned, unplanned, or even AMA discharges .The resident is supposed to sign it and to be sent to the Ombudsman . During a concurrent interview on 6/4/25 at 12:46 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, .There should be an order from the doctor for discharge .As soon as the resident left, I write the discharge summary .Important because that ' s the recap of the resident ' s stay in the facility and the plan for their discharge . The ADON confirmed there was no order for discharge, no discharge summary, and no notice of the proposed discharge in Resident 1 ' s medical records. During an interview on 6/4/25 at 1:07 p.m. with the Medical Records Director (MRD), the MRD stated, The nurses complete the notice of proposed discharge .It is for all discharges .I expect that this form was completed once the resident got discharged .To make sure that we are doing the correct discharge/transfer, that everything is done correctly and steps are completed correctly . During an interview on 6/4/25 at 1:16 p.m. with the Director of Nursing (DON), the DON stated, .I don ' t think there was an order because the doctor doesn ' t get involved with [Resident 1] .There should be notes from the NP at that time when the resident refused the care .There should be one completed on the nurses side so people are aware why [Resident 1] left . During an interview on 6/4/25 at 2:30 p.m. with the NP, the NP stated, When [Resident 1] got here [the facility], I recognized [Resident 1] name .I went to her room to do her assessment .[Resident 1] was being seen by wound nurse .I came back later .and before I saw the resident again, the wound nurse told me about the lawsuit .I confirmed with the resident that I was part of the lawsuit .I told the resident that [Medical Director] will be following up with the resident and [Resident 1] said okay .At some point, I was informed that she will be sent back to the hospital for alternate placement .I didn ' t document that I told the resident that [Medical Director] will be taking over because [Medical Director] was my supervising physician .I told him right away and he was aware of it .For discharge, there must be signed discharge orders . During a concurrent interview and record review on 6/4/25 at 2:52 p.m. with the Administrator (ADM), the ADM stated, .[NP] went to do assessment and [Resident 1] recognized her .The resident confirmed NP was part of the case .It ' s a conflict .We were calling to arrange [Resident 1] to go back to the referring hospital .We got the okay from the hospital .to send her back .We didn ' t have a physician for her so we have to do it .I don ' t know if [NP] talked to [MD] .I didn ' t talk to [MD] .[MD] is part of the physician group with the lawsuit .It would be hard for [MD] to give that order .As the administrator, I decided to communicate with the hospital to see if they will accept [Resident 1] back . The Administrator confirmed there were no physician order for Resident 1 ' s discharge, no discharge summary, and no notice of proposed discharge in Resident 1 ' s medical records. During a review of the facility ' s policy and procedure (P&P) titled Transfer or Discharge, dated 3/2025, the P&P indicated, .1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: a. The basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or legal representative; .f. A summary of the resident ' s overall medical, physical, and mental condition . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555337 If continuation sheet Page 2 of 3 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 06/04/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility ' s P&P titled Discharging a Resident Without a Physician ' s Approval, revised 3/2025, the P&P indicated, A physician ' s or provider ' s order is obtained for discharges, unless a resident or representative requests the discharge against medical advice .1. An order of an approved discharge must be signed and dated by the physician or provider and recorded in the resident ' s medical record no later than seventy-two (72) hours after the discharge .5. Regardless of the resident or representative ' s request to leave the facility against medical advice, the facility will provide a Notice of Discharge, discharge orientation, and a Discharge Summary .before the resident leaves the facility . Event ID: Facility ID: 555337 If continuation sheet Page 3 of 3