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Complaint Investigation

Citrus Post-acute

August 22, 2024 · Santa Ana, CA · 1929 N. Fairview Street
Citations 2
CMS Rating 3/5
Beds 144
Provider ID 555093
Healthcare Facility
Citrus Post-acute
Santa Ana, CA  ·  View full profile →
Inspection Summary

Citrus Post-Acute in SANTA ANA, CA — inspection on August 22, 2024.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF656
TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37726 Few medications were administered as ordered for one of two sampled residents (Resident 1). affected

Review of the facility's P&P titled Unavailable Medications dated 5/2022 showed the medications used by the residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion.

The nursing staff shall notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy that is available.

Medical record review for Resident 1 was initiated on 8/19/24. Resident 1 was admitted to the facility on [DATE].

Review of Resident 1's Order Summary Report showed the physician's orders for the following medications:

* enoxaparin sodium 120 mg/0.8 ml subcutaneous injection every 12 hours for DVT prophylaxis, dated 7/3/24.

* levetiracetam 1000 mg orally twice a day for seizures, dated 7/3/24.

* desmopressin acetate 20 mcg nasal solution twice per day for central cranial diabetes insipidus dated 7/4/24.

* methocarbamol 250 mg orally three times a day for muscle spasm, dated 7/3/24.

Review of Resident 1's Medication Administration Record dated July 2024 showed documentation the following medications were not administered on the following dates and times due to a lack of availability:

555093

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555093 B.

Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Edna Subacute and Rehabilitation Center 1929 N.

Fairview Street Santa Ana, CA 92706

Review of the facility's P&P titled Change of Condition dated 2016 showed the purpose of the Change of Condition policy is to appropriately assess, document, and communicate changes of condition to the primary care provider. To provide treatment and services to address changes in accordance with resident needs.

Procedure includes to document assessment findings and communications as soon as practical. To notify the resident and/or responsible party of current status and subsequent actions/orders.

1.

Medical record review for Resident 1 was initiated on 8/19/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 7/7/24.

Review of Resident 1's medical record showed Resident 1 was admitted to the facility with a PICC located on his right upper arm.

Review of Resident 1's H&P examination dated 7/3/24, showed Resident 1 had a right upper arm PICC with slight swelling.

Review of Resident 1's care plan problem titled Potential for Infection related to right upper extremity PICC line initiated 7/5/24, showed Resident 1 would have no signs and symptoms of IV related complications.

The interventions included to change the catheter site dressing and to measure the PICC external catheter length and upper arm circumference as ordered.

555093

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555093 B.

Wing 08/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

St Edna Subacute and Rehabilitation Center 1929 N.

Fairview Street Santa Ana, CA 92706

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANTA ANA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Citrus Post-Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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