Inspection Reports for
The Courte at Citrus Heights

The visit was a supplemental report to complaint investigation #59-AS-20250929201436. The allegation that staff prescribed medication without the resident's responsible party's consent was found to be unsubstantiated.

The allegation was found to be unsubstantiated due to conflicting information about who recommended the prescription of two behavioral medications. However, the resident's responsible person was billed for these medications without authorization, and staff attempted to administer one medication without consent, posing a potential health and safety risk.

The visit was complaint-related, investigating an incident on August 18, 2025, involving physical and verbal abuse of resident (R1) by staff (S1). The verbal abuse was substantiated. The facility did not timely report the suspected abuse to the resident's family within 24 hours.

The investigation substantiated that staff (S1) verbally abused resident (R1) on August 18, 2025, and the facility failed to timely notify the resident's family of the suspected abuse within 24 hours. Two deficiencies were cited related to abuse and reporting requirements.

The complaint investigation was triggered by an incident on August 18, 2025, involving staff (S1) verbally and physically abusing resident (R1). The Ombudsman and law enforcement were notified. The investigation found a preponderance of evidence substantiating verbal abuse by (S1) and failure to timely notify the resident's family.

The investigation substantiated that staff member (S1) verbally abused resident (R1) on August 18, 2025, and the facility failed to timely notify the resident's family of the suspected abuse within 24 hours. Two deficiencies were cited related to abuse and reporting requirements.

The complaint was substantiated based on staff interviews, observations, and documentation review. The allegation that staff were not meeting the needs of residents requiring two-person assists in a timely manner was found valid due to reduced staffing levels and delayed care.

The investigation substantiated the complaint, finding that staffing levels were significantly reduced since September 1, 2025, resulting in delays in care for residents needing two-person assists. Staffing shortages caused residents to wait longer for care, showers were delayed, and staff reported increased stress and insufficient time for breaks.

The facility had not paid all applicable and accrued licensing fees by the required date, posing a potential health and safety risk to residents. A citation was issued for failure to pay licensing fees, but the plan of correction was cleared on the day of the inspection.

The facility had an outstanding balance for licensing fees that was not paid by the required date, posing a potential health and safety risk. The balance was paid during the inspection, and a citation was issued for failure to pay fees on time.

The visit was triggered by two incident reports: one involving a resident (R1) who had seizures and was treated with medication, and another involving a resident (R2) found sitting in a wheelchair with a sling attached to a hoyer lift improperly. The staff member (S1) involved was placed on administrative leave and left employment before the investigation was completed.

The inspection found that one resident was treated for seizures and another was found sitting in a wheelchair with a sling attached to a hoyer lift, which was not properly followed by staff. The staff member involved was placed on administrative leave and later left employment. A deficiency was cited for failure to ensure staff followed approved training protocols for using the hoyer lift, resulting in potential risk to residents.

The visit was triggered by two incident reports: one involving a resident (R1) who had seizures and was given medication after a second incident, and another involving resident (R2) found asleep in a wheelchair with the sling attached to the hoyer lift. Staff member (S1) was placed on administrative leave and then left employment before the investigation was completed.

The facility failed to ensure that staff member (S1) followed approved training protocols for using the hoyer lift, resulting in a potential risk to residents. The facility provided follow-up training and documentation. No further plan of correction was required at this time.

The complaint was substantiated. The allegation was that the licensee did not provide the responsible party with a refund. The resident passed on 07/20/2024, belongings were removed on 07/25/2024, and the refund was due by 08/09/2024. The refund was not issued timely but was sent on 09/24/2024.

The investigation substantiated the allegation that the facility failed to issue a refund within 15 days after the resident's belongings were removed. A refund check was eventually issued on 09/24/2024 and sent by overnight mail to the responsible person.

The visit was complaint-related due to missed medications for eight residents. The complaint was substantiated as evidenced by the deficiency issued.

The inspection found that medications were not administered as ordered for eight residents between 6/11/24 and 6/24/24, posing an immediate health and safety risk. No adverse reactions or harm were noted, and corrective actions including incident reporting, resident alerts, and physician notifications were completed.

The visit was complaint-related due to missed medications for eight residents. The incident report was submitted on 6/28/24. No adverse reactions or harm were noted, and the complaint was substantiated by the deficiency issued.

The inspection found that medications were not administered as ordered for eight residents between 6/11/24 and 6/24/24, posing an immediate health and safety risk. Staff disciplinary actions and additional medication training were implemented, and a daily monitoring report was established to prevent recurrence.

The visit was complaint-related, following a serious incident report about a medication error where a resident received another resident's medications. The error was substantiated and corrective actions were discussed.

It was found that a nurse on duty became distracted and administered four medications prescribed to a different resident to R1. The error was immediately reported to the resident's doctor and family, and the resident was monitored with no adverse reactions reported. Deficiencies related to medication administration were cited.

The visit was complaint-related, following a serious incident report of medication error. The report details the incident, the immediate response, and monitoring of the affected resident. Substantiation status is not explicitly stated.

The inspection found that on 08/04/2021, a nurse administered four medications prescribed to a different resident to R1 due to distraction. The error was immediately identified, the resident was monitored with no adverse reactions reported, and the resident's doctor and family were informed. A plan of correction involving medication training for staff was established.

The complaint investigation was triggered by allegations received on 02/11/2021 regarding unexplained injuries to a resident, lack of supervision, inappropriate staff communication, medication destruction record keeping, failure to update resident reappraisals, and medication administration issues. The investigation was unannounced and conducted by Licensing Program Analyst Bethany Mirlohi. The allegation of medications not administered as prescribed was substantiated; all others were unsubstantiated or unfounded.

The investigation found most allegations unsubstantiated, including unexplained injuries, supervision, staff communication, medication destruction records, and reappraisals. However, the allegation regarding medications not administered as prescribed was substantiated, with specific medication doses missed. Deficiencies were cited related to medication administration.

The complaint investigation was substantiated. The allegation involved inadequate supervision that led to Resident 1 being thrown to the ground by Resident 2, causing injury and eventual death. The Department reviewed the incident, including witness statements and the coroner's report listing the cause of death as homicide due to blunt force trauma.

The licensee was found to have failed in properly observing and documenting behavioral changes of the aggressive resident, failed to notify the physician timely, did not update the care plan, and failed to provide appropriate staff training. These failures led to inadequate supervision and protection of residents, resulting in the injury and death of a resident. A civil penalty was issued for these violations.

The complaint was substantiated. The allegation that facility staff did not keep emergency exits clear of obstruction was found valid based on the preponderance of evidence including staff interviews and photographic evidence.

The Licensing Program Analyst investigated the allegation by interviewing staff, inspecting the facility, and reviewing documentation. The allegation was substantiated based on staff interviews, photographic evidence of chairs and tables blocking emergency exits, and facility plan review.

The complaint investigation was substantiated for allegations that residents sustained multiple falls and that staff neglect resulted in a resident's death. The resident (R1) was found outside in the courtyard with high body temperature and sunburn, leading to cardiac arrest and death. Staffing shortages and inadequate supervision were noted. Allegations related to pest control, outbreak management, and universal precautions were unsubstantiated or unfounded.

The investigation substantiated allegations that residents sustained multiple falls due to insufficient staffing and that staff neglect resulted in a resident's death, leading to a $500 civil penalty. Allegations regarding pest control, outbreak management, and universal precautions were found to be unsubstantiated or unfounded.