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F0921
F

Environmental Safety and Resident Dignity Deficiencies

Sacramento, California Survey Completed on 06-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, a wheelchair and a standing fan were found partially blocking an emergency exit in one of the facility's wings, which could impede access in the event of an emergency. Additionally, two Hoyer lifts were stored in the same area with their wheels unlocked, presenting a risk of equipment movement and potential injury. The facility's policy requires that all equipment and clinical devices be stored in a safe manner, but this was not followed in these instances. Further deficiencies were identified in the treatment of residents with dignity and respect. One resident's urinary catheter bag was not covered by a dignity bag, compromising privacy. Two residents were assisted with feeding by staff who were standing rather than sitting, which does not align with best practices for respectful care. Additionally, two other residents were not asked about their preference regarding the use of clothing protectors during meals. These actions failed to ensure that residents were treated with dignity and respect as required.

Plan Of Correction

How the corrective action(s) will be monitored to ensure the practice will not recur: Maintenance director and Administrator will conduct daily rounds for 2 weeks, then weekly rounds to verify adherence to the policy of Equipment and device storage. Any issues identified during these audits will be immediately corrected. This plan of correction has been integrated into the facility's Quality Assurance program, and the results of these audits will be reviewed quarterly until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 921

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