Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Folsom Care Center during CMS and state inspections, most recent first.
Medication storage and security practices were not followed. An LPN left the med room door unsecured when the automatic closing mechanism failed, two med room refrigerators were not consistently monitored and were inaccurately documented, light-sensitive lorazepam was stored in clear-door refrigerators with the lights on, a family-supplied Ozempic box for a resident lacked pharmacy labeling and directions, and a med cart was left unlocked and unattended at the nursing station.
A nurse prepared a hazardous medication without gloves or other PPE after the label identified it as hazardous. Nursing staff also gave an opioid pain medication outside the ordered pain range for a resident with chronic pain conditions, and an unclear PRN lorazepam order for a resident with dementia-related behaviors was not clarified before use. The DON confirmed the pain order parameters and acknowledged the lorazepam order was unclear.
The facility failed to ensure annual performance evaluations were completed for most sampled CNA personnel records. The Adm, DON, DSD, and a UM all confirmed the evaluations had not been done for quite some time, and record review showed several CNA files lacked completed APEs. The DON stated the evaluations were used to assess staff performance, identify issues, and determine whether additional training was needed.
Nursing staff did not destroy refused or dropped meds right away at the med cart and instead kept them in the cart for later disposal, including a metoprolol dose and a cup containing multiple tablets. Surveyors also found a medication destruction container in the med storage room holding hundreds of meds in their original form, an opened E-kit that had not been replaced within the expected timeframe, and incomplete shift-to-shift controlled drug count documentation with many missing signatures.
Medication administration errors exceeded the allowed rate when three errors were observed during med pass. A nurse delayed aspirin EC for a resident because it was not immediately available in the ADC, gave Multaq to another resident well after breakfast without food, and incorrectly measured ferrous sulfate for a resident with a PEG tube by reading the syringe at the wrong stopper ring. The DON confirmed the late aspirin administration and the syringe measurement method were errors, and the CP stated Multaq should be given with food for proper absorption.
Infection control practices were not followed when a laundry staff member reused the same gown while handling soiled linens, despite the gown being contaminated after use. In addition, incentive spirometers were left unlabeled at the bedside for three residents, including residents with respiratory and swallowing-related diagnoses. The IPCN confirmed the gown reuse and the need to label the personal devices.
Informed consent was not obtained before PRN lorazepam was given to a resident with dementia, Alzheimer's disease, depression, and anxiety. An LN found consent only for the routine dose, and the DON also did not find a consent for the PRN order, stating each lorazepam order required its own form.
Failure to implement an eyeglasses care plan intervention for a resident with impaired vision, cataracts, and Alzheimer’s disease. The resident was observed in bed without glasses in place, the RP said the resident wore glasses and had not been seen wearing them during visits, and staff confirmed the resident had two pairs of glasses listed but the glasses frame was broken and the care plan was not being followed.
Unsafe Walking Pathway in Resident Room: A resident with a history of falls, gait and mobility issues, and osteoporosis had wheelchair footrests left on the floor in her room’s walking path to the bathroom. The resident had recently fallen while trying to go to the bathroom, and staff confirmed the footrests were in the pathway and that clear pathways were expected to reduce fall risk. The facility could not provide a specific fall policy, and its Resident Rights policy stated residents have the right to a safe, clean, and homelike environment.
A resident with bed confinement status, pressure ulcer, and Alzheimer's disease was prescribed sulfamethoxazole-trimethoprim via NG tube for UTI prophylaxis despite no documented positive urine culture or UTI symptoms. Staff confirmed the antibiotic was given for prevention, the resident had clear yellow urine and no urinary complaints, and the MD later confirmed there was no indication for the ABX.
Inaccurate Medication Order for Bisoprolol: A resident with HTN and atherosclerosis had a bisoprolol order that still listed hold parameters even though the physician had removed the BP-check requirement because the resident's BP had stabilized. A nurse confirmed the electronic prompt for BP and pulse checks had been removed, but the order was not updated with the pharmacy, and the DON stated the facility was responsible for notifying the pharmacy when orders changed.
Failure to Notify Physician of UTI Criteria Results: A resident admitted with ischemic heart disease and coronary angioplasty received doxycycline for a presumed UTI, but the IPCN confirmed McGeer’s criteria were not met. The record lacked physician acknowledgment of the criteria findings, and the IPCN stated the physician was not notified of the outcome despite the facility’s antibiotic stewardship/ATO process.
Excess Resident Occupancy in Multiple Rooms: Surveyors found 13 resident rooms configured for five residents each, with a shared bathroom and one exit door, exceeding the limit of no more than four residents per room. The rooms were divided by a floor-to-ceiling wall, with two beds on one side and three on the other, and privacy curtains around each bed. A Maintenance Supervisor confirmed the room layouts and measured resident space, while a resident, an LPN, and a CNA reported no issues with room space or maneuvering.
A facility failed to ensure 11 resident rooms met the minimum 80 sq. ft. per resident requirement. A facility letter stated rooms 300-310 measured below the required size, and a Maintenance Supervisor confirmed one room configured for two beds had 72.5 sq. ft. per resident. CNAs, an LPN, and the ADM reported no complaints and said staff could maneuver residents and equipment in the rooms.
A resident with moderate cognitive impairment and dementia pushed another resident with severe cognitive impairment, Alzheimer's disease, and wandering behavior to the floor after becoming frustrated with the other resident entering her room. The pushing incident was documented as an unwitnessed altercation, and the aggressor resident stated she pushed the other as hard as she could so he would "learn his lesson." Facility leadership, including the DON and Administrator, acknowledged that the wandering resident frequently approached others and did not understand boundaries. This conduct occurred despite a written abuse prevention policy stating that residents must be free from physical and other forms of abuse, including abuse by other residents.
Two residents with cognitive impairments and documented histories of behavioral issues physically struck other residents who had dementia, depression, and trauma related to prior resident-to-resident altercations. In one hallway incident, a resident with severe memory impairment and poor impulse control swung an arm and hit another resident in the stomach, which was witnessed by a CNA and reported by the victim as painful. In a separate room incident, a roommate with severe memory impairment was observed by a CNA hitting a resident in bed twice on the shoulder. These events occurred despite a facility policy intended to prevent abuse and protect residents’ rights.
A resident with traumatic brain injury and dementia, and a known history of entering others’ personal space and inappropriate touching, was witnessed touching another resident in the groin area. The other resident, who had impaired cognition, later admitted the touching occurred. The DON and a housekeeper both confirmed the event, and the DON stated the resident should have been watched more closely because the behavior had happened before.
A resident with severe cognitive impairment and multiple medical conditions was observed with long, discolored nails with a brown substance underneath, indicating a failure in providing adequate nail care. The resident expressed a desire for nail trimming, and staff confirmed the condition but could not recall the last time nail care was provided. The DON acknowledged the need for rigorous nail care, but the facility's nail care policy was not available for review.
The facility failed to implement effective infection control practices during a norovirus outbreak, with no training provided by the Infection Prevention nurse. Resident 335's care was compromised by a urinary catheter drainage bag on the floor, unlabeled IV tubing, and a dirty pillow used without cleaning. The Director of Staff Development and Director of Nursing acknowledged the lack of specific training and checklists for these procedures.
The facility was found to have 13 rooms accommodating five residents each, exceeding the regulatory limit of four residents per room. Observations showed rooms divided by a wall with shared bathrooms, and measurements indicated insufficient living space per resident. Despite this, residents and staff reported no significant issues with space or maneuverability. A room waiver was recommended by the Department.
The facility failed to meet the minimum space requirement of 80 square feet per resident in 11 rooms. Despite staff and residents not reporting issues with maneuverability, measurements confirmed the deficiency, with some rooms providing only 72.5 square feet per resident.
The facility failed to provide accessible call light buttons for two residents, one with cardiomyopathy and dementia and another with atherosclerosis and dementia. The call light buttons were found in locations that were not within the residents' reach, making it difficult for them to call for help when needed. The DON and UM confirmed that the call light buttons should be accessible to ensure resident safety.
Medication Storage, Labeling, and Security Failures
Penalty
Summary
Medication storage rooms were not kept secure when the automatic closing mechanism failed. During observations, a licensed nurse exited the medication storage room that housed the ADC and did not verify that the door had closed and locked; the door remained ajar until it was brought to her attention. A second observation showed the same issue when the nurse again left the room and the door did not shut completely. The Head of Maintenance later observed the automatic closing mechanism and stated there was a problem with the closing mechanism and that the lodge mechanism was not fitting with the door. Two medication storage room refrigerators were not monitored according to facility policy, and the temperatures were not accurately documented. Review of the temperature logs showed multiple shifts in which nursing staff did not document refrigerator temperatures, including 14 missed shifts for one refrigerator and 11 missed shifts for the other. Staff documented the Sutter Station refrigerator as 40 degrees Fahrenheit while the digital readout showed 4.0 C, and the RN/UM confirmed that 4.0 Celsius was different than 40 degrees Fahrenheit. The DON stated the logs were incomplete and incorrectly documented, and that temperature monitoring was expected at least twice daily. Emergency medications were not stored according to manufacturer specifications, and medication brought in by family for a resident was not labeled in accordance with facility policy. Two clear glass vials of lorazepam in refrigerated E-Kits were stored in refrigerators with clear glass doors and lights that stayed on at all times, despite the manufacturer labeling stating to protect from light and use the carton to protect contents from light. In addition, a sample box of Ozempic for a resident had the resident’s name written on it but did not have a pharmacy label, prescriber name, or directions for use. The DON stated that family-supplied medication needed to be sealed and have a pharmacy label or printed instructions. Medication carts were also observed unlocked and unattended at the nursing station, and the nurse confirmed she had walked away without locking the cart.
Unsafe medication handling and unclear or incorrect medication administration
Penalty
Summary
Nursing staff failed to follow professional standards when preparing a hazardous medication for a resident with sarcoidosis of the lung. During a medication pass, a nurse prepared mycophenolate mofetil 500 mg, two tablets, for a resident with an order for the medication twice daily for immunosuppression, but did so without wearing gloves or any other personal protective equipment. The pharmacy label on the bubble pack identified the medication as hazardous, and the nurse stated she was not aware that mycophenolate required PPE and had only just noticed it. Nursing staff also administered hydrocodone/acetaminophen to a resident with osteoarthritis and spondylolisthesis outside the physician’s ordered pain parameters. The order was for one tablet every four hours as needed for severe pain rated 7 to 10, but the MAR showed multiple administrations when the resident’s pain was documented at levels 0, 5, and 6. The DON confirmed the order required pain levels of 7 to 10 and stated the resident also had an ibuprofen order for moderate pain levels of 5 and 6, but nursing staff either should have contacted the physician to change the hydrocodone/acetaminophen parameters or given ibuprofen when pain was rated 5 or 6. An unclear PRN lorazepam order for a resident with dementia with behavioral disturbance and adjustment disorder was not clarified before administration. The order included two different doses for anxiety manifested by continuous shouting: 0.5 mg every four hours as needed for 14 days and 1 mg every four hours as needed for severe anxiety manifested by continuous shouting for 14 days. An LPN stated the order was unclear and should have been clarified, and the DON agreed the order was unclear and should have been clarified. The facility policy stated medications are to be administered in accordance with written physician orders and that unclear or potentially unrelated orders are to be clarified before administration.
Missing Annual Performance Evaluations for CNA Personnel Files
Penalty
Summary
The facility failed to ensure that four of five sampled employee personnel records included annual performance evaluations. During a concurrent interview and record review with the DSD and the Administrator, the Certified Nursing Assistants’ personnel records reviewed did not contain completed Annual Performance Evaluations. The Administrator stated the evaluations had not been completed in a while and that they had not been on the facility’s radar. The Administrator also stated the evaluations were used to ensure staff performed up to current laws and regulations and to maintain staff skills for patient care. During interviews, the DON confirmed that performance evaluations were completed on employees’ anniversary dates of hire, but stated they had not been done for quite a while. The DON said the annual performance evaluation was used as a tool to know how staff were doing, identify performance issues, and determine whether additional training was needed. The DON also stated that Unit Managers on each station should complete the evaluations for staff in their units. Review of personnel files confirmed that CNA 5, CNA 6, CNA 7, and CNA 8 did not have completed annual performance evaluations, while CNA 3 was not yet due. The DON further stated that some managers had not had a completed annual performance evaluation for quite some time, and a Unit Manager stated she personally had not had a performance evaluation in years. A request was made for performance evaluation policies and procedures, but none was provided by the end of survey.
Medication disposal, emergency kit replacement, and controlled substance count failures
Penalty
Summary
Nursing staff did not dispose of prepared medications in accordance with facility policy. During a medication pass observation, an LPN prepared metoprolol succinate ER 25 mg for a resident with high blood pressure, then withheld the dose after reviewing the resident’s vital signs because the blood pressure was below the medication parameters. Instead of destroying the dose immediately at the medication cart, the LPN placed the tablet in a paper cup in the top drawer of the med cart and stated it would be disposed of later in the medication storage room. Two hours later, the tablet was still in the cart drawer. Another LPN stated she also kept dropped or refused noncontrolled medications in a paper cup in the med cart and disposed of them later, and a paper cup in the cart was found containing eight tablets. The DON and consultant pharmacist stated refused or dropped medications were expected to be destroyed right away at the med cart. Medications for destruction were also stored in a manner that allowed retrieval. In the medication storage room, surveyors observed a large white plastic container with a blue pop-open lid containing hundreds of tablets, capsules, injectable vials with medication inside, and unopened vials for nebulization. The medications were in their original form and the opening of the container was large enough to allow someone to reach in and remove or pour out medication. The DON stated the container should have had liquid, cat litter, or coffee grounds added initially to limit diversion. The consultant pharmacist confirmed the container was intended for nonnarcotic medications that were discontinued or not going home with a resident, and that medications kept in their original form could be easily removed. The facility also failed to replace an opened emergency medication kit in a timely manner and failed to maintain complete controlled substance shift counts. An opened injectable/sublingual/nasal/oral suspension E-kit was found with a log dated 10 days earlier, and nursing leadership stated opened E-kits were expected to be reordered immediately and replaced within 48 to 72 hours. In addition, review of two medication cart narcotic count records showed missing signatures between shift changes: one record had 95 missing signatures and the other had 37 missing signatures over the review period. Nursing staff and the DON stated two licensed nurses were expected to count controlled medications at each shift change and document the count on the accountability record.
Medication Administration Errors Exceeded the Allowed Rate
Penalty
Summary
The facility had a 7.69% medication error rate, with three medication errors identified out of 39 opportunities during medication pass observations for three residents. The errors involved medications not being given in accordance with the prescriber’s order and were observed during direct surveyor observation, interview, and record review. For one resident, an order for aspirin delayed release 81 mg twice daily for VTE prophylaxis was not administered during the initial medication pass because the medication was not immediately available in the medication cart or under the resident’s profile in the ADC. The nurse stated the aspirin was stocked in the ADC and later in the facility’s OTC supply, but the medication was not administered until more than two hours after the initial observation, and the DON stated the late administration was a medication error. For a second resident, Multaq 400 mg was ordered twice daily with morning and evening meals for A-fib. During observation, the medication was prepared and later administered approximately two hours after breakfast had been served. The nurse acknowledged she should have offered food with the medication, and the DON stated that if more than two hours had passed, staff were expected to give something extra such as a snack or milk. The CP stated that giving Multaq with food helps its absorption and that not giving it with food could affect bioavailability. For a third resident, ferrous sulfate elixir 220 mg/5 ml, 7 ml via PEG tube daily, was measured incorrectly during medication preparation. The nurse initially estimated the dose in a medicine cup, then used a syringe but measured the liquid using the bottom ring of the rubber stopper instead of the correct top ring. The nurse stated she was not aware the dose had been measured incorrectly, and the DON confirmed that the method used was not the correct way to measure with the syringe.
Infection Control Lapses With Reused Gown and Unlabeled Incentive Spirometers
Penalty
Summary
The facility failed to implement infection prevention and control practices when Laundry Staff 1 reused a gown while handling soiled linens in the laundry room. During observation, the staff member put on a gown and gloves, sorted soiled linens, removed the gown and placed it on a shelf, then later put the same gown back on and continued loading soiled linens into washers. The staff member stated the gown was reused throughout an eight-hour shift and agreed it was likely contaminated after the first use. The Infection Prevention and Control Nurse confirmed that gowns were not expected to be reused in the laundry room because of the risk of cross-contamination and spread of infection. The facility policy for the laundry department stated that protective clothing must be worn before handling soiled linen and removed when washers are full. The facility also failed to label incentive spirometers at the bedside for three residents. Resident 21 had chronic respiratory failure and dependence on supplemental oxygen; Resident 56 had aftercare for surgery on the digestive system and dysphagia; and Resident 101 had pulmonary fibrosis and multiple rib fractures. Unlabeled incentive spirometers were observed on the nightstands in each of their rooms, and the Infection Prevention and Control Nurse confirmed that the devices were personal items that needed to be labeled. The facility policy on theft and loss stated that personal articles brought into the facility should be engraved with the resident's name or identified by other methods.
Informed consent not obtained for PRN lorazepam
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering PRN lorazepam for one resident who had diagnoses including dementia, Alzheimer's disease, depression, and anxiety. The resident had physician orders for lorazepam 0.5 mg by mouth in the afternoon for anxiety manifested by restlessness related to anxiety disorder, and also lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety manifested by restlessness related to anxiety disorder for 14 days. During a concurrent interview and record review, an LN reviewed the resident's informed consents and stated she only saw one consent for the routine lorazepam dose and not the PRN dose. The DON also reviewed the record and stated he did not see a consent for the resident's as needed lorazepam order, and stated each lorazepam order required its own form. The facility policy on Medication Management stated the resident is evaluated before initiating, withdrawing, or withholding medications, including refusal of care and treatment and pertinent alternatives.
Failure to Implement Eyeglasses Care Plan
Penalty
Summary
The facility failed to implement the care plan intervention for eyeglasses for one resident who had diagnoses including bed confinement status, bilateral cataracts, and Alzheimer's disease. The resident's care plan identified impaired visual function with interventions that included environmental factors and use of glasses for visual support, and the resident's valuable list documented two pairs of eyeglasses present on admission. During observations, the resident was found lying in bed with eyes open and without glasses in place. The responsible party stated the resident wore glasses and had not been observed wearing them during visits, and said the glasses were important to the resident's dignity and quality of care. A CNA confirmed the resident had two pairs of glasses and expected the resident to have glasses on to avoid eye injury. The unit manager retrieved the glasses from a drawer and confirmed the frame was broken, and also confirmed the responsible party had requested the glasses for the resident to use and that they were important to assist with reading and recognition of caregivers. Other staff stated the resident had not been seen wearing glasses for months, and the DON stated glasses were expected to be worn and the care plan was to be followed.
Unsafe Walking Pathway in Resident Room
Penalty
Summary
The facility failed to maintain a safe environment for one of 22 sampled residents when wheelchair footrests were found lying on the floor in Resident 80’s room and directly in her walking pathway to the restroom. Resident 80 was admitted with diagnoses including history of falling, muscle weakness, abnormalities of gait and mobility, lack of coordination, and osteoporosis. Her MDS indicated she had decision-making capacity, was at risk for falls, and required a wheelchair, walker, and staff assistance for mobility. Her care plan identified her as high risk for falls and included interventions to modify the environment and keep floors free from clutter. Resident 80 had a recent fall and was found lying on the floor next to her bed while attempting to go to the bathroom. During observation, she stated she could get up and use the restroom independently when necessary. LN 7 confirmed the wheelchair footrests were in the walking pathway and said they were not expected to be in front of the door and should have been placed under the table to prevent tripping accidents. CNA 4 and LN 5 stated pathways should be kept clear to reduce fall risk and prevent falls and injury. The DON stated it was the expectation that obstructions be moved and stored safely to avoid falls. The facility was unable to provide a specific fall policy, and its Resident Rights policy stated residents have the right to a safe, clean, and homelike environment.
Unnecessary antibiotic use for UTI prophylaxis
Penalty
Summary
The facility failed to ensure one resident remained free from unnecessary drugs when the resident was prescribed sulfamethoxazole-trimethoprim via NG tube for UTI prophylaxis. The resident had diagnoses including bed confinement status, pressure ulcer, and Alzheimer's disease, and the MDS indicated the resident lacked decision-making capacity. The care plan included monitoring and reporting signs and symptoms of UTI related to incontinence and a urinary catheter, but the order summary showed an antibiotic ordered specifically for prevention of UTI rather than for a documented active infection. During record review and interviews, staff confirmed there was no documented positive urine culture or UTI symptoms supporting the antibiotic use. The resident's progress note stated the resident received antibiotics for UTI prevention despite clear yellow urine and no urinary complaints. The IPCN confirmed the most recent positive urine culture was in 2021 and that the resident's recent hospital urine culture recommended recollection and repeat testing after readmission, which had not been completed. The MD confirmed the antibiotics had no indication, and the facility's policy referenced use of McGeer Criteria for LTC surveillance.
Inaccurate Medication Order for Bisoprolol
Penalty
Summary
The facility failed to maintain an accurate medication record for one resident with diagnoses including hypertension and atherosclerosis. The resident had a physician order for bisoprolol 5 mg by mouth at bedtime with hold parameters for systolic blood pressure less than 110 and pulse less than 60, dated 11/11/25. During record review, a nurse confirmed the order still showed hold parameters, but the computer prompt that directed staff to measure and document blood pressure and pulse before administration had been removed. The nurse stated the physician had removed the parameter to take the resident's blood pressure before giving bisoprolol because the resident's blood pressure had stabilized and no longer required daily monitoring. The nurse also stated it had been about four months since the physician removed the hold parameter, but the medication order had not been updated with the pharmacy. The DON confirmed the facility was responsible for updating the pharmacy when an order changed and stated the resident's bisoprolol order should have been updated to reflect removal of the hold parameters but had not been.
Failure to Notify Physician When UTI Criteria Were Not Met
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol when the physician was not notified that McGeer’s criteria for a urinary tract infection were not met for one resident. Resident 53 was admitted in April 2026 with diagnoses including ischemic heart disease and coronary angioplasty. The resident’s MAR showed doxycycline 100 mg twice daily was administered from 4/7/26 through 4/10/26 for a total of 8 doses. During a concurrent interview and record review, the Infection Prevention and Control Nurse provided McGeer’s criteria documentation for the resident’s UTI evaluation on 4/7/26 and confirmed the criteria were not met. The document did not include the physician’s acknowledgment of the McGeer’s criteria conclusions, and the IPCN stated she did not notify the physician of the outcomes. The facility’s Antibiotic Stewardship Program policy described an antibiotic review process, also called an antibiotic time-out, for reassessing the ongoing need for antibiotics when diagnostic test results or symptoms do not support infection.
Excess Resident Occupancy in Multiple Rooms
Penalty
Summary
The facility failed to ensure 13 of 32 resident rooms accommodated no more than four residents in each room. A facility letter dated 4/24/26 stated that 13 rooms would accommodate five residents each with one shared bathroom, and that each resident would have reasonable privacy, appropriate furnishings and storage, and sufficient space for staff to provide care and for residents to ambulate and use assistive devices. During observation on 4/21/26 at 8:07 a.m., surveyors found rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214 configured with a solid wall from floor to ceiling dividing the space, a shared bathroom, and one exit door shared by five residents. Two beds were on one side of the wall and three beds were on the other side, with privacy curtains around each bed. During a concurrent observation and interview on 4/24/26 at 10:42 a.m., the Maintenance Supervisor confirmed room [ROOM NUMBER]/110 was configured with two beds and a shared bathroom, and that the measured living space per resident was 117.5 sq. ft.; room [ROOM NUMBER] was configured with three beds and the measured living space per resident was 88 sq. ft. Resident 86 stated she did not have problems with her space and could move about easily. Resident 7 stated she could maneuver her wheelchair, get into the bathroom, and transfer in and out of bed with assistance and had no problems with room space. An LPN stated she provided care in rooms accommodating five residents and had sufficient space to maneuver beds, equipment, wheelchairs, and walkers. A CNA stated he was assigned to rooms accommodating five residents and did not have issues maneuvering residents. The Department recommended granting a room waiver per the facility request.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure 11 of 32 resident rooms, including rooms 300 through 310, met the minimum requirement of 80 square feet per resident. A facility letter dated 4/24/26 stated that these 11 rooms measured less than 80 square feet per resident and noted that each resident should have reasonable privacy, appropriate furnishings and storage space, and sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During an observation of a room on 4/23/26 at 10:32 a.m., staff assisted a resident using a walker in the room, and both the staff member and resident had adequate space to maneuver without complaints. CNA 3, who was assigned to rooms 300-310, stated he did not have issues maneuvering residents or their equipment and could not recall any complaints from family or residents about space. LN 5, who oversaw staff assigned to rooms 300-310, stated she had not received complaints about room space and said there was enough space for residents to get to the bathroom using walkers or wheelchairs. During a concurrent observation and interview on 4/24/26, the Maintenance Supervisor measured a room configured for two beds and confirmed the living space per resident was 72.5 square feet. The Administrator stated he had not received complaints from residents or family about space in rooms 300-310.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another to the floor. Resident 1, admitted in July 2024 with degenerative disorders of the nervous system and dementia, had a BIMS score of 11 indicating moderate cognitive impairment. Resident 2, admitted in October with Alzheimer's disease and dementia, had a BIMS score of 3 indicating severe cognitive impairment and was described by the DON as a wanderer who goes near others and does not understand boundaries. According to the Administrator, Resident 2's wandering behavior could be a danger to himself and others because he gets physically too close to others, which can be an annoyance. A progress note dated 3/22/26 at 10:15 p.m. documented that Resident 1 pushed Resident 2 to the floor in an unwitnessed altercation. Resident 1 stated she was tired of Resident 2 going into her room, that she pushed him as hard as she could, and that she hoped he learned his lesson. In a subsequent interview, Resident 1 reiterated that she did not like Resident 2 and wanted him to stay away from her, which was why she pushed him. The facility’s abuse prevention policy, revised 10/17, states that each resident has the right to be free from physical and other forms of abuse and that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, resulting in Resident 2 being pushed to the ground by Resident 1.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse when two residents were involved in separate resident-to-resident physical altercations. In the first incident, a resident with dementia and adjustment disorder but no documented memory impairment, and with a care plan noting trauma related to prior resident-to-resident abuse, was walking in a hallway when another resident approached from the opposite direction and swung her right arm, striking the resident in the stomach. The aggressor resident had dementia, anxiety, adjustment disorder with depressed mood, a BIMS score of 0 indicating severe memory impairment, and a care plan documenting a history of harm to others, poor impulse control, and prior hitting of another resident. Progress notes documented the altercation, and a CNA witness stated she saw the aggressor resident swing her arm and hit the other resident’s stomach; the victim resident reported being hit and experiencing pain at the time of the incident. In the second incident, a resident with Parkinson’s disease, dementia, Alzheimer’s disease, depression, moderate memory impairment, and a care plan noting trauma related to being a victim of resident-to-resident altercation was in bed when his roommate, who had Alzheimer’s disease, dementia, depression, anxiety, and severe memory impairment, hit him on the left shoulder. Progress notes for both residents documented that the roommate was witnessed hitting the resident’s left shoulder. A CNA reported hearing the resident yelling, entering the room, and observing the roommate hit the resident twice on the left shoulder. The DON acknowledged that residents have the right to be free from abuse and confirmed both incidents of one resident hitting another, despite the facility’s written policy on abuse prevention and reporting of alleged abuse and suspicion of crime intended to ensure residents’ rights are protected and to prevent any type of resident abuse.
Inadequate supervision allowed inappropriate touching between residents
Penalty
Summary
The facility failed to provide adequate supervision to ensure a safe environment for one resident when another resident with a history of wandering into others’ personal space and inappropriate touching was witnessed touching the resident in the groin area. Resident 1 had diagnoses including traumatic brain injury and dementia, and the MDS indicated some understanding with a BIMS score of 12 out of 15. Resident 1’s care plan, initiated on 7/8/24, identified a behavior problem of entering the personal space of others and making them feel uncomfortable, and the MDS behavior section indicated the behavior had occurred before. Resident 2 had a diagnosis including COPD and an MDS BIMS score of 4 out of 15, indicating no full understanding. Resident 2’s progress notes documented that Resident 2 admitted Resident 1 touched her vagina. The DON stated that Resident 1 was witnessed touching Resident 2 on the groin, that Resident 1 had a history of going into other residents’ personal space and inappropriate touching, and that he should have been watched more closely because it had occurred before. A housekeeper also stated they witnessed Resident 1 touching Resident 2 on the groin area. The facility policy titled Resident Rights stated residents are to be free from mental and physical abuse.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care assistance to a resident, identified as Resident 16, who was observed with long, discolored nails with a brown substance underneath. Resident 16, who was readmitted to the facility in 2021, has a medical history that includes major depressive disorder, anxiety disorder, dementia, hepatitis C, nail dystrophy, and other nail disorders. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for assistance with personal hygiene and dressing. The care plan for Resident 16, revised in early 2025, stated that the resident was totally dependent on staff for personal hygiene and oral care. During observations and interviews conducted in February 2025, Resident 16 expressed a desire to have her nails trimmed. Nursing staff, including a Nursing Assistant and Unit Manager, confirmed the condition of the nails and acknowledged that they were long and had a brown substance underneath. The Certified Nursing Assistant (CNA) also confirmed the condition of the nails but could not recall the last time nail care was provided. The Director of Nursing (DON) agreed that the resident's nails should be clean and trimmed, especially given her medical condition. Despite requests, the facility's policy on nail care was not provided for review.
Infection Control Lapses During Norovirus Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control practices during a norovirus outbreak, as evidenced by the lack of training provided by the Infection Prevention nurse. Despite the outbreak affecting 15 residents with gastrointestinal symptoms, there was no documentation of preventive practices training or in-services conducted to protect patients and healthcare workers. Interviews with the Infection Prevention nurse, Director of Staff Development, and Director of Nursing confirmed the absence of such training, which was a critical oversight in managing the outbreak. Resident 335's care was compromised by several infection control lapses. The resident's urinary catheter drainage bag was found on the floor, contrary to proper infection control practices, which require it to be hung off the floor to prevent contamination. Additionally, the resident's intravenous tubing was not labeled with the date and time, a necessary step to ensure safe and effective IV therapy. The Unit Manager acknowledged the lack of labeling and the use of previously hung IV tubing, which was against facility policy. Further, a licensed nurse placed a dirty pillow under Resident 335's leg without cleaning or sanitizing it, despite the room not being cleaned after the previous resident's discharge. The housekeeping staff confirmed that the room had not been cleaned, highlighting a failure in communication and adherence to infection control protocols. The Director of Staff Development and Director of Nursing acknowledged the absence of specific training and checklists for these procedures, underscoring systemic issues in the facility's infection control practices.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to ensure that 13 of 32 resident rooms accommodated no more than four residents per room, as required by regulations. Observations during a facility tour revealed that these rooms were configured to house five residents each, with a solid wall dividing the space and a shared bathroom. The rooms had two beds on one side of the wall and three beds on the other, with privacy curtains separating the residents. Measurements taken during the survey indicated that the living space per resident was below the required standard, with one side of the room providing 117.5 square feet per resident and the other side providing only 88 square feet per resident. Interviews with residents and staff indicated that, despite the overcrowding, there were no significant complaints about space adequacy. Residents reported having enough space to move about and store personal belongings, while staff members, including a CNA and a licensed nurse, stated that they could maneuver residents and equipment without issues. The facility had requested a room waiver, and the Department recommended granting it, despite the potential for inadequate space for the provision of care.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 11 of 32 resident rooms met the minimum requirement of 80 square feet per resident. This deficiency was identified through observation, interviews, and record reviews. A facility letter dated 2/11/25 confirmed that these rooms measured less than the required space per resident. Despite this, the letter claimed that each resident had a reasonable amount of privacy and that the rooms provided sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During a tour and interviews with staff, it was observed that staff and residents could maneuver within the rooms without complaints. A Certified Nursing Assistant and a Licensed Nurse, both frequently assigned to the affected rooms, reported no issues with space or complaints from residents or families. The Assistant Administrator also confirmed no complaints had been received. However, a concurrent observation and interview with the Maintenance Supervisor and Assistant Administrator revealed that the living space per resident in one of the rooms was only 72.5 square feet, confirming the deficiency.
Inaccessible Call Light Buttons for Residents
Penalty
Summary
The facility failed to provide an accessible call system for two residents, resulting in a deficiency. Resident 1, who has cardiomyopathy and dementia, was unable to locate his call light button, which was found inside the top shelf of his bedside drawer, approximately 2 feet away from his bed. This placement made it difficult for Resident 1, who requires substantial assistance with various activities, to reach the call light button, especially in an emergency. The Certified Nurse Assistant (CNA) confirmed that the call light button should be within the resident's reach, but it was not in this case. Similarly, Resident 6, who has atherosclerosis and dementia, was also unable to locate her call light button, which was found on the bottom of her bed, touching the floor. Resident 6 requires substantial assistance with multiple activities and would not be able to reach the call light button in its current position. The CNA confirmed that the call light button should be next to the resident to ensure they can call for help when needed. The Director of Nursing (DON) and the Unit Manager (UM) acknowledged that the call light buttons should be accessible to residents. The facility's policy on resident rights emphasizes the importance of a safe and homelike environment, which includes having an accessible call system. The Centers for Medicare & Medicaid Services also require that the call system be accessible to residents while in their bed or other sleeping accommodations within the resident's room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Folsom
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Healthcare Center | 5.1 mi | ★★★★★ | 23 | 0 |
| Citrus Heights Post Acute | 6 mi | ★★★★★ | 13 | 0 |
| Roseville Care Center | 6.4 mi | ★★★★★ | 2 | 0 |
| Pine Creek Care Center | 6.4 mi | ★★★★★ | 1 | 0 |
| Roseville Point Health & Wellness Center | 6.7 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.