Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Vacaville Ranch Post Acute during CMS and state inspections, most recent first.
Food service safety practices were not followed when clean sheet pans were stored wet and with debris, multiple opened or stored food items lacked required dates, the ice machine had a slimy gray substance on the water curtain, and the red sanitizing bucket tested at 0 ppm instead of the expected Quat range. The DM and RD confirmed the observations, and facility policies required clean, dry dishware, proper dating of food items, routine ice machine cleaning, and sanitizer concentrations within the established range.
Uncovered Garbage Dumpsters: Two garbage dumpsters were observed with lids left open during an observation with the DM. The DM confirmed the lids should have been closed, and the RD stated the lids were expected to be closed and that open lids created a risk for contamination. Facility policy required food waste to be placed in covered garbage and trashcans and for dumpster lids to be closed.
Failure to Offer and Document Advance Directives: The facility did not ensure advance directives were offered or documented for 14 sampled residents with diagnoses including CVA, dementia, anoxic brain injury, aphasia, CHF, seizures, sepsis, and other serious conditions. Record review showed no ADs in the charts for several residents and no evidence that the SSD or nursing staff documented offering assistance to complete one, despite the facility policy requiring written information and inquiry about ADs at or upon admission.
A facility failed to follow the posted menu during lunch meal service for residents on therapeutic diets. Twelve residents on a Mechanical Soft/Soft and Bite sized diet received whole green beans and hard bread instead of the soft, chopped, and buttered items listed, and four residents on a Pureed diet received an incorrect garlic bread portion. The RD acknowledged the menu discrepancies, and facility policy required menus to be followed as written.
Staff failed to follow EBP during high-contact care for three residents. An LPN and the IP assisted a resident with a heel pressure injury and Foley catheter without gowns and gloves, a PT transported and transferred a resident with sepsis, osteomyelitis, a PICC, and IV antibiotics without PPE, and a CNA and PT transferred another resident with a Foley and open wounds while changing linens without gowns and gloves. The DON and IP acknowledged the expected use of gowns and gloves for residents on EBP.
Failure to Provide Written Bed-Hold Notice at Transfer: The facility did not ensure written bed-hold notices were provided when two residents were transferred to the hospital. The DON and SSD confirmed there was no documented evidence that either resident or their representative was notified in writing of the bed-hold policy upon transfer, despite facility policy requiring a bed-hold notification form to be given.
Failure to Notify Physician and Incomplete Wound Documentation: Nursing staff did not notify the MD of a resident’s fluid imbalance despite low urine output documented on the I/O record, and an LPN failed to accurately and completely document another resident’s left heel wound assessments. The DON confirmed the fluid imbalance was not reported and the wound assessments were incomplete, with the wound location initially charted incorrectly and later changed to the heel.
Controlled Medications Not Jointly Counted at Shift Change: An LPN observed that active narcotics were counted at shift change, but discharged/discontinued narcotics were not counted with the oncoming nurse. Bubble packs for the discontinued controlled meds were found without the narcotic count sheet attached. The DON stated both the outgoing and oncoming nurses must count all physical controlled meds together and document the count on the Narcotic Count Sheet.
The facility failed to ensure proper labeling and dating of food items in the kitchen refrigerator, leading to potential foodborne illness. Observations revealed unlabeled sliced tomatoes, meats, and hash browns, as well as soy milk without open and use-by dates. Additionally, utensil storage was unsanitary, with food crumbs present, and contaminated brown rice was improperly returned to its container. The Registered Dietician confirmed these actions violated facility policy and posed risks of cross-contamination and allergies.
The facility failed to remove two expired multi-dose vials of Tuberculin skin test solution from use. During an observation, two vials with expired dates were found in the Medication Storage Room Refrigerator. Licensed Staff A confirmed the vials were expired and should have been discarded. The facility's policy requires that outdated drugs be returned to the pharmacy or destroyed.
The facility failed to provide appetizing and palatable meals, as evidenced by three residents who reported the fish served was dry and tasteless. The Dietary Assistant confirmed the issue, and the Registered Dietician noted the difficulty in keeping the thinly sliced fish moist. This failure to adhere to the facility's food preparation policy could impact residents' food intake and nutritional status.
A LTC facility failed to provide prescribed medications for two residents, leading to significant care deficiencies. One resident did not receive her Spiriva inhaler for four days, causing shortness of breath and anxiety. Another resident received nine scheduled medications nearly two hours late. The facility's policies on timely medication administration were not followed, and there was a lack of communication and follow-up with the pharmacy.
The attending Physician failed to document responses to the Pharmacist's recommendations over five months, leaving 26 recommendations unacknowledged. Licensed Staff A confirmed that the process involved verbal discussions without written documentation, contrary to facility policy. This oversight posed potential risks for 49 residents.
The facility failed to follow hand hygiene protocols during medication administration and meal service. A licensed staff member did not perform hand hygiene before or after administering medications to two residents, and an unlicensed staff member did not ensure hand hygiene before assisting a resident with their meal. These actions were contrary to the facility's policy, which requires hand hygiene in these situations.
A resident expressed a preference to get out of bed for meals, but the facility failed to assist her on multiple occasions, resulting in her eating meals in bed. Staff interviews revealed inconsistencies in care, with some unable to explain why the resident's preferences were not honored.
The facility failed to remove expired medications from stock, as six bottles of Docusate Sodium 50 MG/5 ML were found in the medication storage room two months past their expiration date. Licensed Staff A confirmed the oversight, noting that the medications were stored on a higher shelf and missed during monthly checks by the AM Unit Manager.
The facility failed to follow its antibiotic stewardship policies, leading to inappropriate antibiotic prescriptions for two residents with suspected UTIs. One resident was given Macrobid before culture results showed no infection, and another received Keflex despite having a bacteria resistant to it. Staff confirmed that neither resident met the criteria for antibiotic use, highlighting a breach in protocol.
A resident developed sheared skin on the coccyx, but the responsible party was not notified, despite a physician's order indicating the resident lacked decision-making capacity. The facility's policy requiring notification of significant changes was not followed, leading to a deficiency.
A resident with severe cognitive impairment experienced a loss of personal belongings during their stay at the facility. Despite family reports of missing clothes, the facility failed to properly document and verify the return of items upon discharge. The inventory sheet was incomplete, and the Social Service Director was not informed of the loss, indicating a lapse in following the facility's policy.
The facility failed to provide adequate supervision and fall prevention for two high-risk residents, resulting in multiple falls and injuries. One resident fell and fractured her hip due to lack of supervision and absence of a call light, while another experienced three falls within two weeks due to inadequate interventions.
A resident experienced severe pain that was not adequately managed by the facility. Despite continuous complaints of an 8/10 pain level, the staff administered only acetaminophen, ignoring the physician's order for a higher dose of morphine. The facility also prioritized the family's preferences over the resident's comfort, leading to prolonged pain and distress.
The facility failed to submit required staffing information to CMS for several months due to operating under the previous owner's provider number. The pending Change of Ownership (CHOW) process prevented the Office Manager from accessing the system needed for the electronic submission of Payroll-Based Journal (PBJ) data.
The facility failed to ensure hot water in the sink of bathrooms used by seven residents. Residents reported waiting up to 15 minutes for hot water, and the Director of Maintenance confirmed that it took up to ten minutes for the water to get hot. Observations showed that water temperatures started cold or lukewarm and took several minutes to reach 100 F.
The facility failed to ensure staff were aware of what a Basic Care Plan (BCP) was and its completion time frame, resulting in no BCPs being completed for four sampled residents. Interviews with various staff members revealed a lack of awareness and understanding of the BCP and its importance. The facility was using an Interim Care Plan (ICP) instead, which did not include essential information, putting residents' safety at risk and potentially leading to inadequate and inappropriate care.
The facility failed to ensure that food meant for residents was not stored in the staff refrigerator, that residents' food items were properly labeled with names and dates, and that expired food items were discarded. The removal of the residents' refrigerator in the Activity Room left staff uncertain about where to store residents' perishable food brought in by family or visitors, leading to potential safety risks.
The facility failed to ensure proper hand hygiene for residents before and after meals, improperly stored residents' valuables with medications, did not require laundry staff to use protective clothing, and lacked a detailed water system diagram to prevent Legionella growth.
The facility failed to maintain an updated surveillance log for residents receiving antibiotics, as confirmed by the Infection Preventionist. Despite eight residents currently on antibiotics, the log for February 2024 contained data for only one resident, contrary to the facility's policy on Antibiotic Stewardship.
The facility failed to ensure that three residents were offered and provided COVID-19 vaccines, and did not maintain documentation that staff were educated about and offered the COVID-19 vaccine. Additionally, the facility's COVID-19 policies and procedures had not been updated since June 2020.
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to a resident who no longer qualified for Medicare Part A skilled services but had not exhausted all her Medicare benefit days. Interviews with staff revealed a lack of knowledge and understanding regarding the correct notice to issue, and the facility did not provide a policy for Medicare Beneficiary Notice when requested.
The facility failed to follow the care plan for a Spanish-speaking resident, resulting in a lack of daily visits, Spanish music, TV channels, and religious services. Additionally, the facility did not have an effective communication system for non-English speaking residents, relying on untrained staff and family members for interpretation, leading to potential miscommunication and unmet care needs.
A resident did not receive physician visits every 60 days, resulting in over 8 months without a documented visit. The DON confirmed the lapse and noted that the hospice provider was responsible for the resident's care but failed to provide the necessary documentation.
The Consulting Pharmacist failed to accurately review and provide recommendations on antibiotic usage for two residents. One resident was prescribed Doxycycline Hyclate indefinitely without an end date, and the PharmD did not review the medical record for the duration of treatment. Another resident was prescribed Keflex for six months without an initial indication of the reason for use, which was only added later. The facility's policies require clear indications and periodic re-evaluations for antibiotic use.
The facility failed to ensure proper antibiotic usage for two residents, with one resident lacking an end date for Doxycycline and another resident's Keflex usage not being properly documented or re-evaluated. This led to potential antibiotic resistance.
The facility failed to ensure the medical record of a resident admitted to hospice care was complete and readily accessible. The DON acknowledged the absence of documented physician visits and initially lacked hospice records, which were later received by fax.
The facility failed to ensure that binding arbitration agreements were explained in a language and form residents understood, leading to a deficiency for one resident. The resident's Responsible Party signed the agreement without understanding its implications, as confirmed through interviews and record reviews.
The facility failed to post the daily direct care staffing schedule in a visible and accessible location for all residents, staff, and visitors. The schedule was kept inside a binder and taped inside the Nurses' Station counter, making it only visible to staff. Additionally, the schedule lacked essential information such as the resident census, the number of nursing personnel, and the actual time worked during the shift.
Food Storage, Ice Machine, and Sanitizer Deficiencies
Penalty
Summary
Food service safety practices were not followed when several metal sheet pans stored in clean, ready-to-use areas were observed wet, with food debris and a brown substance on the outside surfaces. During the kitchen tour, the Dietary Manager and Registered Dietician confirmed the pans were wet and dirty, and the Registered Dietician stated they should have been completely air-dried and clean before storage. The facility policy for dish and utensil procedures stated dishes, trays, and utensils should be routinely checked for stains or spots, air dried before storage, and any tray with debris should not be used. Food items in dry storage, the refrigerator, and the freezer were found without required dates or with illegible dates. These included 12 opened bottles of spices without a use-by date, one opened bin of chicken soup base without a use-by date, one opened loaf of bread without a use-by date, four pallets of bread without a receive date, one package of thawed country fried steak without a pull date, one opened box of frozen beef patties without an open or use-by date, and one opened package of frozen cookie dough with an illegible open and use-by date. The Registered Dietician confirmed the items were not labeled as required and stated opened packages should have use-by dates, bread should have receive dates, and food removed from the freezer for thawing should have a pull date. The facility policy for food storage stated products should be dated upon receipt, when opened, and when prepared. The ice machine was also observed with a slimy gray substance on the upper right portion of the water curtain when the Maintenance Supervisor removed the top access panel. The Maintenance Supervisor confirmed the substance was present and not clean. In addition, the red sanitizing bucket tested at 0 ppm during observation, while the Dietary Manager stated the facility used Quat and that the expected concentration range was 200 to 400 ppm. The Registered Dietician confirmed the expectation was for the red sanitizing bucket to have an appropriate disinfectant concentration. The facility policies for the ice machine and sanitizer use concentrations required routine cleaning of the ice machine and use of chemical sanitizers in accordance with the label and established ppm ranges.
Uncovered Garbage Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage when two garbage dumpsters were observed uncovered during a concurrent observation and interview with the Dietary Manager. The census was 47, and the dumpsters were left open instead of being closed. The Dietary Manager confirmed the lids were open and should have been closed. During a later interview, the Registered Dietician stated the expectation was for the dumpster garbage lids to be closed and that there was a risk for contamination in the facility when the dumpster garbage lids were left open. Review of the facility policy titled "Garbage and Trashcans" showed that all food waste must be placed in covered garbage and trashcans, the dumpster area must be free of debris, and the lid must be closed.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were offered and documented for 14 of 17 sampled residents, including residents with diagnoses such as cerebral infarction, dementia, anoxic brain damage, aphasia, depression, anxiety disorder, sepsis, osteomyelitis, heart failure, seizures, metabolic encephalopathy, osteoarthritis, fractures, chronic respiratory failure, muscle weakness, and neuromuscular bladder dysfunction. Review of the records for these residents showed that several had no completed advance directive in either the electronic record or the physical chart, and for others there was no documentation that an advance directive had been offered. During interviews, the SSD confirmed that advance directives were expected to be asked about on admission and that residents or family members would be offered assistance if no directive was in place. However, after reviewing the records for multiple residents, the SSD confirmed there were no advance directive documents on file and no documentation showing that the residents or families had been offered help to complete one. LN 4 and the DON stated that residents admitted without an advance directive were to be referred to SSD for follow-up and assistance in completing the document. The facility policy titled "Advance Directives" stated that residents should be provided written information upon admission, that the existence of any written advance directive should be inquired about prior to or upon admission, and that if none existed, staff would offer assistance in establishing one. The records reviewed for residents 16, 30, 32, 37, 43, 60, 4, 57, 58, 59, 2, 6, 9, and 29 did not contain advance directives or documented evidence that the offer had been made.
Therapeutic Diet Menu Not Followed During Lunch Service
Penalty
Summary
The facility failed to follow the menu for the therapeutic diets served at lunch during an observed meal service. Twelve residents on a Mechanical Soft/Soft and Bite sized diet received whole green beans instead of soft and chopped green beans, and hard bread instead of soft and buttered bread as listed on the facility’s daily spreadsheet menu for that diet. Four residents on a Pureed diet received 2.07 oz of garlic bread instead of the 2.78 oz portion listed on the same menu. During the meal observation, the Registered Dietician acknowledged the issues identified during service and stated that residents should have received food items as reflected on the menu. Record review showed the facility’s Cycle Menus policy required menus to be followed as written except for substitutions related to ethnic, cultural, geographic, or religious preferences. Review of the Cook job description showed responsibility for ensuring appropriate portioned servings according to portion control standards and recipes.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) for three sampled residents during direct care activities. Resident 4 was admitted with diagnoses including a pressure-induced deep tissue injury of the left heel and diabetes, and had a Foley catheter and a left heel pressure ulcer documented in the record. During observation in the resident’s room, EBP signage was posted at the door indicating gowns and gloves were required for high-contact resident care activities, but LN 3 and the IP were observed assisting the resident to turn onto her side without wearing gowns and gloves. Both later acknowledged that the resident was on EBP and that gowns and gloves should have been worn during direct care. Resident 43 was admitted with diagnoses including sepsis and osteomyelitis, and the record showed a PICC line and IV vancomycin for osteomyelitis. During a concurrent observation and interview, the PT transported the resident to the gym in a wheelchair for exercises and then assisted her back to bed without wearing a gown and gloves. The PT acknowledged the resident was on EBP and stated he should have worn gown and gloves while assisting the resident. The DON later stated staff were expected to always practice infection control to avoid the spread of infection and that LN 3 and the IP should have worn gowns and gloves when rendering direct nursing care to residents on EBP. Resident 29 was admitted with diagnoses including neuromuscular dysfunction of the bladder and dementia. A sign outside the room indicated EBP, and during observation the CNA 2 and PT entered the room without gowns and gloves while transferring the resident from bed to wheelchair. The PT pushed the resident into the hallway, and CNA 2 began changing bed linens. CNA 2 confirmed they did not wear gowns and gloves during the transfer. The IP later confirmed the resident was on EBP for a Foley catheter and open wounds and stated that staff must wear gowns and gloves during high-contact resident care activities such as transferring and changing linens.
Failure to Provide Written Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that a written bed-hold notice was provided at the time of transfer for two sampled residents. Resident 54 was admitted with a diagnosis including heart failure, and the record review and interview with the DON confirmed there was no documented evidence that Resident 54 received a document related to the facility’s bed-hold policy before transfer to the hospital. The SSD stated that the admission packet included the bed-hold policy, but the facility did not provide the bed-hold policy upon transfer, and there was no documented evidence that Resident 54 or the resident representative was notified in writing of the bed-hold policy before the hospital transfer. Resident 6 was admitted with a diagnosis including congestive heart failure, and the DON confirmed there was no documented evidence that Resident 6 received a document related to the facility’s bed-hold policy before transfer to the hospital. The SSD stated that the admission packet had the bed policy, but the facility did not provide bed-hold notice upon transfer, and there was no documented evidence that Resident 6 or the resident representative was notified in writing of the facility’s bed-hold policy before each hospital transfer on 2/11/25, 2/26/25, 6/12/25, and 6/27/25. The ADM stated that no bed-hold notification form was given upon transfer, although facility policy required that a bed-hold notification be given to residents.
Failure to Notify Physician of Fluid Imbalance and Incomplete Wound Documentation
Penalty
Summary
Nursing staff failed to notify the physician of Resident 58’s fluid imbalance. Resident 58 was admitted in August 2025 with diagnoses including atherosclerotic heart disease and had a Foley catheter ordered on 8/5/25 due to urinary retention. The input and output record showed multiple days of low urine output compared with intake, including 8/3/25, 8/4/25, 8/5/25, and 8/7/25. The clinical record contained no documented evidence that the physician was notified of the fluid imbalance. During a concurrent interview and record review on 8/7/25, the DON confirmed the input and output record showed a fluid imbalance and confirmed a physician was not notified and follow-up was not done. The DON stated staff were expected to notify the physician of changes in a resident’s condition, including a fluid imbalance. The facility’s policy for catheter care stated input and output should be observed and decreases or increases in urine level reported to the physician or supervisor. Nursing staff also failed to document Resident 29’s left heel wound accurately and completely. Resident 29 was admitted in May 2025 with dementia and severe protein calorie malnutrition. On observation, Resident 29 was lying on a low air loss mattress with pillows positioned under both heels. The wound record showed a left heel deep tissue injury with ordered treatment, but the skin and wound evaluations dated 7/19/25, 7/28/25, 8/1/25, 8/4/25, and 8/8/25 were not completed and filled out by LN 5. LN 5 confirmed the original wound location had been documented incorrectly as the left malleolus and later changed to the left heel, and confirmed the documentation was inaccurate and incomplete. The DON confirmed the assessments were incomplete and stated licensed nurses were expected to document in all categories of the skin and wound evaluation.
Controlled Medications Not Jointly Counted at Shift Change
Penalty
Summary
The facility failed to ensure that discharged and discontinued controlled medications were jointly counted by the outgoing nurse and an oncoming nurse. During a concurrent observation and interview on 8/5/25 at 10:45 a.m., LN 2 unlocked the narcotic box on the medication carts for A hall and part of B hall and stated that the outgoing night shift nurse and she counted the active narcotic medications, but did not count the discharged/discontinued narcotic medications. Bubble packs for the discharged/discontinued narcotic medications were observed without the narcotic count sheet attached as required by policy. LN 2 was unable to explain how diversion, patient safety, and accurate accounting of discharged/discontinued controlled substances could be prevented without medication reconciliation during shift change. During an interview on 8/6/25 at 3:45 p.m., the DON stated nurses must count both active and discharged/discontinued narcotic medications, and that the outgoing nurse and an oncoming nurse must count the physical medications together and document and sign the Narcotic Count Sheet. The facility policy titled Controlled Medication Storage, effective March 2018, stated that controlled substances are subject to special handling, storage, disposal, and recordkeeping, and that at each shift change a physical inventory of all controlled medications is conducted by two licensed nurses and documented on the controlled medication accountability record.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen refrigerator, which could lead to misidentification and potential foodborne illness. During observations, it was noted that sliced tomatoes, sliced meat, cut-up meat, and opened hash browns were not labeled with open and use-by dates. Additionally, a carton of soy milk was found without an open and use-by date. The facility's policy requires all food items to be labeled and dated to ensure freshness and safety for residents' consumption. The Registered Dietician confirmed the importance of labeling to prevent food poisoning and acknowledged that the facility policy was not followed. The facility also failed to maintain sanitary conditions for utensil storage and proper disposal of contaminated food items. Observations revealed that a drawer containing utensils was dirty with food crumbs, including a cooked macaroni noodle, which could attract pests and lead to cross-contamination. Furthermore, an incident was observed where brown rice was poured back into its container after being placed in a greased pan, which was acknowledged as a mistake by the staff member involved. The Registered Dietician highlighted the risk of cross-contamination and allergy concerns due to this action. The facility lacked specific policies for cleaning utensil storage and discarding contaminated food items.
Expired Tuberculin Vials Not Removed from Use
Penalty
Summary
The facility failed to remove two expired multi-dose vials of Tuberculin skin test solution from use, which are used to test for tuberculosis (TB). During an observation and interview, two vials were found in the Medication Storage Room Refrigerator, both labeled with expired dates. Licensed Staff A acknowledged that the vials were expired and should have been discarded. According to the drug information on Tubersol, a vial that has been opened and in use for 30 days should be discarded and not used after its expiration date. The facility's policy on the storage of medications also states that discontinued, outdated, or deteriorated drugs or biologicals should not be used and must be returned to the dispensing pharmacy or destroyed.
Facility Fails to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure that food served to residents was appetizing and palatable, as evidenced by the experiences of three sampled residents. Resident 42, who has Type II Diabetes Mellitus, Chronic Pain Syndrome, and Anemia, reported that the fish served for lunch was dry and tasteless. Similarly, Resident 208, diagnosed with Depression, Anxiety Disorder, and Cellulitis, stated that the fish was dry and unpalatable. Resident 33, who has Dysphagia, Essential Hypertension, and Hyperlipidemia, also found the fish to be too dry, chewy, and lacking in taste. These observations were corroborated by the Dietary Assistant, who agreed that the fish was dry and not flavorful. The Registered Dietician acknowledged the issue with the fish being dry, attributing it to the thin slicing of the fish, which made it difficult to keep moist. The facility's policy and procedure on food preparation emphasize that food should be prepared to conserve nutritive value, flavor, and appearance, and that prepared food should be sampled to ensure satisfactory flavor and consistency. However, the failure to adhere to these guidelines resulted in the residents' dissatisfaction with the meal, potentially impacting their food intake and nutritional status.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide prescribed medications as ordered for two residents, leading to significant deficiencies in care. Resident 153, who was admitted with chronic heart failure and Chronic Obstructive Pulmonary Disease (COPD), did not receive her prescribed Spiriva inhaler for four days due to its unavailability in the facility. Despite notifying the nursing staff about her medication needs, the resident was informed that the medication was not yet available. This oversight resulted in the resident experiencing shortness of breath and anxiety, as she was unable to receive her necessary treatment for COPD. Additionally, the facility failed to administer nine scheduled medications to Resident 208 at the prescribed times. These medications, which included treatments for heart failure, hypertension, and anemia, were administered one hour and forty-five minutes past the scheduled time. The facility's policy required medications to be administered within 60 minutes of the scheduled time, but this was not adhered to, as confirmed by the Medication Administration Audit Report and staff interviews. The deficiencies were further highlighted by the lack of communication and follow-up actions by the nursing staff and the pharmacy. Licensed staff did not notify the physician of the missed doses for Resident 153, nor did they follow up with the pharmacy or check if the resident could bring medications from home. The pharmacist consultant expressed concerns about the lack of urgency and communication regarding the delayed delivery of medications. These failures in medication management and administration compromised the health and safety of the residents involved.
Physician's Failure to Document Pharmacist Recommendations
Penalty
Summary
The attending Physician at the facility failed to document the review of the Pharmacist's findings and the actions taken or not taken in response to these recommendations over a five-month period from February 2024 to June 2024. This oversight was identified during a record review of the Medication Regimen Review (MRR) Binder, which revealed that the Physician/Prescriber Response sections for 26 Pharmacist recommendations were left blank. The recommendations included various suggestions for medication adjustments, but there was no written acknowledgment or rationale provided by the Physician for agreeing or disagreeing with these recommendations. Interviews with Licensed Staff A and Pharmacist Consultant J highlighted a lack of clarity in the process for documenting the Physician's responses to the Pharmacist's recommendations. Licensed Staff A indicated that the current practice involved verbal discussions with the Physician, and any changes to medication were made if the Physician agreed with the recommendations. However, if the Physician disagreed, there was no documentation of the rationale for this decision. The facility's policy required that recommendations be acted upon and documented, with explanations provided for any disagreements, but this was not adhered to, leading to potential risks for the 49 vulnerable residents.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to standard precautions for infection prevention and control, specifically in the area of hand hygiene. During medication administration, a licensed staff member did not perform hand hygiene before preparing medications, before entering the room, or after leaving the room for two residents. Interviews with other licensed staff revealed inconsistencies in the understanding and application of hand hygiene protocols, with some staff indicating that hand hygiene was only performed if hands were visibly soiled, contrary to the facility's policy. Additionally, during meal service, an unlicensed staff member did not perform hand hygiene while assisting a resident with their meal tray. The staff member was unable to confirm if hand hygiene was provided to the resident before the meal, despite the facility's policy requiring hand hygiene before and after assisting residents with meals. The facility's policy, dated August 2015, clearly outlines the need for alcohol-based hand rub or soap and water in these situations, yet these guidelines were not followed, potentially exposing residents to infectious agents.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to accommodate the preferences of a resident, identified as Resident 6, who expressed a desire to get out of bed to have meals either in her wheelchair in her room or in the dining room. Despite her preference, the facility did not assist her in getting out of bed for meals on multiple occasions. This was confirmed through interviews and observations conducted over several days. On 7/8/24, Resident 6 mentioned she liked to get out of bed for meals, but the facility did not assist her. Observations on subsequent days showed Resident 6 eating meals in bed, and staff were unable to provide a reason for this deviation from her usual routine. Interviews with staff revealed inconsistencies in the care provided to Resident 6. Unlicensed Staff F and Licensed Staff A acknowledged that Resident 6 typically got up for meals but could not explain why she remained in bed on certain days. Unlicensed Staff H noted that Resident 6 did not get up on 7/8/24 because they were not working that day. These observations and interviews indicate a lack of consistent adherence to Resident 6's preferences, resulting in her remaining in bed for meals on several occasions, contrary to her expressed wishes.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to ensure expired medications were promptly removed from stock and disposed of, as evidenced by the presence of six bottles of Docusate Sodium 50 MG/5 ML in the medication storage room that had expired two months prior. During an observation and interview, Licensed Staff A confirmed the expiration of these medications. Licensed Staff A stated that the expiration dates of medications were checked monthly by the AM Unit Manager, but the expired bottles were overlooked because they were stored on a higher shelf. The facility's policy, dated March 2018, requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures.
Failure to Implement Antibiotic Stewardship Policies
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policies and procedures, resulting in the inappropriate prescription of antibiotics to two residents with suspected urinary tract infections (UTIs). Resident 34 was prescribed Macrobid for three days before the results of a urine culture sensitivity test were available, which later showed no growth, indicating no infection. Similarly, Resident 31 was given Keflex for seven days after reporting abdominal pain and purulent discharge from a catheter, but the urine culture revealed the presence of Pseudomonas aeruginosa, a bacteria resistant to the prescribed antibiotic. Licensed Staff B confirmed that neither resident met the criteria for antibiotic use according to the McGreer Criteria for UTIs, which requires at least one sign or symptom and culture sensitivity test results before starting antibiotics. The Medical Director emphasized the importance of waiting for culture sensitivity results to avoid the risk of residents developing multi-drug-resistant organisms (MDROs) due to inappropriate antibiotic use. The facility's policy on antibiotic stewardship, dated December 2016, mandates that antibiotics be prescribed based on pathogen susceptibility and clinical definitions of active infection, which was not followed in these cases.
Failure to Notify Responsible Party of Resident's Skin Condition
Penalty
Summary
The facility failed to implement its policy on change of condition/notification for a resident when the responsible party was not informed of a new skin issue. The resident, who was admitted with no skin issues, developed sheared skin on the coccyx, a condition that can occur during transfers or repositioning. Despite a physician's order indicating the resident lacked the capacity to make healthcare decisions, the responsible party was not notified of the new wound. This oversight did not allow the responsible party to be informed or participate in the resident's care and treatment. Interviews and document reviews revealed that the facility's staff did not follow the policy requiring immediate notification of the resident, physician, and responsible party in the event of a significant change. The DON acknowledged that the responsible party should have been informed, as the resident was not capable of making healthcare decisions. The facility's policy, effective since 2016, mandates such notifications, but it was not adhered to in this case, leading to the deficiency.
Failure to Safeguard Resident's Belongings
Penalty
Summary
The facility failed to safeguard a resident's personal belongings, resulting in missing clothes upon discharge. The resident, who had a severe cognitive impairment with a BIMS score of 7, was admitted with a diagnosis of cerebral infarction and dementia. During the resident's stay, family members reported missing items, including gray pants, compression socks, underwear, and a black shirt. Despite notifying the facility staff, the family was only informed that a search would be conducted, and clothes from other residents were mistakenly sent home with the resident. The facility's policy required that all personal belongings be recorded upon admission and verified upon discharge, with signatures from the resident or their representative. However, the inventory sheet for the resident was incomplete, with no checkmarks indicating the return of items, and the resident, despite cognitive impairment, signed the document. Interviews with staff revealed inconsistencies in following the policy, as the Social Service Director was not informed of the missing items, and there was no record of a search or a report of the loss being processed.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and fall prevention interventions for two residents at high risk for falls. Resident 20, who had diagnoses including generalized muscle weakness, abnormalities of gait and mobility, and senile degeneration of the brain, fell and fractured her hip due to the lack of supervision and the absence of a call light within her reach. Despite being at high risk for falls, as indicated by her care plan and Morse Fall Scale, Resident 20 was left unsupervised in the hallway, leading to her attempting to pick up an object from the floor and subsequently falling out of her wheelchair. The incident occurred during a shift change, and no staff were present in the hallway to monitor her at the time of the fall. The DON confirmed that the fall prevention interventions in place were insufficient to prevent the fall, as Resident 20 did not have access to a call light and was not being actively supervised when the fall occurred. The fall resulted in a right hip fracture, and Resident 20 was taken to the hospital for evaluation and treatment of her injuries. Resident 14, who had diagnoses including generalized muscle weakness, difficulty walking, and dementia, experienced three falls within a two-week period due to inadequate supervision and fall prevention measures. Despite being identified as high risk for falls, as indicated by her care plan and Morse Fall Scale, the facility failed to implement effective interventions after each fall. The first fall occurred when Resident 14 was seen standing unassisted with a walker in front of the nurse's station and lost her balance. No new fall interventions were implemented after this incident. The second fall happened when Resident 14 attempted to get up from her bed to use the bathroom and tripped on a blanket, with the bed alarm being disconnected at the time. The third fall occurred in the activities room when Resident 14 attempted to get up from a table using her walker, which rolled out from under her, causing her to fall. The facility's response to these falls was inadequate, with only minimal new interventions being implemented after each incident. The facility's policies on fall risk management and dementia care were not effectively followed, leading to repeated falls and injuries for both residents. The staff failed to provide the necessary supervision and timely interventions to prevent these falls, despite the residents' high-risk status and documented care plans. The lack of adequate monitoring, failure to ensure call lights were within reach, and insufficient implementation of fall prevention measures directly contributed to the residents' falls and subsequent injuries.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to ensure adequate pain relief for Resident 34, who was experiencing severe pain. Despite Resident 34's continuous complaints of an 8 out of 10 pain level, the nurse administered only acetaminophen (APAP) 650 mg, which was insufficient for such severe pain. The resident had received a dose of morphine at 6:30 a.m., but when the pain persisted, the staff did not follow the physician's order to administer a higher dose of morphine for severe pain. Instead, they opted for APAP, which did not alleviate the resident's pain, leading to continued discomfort and distress. The facility also failed to prioritize Resident 34's comfort over the family's preferences. The Director of Nursing (DON) acknowledged that the family was heavily involved in the resident's care and often interfered with pain management decisions. Despite the resident being capable of making his own decisions, the staff felt intimidated by the family's wishes and did not administer the appropriate pain medication as per the physician's order. This resulted in the resident experiencing prolonged severe pain without adequate relief. Additionally, the facility did not adhere to its pain management policy, which required staff to notify the physician if the prescribed pain medication was ineffective. The staff did not reassess the resident's pain or seek further medical advice when the initial dose of morphine did not provide relief. The Medical Director confirmed that the nurse should have contacted him for an additional dose of morphine. The failure to follow the pain management protocol and the physician's orders led to Resident 34 enduring significant pain and discomfort unnecessarily.
Failure to Submit PBJ Data Due to Pending CHOW
Penalty
Summary
The facility failed to electronically submit the required staffing information to CMS for the months of September, October, November, December 2023, and January 2024. This failure was due to the facility operating under the previous owner's provider number, which prevented the Office Manager from accessing the system to submit the Payroll-Based Journal (PBJ) data. The Change of Ownership (CHOW) process was still pending, and as a result, the facility did not have its own provider number to facilitate the electronic submission of staffing data. During an interview on February 8, 2024, the Office Manager and Administrator confirmed the inability to submit the PBJ data electronically. The Office Manager stated that he had no access to the computer system required for the submission due to the pending CHOW. The Administrator corroborated this, explaining that the lack of an approved provider number was the reason for the submission failure. This non-compliance with the Health & Safety code S483.70(q) had the potential to result in inaccuracies in the reported numbers of licensed and unlicensed nurses available to provide care to residents, thereby impacting their health and safety.
Failure to Ensure Hot Water in Resident Bathrooms
Penalty
Summary
The facility failed to ensure hot water in the sink of bathrooms used by seven of ten residents. During a resident group interview, two residents reported that there was no hot water in their bathroom sinks, and they had to wait up to 15 minutes for the water to get hot. This issue was confirmed by the Director of Maintenance (DM), who stated that the water in some resident bathrooms took up to ten minutes to get hot. Observations and measurements of water temperature in the bathrooms used by Residents 29, 30, 33, 92, 95, 192, and 243 showed that the water temperature started at a cold or lukewarm level and took several minutes to reach a hot temperature of 100 F. During the observations, the DM measured the water temperature in the bathrooms and found that it took between three to ten minutes for the water to reach a hot temperature. For example, in the bathroom used by Resident 192, the water temperature was 68 F initially and took ten minutes to reach 100 F. Similarly, in the bathroom used by Residents 30 and 33, the water temperature started at 63 F and took seven and one-half minutes to reach 99 F. The facility's policy on maintenance service, revised in December 2009, indicated that the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Failure to Complete Basic Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure staff were aware of what a Basic Care Plan (BCP) was and its completion time frame, resulting in no BCPs being completed for four sampled residents. Resident 34, who was dependent on staff for Activities of Daily Living (ADLs) and a recipient of hospice care, did not have a BCP completed within 48 hours of admission. Similarly, Resident 13, who had severe cognitive impairment and needed assistance with ADLs, also did not have a BCP completed within the required timeframe. Resident 242, with moderately impaired cognition and requiring assistance with ADLs, and Resident 41, who needed supervision for ADLs, were also without a BCP within 48 hours of admission. Interviews with various staff members, including the Minimum Data Set (MDS) Coordinator, Activity Director (AD), Director of Rehabilitation (DOR), Registered Dietician (RD), and Assistant Director of Nursing (ADON), revealed a lack of awareness and understanding of the BCP and its importance. The MDS Coordinator and other staff members were not familiar with the BCP process and its completion time frame, and the facility was using an Interim Care Plan (ICP) instead, which did not include essential information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or PASARR recommendations. The facility's policy and procedure indicated that a BCP should be developed within 48 hours of admission to meet residents' immediate care needs. However, the ADON confirmed that BCPs for late Friday admissions were completed the following Monday, making them late. The ICP used by the facility was completed by the Admission Nurse only, without input from the interdisciplinary team, the resident, or the Responsible Party (RP). This lack of a timely and comprehensive BCP put residents' safety at risk and could lead to inadequate and inappropriate care.
Failure to Properly Store and Label Residents' Food
Penalty
Summary
The facility failed to ensure that food meant for residents was not stored in the staff refrigerator, that residents' food items were properly labeled with names and dates, and that expired food items were discarded. During observations, it was found that dough and a box of tater tots were stored in the staff refrigerator/freezer, which posed a risk for cross-contamination. The Dietary Manager and other staff confirmed that these items should not have been there due to the risk of residents getting sick from cross-contamination and infection. Additionally, the residents' refrigerator in the Activity Room contained various food items such as sorbets, popsicles, and yogurt that were not labeled with resident identifiers or expiration dates. Some of these items were expired, and staff acknowledged that keeping expired food items in the refrigerator put residents at risk for food poisoning and gastrointestinal illnesses. Multiple staff members, including the Activity Director and Licensed Staff, confirmed that the facility's policy required food to be labeled with the resident's name and discard date, and that expired food should be discarded. The facility had recently removed the residents' refrigerator in the Activity Room, leaving staff uncertain about where to store residents' perishable food brought in by family or visitors. Several staff members, including the Director of Nursing and the Assistant Director of Nursing, were unaware of the removal and acknowledged that the facility did not have a plan in place to safely store residents' food. This lack of a dedicated refrigerator for residents' food led to confusion and potential safety risks, as staff did not know where to keep perishable food items until the residents were ready to consume them.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene (HH) practices for six sampled residents before and after meals. Observations revealed that staff did not offer or perform HH for residents before they started eating. Interviews with residents and staff confirmed that HH was not consistently provided, which is against the facility's hand-washing policy. The policy emphasizes the importance of HH in preventing the spread of infections, including gastrointestinal infections and food-borne illnesses like norovirus. The Director of Nursing (DON) and other staff acknowledged that the lack of HH was an infection control issue and could lead to sickness or disease among residents. The facility also failed to properly manage residents' valuables, which were found mixed with medications in the medication carts. Observations and interviews with staff revealed that residents' personal items, such as reading glasses and bracelets, were stored in the narcotic drawers of medication carts. Staff admitted that this practice posed a risk of cross-contamination and infection. The facility did not provide a specific policy for the safekeeping of residents' valuables, but the DON and other staff recognized that mixing personal items with medications was an infection control issue. Additionally, the facility did not ensure that laundry staff used aprons or gowns while handling clean resident laundry. An observation showed a laundry staff member folding clean linen without any protective clothing, allowing the linen to touch his clothing. The Infection Preventionist (IP) confirmed that protective clothing should be worn to prevent contamination. Furthermore, the facility lacked a detailed description and diagram of the water system, which is necessary for identifying areas that could encourage the growth and spread of Legionella bacteria. The Administrator admitted that the facility did not have this documentation, which is required by their Legionella Water Management Program policy.
Failure to Maintain Updated Antibiotic Surveillance Log
Penalty
Summary
The facility failed to maintain a system to monitor and track antibiotic use, as evidenced by an incomplete and outdated surveillance log of residents receiving antibiotics. During an interview and record review, the Infection Preventionist (IP) confirmed that the facility's Infection Prevention and Control Surveillance Log for February 2024 contained data for only one resident, despite there being eight residents currently receiving antibiotics. The IP acknowledged that the log was not updated with the necessary information and data for all residents on antibiotics. A review of the facility's policy on Antibiotic Stewardship indicated that all resident antibiotic regimens should be documented on a facility-approved antibiotic surveillance tracking form, including detailed information such as resident name, medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. The failure to maintain an updated surveillance log placed residents at risk of receiving antibiotics for longer than needed and developing antibiotic-resistant organisms.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to ensure that three of five sampled residents were offered and provided COVID-19 vaccines. Specifically, Resident 13 had not received the latest COVID-19 booster, and there was no documentation in his clinical record indicating he was offered or declined the booster. Resident 34 had consented to the latest COVID-19 booster but had not received it because the facility had not ordered the booster. Resident 30 had not received the latest COVID-19 booster, and there was no documentation in his clinical record that he was offered or refused the booster. Additionally, the facility failed to maintain documentation that staff were provided education regarding the benefits and risks of COVID-19 vaccines and were offered the COVID-19 vaccine. The Infection Preventionist (IP) stated that all staff were offered education and COVID-19 vaccines, but there was no documentation of it. Furthermore, the facility's COVID-19 policies and procedures had not been updated or revised since June 2020, as evidenced by the outdated COVID-19 Mitigation Plan provided by the IP.
Failure to Issue SNF ABN for Resident with Remaining Medicare Days
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to a resident (Resident 13) who no longer qualified for Medicare Part A skilled services but had not exhausted all her Medicare benefit days. Resident 13, who had severe cognitive impairment and required assistance with activities of daily living, was discharged from Medicare Part A but elected to stay at the facility. The Social Services Director (SSD) confirmed that the SNF ABN was not issued, and other staff members, including the MDS coordinator, Director of Nursing (DON), and Business Office Manager (BOM), were unsure of the correct notice to issue in such situations. Interviews with the SSD, MDS coordinator, DON, and BOM revealed a lack of knowledge and understanding regarding the issuance of the SNF ABN when a resident still had Medicare days but chose to remain at the facility. The SSD acknowledged the potential for miscommunication and resident frustration due to the failure to issue the SNF ABN. The facility did not provide a policy for Medicare Beneficiary Notice when requested, indicating a possible gap in their procedures and staff training related to Medicare coverage notifications.
Failure to Follow Care Plan and Provide Adequate Communication for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure that Resident 34 received the necessary care and services to maintain his highest practicable physical, mental, and psychosocial well-being. The activity care plan for Resident 34 was not followed, as evidenced by the lack of daily visits from activity staff, the absence of Spanish music or TV channels, and the failure to provide Spanish newspapers or religious services. Despite the care plan indicating daily visits and specific activities, the activity staff did not engage with Resident 34 as required, leading to potential risks of depression, frustration, and isolation for the resident. Additionally, the facility did not have an effective system for communicating with Spanish-speaking residents like Resident 34. Staff relied on Spanish-speaking employees or the resident's daughter to interpret, which is against the facility's policy. This lack of a proper communication system led to difficulties in understanding and addressing Resident 34's needs, as most of the staff, including nurses and hospice care providers, spoke only English. The reliance on untrained staff and family members for interpretation posed significant risks of miscommunication and unmet care needs. Interviews with various staff members, including the Activity Director, unlicensed staff, licensed staff, and the Director of Nursing, confirmed the absence of a structured communication system for non-English speaking residents. The facility's policy required the use of trained and competent interpreters, but this was not implemented. The failure to follow the care plan and the lack of proper communication methods compromised Resident 34's care and well-being, highlighting significant deficiencies in the facility's operations.
Failure to Ensure Regular Physician Visits for Hospice Resident
Penalty
Summary
The facility failed to ensure that Resident 2 received physician visits every 60 days, resulting in a lapse of over 8 months without a documented physician visit. Resident 2 was admitted to the facility and later to hospice care. The Director of Nursing (DON) confirmed that there were no documented physician visits for Resident 2 since the admission to hospice care. The DON initially stated that the hospice provider was responsible for the resident's care and physician visits but later admitted that the facility did not have the hospice records. Upon receiving the hospice records, it was confirmed that there were no physician visits documented after the resident's admission to hospice care.
Pharmacist Fails to Review and Recommend Antibiotic Usage
Penalty
Summary
The Consulting Pharmacist (PharmD) failed to perform the Medication Regimen Review (MRR) accurately and safely provide recommendations on antibiotic usage for two residents, Resident 5 and Resident 25. For Resident 5, the PharmD did not review the medical record to check the duration of antibiotic treatment for Doxycycline Hyclate, which was prescribed indefinitely without an end date. Additionally, the PharmD reviewed the MRR but did not provide any recommendations on the antibiotic usage for Resident 5, despite the order lacking an end date and reason for treatment. This oversight was confirmed during a telephone interview where the PharmD admitted to not reviewing the medical record for the duration of treatment and not providing recommendations in the MRR dated 1/31/24. For Resident 25, the PharmD also failed to provide recommendations on the antibiotic usage of Keflex, which was prescribed for prophylactic use for six months without an indication of the reason for the antibiotic usage. The initial physician order did not specify the reason for the antibiotic, which was only added later on 2/8/24. The facility's policies and procedures require that the medication order must have a reason for the antibiotic usage and that the physician and staff periodically re-evaluate the conditions and symptoms for which each resident is receiving medications. The PharmD acknowledged that the use of terms like 'Indefinitely' or 'STOP DATE PENDING' should not be used in antibiotic orders and emphasized the need for monthly evaluations and clear indications for antibiotic use.
Failure to Ensure Proper Antibiotic Usage
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically antibiotics. For Resident 5, the doctor's order for Doxycycline did not include an end date, and the care plan did not specify when to re-evaluate the effectiveness of the antibiotic. The medication label also indicated 'STOP DATE PENDING,' which was not acceptable. The Assistant Director of Nursing (ADON) acknowledged that the Infection Preventionist should have addressed this issue immediately, and the Licensed Nurse should have clarified the order with the doctor and notified the pharmacy of the discrepancy. For Resident 25, the doctor's order for Keflex did not initially indicate the reason for the antibiotic usage, and the urine culture and sensitivity test did not test for the effectiveness of Keflex. The care plan noted the antibiotic therapy but did not document the indication for its use until a later date. The ADON stated that the urine analysis and culture sensitivity were not repeated for re-evaluation since the resident was already on antibiotics. The Medical Director confirmed that antibiotic orders should have an end date and be re-evaluated for effectiveness after one month. These deficiencies were identified through interviews and record reviews, revealing that the facility did not follow proper protocols for antibiotic usage, potentially leading to antibiotic resistance. The ADON and Medical Director both acknowledged the lapses in procedure, emphasizing the need for clear documentation and regular re-evaluation of antibiotic treatments.
Incomplete Medical Record for Hospice Resident
Penalty
Summary
The facility failed to ensure the medical record of one resident was complete and readily accessible. Resident 2 was admitted to the facility and later to hospice care. During an interview and record review, the Director of Nursing (DON) acknowledged that there were no documented physician visits for Resident 2 since the admission to hospice care. The DON stated that the hospice provider was responsible for the resident's care and physician visits. Upon request, the DON admitted that the facility did not have the hospice records for Resident 2 but later received them by fax from the hospice provider, which included 34 pages of hospice records.
Failure to Explain Arbitration Agreements Properly
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were explained to residents in a language and form they understood, resulting in a deficiency for one of three residents (Resident 94). During an interview, the Administrator stated that arbitration agreements were offered to all residents upon admission, and the Director of Admissions was responsible for these agreements. However, it was found that Resident 94's Responsible Party (RP) signed the arbitration agreement without understanding its implications. The RP admitted to signing many forms during the admission process but did not recall signing an arbitration agreement or understanding what it entailed. When the concept of arbitration was explained, the RP stated she would not have signed the agreement if she had known its meaning. The deficiency was identified through interviews and record reviews. The Director of Admissions confirmed her responsibility for the arbitration agreements and provided copies of the agreements signed by three sampled residents, including Resident 94. The RP of Resident 94, who signed the arbitration agreement, was unaware of its significance and stated she did not understand that signing the agreement meant giving up the right to sue in court. This lack of understanding and proper explanation led to the deficiency noted in the report.
Failure to Post Daily Direct Care Staffing Schedule
Penalty
Summary
The facility failed to post the daily direct care staffing schedule in a location that was visible and accessible to all residents, staff, and visitors. The daily staffing schedule was found to be inserted in a binder inside the Nurses' Station and taped inside the Nurses' Station counter, making it only visible to CNAs and other staff. This deficiency was confirmed through observations and interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing. The daily staffing schedule lacked essential information such as the resident census at the beginning of the shift, the number of nursing personnel responsible for providing direct care, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed staff working for the posted shift. A review of the facility's policy and procedure titled
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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 Vacaville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vacaville Convalescent And Rehabilitation Center | 2.7 mi | ★★★★★ | 12 | 0 |
| Laurel Creek Health Center | 3.8 mi | ★★★★★ | 15 | 0 |
| Greenfield Care Center Of Fairfield | 7.3 mi | — | 30 | 0 |
| Emmanuel Care Center - Travis | 7.3 mi | — | 21 | 0 |
| Fairfield Post Acute Rehabilitation | 7.3 mi | ★★★★★ | 18 | 0 |
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