Folsom Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Medication storage rooms were kept secure when the automatic closing mechanism failed and the door was unlocked and accessible;2. Two of two medication storage room refrigerators were not monitored according to facility policy and procedure (P&P), and temperatures were not accurately documented;3. Emergency medications were not stored according to manufacturer specifications;4. Medication brought by family for Resident 69 was not labeled in accordance with facility P&P; and5. Medication carts were not kept locked and secure when unattended by nursing staff. These failures had the potential for diversion of medications, residents exposed to medications with unsafe or reduced potency, and incorrect or unsafe administration of medication from the absence of labeling on the container.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed when: Nursing staff did not wear appropriate personal protective equipment (PPE) while handling hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately). Pain medication was not administered in accordance with the physician's order. An unclear PRN (as need) psychotropic medication order for Resident 11 was not clarified for indication for use prior to administration. These failures had the potential to result in worsening resident health conditions and unwanted exposure to hazardous medications leading to health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure four out of five sampled employee personnel records included annual performance evaluations (formal, written, mandated processes typically occurring annually and during probationary periods to assess skill, knowledge, and work habits). This failure had the potential to result in poorly trained and managed employees, decreased quality of care provided, and safety risks for a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: Nursing staff disposed of medication that was prepared but not administered in accordance with facility policy and procedure;Medications for destruction were disposed of in a manner that limited potential for diversionEmergency medications (E-kit) were replaced timely for a census of 84;Two of 2 randomly selected medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were signed by the outgoing and incoming nursing shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.69% error rate when three medication errors out of 39 opportunities were observed during a medication pass for three of nine Residents (Residents 73, 84, and 103). This failure resulted in medications not given in accordance with the prescriber's order and potential to affect the residents' clinical conditions. 1. During a medication pass (med pass) observation on 4/21/26 at 8:22 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing two medications for Resident 103 including aspirin (a medication to prevent blood clots) EC (enteric coated, a special delayed release coating to prevent stomach irritation) 81 milligrams (mg, a unit of measurement), 1 tablet. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement infection control and prevention practices when:1. Laundry Staff 1 (LS 1) reused a gown after handling soiled linens;2. Incentive spirometers (IS, a handheld device designed to encourage deep breathing) were not labeled for 3 out of 22 sampled residents (Resident 21, Resident 56, Resident 101). These failures increased the potential for the spread of infections among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of as needed (PRN) lorazepam (a psychotropic medication to treat anxiety) for one of 22 sampled residents (Resident 3). This failure increased the potential for Resident 3's Responsible Party (RP) to not be informed of the risks and benefits of the medication and possible alternatives. A review of Resident 3's medical record indicated he was admitted to the facility in October 2025 with diagnoses which included dementia, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), depression, and anxiety. A review of Resident 3's medical record indicated the following physician's orders for lorazepam:- Lorazepam 0.5 milligram (mg, a unit of measurement): [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement a care plan intervention for the use of eyeglasses for one of 22 sampled residents (Resident 8), when Resident 8's glasses were not applied. This failure had the potential to negatively affect Resident 8's communication needs and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for one of 22 sampled residents (Resident 80), when wheelchair footrests were found in Resident 80's room walking pathway. This failure had the potential risk to result in accidents or injuries of Resident 80.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 8) remained free from unnecessary medication, when Resident 8 was prescribed and administered with antibiotics (ABX, medications that treat bacterial infections) for prophylactic (preventative medical measure or medication designed to stop a disease, infection, or health condition before it occurs) for a urinary tract infection (UTI, an infection in the bladder/urinary tract). This failure had the potential for antibiotic resistance and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate records were maintained for one of 22 sampled residents (Resident 3) when the physician updated Resident 3's bisoprolol (medication to treat high blood pressure) order to remove hold parameters (specific, pre-determined safety rules that tell a nurse or caregiver to skip a dose of medication if a resident's vital signs or lab results are not in a safe range) for blood pressure medication and nursing staff did update Resident 3's medication order to reflect the change. This failure resulted in an inaccurate medication order for Resident 3 and had the potential for Resident 3 to not receive blood pressure lowering medicine when it was scheduled to be administered.

Inspectors wroteBased on the interview and record review, the facility failed to implement the antibiotic stewardship protocol when the physician was not notified that McGeer's criteria (standardized surveillance definitions used in long-term care facilities to detect infections) for diagnosis of urinary tract infection (UTI) were not met for one resident (Resident 53) in a census of 84. This failure increased the potential for Resident 53 to receive unnecessary antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 13 of 32 resident rooms (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) accommodated no more than four residents in each room. This failure had the potential to result in inadequate space for the provision of residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 32 resident rooms (rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the minimum requirement of 80 square feet (sq. ft.) per resident. This failure had the potential to result in inadequate space for the provision of residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) was free from abuse when Resident 1 pushed Resident 2 and caused him to fall. This failure had the potential to cause physical harm to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) were free from abuse, when:1. Resident 2 swung her right arm and hit Resident 1's stomach; and2. Resident 4 hit Resident 3's shoulder while Resident 3 was in bed. These failures had the potential to negatively impact Resident 1 and Resident 2's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to ensure a safe environment for one of two sampled residents (Resident 2) when Resident 1, who had a history of wandering and touching residents was witnessed to touch Resident 2 in the groin area. This failure had the potential to cause physical and emotional distress to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was provided assistance with nail care when Resident 16 was observed with long untrimmed nails with a brown substance underneath. These findings had the potential for increased infections, shame, discomfort, and feelings of frustration for Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and preventive practices when: 1. There was no infection control and preventive practices training provided by the Infection Prevention nurse (IP, who specializes in preventing and controlling infections in healthcare settings) during a norovirus outbreak (a very contagious virus that causes stomach inflammation, vomiting, diarrhea, and stomach cramps); 2. Resident 335's urinary catheter (a hollow tube inserted into the bladder (a hollow organ of the lower stomach that holds urine before it leaves the body) drainage bag (a bag that collects urine) was found on the floor; 3. Resident 335's intravenous (IV- a needle or tube inserted into a vein) tubing was not dated; and, 4. Licensed Nurse (LN) placed a dirty pillow under Resident 335's leg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 13 of 32 resident rooms (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) accommodated no more than four residents in each room. This failure had the potential to result in inadequate space for the provision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 32 resident rooms (rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the minimum requirement of 80 square feet (sq. ft.) per resident. This failure had the potential to result in inadequate space for the provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an accessible call system for two of six sampled residents (Resident 1, and Resident 6) when Resident 1 and Resident 6's call light buttons were not within their reach. This failure has the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a water management plan to address potential Legionella contamination (a pathogenic microorganism that tends to colonize water systems and capable of causing pneumonia). This failure decreased facility's potential for early detection, prevention, and mitigation of Legionella-associated infections for a census of 77 residents. Findings During a concurrent interview and record review on 1/25/24 at 11:30 a.m. with the Infection Preventionist (IP), the facility's infection control policies and practices were reviewed. The IP stated she wasn't sure about water testing for Legionella and if the facility has a water management plan to address potential contamination. In a follow-up interview on 1/26/24 at 1:39 p.m., the IP stated, It [water management plan] doesn't exist. In an interview on 1/26/24 at 1:54 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure emergency medications (E-kit) were replaced timely for a census of 77 residents; and 2. Dispose of medications in accordance with facility policy and procedure. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and the potential for diversion of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Medication refrigerator temperatures were monitored twice daily; 2. An opened multi-dose biological was dated with an open and discard date to ensure it was not used beyond the discard date; 3. Single resident over-the-counter (OTC) products and prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and 4. Expired medications were available for resident use. The deficient practices had the potential for residents to receive unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage, medications with unsafe and reduced potency from being used past their discard date, and incorrect medications from inadequate labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when Dietary Aide (DA) 1 and DA 2 were unable to demonstrate and verbalize the procedure for verifying sanitizer strength for contact surfaces to ensure effective sanitation. This failure had a potential to result in ineffective sanitation and cause food borne illness in a high-risk population of 75 out of 75 residents who consumed food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide updated COVID-19 (Coronavirus Disease, an infection affecting the lungs) vaccinations to four out of five sampled residents (Resident 4, Resident 17, Resident 27, and Resident 43). This failure placed Resident 4, Resident 17, Resident 27, Resident 43 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 19 sampled residents (Resident 573) when nursing staff administered the wrong narcotic (pain) medication to Resident 573. This failure had the potential for worsening their clinical condition.

Inspectors wroteBased on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues for one of 19 sampled residents (Resident 57), when the CP failed to identify the lack of target behavior monitoring and inadequate indication for use of antipsychotic medications. These failures had the potential for unsafe medication use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 57) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 57 received psychotropic medications without adequate indication for use and was not being appropriately monitored. This failure resulted in unnecessary medications for the resident, which had the potential for increased risks and exposure of side effects associated with psychotropic medications such as sedation, falls, abnormal involuntary movements, and memory loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 31) was free of a significant medication errors when Resident 31's budesonide/formoterol inhaler (a medication to treat asthma, swelling of the airways making it difficult to breathe) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) was continuously given after it had expired. This deficient practice resulted in Resident 31 receiving expired medication and had the potential for worsening Resident 31's medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer pneumococcal vaccine (immunization against pneumonia [an inflammatory condition of the lung]) to one of five sampled residents (Resident 27). This failure placed Resident 27 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms.

Inspectors wroteBased on observation and interview, the facility failed to ensure 13 resident rooms accommodated no more than 4 residents per room. This failure had the potential to result in inadequate space for the provision of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure 11 resident rooms (Rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as 145 sq. ft. for a two resident occupancy or 72.5 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of care.