Vacaville Convalescent and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident1) in a census of 88 was free from restraints when a bedsheet was knotted around his torso and tied in the back of his wheelchair (W/C) so he could not untie it. This failure resulted in Resident 1 being unable to independently free himself from the wheelchair.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with the current professional standards of nursing practice for two of 24 sampled residents (Resident 40 and Resident 124), when:Wound care orders were not updated and implemented as written for Resident 40; and,Wound care orders were not updated and implemented per the physician's verbal order for Resident 124. These failures had the potential for Resident 40 and Resident 124 to receive inadequate wound care with increased risk of complications.

Inspectors wroteBased on observations and interviews the facility failed to ensure the facility garbage and refuse was properly contained for a census of 87, when two out of two dumpsters were continually left open and uncovered. This failure had the potential for pest infestations, environmental hazards and foul odors to affect the residents' surrounding environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 42) was free from unnecessary medications, when Resident 42 was prescribed a psychotropic medication (any drug that affects behavior, mood, thoughts or perception) with no adequate indications. This failure had the potential to place Resident 42 at risk for adverse effects of the psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention practices when materials that had contact with room surfaces were brought from Resident 124's and Resident 129's rooms back to the clean treatment cart. This failure increased the potential for the spread of infections among residents in a census of 87.

Inspectors wroteBased on observation and interview, the facility failed to ensure hazardous chemicals were secured and inaccessible to residents when a housekeeping closet containing cleaning chemicals was left unattended, with the key hanging on the wall next to the door. This deficiency increased the risk of unauthorized access to hazardous chemicals and potential harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored according to accepted professional principles for a census of 82 residents, when loose pills were found in a medication cart and medication refrigerators were not maintained. This deficiency had the potential for residents to have an increased risk of receiving compromised medications. Findings During a concurrent observation and interview on 12/4/24 at 2:07 p.m., with Licensed Nurse 2 (LN 2) of north hall medication cart A, 8 loose pills were found in the bottom of the medication drawer. LN 3 confirmed the presence of the loose pills and stated that loose pills could be accidently given to residents. During a concurrent observation and interview on 12/4/24 at 2:31p.m. of north station medication room with LN 1, LN 1 confirmed the medication refrigerator was: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. The wound treatment nurse (TN): took a container of medication from a resident's room and put back in the clean supply cart, failed to sanitize equipment between uses for different residents, and did not label wound dressings. 2. Housekeeping staff did not perform hand hygiene between cleaning different resident rooms and the same mop and sanitizing solution was used to clean multiple rooms. 3. Enhanced Barrier Precautions were not applied for residents with wounds and indwelling medical devices. These failures had the potential to result in infection spread among a facility census of 82 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Certified Nursing Assistants (CNAs) were provided mandatory abuse training when documentation for the required training was unavailable for the 13 CNAs assigned to the night (NOC) shift. This failure had the potential for all 82 residents in facility to experience physical, mental, or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure baseline care plans (instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) were developed and implemented within 48 hours of admission for one (1) out of 21 sampled residents (Resident 238) when Resident 238 had been ordered anti-seizure medication without related seizure monitoring and care plan. This failure had the potential to place Resident 238 at risk for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to provide services according to professional standards when anticoagulant (medications that prevent or reduce blood clotting) monitoring was not in place for Resident 63. This failure had the potential to put Resident 63 at risk for having complications related to excessive bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of care and facility policy, for one (1) resident (Resident 240), out of 21 sampled residents, when: 1. Resident 240's nasal cannula (NC- nasal cannula, special tubing that delivers gas to the nostrils) was unlabeled with a date it was changed; and 2. facility's orders and practices in changing humidifier bottle (a bottle of distilled water inserted into an oxygen delivery system to add moisture when being administered oxygen) and nasal cannula were not in agreement with facility's policy. These failures increased the risk for resident 240 to develop respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive dementia (a progressive state of decline in mental abilities) care plan for one out of 21 sampled residents (Resident 57), when there was no dementia care plan for Resident 57. This deficient practice had the potential to delay dementia treatments and services needed for Resident 57.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure complete nurse staffing data was displayed and accessible for residents and visitors, for a census of 82 residents, when actual hours worked was not displayed. This failure had the potential to mislead residents and visitors of the actual hours worked by staff responsible for providing direct care to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of abuse when Resident 2 slapped Resident 1 on the back. This failure resulted in an increase in Resident 1's potential for social withdrawal and fear for his safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement guidance and recommendations to prevent the spread of Covid 19 infections to 18 out of 54 residents, Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 20, one (1) contractor and one (1) staff when: 1) The facility did not screen staff and visitors for any sign and symptoms of fever and cough before entering the facility. The staff, visitors and residents did not wear a N95 mask in the facility. The facility continued communal dining, activity, and physical therapy sessions. 2) The facility did not inform the Local Department Public Health in a timely manner when a Covid-19 outbreak, three (3) or more confirmed residents with Covid-19, occurred on 4/1/24. The facility reported the outbreak on 4/2/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation that an alleged abuse violation was thoroughly investigated. This failure to maintain documentation of an abuse investigation had the potential to delay implementation of corrective action(s) to protect the resident from further abuse and/or emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Advanced Beneficiary Notice of Noncoverage (SNF-ABN, a notice provided to Medicare recipients informing them of the upcoming end of Medicare reimbursement for a particular medical service) to the responsible parties for two of three sampled residents (Residents 47 and 62) receiving Medicare Part A benefits, when facility stated they did not know the facility had to provide a SNF-ABN. This failure did not ensure resident rights to appeal the non-coverage determination and had the potential to expose each resident to unnecessary financial liability associated with receiving non-covered services (e.g., services not covered by Medicare Part A).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool completed by clinical staff) was accurately completed for five of five sampled residents (Resident 4, 50, 8, 29, and 42) when Residents 4, 50, 8, 29, and 42 did not receive follow-up Pneumococcal vaccination as recommended by the Centers for Disease Control and Prevention (CDC) but the MDS for each resident indicated their Pneumococcal vaccination was up-to-date. This failure resulted to residents not getting the recommended Pneumococcal vaccine, putting each at-risk for increased respiratory infection. (Reference F883).

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's Protocol for Constipation for one of 5 sampled residents (Resident 280), causing Resident 280 to not have a bowel movement (BM) for eight days in a row. This had the potential for Resident 280's abdomen feeling full and bloated, and cause pain, hemorrhoids (swollen veins in your lower rectum) and unexplained weight loss, which could lead to Resident 280 being hospitalized .

Inspectors wroteBased on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases) for five of five sampled residents (Resident 4, 50, 8, 29, and 42). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result to serious respiratory infections.