Vacaville Ranch Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. Several metal sheet pans in clean and ready-to-use storage areas:a. Were stacked wet while stored awayb. Had food debris and brown substance on outside surface; 2. There were opened bags of food items in dry storage, refrigerator, and freezer with issues:a. 12 opened bottles of spices did not have a use by dateb. One opened bin of chicken soup base did not have a use by date c .One opened loaf of bread did not have a use by dated. Four pallets of bread did not have a receive date e. One package of thawed country fried steak did not have a pull datef. One opened box of frozen beef patties did not have an open or use by dateg .One opened package of frozen cookie dough had an illegible open and use by date 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage for a census of 47, when garbage dumpsters were left uncovered. This failure had the potential to expose the facility to pests, disease, and odors.

Inspectors wroteBased on interview and record review, the facility failed to ensure 14 of 17 sampled residents (Resident 16, Resident 30, Resident 32, Resident 37, Resident 43, Resident 60, Resident 4, Resident 57, Resident 58, Resident 59, Resident 2, Resident 6, Resident 9, and Resident 29) were offered an advance directive (a legal document where a competent adult specifies their future medical care wishes in the event they cannot communicate them themselves, often due to illness or injury). This failure had the potential to result in the residents' medical wishes not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for the therapeutic diet for lunch on 8/6/25 when:1. 12 residents (Resident 5, Resident 6, Resident 9, Resident 15, Resident 18, Resident 21, Resident 29, Resident 31, Resident 35, Resident 39, Resident 41, and Resident 48) who were on a Mechanical Soft/Soft and Bite sized diet (a diet for people with mild to moderate chewing and/or swallowing difficulty) received whole green beans instead of soft and chopped green beans and hard bread instead of soft and buttered bread as indicated on the menu; and,2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow guidelines for Enhanced Barrier Precaution (EBP, an infection prevention and control intervention and guidance on what and how to properly wear the PPE, [personal protective equipment]) to reduce transmission of multi-drug-resistant organisms) that utilize the use of gowns and gloves during direct care activities for three of 17 sampled residents (Resident 4, Resident 43 and Resident 29) when:1. Licensed Nurse (LN) 3 and Infection Preventionist (IP) did not wear gowns and gloves when they turned Resident 4 to her side;2. Physical Therapy (PT) staff did not wear a gown and gloves when he brought Resident 43 to the gym and back to her room; and,3. Certified Nursing Assistant (CNA) 2 and Physical Therapy staff did not wear gowns and gloves with Resident 29. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold at the time of transfer was provided for two of 17 sampled residents (Resident 54 and Resident 6). This failure resulted in Resident 6 and Resident 54 not being fully informed about bed-hold options and rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care received for two of 17 sampled residents (Resident 58 and Resident 29) met professional standards, when:1) Nursing staff did not notify the physician of Resident 58's fluid imbalance; and2) Nursing staff did not document Resident 29's left heel wound accurately and completely. These failures had the potential to result in Resident 58 having fluid overload, electrolyte imbalance, or urinary retention and Resident 29's left heel to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure discharged /discontinued controlled medications (substances that have the potential for abuse and addiction and are therefore regulated by law) were jointly counted by the outgoing nurse and an oncoming nurse. This failure had the potential for diversion (obtain or use of prescription medicines such as controlled medications illegally), medication errors, and/or misuse of controlled medications in the facility. During a concurrent observation and interview on 8/5/25 at 10:45 a.m. with Licensed Nurse (LN) 2 of medication carts for A hall and part of B hall, LN 2 unlocked the narcotic box that contained active (active means, in-patient narcotic medications) and discharged /discontinued narcotic medications. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure: 1. Food items inside the refrigerator in the facility kitchen were labeled, open dated and had a use by date. These failures could lead to misidentification of food item and a potential for food borne illness (food poisoning) from consuming expired or spoiled items. 2. The utensils were stored in a sanitary condition when the drawers where utensils were stored were dirty with food crumbs and other residue from preparing food. This failure could result to cross contamination and the spread of bacteria. 3. A contaminated food item was not discarded properly. This failure could lead to consumption of unsafe food, diseases, and food borne illnesses.

Inspectors wroteBased upon observation, interview and record review, the facility failed to remove two expired multi-dose vials of Tuberculin skin test solution (used to test for tuberculosis (TB), which is an airborne bacterial infection that primarily affects the lungs) with expired dates from use. Failure to remove the opened, expired vials of Tuberculin skin test solution decreased the facility's potential to safely administer medication and ensure residents benefitted from the full effects of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure food was appetizing and palatable for three out of three sampled residents (Residents 42, 33, and 208). This failure put the residents at risk for decreased food intake and decline in their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prescribed medications, as ordered, for two of two sampled residents (Residents 153 and Resident 208), when: 1. Resident 153's Spiriva (an inhaled medication used to treat Chronic Obstructive Pulmonary Disease) was unavailable in the facility for four days; and, 2. Nine of nine scheduled medications (medications to be administered at a specific time) for Resident 208 were administered one hour and forty-five minutes past the scheduled administration time. These failures resulted in: 1. Resident 153 feeling anxious and increased the potential for an exacerbation of her chronic respiratory disease, which may have led to breathing difficulties, increased coughing, fatigue, and trouble sleeping or doing daily activities. 2. [...]

Inspectors wroteBased on interview and record review, the attending Physician failed to document that he or she reviewed the Pharmacist's findings and/or failed to document the action taken or not taken to address said recommendations for a period of five months (February 2024 to June 2024). This failure has the potential for all 49 vulnerable residents to experience adverse consequences from medication use, such as errors due to drug-drug interactions, omissions, duplication of therapy, or miscommunication between care providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow guidelines for standard precautions (infection prevention practices that apply to all residents. Standard precautions are based on the principal that all blood, body fluids, secretions .may contain transmissible infectious agents. Standard precautions include hand hygiene .), when one licensed staff did not perform hand hygiene (refers to hand washing, antiseptic hand wash, and alcohol-based hand rub) during: 1. the administration of medications for two of five sampled residents (Residents 14 and 209); and, 2. prior to one of one sampled residents (Resident 9) eating her meal. These failures had the potential to expose residents to infectious agents causing illness and potentially death.

Inspectors wroteBased on observation and interview the facility did not ensure one of one sampled (Resident 6) residents had her preferences honored when she wanted to get out of bed to have meals and was not assisted. This failure had the result of not being able to enjoy meals while out of bed, reduced respiratory exercise from not getting out of bed and increased skin breakdown by staying in bed all day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were immediately removed from stock and disposed of, when six bottles of medication were in the medication storage room two months after their expiration date. This failure had the potential to expose residents to medications that were less effective or risky due to a decrease in strength or a change in chemical composition.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures on antibiotic stewardship, when two of 18 residents, who acquired Urinary Tract Infections (UTIs), were prescribed antibiotics prior to the results of a culture sensitivity test (Residents 34 and 31). [A culture sensitivity test is a test to find germs, such as bacteria or a fungus, that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotics, will work best to treat the illness or infection]. This failure resulted in the inappropriate use of antibiotics and increased the risk for Residents 34 and 31 to develop multi-drug-resistant organisms and other antibiotic-related complications.

Inspectors wroteBased on interviews and records review, the facility failed to implement their policy on change of condition/ notification for one of two sampled residents (Resident 1) when Resident 1's Responsible Party was not notified of Resident 1's new sheared skin (one of the major causes of skin breakdown in sitting and occurs during transfers, reaching, weight shifts or repositioning) to his coccyx (small bone at the bottom of the spine). This failure did not ensure Resident 1's Responsible Party could exercise her right to be informed and to participate with Resident 1's care and treatment.

Inspectors wroteBased on interviews and records review, the facility failed to safeguard resident's property for one of two sampled residents (Resident 1). This failure resulted in Resident 1's missing clothes upon discharge from the facility.