Folsom Care Center

In the surveyor’s words

From the most serious findings on record at Folsom Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Apr 24, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jan 26, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF658Apr 24, 2026

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF730Apr 24, 2026

  Based 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.Findings: During a concurrent interview and record review on 4/23/26 at 8:53 a.m. with the Director of Staff Development (DSD) and the Administrator (Adm), the Certified Nursing Assistants (CNAs) personnel records reviewed did not have a completed Annual Performance Evaluations (APE). […]

• No harm, potential for more than minimal, patternF755Apr 24, 2026

  Based 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. […]