Rancho Seco Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF606Feb 24, 2025

  Based on interview and record review, the facility failed to protect nine out of 97 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) from sexual abuse and the potential to affect all residents in the facility when the facility knowingly employed Certified Nursing Assistant 1 (CNA 1) with a history of a criminal misdemeanor (an offense punishable under criminal law). This failure led to nine residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8 and Resident 9) being sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. […]

• Immediate jeopardy, patternF600Feb 24, 2025

  Based on observation, interview, and record review, the facility failed to protect the residents ' right to be free from sexual abuse by a staff member for nine of ten sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) when Certified Nursing Assistant 1 (CNA 1) sexually assaulted (sexual contact upon a person without their consent or on a person who is incapable of providing consent. Includes rape, unwanted sexual touching, oral sex and exposure) Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9. […]

• Actual harm, isolatedF689Mar 13, 2024

  Based on interview and record review, the facility failed to implement measures to safely transfer one of three sampled residents (Resident 1) when staff did not follow facility Policy and Procedures (P&P) for safe resident handling/transfers and the Physical Therapy (PT) recommendations for the use of a sit to stand lift (a device designed to assist patients who have some mobility but need help to rise from a sitting position) with (2) staff assistance. This failure resulted in a fracture (break) of the bone in the lower leg and increased pain for Resident 1. […]

• Actual harm, isolatedF600Jun 20, 2023

  Based on observation, interview and record review, the facility failed to protect one of five residents (Resident 1) from neglect, when a severe left leg injury of unknown origin was originally observed by facility staff on 5/23/23, but not assessed, treated and reported until 5/27/23. This failure resulted in Resident 1 experiencing prolonged, under-treated and unnecessary pain. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in the winter of 2013 with diagnoses which included dementia, (problems with memory, language and other thinking abilities), osteoarthritis (joint disease), and chronic pain syndrome (pain lasting 3-6 months or longer associated with depression and anxiety). […]

• No harm, potential for more than minimal, widespreadF812Apr 11, 2025

  Based on observation, interview and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety when: 1. One bag of grits was found open and left unsealed, and was without open and use-by dates, 2. Kitchen environment was not maintained (e.g. walk-in refrigerator floor sealant was worn off with areas of missing metal and texture coating, kitchen walls and ceiling had areas of missing texture and paint, and showed signs of water damage), 3. Fruit and vegetable sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink), 4. […]