Solano Post Acute

In the surveyor’s words

From the most serious findings on record at Solano Post Acute, in the surveyor’s own words.

• Actual harm, patternF689Apr 12, 2022

  Based on observation, interview and record review, the facility failed to keep four residents safe when: 1. The facility did not revise the plan of care to reflect the IDT (interdisciplinary team) recommendations and did not assess the effectiveness of the interventions to prevent two out of six sampled residents (Resident 15 and Resident 19) from falling as evidenced by: a.) Resident 15 had eight falls within a 11-month period from 4/1/21 to 3/9/22. Resident 15 sustained a [CONDITION(S)] from the fall on 11/17/21 which required Resident 15 to be sent to an acute care hospital and underwent a surgical repair of the [CONDITION(S)]. After 11/17/21, Resident 15 had two more falls on 2/25/22 and 3/9/22; and b.) Resident 19 had four falls during a 10-month period from 5/26/21 to 3/10/22. […]

• Actual harm, isolatedF726Jul 15, 2024

  Based on interviews and record reviews, the facility failed to ensure: 1. Staff were aware of what was sepsis (a serious complication of an infection, without prompt treatment, it can lead to organ failure, tissue damage and death) and its symptoms. 2. Staff were monitoring for signs and symptoms of Urinary Tract Infection (UTI, A condition in which bacteria invade and grow in the urinary tract system, which removes waste from the blood, in the form of urine) for one out of two sampled residents (Resident 1). These failures resulted in Resident 1 hospitalization on [DATE], due to Sepsis. […]

• Actual harm, isolatedF677Jan 19, 2024

  Based on observation, interviews, and record reviews, the facility did not provide one of three sampled residents, Resident 1, a resident who was unable to carry out some ADLs (Activities of Daily Living- e. g. showers, bed baths, etc.), the necessary services to maintain good grooming and personal hygiene, when Resident 1 reported to this surveyor that the last shower she got was approximately a year ago, and was not given any explanation why she was only getting bed baths instead of showers. […]

• Actual harm, isolatedF610Nov 9, 2023

  Based on interviews and record reviews, the facility failed to ensure: 1. an abuse allegation was investigated for one out of three sampled residents (Resident 1) on two separate occasions on these dates: 2/2023 and 9/19/23; and, 2.facility staff was aware of the correct reporting time frame for abuse allegations. These failures put the residents at risk for further potential abuse as the alleged perpetrator had continued access to the alleged victim and/or other vulnerable residents. […]

• Actual harm, isolatedF686Nov 9, 2023

  Based on observation, investigation and record review, the facility failed to ensure residents were receiving care to prevent pressure ulcers and did not develop pressure ulcers, for one out of three sampled residents (Resident 1). This failure resulted in Resident 1 acquiring a Stage 4 pressure ulcer (PU, the most serious type of pressure ulcer. This ulcer extends below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments and in more severe cases, they can extend as far down as the cartilage or bone) on her sacrum (the bottom of the spine and is a triangular-shaped bone) which at one point got infected and was treated with debridement (the removal of dead (necrotic) or infected skin tissue to help a wound heal), antibiotics (medicines that fight infections… […]