Vacaville Convalescent and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Vacaville Convalescent and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF658Mar 6, 2026

  Based 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.Findings: 1. […]

• No harm, potential for more than minimal, patternF814Mar 6, 2026

  Based 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.Findings: During an observation on 3/3/26 at 7:33 a.m. in the small parking lot adjacent to the facility kitchen, a gray metal dumpster was observed with the lid open. During a concurrent observation and interview on 3/3/26 at 8:35 a.m. with the Registered Dietician (RD) and the Dietary Services Supervisor (DSS), in the small parking lot, two large dumpers were observed uncovered. […]

• No harm, potential for more than minimal, patternF761Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF947Dec 6, 2024

  Based 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. Findings: During an interview on 12/04/24 at 4:21 p.m. with the DSD, the DSD stated in-services were scheduled two times a week on Tuesday's and Thursday's from 2:30 p.m. to 3:30 p.m. When questioned if the DSD provided in-services to the NOC shift staff, the DSD did not provide a response. During an interview on 12/05/24 at 8:09 a.m. […]