Vacaville Ranch Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF584Jul 29, 2021

  Based on observations, interviews, and record reviews, the facility failed to provide a safe and comfortable environment to 19 out of 49 residents, (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 ,10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) when the air temperatures in their rooms and Hall A, where Rooms # 1-9 were located, exceeded 81degrees F (Fahrenheit), ranging from 82 degrees F to 94.7 degrees F. This failure resulted in residents feeling too warm or too hot, and exposed to excessive heat that could potentially cause heat stroke, serious harm, or death. […]

• Immediate jeopardy, patternF725Jan 15, 2021

  Based on observation, interview and record review, the facility failed to provide sufficient staffing to meet resident needs for 24 of 24 residents in the COVID Unit. This failure resulted in the residents not being assisted with Activities of Daily Living (cross-reference to F677), not having vital signs monitored and not receiving RNA Program (cross-reference to F684), not receiving treatments to prevent and heal pressure ulcers (cross-reference to F686), not having their pain assessed and treated (cross-reference to F697), not receiving scheduled medications (cross-reference to F755), not having laboratory exams done (cross-reference to F770), not receiving safe, timely and hot meals (cross-reference to F804, F809 and F812) and not having care and treatments correctly documented in… […]

• Immediate jeopardy, patternF880Jan 15, 2021

  Based on observation interview and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when: 1) PPE was not readily available in resident care areas; 2) Staff did not use PPE properly in resident care areas; 3) Staff did not perform hand hygiene before and after resident care; 4) The facility allowed a non-infected resident to share a room with two infected residents without precautions to prevent spread of COVID-19; 5) The facility transported two COVID-19 positive residents through the non-COVID unit without wearing masks or other PPE; 6) The facility's screening form… […]

• Actual harm, isolatedF689Feb 9, 2024

  Based on interview and record review, the facility failed to provide supervision and other fall prevention interventions to prevent falls for two of two residents at risk for falls (Residents 20 and 14). For Resident 20, the facility failed to supervise and monitor Resident 20 and failed to ensure Resident 20 had access to a call light to ask for help when she needed to ambulate. These failures resulted in Resident 20 falling and fracturing her hip. For Resident 14, the facility failed to supervise and monitor Resident 14 to prevent falls resulting in Resident 14 sustaining three falls within a period of two weeks and placing her at risk of injuries. Findings: RESIDENT 20 A review of Resident 20's Admission Record indicated a date of initial admission of 3/25/29. […]

• Actual harm, isolatedF697Feb 9, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure adequate pain relief for one out of one sampled resident (Resident 34), when: 1. the nurse administered acetaminophen (APAP, a non-opioid analgesic and antipyretic agent utilized for treating pain) 650 milligram (mg, a unit of weight) for an 8 out of 10 pain level (8/10 PL, severe pain, hard to do anything at all); 2. the facility honored the family's preference over Resident 34's comfort; and, 3. the facility did not follow the physician's order to relieve Resident 13's severe pain. These failures led to resident grimacing, moaning and continuously complaining of 8/10 PL. Findings: A review of Resident 34's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. […]