Inspection visit

Health inspectionJanuary 26, 2024

Folsom Care CenterCMS #05517312 citations on this visit

12 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 19 sampled residents (Resident 573) when nursing staff administered the wrong narcotic (pain) medication to Resident 573. Residents Affected - Few This failure had the potential for worsening their clinical condition. Findings: During a concurrent observation, interview and record review on 1/23/24 at 10:48 a.m. with the Director of Nursing (DON) at the Natoma nursing station, the First Dose Narcotic Emergency box (E-kit) was observed with a white plastic tie indicating it had been opened by nursing staff. Inside the narcotic medication E-kit were three E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply). The latest entry into the kit was documented on 1/16/24, for one tablet of Oxycodone (a narcotic pain medication to treat moderate to severe pain) 5 mg (milligram, a unit of measurement), one tablet as needed for pain, for Resident 573. A review of the E-kit inventory list from pharmacy indicated there were eight tablets of Oxycodone IR (immediate release) 5 mg stocked and there were currently eight tablets of Oxycodone IR in the E-kit. The DON confirmed there were still eight tablets of Oxycodone IR in the E-kit. A medication reconciliation of the E-kit was done with the DON, which revealed one missing Oxycodone/APAP (acetaminophen) 5/325 mg tablet. The DON verified there should be eight tablets of Oxycodone/APAP 5/325 mg but there were only seven tablets in the E-kit. The DON stated, I'm sure [the nurse] gave the tablet that has the Tylenol [acetaminophen] instead of the Oxycodone IR. The nurse should have done the five medication rights [the right: patient, drug, time, dose and correct route] and done it more than once. The DON verified Resident 573's Physician Orders, dated 1/2024, indicated an order with a start date of 1/15/24 for Oxycodone 5 mg, one tablet, by mouth every four hours as needed for moderate to severe pain. The DON acknowledged, The doctor ordered the Oxycodone IR 5 mg, not the Oxycodone with Tylenol [acetaminophen]. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated March 2018, the P&P stipulated, Medications are administered as prescribed with good nursing principles and practices .Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, the medication and dosage .on the resident's medication administration record (MAR) is compared with the label. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 19 Event ID: 055173 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Ensure emergency medications (E-kit) were replaced timely for a census of 77 residents; and 2. Dispose of medications in accordance with facility policy and procedure. These failures had the potential for emergency medications to be unavailable when needed, the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions, and the potential for diversion of medications. Findings: 1. During a concurrent observation and interview on 1/23/24 at 10:38 a.m. in the Mill station medication storage room with the Director of Nursing (DON), the First Dose Oral Medications E-kit was observed with a white plastic tie indicating it had been opened by nursing staff. Inside the oral medication E-kit were two E-kit logs (a document completed by nursing staff whenever a medication is removed from the emergency supply), with the earliest entry into the kit documented on 1/13/24. The DON confirmed the E-kit had been opened and stated, E-kits need to be replaced 72 hours after opening. During a concurrent observation and interview on 1/23/24 at 10:48 a.m. of the Natoma station medication cart with the DON, the First Dose Narcotic E-Kit was observed with a white tag indicating the E-kit had been opened by nursing staff. Inside the narcotic E-kit were logs indicating medications were removed on three separate occasions: twice on 1/12/24 and once on 1/16/24. The DON confirmed the E-kit had been opened and E-kits need to be replaced 72 hours after opening. During a review of the facility's policy and procedure (P&P) titled, Emergency Pharmacy Service and Emergency Kits, dated March 2018, the P&P indicated, .Opened kits are replaced with sealed kits within 72 hours of opening. 2. During an observation and interview on 1/23/24 at 9:50 a.m. in the Central Supply medication room with the DON, the DON stated each medication cart had a drug destruction container with a red lid. The DON stated whenever medications were dropped or refused by a resident, nursing staff were expected to immediately place it in the drug destruction container. During a concurrent observation and interview on 1/23/24 at 1:55 p.m. of the Sutter station medication cart with Licensed Nurse (LN) 2, a small paper cup with 12 unidentified pills was observed in the top drawer of the medication cart. LN 2 stated the medications were doses that were refused by residents and she had placed them in the cup to save herself time from having to go back and forth to the drug disposal container. During an interview on 1/24/24 at 11:39 a.m. with the DON, when asked how medications are disposed of the DON stated, [The LN] Shouldn't be doing that [placing the medications in a paper cup], those should go directly into the drug buster, that's what they're for. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated March 2018, the P&P indicated, .Once removed from the packaging . the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 refused medications are destroyed at the medication cart per facility procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues for one of 19 sampled residents (Resident 57), when the CP failed to identify the lack of target behavior monitoring and inadequate indication for use of antipsychotic medications. These failures had the potential for unsafe medication use. Findings: A review of Resident 57's medical record (MR) indicated Resident 57 was admitted to the facility in March 2022 with diagnoses including dementia (a condition characterized by memory loss) with psychotic disturbance, psychotic disorder with delusions (a mental disorder characterized by a disconnection from reality) and mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function). A review of Resident 57's MR indicated the following physician's orders: - Divalproex (a mood stabilizer used to treat certain psychiatric conditions) DR (delayed release) 125 milligrams (mg, a unit of measurement), take 1 tablet twice a day for mood disorder manifested by mood swings and verbal outbursts, ordered 10/3/23 - Quetiapine (antipsychotic medication that treats several kinds of mental health conditions) 25 mg, take ½ tab (12.5 mg) twice daily for psychotic disorder manifested by refusing needed care, ordered 10/4/23 During a concurrent interview and record review on 1/24/24 at 3:58 p.m. with Licensed Nurse 1 (LN 1), Resident 57's physician's orders were reviewed. When asked if the indication for Resident 57's divalproex was appropriate she stated, I don't see anything regarding verbal outbursts. I'm not sure what [divalproex sodium] is used for off the top of my head. When asked if the indication for Resident 57's quetiapine was appropriate she stated, I don't know if I would describe [refusing care] as a psychotic disorder, I'm not sure. LN 1 confirmed there was no target behavior monitoring related to the use of divalproex and quetiapine for Resident 57. During a concurrent interview and record review on 1/24/24 at 4:20 p.m. with the Director of Nursing (DON), Resident 57's MR was reviewed. The DON confirmed there was no target behavior monitoring for quetiapine. During a concurrent interview and record review on 1/25/24 at 3:17 p.m. with CP, Resident 57's MR was reviewed. When asked if mood swings and verbal outbursts were appropriate indications for the use of divalproex CP stated, It can be an indication for use, but there isn't any documentation of the mood swings or angry outbursts in his chart. A lot of these target behaviors are hard to quantify. When asked if refusing care is an appropriate indication for the use of quetiapine the CP stated, That's not my favorite indication, I admit that. Nursing staff likes to use that because it's easy to track. I can recommend some more target behaviors. The CP confirmed there was no monitoring for target behaviors related to the use of quetiapine for Resident 57. When asked if he provided a recommendation for monitoring a target behavior for quetiapine he stated, No, usually I'll make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 recommendations to add the monitoring if I don't see that monitoring there. I must have missed this one. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (Monthly Report), dated March 2018, the P&P indicated, The consultant pharmacist identifies irregularities through a variety of sources including: Medication Administration Records (MARs) . progress notes of prescriber, nurses and/or consultants . behavior monitoring information . and from interviewing, assessing, and/or observing the resident. The consultant pharmacist's evaluation includes . documented objective findings support each medication order . indication for use and therapeutic goals are consistent with . clinical practice guidelines . Response to drug therapy are evaluated to assure the appropriateness of the medication regimen. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review the facility failed to ensure one of 19 sampled residents (Resident 57) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 57 received psychotropic medications without adequate indication for use and was not being appropriately monitored. This failure resulted in unnecessary medications for the resident, which had the potential for increased risks and exposure of side effects associated with psychotropic medications such as sedation, falls, abnormal involuntary movements, and memory loss. Findings: A review of Resident 57's medical record (MR) indicated Resident 57 was admitted to the facility in March 2022 with diagnoses including dementia (a condition characterized by memory loss) with psychotic disturbance (a mental disorder characterized by a disconnection from reality), and psychotic disorder with delusions and mood disorder (general emotional state or mood is distorted or inconsistent with circumstances and interferes with the ability to function). During a review of Resident 57's MR indicated the following orders: - Ordered on 10/3/23 divalproex sodium (a mood stabilizer used to treat certain psychiatric conditions) DR (delayed release) 125 milligram (mg, a unit of measurement) tab, take ½ tab (12.5 mg) oral twice a day for mood disorder manifested by mood swings, verbal outburst. - Ordered on 10/4/23 quetiapine fumarate (an antipsychotic medication that treats several kinds of mental health conditions) 25 mg tab, take ½ tab (12.5 mg) oral twice daily for psychotic disorder manifested by refusing needed care. A review of Section E (Behavior) of the Minimum Data Set (MDS, an assessment tool), undated, indicated Resident 57 did not exhibit behavioral disturbances; including delusions, verbal behavioral symptoms directed at others, or rejection of care. During an observation on 1/24/24 at 2:15 p.m. in Resident 57's room, Resident 57 was observed lying in bed, under the covers, facing the wall in no apparent distress. During an interview on 1/24/24 at 2:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 described Resident 57, He's energetic and empathetic, talks to other residents and engages in conversations. He's helpful during care, he hasn't had outbursts; one time he was frustrated because he couldn't use the bathroom, but he couldn't verbalize it. CNA 1 denied Resident 57 had episodes of psychosis or refusing care. During an interview on 1/24/24 at 2:23 p.m. with Licensed Nurse (LN) 2, LN 2 described Resident 57, He's super relaxed .cooperative, able to communicate his needs .if he doesn't want to do something, then he won't do it and he'll verbalize it. He might initially refuse medications, but if you give him some time and come back, he will take his medications. LN 2 denied Resident 57 had episodes of psychosis and stated, He doesn't lose touch with reality when angry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 1/24/24 at 3:58 p.m. with LN 2, Resident 57's MR was reviewed. LN 2 confirmed there was no monitoring for divalproex sodium or quetiapine fumarate target behaviors. LN 2 confirmed there were no progress notes indicating Resident 57 was experiencing delusions, verbal outbursts or refusing care prior to receiving psychotropic medications. During an observation on 1/24/24 at 4:15 p.m. Resident 57 was observed in his room lying in bed, on his back, under the covers with his eyes closed in no apparent distress. During a concurrent interview and record review on 1/24/24 at 4:20 p.m. with the Director of Nursing (DON), the DON confirmed there were no progress notes indicating Resident 57 was experiencing delusions, verbal outbursts, or refusal of care. The DON verified there were no orders for monitoring the target behaviors related to divalproex sodium or quetiapine fumarate. When asked if there were any non-pharmacological (non-drug) interventions attempted before initiating these psychotropic medications the DON stated, No, I don't see any notes. During a concurrent observation and interview on 1/25/24 at 9:06 a.m. in Resident 57's room, Resident 57 was sitting up in his wheelchair by the side of the bed, appropriately groomed, with his tray table in front of him. Resident 57 engaged appropriately in conversation and stated he enjoys playing bingo with other residents. During a concurrent interview and record review on 1/25/24 at 10:25 a.m., Resident 57's medical record was reviewed with the facility's Consultant Pharmacist (CP). The CP stated he reviews a resident's medical record when reviewing the use of psychotropic medications. The CP stated, There would normally be a progress note documenting what they [physicians and nursing staff] are seeing and why the physician wants to use that specific medication and if they [nursing staff] are tracking that behavior. The CP confirmed there was no documentation of Resident 57's mood swings, angry outbursts or refusal of care and there were no orders for monitoring the target behaviors related to the use of divalproex sodium or quetiapine fumarate. During a concurrent interview and record review on 1/25/24 at 11:08 a.m. Resident 57's MDS, Section E, dated 9/28/23, was reviewed with the DON. The DON confirmed Resident 57 did not exhibit behavioral disturbances; including delusions, verbal behavioral symptoms directed at others, or rejection of care. During a review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Medication Use, dated September 2012, the P&P indicated, Psychotherapeutic medications are only considered for use after alternative methods have been tried unsuccessfully .Residents on psychotherapeutic medications will be monitored for appropriate use, effectiveness .Routinely, the licensed nurse will evaluate the resident for overall effectiveness of the psychotherapeutic medication and record side effects noted. The Interdisciplinary Team will review the report and recommendations will be documented in the resident's health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 31) was free of a significant medication errors when Resident 31's budesonide/formoterol inhaler (a medication to treat asthma, swelling of the airways making it difficult to breathe) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) was continuously given after it had expired. Residents Affected - Few This deficient practice resulted in Resident 31 receiving expired medication and had the potential for worsening Resident 31's medical conditions. Findings: A review Resident 31's medical record indicated she was admitted to the facility in 11/2023 with diagnoses that included COPD and asthma. A review of Resident 31's medical record indicated a physician's order, dated [DATE], for budesonide/formoterol 80/4.5 microgram (mcg, a unit of measurement) inhaler, administer 2 puffs twice daily for COPD. During a concurrent observation and interview on [DATE] at 2:07 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed Resident 31's budesonide/formoterol inhaler had been expired since [DATE]. LN 1 verified Resident 31 has been continuously receiving the inhaler past its expiration date. LN 1 agreed residents should not be administered an expired medication and stated, The [expired] medication will lose its efficacy. I usually check the expiration dates, but I missed this one. During a concurrent interview and record review on [DATE] at 10:48 a.m. with LN 1 and LN 3, Resident 31's Medication Administration Records (MAR) dated [DATE] through [DATE] were reviewed. LN 1 and LN 3 confirmed Resident 31 had received the expired budesonide/formoterol inhaler 25 times in [DATE] times in [DATE] and 38 times in [DATE]. During an interview on [DATE] at 11:52 p.m. with the Director of Nursing (DON), when questioned why the nursing staff would continuously administer an expired medication the DON stated, I don't know what is going on. If the nurse was actually giving it [the medication], it would have already been gone. The nurse should inform the doctor that the resident has been receiving an expired medication. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated [DATE], the P&P indicated, Outdated . medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some 1. Medication refrigerator temperatures were monitored twice daily; 2. An opened multi-dose biological was dated with an open and discard date to ensure it was not used beyond the discard date; 3. Single resident over-the-counter (OTC) products and prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and 4. Expired medications were available for resident use. The deficient practices had the potential for residents to receive unsafe or ineffective medications or biologicals from inadequate temperature monitoring and storage, medications with unsafe and reduced potency from being used past their discard date, and incorrect medications from inadequate labeling. Findings: 1. During a concurrent observation, interview and record review on 1/23/24 at 10:10 a.m., in the Sutter nursing station medication room, with the Director of Nursing (DON), the Medication Refrigerator Daily Temperature Records dated 11/1/23 through 1/23/24 were reviewed. The DON confirmed the logs were incomplete and nursing staff did not monitor and record the temperature on 21 shifts between the reviewed dates and stated, Temperatures are taken twice a day, on each shift. During a concurrent observation and interview on 1/23/24 at 11:09 a.m., in the Natoma nursing station medication room with the DON, the Medication Refrigerator Daily Temperature Records from 11/1/23 through 1/23/24 were reviewed. The DON confirmed nursing staff did not monitor and record temperatures on 41 shifts between the review dates and reiterated temperatures are to be taken twice a day. A review of the facility's Medication Refrigerator Daily Temperature Records indicated, Refrigerator temperature to be monitored and documented on every shift to maintain a desired refrigerator temperature . 2. During a concurrent observation and interview on 1/23/24 at 11:09 a.m. in the Natoma station medication room, with the DON, an opened multi-dose vial of tuberculin (a combination of proteins that are used in the diagnosis of tuberculosis) was observed without an open date. The DON confirmed the vial did not have an open date and stated the vial needed to be discarded 30 days once opened. A review of the manufacturer's packaging for tuberculin indicated, Short exp. [expiration] date, discard 30 days after opening. A review of the facility's policy and procedure (P&P), titled, Medication Labels, the P&P stipulated, Each prescription medication label includes .expiration date of the medication . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm 3. During a concurrent observation and interview on 1/23/24 at 1:28 p.m. at the Sutter station medication cart, with Licensed Nurse (LN) 2, LN 2 confirmed there were: - Four OTC eye drops (artificial tears) that did not have a pharmacy label or resident specific identification on the individual containers; Residents Affected - Some - One OTC eye ointment (lacrilube) that did not have a pharmacy label or resident specific identification on the container; and, - Two prescription inhalers placed in the incorrect containers without pharmacy labels or resident specific identification on the individual inhalers. LN 2 confirmed the OTC and prescription medications did not have resident specific information or opened dates on the medication containers. She stated the medication should have at least the resident's name and opened date. LN 2 stated, If it's [resident's medication] not labeled with the resident's name it could be given to another resident and that would cause an issue. During a review of the facility's P&P titled, Medication Labels, the P&P stipulated, If a label does not fit directly onto the product, e.g., eye drops, .the resident's name, at least, must be maintained directly on the actual product container .Each prescription medication label includes .Resident's name .expiration date of medication . 4. During a concurrent observation and interview on 1/23/24 at 1:28 p.m. at the Sutter station medication cart, with LN 2, LN 2 confirmed the following: - One lacrilube eye ointment had an expiration date of 1/19/24; and, - Two inhalers (Serevent 50 mcg [microgram, a unit of measurement] Diskus and Fluticasone Propionate/Salmeterol Diskus 500/50 mcg inhaler) were placed in the incorrect box. The open dates were illegible and there was no resident specific identification on the inhalers. LN 2 confirmed the open dates on the inhalers were illegible stating, I can't read that, it's too hard to read. LN 2 stated, The opened date needs to be written on the inhalers because you're supposed to use it within 30 days of opening them. During a concurrent observation and interview on 1/23/24 at 2:07 p.m. at the Mill station medication cart, with LN 1, LN 1 confirmed the following: - Two Spiriva Respimat inhalers did not have resident specific labels or opened dates; - Resident 31's Budesonide/Formoterol Fumarate Dihydrate inhaler did not have a resident specific label on the container and expired on 11/26/23; - One bottle of restful legs homeopathic tablets expired on 12/2023; and, - One Fluticasone Propionate/Salmeterol Diskus inhaler did not have a resident specific label or an open date. LN 1 confirmed the medications needed an open date because some medications need to be discarded after 30 days and agreed the medications needed to be labeled with resident specific labels for identification purposes. LN 1 confirmed Resident 31's medication had expired on 11/26/23 and the resident had continued to receive the expired medication. LN 1 stated residents should not be receiving expired medications since the medication will lose its efficacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a review of the facility's P&P titled, Medication Storage in the Facility, the P&P stipulates, Outdated .medications .are immediately removed from stock, disposed of .and reordered from the pharmacy . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when Dietary Aide (DA) 1 and DA 2 were unable to demonstrate and verbalize the procedure for verifying sanitizer strength for contact surfaces to ensure effective sanitation. This failure had a potential to result in ineffective sanitation and cause food borne illness in a high-risk population of 75 out of 75 residents who consumed food from the kitchen. Findings: During an initial kitchen tour observation and concurrent interview on 1/23/24, at 9:47 a.m., Dietary Aide (DA) 1 was sanitizing resident meal carts using a solution from a red bucket (the bucket is used as a standard of practice to contain sanitizer solution). The surveyor asked DA 1 to verbalize the procedure for testing the concentration of the sanitizer using the test strip. She stated she would dip the test strip in the sanitizer for one minute and the concentration should be at 150-200 ppm (parts per million-a unit to measure concentration). DA 1 demonstrated the procedure. She dipped the test strip dipped in the sanitizer for 16 seconds and the result was 150 ppm. A concurrent review of the test strip instruction on the test strip box with DA 1, it stated the test strip should immerse in the sanitizer for 10 seconds. During a follow up observation and concurrent interview with DA 2 on 1/24/23, at 9:01 a.m., DA 2 was sanitizing patient meal carts using the sanitizer solution in the red bucket. DA 2 demonstrated testing the sanitizer concentration in the red bucket by dipping the test strip in the solution for 12 seconds. She stated the sanitizer concentration should be at 100 ppm. The test strip indicated the strength of the solution was 150 ppm. DA 2 changed her answer and stated the concentration should be at 150 ppm. During a follow up interview with the RD on 1/25/24, at 12:23 p.m., the RD stated the kitchen staff should have the knowledge to properly test and prepare the sanitizer solution with the correct concentration. A review of departmental policy and procedure, titled Quaternary Ammonium Log Policy, dated 2018, it read, .the concentration will be tested at least every shift or when the solution is cloudy .the solution will be replaced when the reading is below 200 ppm . During a review of employee files of DA 1 and DA 2 on 1/24/24, at 4:01 p.m., it indicated DA 1 had a date of hire (DOH) of 10/20/97, and DA 2 had a DOH of 9/25/23. Neither DA 1 or DA 2 had current performance evaluations. A review of undated department document, titled Job Description: Diet Aide 1, it indicated, .Job Duties .Responsible to keep carts clean and sanitized .to maintain proper food handling practices .maintaining proper sanitation and safety standards .proper chemical use . An interview and concurrent review with the Nutrition Supervisor (NS) on 1/25/24, at 8:42 a.m. was conducted. A review of departmental documents, completed by the NS, titled Verification of Job Competency Demonstration, for DA 1 (completed on 7/20/20) and DA 2 (completed on 10/27/23), indicated DA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 and DA 2 demonstrated competency in the preparation, testing and recording of sanitizer solution concentration results. The NS confirmed the most recent competency for DA 1 was done on 7/20/20. She stated she did not perform staff competency checks yearly. A review of department document, titled Personal Management, dated 2018, indicated, .Responsibilities of FNS (Food and Nutrition Services) Director .food & Nutrition service .supervision, staff training and in-servicing .All Food & Nutrition Service employees shall receive a competency check and a written review by the FNS Director on an annual basis . A review of department in-service document, titled Chemical Sanitizer, completed on 11/16/23, it indicated DA 1 and DA 2 attended the in-service. A review of departmental documents, completed by the RD, titled Sanitation and Food Safety Checklist, completed on 12/8/23, 11/10/23, and 10/2/23 indicated a satisfactory rating in the area of Sanitizing solution test kit present, used, recorded, is within desired range per direction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Many 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. In a follow-up interview on 1/26/24 at 1:39 p.m., the IP stated, It [water management plan] doesn't exist. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) confirmed he expected the facility to have a water management plan addressing potential Legionella contamination. In an interview on 1/26/24 at 3:25 p.m. the Facility's Administrator (Admin) confirmed the facility did not have a water management plan to address the potential for a Legionella contamination, and the facility relied on the municipal water testing data. The Admin also confirmed there was no in-facility testing nor were related water management services completed. Facility's Policies and Procedures (P&P) addressing water management and Legionella control were requested but were not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer and administer pneumococcal vaccine (immunization against pneumonia [an inflammatory condition of the lung]) to one of five sampled residents (Resident 27). Residents Affected - Few This failure placed Resident 27 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms. Findings: A review of Resident 27's Face Sheet indicated Resident 27 was admitted to the facility in Fall of 2019. During a concurrent interview and record review on 1/26/23 at 1:39 p.m. with the Infection Preventionist (IP), Resident 27's vaccination records were reviewed and indicated Resident 27 received a Pneumococcal Polysaccharide Vaccine (PPSV23) on 8/22/15, (before turning [AGE] years old) and a Pneumococcal 13-valent Conjugate Vaccine (PCV 13) on 10/18/19, (after turning [AGE] years old). The IP confirmed Resident 27's records and acknowledged Resident 27 needed to be reassessed for vaccine eligibility based on age and CDC (Centers for Disease Control, the national public health agency) guidelines. The IP also confirmed there was no documented evidence that indicated the vaccine was offered. A review of CDC guidelines for Pneumococcal vaccinations titled, Pneumococcal Vaccine Timing for Adults, published on 3/15/23, indicated for adults who received the PCV 13 at any age and the PPSV23 prior to turning [AGE] years old, the Pneumococcal 20-valent Conjugate Vaccine (PCV20) or PPSV23 should be administered in at least 5 years from the last administration of the PPSV23 or in at least one year after administration of PCV13. A review of Resident 27's vaccination records and the CDC guidelines indicated Resident 27 qualified to receive either the PPSV23 or the PCV20 starting as of 10/18/20. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) stated he expected vaccinations to be offered per the CDC guidelines. The DON also stated if consents or declination responses were not received from the resident representatives, he expected facility staff to follow up within 30 days. A review of the facility's policy titled, Pneumococcal Vaccine, effective date 12/22/16, indicated, It is the policy of [facility's name] to provide pneumococcal vaccine to residents in accordance with CDC recommendations and physicians orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on interview and record review, the facility failed to offer and provide updated COVID-19 (Coronavirus Disease, an infection affecting the lungs) vaccinations to four out of five sampled residents (Resident 4, Resident 17, Resident 27, and Resident 43). This failure placed Resident 4, Resident 17, Resident 27, Resident 43 at an increased risk for illness that the vaccine could have prevented or decreased the severity of symptoms. Findings: A review of Resident 4's Face Sheet document indicated Resident 4 was admitted to the facility in summer of 2023. A review of Resident 4's vaccination record indicated Resident 4's latest COVID-19 vaccine was administered on 9/11/22. A review of Resident 17's Face Sheet document indicated Resident 17 was readmitted to the facility in winter of 2023. A review of Resident 17's vaccination record indicated Resident 17's latest COVID-19 vaccine was administered on 2/26/21. Vaccination record also indicated that resident was at the facility with initial admission from Summer of 2023 to December of 2023. A review of Resident 27's Face Sheet document indicated Resident 27 was admitted to the facility in Fall of 2019. A review of Resident 27's vaccination record indicated resident 27's latest COVID-19 vaccine was administered on 11/17/22. A review of Resident 43's Face Sheet document indicated Resident 43 was admitted to the facility in spring of 2021. A review of Resident 43's vaccination record indicated Resident 43's latest COVID-19 vaccine was administered on 11/17/22. During a concurrent interview and record review on 1/26/24 at 1:39 p.m. with the Infection Preventionist (IP), Resident 4's, Resident 17's, Resident 27's, Resident 43's vaccination records were reviewed. The IP confirmed all four residents did not have a current 2023-2024 COVID vaccine and the IP did not have documented evidence the vaccine was offered. The IP also provided and discussed COVID-19 test results which indicated Resident 17 tested COVID-19 positive on 11/29/23, and Resident 4 tested COVID-19 positive on 12/2/23. The IP added Resident 17 consented to the COVID-19 vaccination today and will be getting it shortly. The IP provided Resident 59's vaccination record and confirmed Resident 59 was current with the COVID-19 vaccination and received the vaccine at the facility. A review of Resident 59's (additional sample resident) Face Sheet document indicated Resident 59 was admitted to the facility early in 2020. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 59's vaccination record indicated Resident 59's latest COVID-19 vaccine was administered at the facility on 11/10/23., which confirmed the availability of the newer COVID-19 vaccines in November of 2023 when Resident 4, Resident 17, Resident 27, Resident 43 were at the facility and before Resident 4 and Resident 17 tested positive for COVID-19. In an interview on 1/26/24 at 1:54 p.m. the Director of Nursing (DON) stated he expected vaccines to be offered per CDC guidelines. The DON also stated if consents or declination responses were not received from the resident representatives, he expected facility staff to follow up within 30 days. A review of CDC guidelines for COVID-19 vaccinations, titled Stay Up to Date with Vaccines, updated 1/18/24, indicated, People aged 12 years and older who got COVID-19 vaccines before September 12, 2023, should get 1 updated [listed 3 brand names of vaccines] COVID-19 vaccine. A review of the facility's policy titled, COVID Vaccine, effective date 1/26/24, indicated, The Covid-19 vaccine is, generally, offered to all residents on admission and when new vaccine is available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Potential for minimal harm Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Based on observation and interview, the facility failed to ensure 13 resident rooms accommodated no more than 4 residents per room. Residents Affected - Some This failure had the potential to result in inadequate space for the provision of care. Findings: A variation was applied for and approved under §483.90(e)(1)(i) to accommodate 5 residents per room for 13 rooms (Rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214). The variation was continued after the 11/2021 recertification survey. Observations of these rooms were made throughout the survey. The rooms were uncluttered and residents had adequate space for safe mobility around each bed. Interviews were conducted with residents currently residing in the affected rooms and there were no complaints. The residents verbalized comfort and safety in the rooms. The Department recommends the continuation of the variation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, the facility failed to ensure 11 resident rooms (Rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as 145 sq. ft. for a two resident occupancy or 72.5 sq. ft. per resident. This failure had the potential to result in inadequate space for the provision of care. Findings: Observations were made throughout the survey of the rooms with two resident occupancy. The space was adequate to store assistive devices in the room (such as wheelchair and/or walker) to facilitate provision of care and needs. Interviews were conducted with available residents currently residing in the affected rooms. The residents verbalized the space was adequate for the provision of care. The Department recommends continuation of the waiver for the above mentioned rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 19 of 19

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Citations

12 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0802GeneralS&S Epotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0887GeneralS&S Epotential for harm
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
0911GeneralS&S Bno actual harm
F911 - Accommodate no more than four residents
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
0912GeneralS&S Bno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

FAQ · About this visit

Common questions about this visit

What happened during the January 26, 2024 survey of Folsom Care Center?

This was a inspection survey of Folsom Care Center on January 26, 2024. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Folsom Care Center on January 26, 2024?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 26, 2024