Health inspection·March 21, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview, and record review, the facility failed to ensure respect and dignity for two of seven sampled residents (Resident 4 and Resident 7), when staff did not label Resident 4 and Resident 7's clothing. This failure had the potential to result in the residents' clothing being lost. Findings: During a review of Resident 4's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 4 was admitted to the facility October 2024 with multiple diagnoses which included atrial fibrillation (a heart rhythm disorder that causes an irregular heartbeat). Resident 4's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/24/24, indicated Resident 4 was cognitively intact. During a review of Resident 7's face sheet, the face sheet indicated, Resident 7 was admitted to the facility December 2021 with multiple diagnoses which included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of left hip. During an interview on 3/21/25 at 9:04 a.m., with Resident 4, Resident 4 stated he had issues with his clothing being lost after being sent to the facility laundry. Resident 4 also stated he recently lost two pairs of grey sweatpants that his wife purchased for him. Resident 4 further stated the sweatpants were sent to the facility laundry without being labeled. During an interview on 3/21/25 at 10:05 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated resident clothing should be labeled. CNA 1 acknowledged there was an issue with missing laundry in the facility when clothing was not labeled. During an interview on 3/21/25 at 11:06 a.m., with the Laundry Supervisor (LS), LS stated clothing should be inventoried and labeled upon admission and when new clothes were brought in by family or purchased by resident. LS further stated CNAs should make sure clothing were labeled before being brought to the facility laundry. During a concurrent observation and interview on 3/21/25 at 11:15 a.m., with the Director of Staff Development (DSD), in Resident 7's room, DSD confirmed three shirts, and one pair of pants were not labeled with Resident 7's name. DSD stated the clothing should have been labeled by staff. During a concurrent observation and interview on 3/21/25 at 11:20 a.m., with DSD in Resident 4's Page 1 of 2 056238 056238 03/21/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room, DSD confirmed one flannel jacket was not labeled with Resident 4's name. DSD stated there is a risk for clothing to be lost if they are not labeled. During a review of the facility's policy and procedure (P&P), titled, Personal Clothing, revised 6/2016, the P&P indicated, .all clothing for residents must be labeled .follow-up is needed to ensure that any clothing brought in by families .is also labeled properly .staff needs to remember to check for lost labels or faded writing on a regular basis . During a review of the facility P&P titled, Resident's Rights, dated February 2021, the P&P indicated, .these rights include the resident's rights to .be treated with respect, kindness, and dignity . 056238 Page 2 of 2