Health inspection·February 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. Residents Affected - Some This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: Record Review of admission Record for Resident 1 indicated admission was on 12/13/23 and pertinent diagnoses are Other Specified Fracture of Unspecified Pubis, Subsequent Encounter for Fracture with Routine Healing and Anxiety Disorder Unspecified. During an interview on 2/20/24 at 12:14 p.m. with the Director of Nursing (DON), the DON stated Licensed Nurse A received an order for Resident 1 for a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) collection of urine for a urinalysis (a lab test of urine to determine the presence of a urinary tract infection) on 12/27/23. During an interview on 2/20/24 at 12:14 p.m. with the DON, the DON further stated that Resident 1's Family Member 1 reported at a Care Conference (meeting of facility management staff, resident and family, if indicated) on 12/29/24 that Resident 1 believed she was sexually assaulted during the catheter procedure. During an interview on 2/20/24 at 12:30 p.m. with the Administrator, the Administrator stated he talked with Licensed Nurse A after he was notified that resident 1 believed she was sexually assaulted during the catheter procedure. Administrator stated he was the Abuse Coordinator, and he did not routinely report alleged abuse until after he had investigated it. Administrator stated he did not believe any abuse occurred, so he did not report the allegation. During an interview on 2/20/24 at 1:25 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she became aware during a Care Conference on 12/29/23 of Resident 1's allegation that she was sexually assaulted during a catheter procedure. The ADON stated she investigated the allegation. During an interview on 2/20/24 at 1:45 p.m. with the Administrator, the Administrator stated he did an internal investigation of the allegation. Administrator further stated he had 24 hours to report abuse to the State Agency. (continued on next page) 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 4 Event ID: 555349 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 555349 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vacaville Convalescent & Rehab 585 Nut Tree Court Vacaville, CA 95687 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)