F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one resident (Resident 1) of two sampled residents
was free of abuse when Resident 2 slapped Resident 1 on the back.
This failure resulted in an increase in Resident 1's potential for social withdrawal and fear for his safety.
Findings:
A review of an admission record indicated Resident 1 was admitted to the facility in 2023 with diagnoses
which included syncope (fainting) and collapse and dementia (a chronic condition which results in a decline
in the person ' s ability to think, remember, and reason). A review of a Minimum Data Set (MDS, an
assessment tool) dated 8/2/24 indicated Resident 1 had a score of 10 on a Brief Interview for Mental Status
(BIMS, a questionnaire used to determine if a person's cognition (the process of thinking) is intact. A score
of 15 suggests intact cognition).
A review of an admission record indicated Resident 2 was admitted to the facility in 2022 with diagnoses
which included orthopedic aftercare (care after surgery involving the musculoskeletal system) and
hypertension (high blood pressure). A review of an MDS dated [DATE] indicated Resident 2 had a BIMS
score of 14.
A review of Resident 2's progress note dated 7/8/24 at 1:45 a.m. indicated, At [1:20 a.m.] .Resident [2]
.[had] an outburst/angry behavior towards the roommate [Resident 1] about his disturbance of sleep
caused by the roommate [Resident 1] .Resident [2] stated that he is really fed up and had enough of his
patience and can't deal with it anymore .
A review of Resident 1's progress note, dated 7/8/24 at 4:04 a.m. indicated, At [1:20 a.m.] Resident [1] was
moved out of the room d/t [due to] the roommate [Resident 2] complaint of sleep disturbance .While the 2
CNA [Certified Nursing Assistants] assigned was assisting the Resident [1], they witnessed the aggressive
behavior of the roommate [Resident 2] approached the Resident [1] yelling at him and slapping Resident [1]
on his upper back while saying to him that he already had enough of the noise and being disturb [sic] on his
sleep .
A review of Resident 1's care plan initiated on 7/8/24 indicated Resident 1 had the potential to experience
social withdrawal and fear for his safety related to an incident of aggression from his roommate, Resident 2.
(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 2
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
09/30/2024
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)
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 9/30/24 at approximately 4:50 p.m., Resident 2 confirmed he had slapped Resident 1 on
the back. Resident 2 stated Resident 1 had become annoying one night when he tried to get some sleep
because Resident 1 kept getting out of bed and was not following the staff's instructions. Resident 2 stated
he had gotten frustrated and lost his temper.
In an interview on 9/30/24 at approximately 5:13 p.m., CNA 1 confirmed she had witnessed Resident 2 hit
Resident 1. The CNA 1 stated Resident 1 had gotten out of bed and was confused so CNA 1 and another
CNA tried to redirect Resident 1 back to bed; however, Resident 2 woke up, got into his wheelchair, and hit
Resident 1. The CNA 1 stated Resident 2 seemed angry when he hit Resident 1 and Resident 2 stated he
was tired of Resident 1's behavior.
A review of the facility's policy titled Abuse Prevention and the Reporting of Alleged Abuse and Suspicion of
Crime revised on November 2016, indicated, .Each resident has the right to be free of .verbal .physical,
mental abuse .Residents must not be subjected to abuse by anyone, including, but not limited to .other
residents .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555349
If continuation sheet
Page 2 of 2
