A list of the most recent deficiencies for Vacaville Convalescent and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-05 | 2023-01-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-16 | 2023-01-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-16 | 2023-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-16 | 2023-01-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-16 | 2023-01-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-22 | 2022-08-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-22 | 2022-08-24 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-26 | 2021-12-21 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-25 | 2019-08-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-17 | 2019-06-17 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-17 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-17 | 2019-06-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-17 | 2019-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-17 | 2019-06-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-17 | 2019-06-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-17 | 2019-06-17 | N |
| 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. | Health | 2019-05-17 | 2019-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-17 | 2019-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-17 | 2019-06-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-17 | 2019-06-17 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-17 | 2019-06-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-17 | 2019-06-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Use approved construction type or materials. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-22 | 2018-09-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-29 | 2018-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-29 | 2018-08-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-29 | 2018-08-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-29 | 2018-08-08 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-06-29 | 2018-08-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-29 | 2018-08-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-29 | 2018-08-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-06-29 | 2018-08-08 | N |
