Folsom Care Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on interview and record review the facility failed to provide adequate supervision to ensure a safe environment for one of two sampled residents (Resident 2) when Resident 1, who had a history of wandering and touching residents was witnessed to touch Resident 2 in the groin area. This failure had the potential to cause physical and emotional distress to Resident 2.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2020 with diagnoses that included Traumatic Brain Injury (an injury to the brain that can range in severity from mild to severe) and Dementia (a decline in memory function). A review of Resident 1's, Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 7/10/25, indicated Resident 1 had
a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 12 out of 15 which indicated Resident 1 had some understanding. A review of Resident 1's, MDS Section E - Behavior under physical behavior symptoms directed at others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) indicated a score of 1 which indicated the behavior had occurred before. A review of Resident's 1's Care Plan, initiated date of 7/8/24, indicated that the resident has a behavior problem entering personal space of others making them feel uncomfortable. A review of Resident 2's admission
Record indicated Resident 2 was admitted to the facility in 2024 with a diagnosis that included Chronic Obstructive Pulmonary Disease (an ongoing inflammation and narrowing of the airways, making it difficult to breathe). A review of Resident 2's, MDS, Cognitive Patterns, dated 7/17/25, indicated Resident 2 had a Brief Interview for Mental Status score of 4 out of 15 which indicated Resident 2 did not have full understanding. A review of Resident 2's Progress Notes, dated 9/8/25 at 1:13 p.m., indicated that Resident 2 admitted that Resident 1 touched her vagina. During an interview with the Director of Nursing (DON) on 9/24/25 at 10:17 a.m., the DON stated, Resident 1 was witnessed by a staff member touching Resident 2
on the groin. The DON further stated, Resident 1 has a history of going into other resident's personal space and inappropriate touching. During an interview with the Housekeeper (HK) on 9/24/25 at 11:13 a.m., the HK stated they had witnessed Resident 1 touching Resident 2 on the groin area. During an interview with
the DON on 9/24/25 at 12:43 p.m., the DON stated, This shouldn't have occurred, and he should have been watched more closely. The DON further stated, He should have been monitored more closely since it has occurred before. A review of the facility policy titled, Resident Rights dated 4/2017 indicated, To be free from mental and physical abuse.
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
Event ID:
FOLSOM CARE CENTER in FOLSOM, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FOLSOM, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOLSOM CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.