Solano Post Acute
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm
surveying/licensing the facility. 2. All alleged violations of abuse. will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse.twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious.injury.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Solano Post Acute
2200 Tuolumne Street Vallejo, CA 94589
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-Tag F0610
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review, the facility failed to timely investigate and report the results of investigation of abuse allegations within five days for one of four sampled residents (Resident 1), when Resident 1 complained of being inappropriately touched by another resident and by a staff member.This failure resulted to the delayed investigation of the allegation and had the potential to result in Resident 1's emotional and psychological distress and further abuse. Resident 1 was admitted to the facility
in the summer of 2025 with multiple diagnoses which included left and right hemiplegia (left and right-side paralysis) and dysarthria (difficulty speaking).During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 6/29/25, the MDS indicated Resident 1 had no memory impairment.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes (PN), dated 8/5/25, the SBAR and PN indicated that on 8/3/25, Resident 1 reported that a male resident allegedly kissed her forehead while she was asleep and also alleged that an X-ray tech touched her inappropriately in her shoulder, forehead and breast and called her beautiful.During a review of the 5-Day Investigation Letter in which Resident 1 was involved as the victim, dated 8/11/25, the letter indicated, On 8/3/25, Resident 1 reported to the charge nurse that a [staff name].touched her arm and her breast.During a review of the Staff to Resident 5-Day investigation Letter in which Resident 1 was involved as the victim, the letter indicated the report was received on 8/11/25 at 4:04 p.m., eight days after the Resident 1's allegation.During a review of the Resident-to-Resident 5-Day Investigation Letter which Resident 1 was involved as the victim, the letter indicated the report was received
on 8/11/25 at 4:15 p.m., eight days after the Resident 1's allegation.During an interview on 8/15/25 at 11:20 a.m. with the Administrator (ADM), the ADM confirmed Resident 1 reported the allegations of inappropriate touching by another resident to the nurse and the inappropriate touching by a staff member on 8/3/25. The ADM confirmed he was the primary investigator and was expected to follow facility investigation policy. The ADM indicated the investigation was not done in a timely manner.During an interview on 8/15/25 at 11:45 a.m. with Resident 1, Resident 1 indicated that she notified the nurse on 8/3/25 about being inappropriately touched on her arm, forehead, and breast, and indicated she felt uncomfortable and felt ignored, and stated
she was disappointed in the facility's lack of urgency.During an interview on 8/15/25 at 1:30 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that all abuse allegations, witnessed or unwitnessed, should be reported according to the facility's protocol and documented, and stated, I witnessed [Resident 1] her crying in her room after the incident.During an interview on 8/15/24 at 3:07 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that if she observed abuse or received a report from a resident, she would immediately report the incident to her supervisor within two hours.During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting dated 2017, the P&P indicated, Reporting: .5.
The Administrator, or their designee, will provide the appropriate agencies.with a written report of the finding of the investigation within five (5) working days of the occurrence of the incident.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Solano Post Acute in VALLEJO, 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 VALLEJO, 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 Solano Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.