Inspection Reports for
Saylor Lane Health Care Center
3500 Folsom Blvd, Sacramento, CA 95816, CA, 95816
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
26.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
568% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
90% occupied
Based on a May 2024 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 13
Date: May 8, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, medication administration, feeding tube care, respiratory care, pharmaceutical services, dietary services, infection prevention and control, and COVID-19 vaccination documentation at Saylor Lane Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to label flush bags properly, incomplete pain assessments, improper handling of hazardous medications, failure to check feeding tube placement, unsafe respiratory care practices, medication administration errors, improper medication storage, dietary service deficiencies including improper dishwashing and menu adherence, infection control lapses such as bare hand contact with food, inadequate cleaning of equipment, and incomplete COVID-19 vaccination documentation for staff.
Deficiencies (13)
Nursing staff failed to label the flush bag attached to the Gastrostomy Tube with date and time.
Pain assessments before and after medication administration were not documented for Resident 19.
Nursing staff failed to wear appropriate personal protective equipment while handling hazardous medication.
Feeding tube placement was not checked before enteral feeding for Resident 8.
Resident 3's oxygen therapy was not administered according to physician's order and nasal cannula was not changed weekly.
Controlled substance medications were not accurately accounted for on medication administration records and controlled drug records.
Medication errors observed during medication pass including failure to prime insulin pens.
Refrigerated medications and biologicals were stored at improper temperatures (28°F) risking medication efficacy.
Dietary aides lacked knowledge of proper manual dishwashing procedures and sanitizer concentration testing.
Menu was not followed for therapeutic diets; mechanical soft diet portions were smaller than prescribed and fortified diets were not provided as ordered.
Food safety violations including unclean ice machine, dirty reach-in freezer, worn can opener blade, cutting boards with deep grooves, wet stacked metal pans, and dietary aide with long artificial nails.
Infection control lapses including staff handling resident food with bare hands, clean linen touching floor and clothes, improper cleaning and disinfecting of glucometer, failure to perform hand hygiene between medication routes, and failure to change nebulizer face mask weekly.
Facility failed to document COVID-19 vaccination status for seven staff members.
Report Facts
Medication error rate: 5.56
Sanitizer concentration: 50
Refrigerator temperature: 28
Nebulizer face mask tubing label date: 24
Blood sugar readings: 310
Blood sugar readings: 341
Blood sugar readings: 329
Blood sugar readings: 311
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Named in medication administration and glucometer cleaning deficiencies | |
| Licensed Nurse 2 | Named in medication administration and hazardous medication handling deficiencies | |
| Licensed Nurse 3 | Named in oxygen therapy and nebulizer face mask deficiencies | |
| Certified Nurse Assistant 1 | Named in food handling deficiency with bare hands | |
| Laundry Aide 1 | Named in linen handling deficiency | |
| Dietary Aide 1 | Named in dishwashing procedure deficiency | |
| Dietary Aide 2 | Named in dishwashing procedure and sanitizer concentration deficiency | |
| Dietary Aide 3 | Named in artificial nails infection control deficiency | |
| Director of Nursing | DON | Named in multiple interviews regarding deficiencies and expectations |
| Director of Staff Development | DSD | Named in infection control and food handling deficiencies |
| Maintenance Supervisor | MS | Named in ice machine cleaning deficiency |
| Registered Dietitian | RD | Named in dietary and infection control deficiencies |
| Laundry Aide 2 | Named in COVID-19 vaccination documentation deficiency | |
| Certified Nursing Assistant 6 | Named in COVID-19 vaccination documentation deficiency | |
| Certified Nursing Assistant 4 | Named in COVID-19 vaccination documentation deficiency | |
| Certified Nursing Assistant 5 | Named in COVID-19 vaccination documentation deficiency | |
| Licensed Nurse 4 | Named in COVID-19 vaccination documentation deficiency | |
| Licensed Nurse 5 | Named in COVID-19 vaccination documentation deficiency | |
| Cook | Named in dietary menu and food safety deficiencies |
Inspection Report
Routine
Deficiencies: 13
Date: May 8, 2025
Visit Reason
Routine inspection of Saylor Lane Healthcare Center to assess compliance with professional standards of quality, medication administration, infection control, dietary services, and facility safety.
Findings
The facility had multiple deficiencies including failure to follow professional standards in medication administration, infection control, dietary services, and equipment maintenance. Issues included unlabeled feeding flush bags, incomplete pain assessments, improper handling of hazardous medications, inadequate care for feeding tubes, improper respiratory care, medication errors, unsafe food handling, and incomplete COVID-19 vaccination documentation for staff.
Deficiencies (13)
F0658: Nursing staff failed to label the flush bag with date and time, document pain assessments before and after medication, verify vitals taken by CNAs before withholding medications, and wear appropriate PPE when handling hazardous medications.
F0693: Facility failed to ensure PEG tube placement was checked before enteral feeding for Resident 8, risking aspiration and regurgitation.
F0695: Resident 3's oxygen therapy was not administered per physician's order, oxygen nasal cannula was not changed weekly, and documentation of oxygen titration was lacking.
F0755: Controlled substance medications were not accurately accounted for on medication records, shift-to-shift counts were missing signatures, narcotic emergency kit was not replaced after use, and routine medication was unavailable for Resident 3.
F0757: Resident 3 received insulin glargine without adequate monitoring and nursing staff failed to notify physician of high blood sugar readings.
F0759: Medication error rate was 5.56% due to insulin pens not being primed before dosing by nursing staff.
F0761: Refrigerated medications and biologicals were stored at 28°F, below the recommended 36-46°F, risking medication efficacy.
F0802: Dietary aides lacked knowledge of proper manual dishwashing procedures and sanitizer concentration; ice machine and freezer were dirty; can opener blade worn; cutting boards had deep grooves; wet pans stored improperly; and dietary aide had long artificial nails.
F0803: Therapeutic diet menus were not followed; residents received incorrect portion sizes and fortified foods were omitted.
F0812: Food safety violations included unclean ice machine, dirty freezer, worn can opener blade, damaged cutting boards, wet pans stored improperly, inadequate dishwashing knowledge and practice, and dietary aide with artificial nails touching food contact surfaces.
F0814: Dumpster lids were deformed and did not close securely, risking pest infestation and disease spread.
F0880: Infection prevention failures included staff handling food with bare hands, clean linen touching floor and clothes, improper cleaning of shared glucometer, lack of hand hygiene between medication routes, bare hand contact with resident meal, and nebulizer face mask not changed weekly.
F0887: Facility failed to document COVID-19 vaccination status for seven staff members, increasing risk of infection transmission.
Report Facts
Medication error rate: 5.56
Sanitizer concentration: 50
Temperature: 28
Medication doses: 0.5
Blood sugar readings: 310
Blood sugar readings: 341
Blood sugar readings: 311
Blood sugar readings: 329
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Handled resident food with bare hands despite having a cut on finger. |
| LN 1 | Licensed Nurse | Did not prime insulin pens before dosing and did not disinfect insulin pen rubber seal before needle attachment. |
| DA 1 | Dietary Aide | Unable to verbalize proper manual dishwashing procedure; competent on emergency dishwashing. |
| DA 2 | Dietary Aide | Unable to verbalize and demonstrate proper sanitizer concentration testing; competent on dishwashing procedures. |
| DA 3 | Dietary Aide | Observed with long artificial nails with gem décor touching food contact surfaces. |
| LN 2 | Licensed Nurse | Did not perform hand hygiene between medication routes and did not change gloves between eye and oral medications. |
| LN 3 | Licensed Nurse | Confirmed nebulizer face mask tubing was not changed weekly. |
| LN 4 | Licensed Nurse | COVID-19 vaccination status not documented. |
| LN 5 | Licensed Nurse | COVID-19 vaccination status not documented. |
| LA 1 | Laundry Aide | Allowed clean linen to touch floor and clothes. |
| LA 2 | Laundry Aide | COVID-19 vaccination status not documented. |
| CNA 4 | Certified Nurse Assistant | COVID-19 vaccination status not documented. |
| CNA 5 | Certified Nurse Assistant | COVID-19 vaccination status not documented. |
| CNA 6 | Certified Nurse Assistant | COVID-19 vaccination status not documented. |
| CK 2 | Cook | COVID-19 vaccination status not documented. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident 1 physically abused Resident 4 by hitting him with a walker in the rehabilitation room.
Complaint Details
The complaint investigation was substantiated by interviews and record reviews showing Resident 1 threw a walker at Resident 4 causing potential harm. The facility did not report the incident to the Department as required. The nursing home disputes the citation.
Findings
The facility failed to protect Resident 4 from physical abuse by Resident 1 and failed to timely report the abuse allegations to the Department. The incident was witnessed by staff and other residents, and the facility treated the event as a behavioral outburst rather than resident-to-resident abuse.
Deficiencies (2)
Failure to protect Resident 4 from physical abuse by Resident 1 who hit Resident 4 with a walker.
Failure to timely report allegations of abuse to the Department for Resident 1 and Resident 4 after the incident.
Report Facts
Residents sampled: 4
BIMS score Resident 1: 14
BIMS score Resident 4: 13
Medication order date: Apr 10, 2025
Discontinue date: Apr 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehab | Director of Rehab (DOR) | Witnessed the abuse incident and confirmed it was resident-to-resident abuse |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Witnessed the abuse incident and assisted in restraining Resident 1 |
| Licensed Nurse 1 | Licensed Nurse (LN 1) | Assigned nurse who interviewed both residents and reported the incident should have been reported to the Department |
| Director of Nursing | Director of Nursing (DON) | Reviewed progress notes and stated the incident was treated as a behavioral outburst, not abuse |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident of resident-to-resident physical abuse where Resident 1 threw a walker at Resident 4 in the rehabilitation room.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews. Resident 1 physically abused Resident 4 by throwing a walker at him. The facility did not report the abuse allegations timely to the Department as required.
Findings
The facility failed to protect Resident 4 from physical abuse by Resident 1 and failed to timely report the abuse allegations to the Department. The incident was witnessed by staff and involved Resident 1 throwing a walker at Resident 4's left knee, causing potential harm and distress.
Deficiencies (2)
F 0600: The facility failed to protect one of four sampled residents from physical abuse when Resident 1 hit Resident 4 with a walker on his left knee in the rehabilitation room. This failure had the potential to cause serious injury, fear, and distress to Resident 4 and other residents present.
F 0609: The facility failed to timely report allegations of abuse to the Department for two sampled residents when Resident 1 was witnessed throwing a walker at Resident 4 hitting his left knee in the rehabilitation room. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.
Report Facts
BIMS score: 14
BIMS score: 13
Date of incident: Apr 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Rehab | Witnessed the incident and confirmed it was resident-to-resident abuse | |
| Physical Therapy Assistant | Witnessed the incident and assisted in restraining Resident 1 | |
| Licensed Nurse 1 | Interviewed residents and reported the incident should have been reported to the Department | |
| Director of Nursing | Reviewed progress notes and stated the incident was treated as a behavioral outburst |
Inspection Report
Routine
Census: 38
Deficiencies: 10
Date: May 17, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and documentation at Saylor Lane Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy, inadequate assistance with activities of daily living, improper wound care, incomplete fluid intake monitoring, improper oxygen therapy administration, incomplete dialysis documentation, unresolved medication regimen irregularities, expired medications stored with active stock, inconsistent food safety logs, inaccurate medical records, and lapses in infection prevention and control practices.
Deficiencies (10)
Failure to ensure residents' rights to personal privacy and confidentiality when meal tray tickets containing personal information were discarded in general trash.
Failure to provide nail care assistance to residents resulting in long, unsanitary fingernails with blackish substance.
Failure to follow physician's orders for stage 3 pressure ulcer treatment and failure to label wound dressings with nurse initials, date, and time.
Failure to assess and evaluate weekly fluid intake and output summaries for residents on fluid restriction.
Failure to follow oxygen therapy orders and failure to place oxygen in use sign outside resident's room.
Failure to consistently document post-dialysis weights and complete dialysis communication sheets.
Failure to act on pharmacist's recommendations regarding antipsychotic medication monitoring and presence of expired flu vaccines mixed with current stock.
Failure to consistently document food storage temperatures and sanitization solution logs.
Failure to maintain accurate, consistent, and complete medical records for multiple residents, including medication administration and fluid intake documentation.
Failure to follow infection prevention and control program including lack of PPE use during mobility assistance for residents on enhanced standard precautions and improper handling of oxygen nasal cannula.
Report Facts
Residents affected: 38
Missing temperature log entries: 4
Missing sanitizing solution log entries: 7
Missing temperature log entries: 14
Expired flu vaccine syringes: 9
Weight loss: 12.2
Fluid restriction: 1500
Fluid restriction: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 4 | Licensed Nurse | Confirmed Resident 233 had no dry dressing on stage 3 pressure ulcer and confirmed nasal cannula handling for Resident 14 |
| Physical Therapy Assistant | Physical Therapy Assistant | Observed not wearing gown or gloves while assisting residents on enhanced standard precautions |
| Director of Nursing | Director of Nursing | Provided statements on expectations for infection control, oxygen therapy, medication monitoring, and documentation |
| Licensed Nurse 2 | Licensed Nurse | Verified missing weekly I&O summaries for residents on fluid restriction |
| Licensed Nurse 3 | Licensed Nurse | Verified expired flu vaccines in medication refrigerator |
| Facility Pharmacist | Pharmacist | Reported unresolved medication irregularities and expired medications in storage |
| Chief Clinical Officer | Chief Clinical Officer | Confirmed awareness of enhanced standard precautions policy |
Inspection Report
Routine
Census: 38
Deficiencies: 11
Date: May 17, 2024
Visit Reason
Routine inspection of Saylor Lane Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to maintain resident privacy, inadequate assistance with activities of daily living, improper wound care, incomplete fluid intake monitoring, improper respiratory care, incomplete dialysis documentation, medication regimen review failures, expired medications stored with active stock, inconsistent food safety monitoring, inaccurate medical records, and lapses in infection control practices.
Deficiencies (11)
F 0583: Facility failed to ensure residents' rights to personal privacy and confidentiality when meal tray tickets containing resident information were discarded in general trash.
F 0677: Facility failed to provide nail care assistance to two residents, resulting in long, unsanitary fingernails with black substance underneath.
F 0684: Facility failed to follow physician's orders for stage 3 pressure ulcer treatment and failed to label wound dressings with nurse initials, date, and time.
F 0692: Facility failed to assess and evaluate weekly fluid intake and output summaries for two residents on fluid restriction.
F 0695: Facility failed to place oxygen in use sign on Resident 14's room and administered oxygen at a higher flow rate than ordered.
F 0698: Facility failed to document post-dialysis weights and complete dialysis communication sheets consistently for Resident 14.
F 0756: Facility failed to act on pharmacist's recommendations regarding antipsychotic medication monitoring and stored expired flu vaccines mixed with current stock.
F 0761: Facility failed to discard expired flu vaccines mixed with non-expired vaccines in medication refrigerator.
F 0812: Facility failed to consistently document food storage temperature and sanitization solution logs, risking foodborne illness.
F 0842: Facility failed to maintain accurate, consistent, and complete medical records for multiple residents, including inaccurate medication and fluid intake documentation.
F 0880: Facility failed to follow enhanced standard precautions; staff did not wear required PPE when assisting residents on enhanced precautions and left oxygen cannula uncovered when not in use.
Report Facts
Residents affected: 38
Missing entries: 4
Missing entries: 7
Missing entries: 14
Expired flu vaccine syringes: 9
Weight loss: 12.2
Fluid restriction: 1500
Fluid restriction: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapy Assistant | Observed not wearing gown or gloves while assisting residents on enhanced precautions | |
| Licensed Nurse 4 | Confirmed lack of wound dressing on Resident 233 and improper oxygen cannula handling | |
| Licensed Nurse 2 | Verified missing weekly I&O evaluations and fluid intake documentation | |
| Director of Nursing | Provided multiple statements confirming expectations and acknowledging deficiencies | |
| Facility Pharmacist | Reported unresolved medication irregularities and missing expired medication removal | |
| Chief Clinical Officer | Confirmed awareness of enhanced standard precautions policy |
Inspection Report
Routine
Census: 39
Deficiencies: 14
Date: May 19, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey of Saylor Lane Healthcare Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' dignity regarding urinary catheter privacy, failure to provide timely transfer/discharge notices, inaccurate resident assessments, inadequate wound care communication, lack of RN coverage for required hours, improper medication storage and labeling, food preparation and sanitation issues, incomplete medical records, and infection control lapses.
Deficiencies (14)
Failure to maintain residents' dignity when urinary catheter bags were not covered with privacy bags for two residents.
Failure to provide written notice of transfer or discharge to the long-term care Ombudsman and to one resident.
Failure to issue a written bed hold notice for one resident transferred to the hospital.
Failure to ensure accurate assessments were documented for one resident, resulting in inaccurate functional status reporting.
Failure to notify physician of a resident's wound and failure to develop a person-centered care plan for wound care within 48 hours of admission.
Failure to provide appropriate treatment and care according to orders and resident preferences, including improper wheelchair fit and inaccessible call light.
Failure to ensure registered nurse coverage for eight consecutive hours a day, seven days per week.
Failure to maintain pharmacy services, including unreplaced opened refrigerated emergency kits.
Failure to properly label and store medications and products, including expired and unlabeled items.
Failure to follow pureed food recipes and maintain proper food temperatures, risking malnutrition and weight loss.
Failure to procure, store, and serve food under sanitary conditions, including unlabeled opened food, expired food, personal items in food prep areas, dirty equipment, and improper mask use.
Failure to maintain complete and accurate medical records for two residents, including inaccurate MDS and incomplete documentation of bed hold notice.
Failure to ensure proper infection control practices, including inadequate hand hygiene, lack of gowns for laundry staff, and urinary catheter bags touching the floor.
Failure to ensure proper PPE usage for unvaccinated staff, including lack of enforcement of N95 mask use.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 39
Residents affected: 39
Residents affected: 4
Residents affected: 2
Residents affected: 39
Residents affected: 2
Residents affected: 39
Staff affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 4 | Licensed Nurse | Acknowledged urinary catheter bag touching floor |
| Director of Nursing | Director of Nursing | Acknowledged catheter bag privacy and wound care notification failures |
| Licensed Nurse 1 | Licensed Nurse | Observed improper hand hygiene during wound care |
| Clinical Consultant | Clinical Consultant | Acknowledged lack of RN coverage and bed hold notice |
| Dietary Supervisor | Dietary Supervisor | Acknowledged food preparation and sanitation deficiencies |
| Physical Therapy Assistant 1 | Physical Therapy Assistant | Confirmed contracture is an impairment |
| Medical Records person | Confirmed no documentation of bed hold for Resident 36 | |
| Infection Preventionist | Infection Preventionist | Confirmed hand hygiene and PPE deficiencies |
| Laundry Staff | Laundry Staff | Confirmed no gown use when handling soiled linen |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Observed wearing surgical mask but not N95 despite exemption |
Inspection Report
Routine
Census: 39
Deficiencies: 15
Date: May 19, 2022
Visit Reason
Routine inspection of Saylor Lane Healthcare Center to assess compliance with regulatory requirements including resident care, infection control, medication management, and facility operations.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, incomplete transfer and discharge notifications, inaccurate resident assessments, inadequate wound care planning, improper medication storage and labeling, unsanitary food handling and preparation, incomplete medical records, and lapses in infection control practices.
Deficiencies (15)
F 0550: The facility failed to maintain residents' dignity when urinary catheter bags for two residents were not covered with privacy bags.
F 0623: The facility failed to provide written notice of transfer or discharge to the long-term care Ombudsman and one resident.
F 0625: The facility failed to issue a written bed hold notice for one resident transferred to the hospital.
F 0641: The facility failed to ensure accurate assessments for one resident, resulting in an inaccurate Minimum Data Set (MDS) assessment.
F 0646: The facility failed to notify the physician of a resident's sacral wound, delaying assessment and intervention.
F 0655: The facility failed to develop a person-centered care plan within 48 hours of admission for a resident with a sacral wound.
F 0684: The facility failed to provide a properly sized wheelchair and ensure a call light was within reach for one resident.
F 0727: The facility failed to ensure Registered Nurse coverage for eight consecutive hours a day, seven days per week.
F 0755: The facility failed to maintain pharmacy services by not replacing two opened refrigerated emergency kits within 72 hours.
F 0761: The facility failed to properly label and store medications and products, including expired and unlabeled items, increasing risk of unsafe medication administration.
F 0804: The facility failed to follow pureed food recipes and maintain proper food temperatures, risking malnutrition and weight loss for residents.
F 0812: The facility failed to ensure food was procured, stored, and served under sanitary conditions, including unlabeled opened foods, expired items, personal items in food areas, dirty equipment, and improper mask use.
F 0842: The facility failed to maintain complete and accurate medical records for two residents, including inaccurate assessments and incomplete documentation of bed hold notices.
F 0880: The facility failed to implement proper infection prevention and control practices, including inadequate hand hygiene, lack of gowns for laundry staff, and urinary catheter bags placed on the floor.
F 0887: The facility failed to ensure proper PPE usage for unvaccinated staff, including failure to enforce N95 mask use.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 39
Staff affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Named in infection control hand hygiene finding | |
| Director of Nursing | Named in multiple findings including catheter bag placement and medication kit management | |
| Licensed Nurse 4 | Acknowledged urinary catheter bag touching floor | |
| Licensed Nurse 5 | Named in wound notification finding | |
| Physical Therapy Assistant 1 | Named in inaccurate assessment finding | |
| Clinical Consultant | Named in multiple findings including RN coverage and medication kit management | |
| Dietary Supervisor | Named in food preparation and sanitation findings | |
| Infection Preventionist | Named in infection control and PPE compliance findings | |
| Certified Nursing Assistant 2 | Named in PPE noncompliance finding |
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