Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Folsom Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and dementia pushed another resident with severe cognitive impairment, Alzheimer's disease, and wandering behavior to the floor after becoming frustrated with the other resident entering her room. The pushing incident was documented as an unwitnessed altercation, and the aggressor resident stated she pushed the other as hard as she could so he would "learn his lesson." Facility leadership, including the DON and Administrator, acknowledged that the wandering resident frequently approached others and did not understand boundaries. This conduct occurred despite a written abuse prevention policy stating that residents must be free from physical and other forms of abuse, including abuse by other residents.
Two residents with cognitive impairments and documented histories of behavioral issues physically struck other residents who had dementia, depression, and trauma related to prior resident-to-resident altercations. In one hallway incident, a resident with severe memory impairment and poor impulse control swung an arm and hit another resident in the stomach, which was witnessed by a CNA and reported by the victim as painful. In a separate room incident, a roommate with severe memory impairment was observed by a CNA hitting a resident in bed twice on the shoulder. These events occurred despite a facility policy intended to prevent abuse and protect residents’ rights.
A resident with severe cognitive impairment and multiple medical conditions was observed with long, discolored nails with a brown substance underneath, indicating a failure in providing adequate nail care. The resident expressed a desire for nail trimming, and staff confirmed the condition but could not recall the last time nail care was provided. The DON acknowledged the need for rigorous nail care, but the facility's nail care policy was not available for review.
The facility failed to implement effective infection control practices during a norovirus outbreak, with no training provided by the Infection Prevention nurse. Resident 335's care was compromised by a urinary catheter drainage bag on the floor, unlabeled IV tubing, and a dirty pillow used without cleaning. The Director of Staff Development and Director of Nursing acknowledged the lack of specific training and checklists for these procedures.
The facility was found to have 13 rooms accommodating five residents each, exceeding the regulatory limit of four residents per room. Observations showed rooms divided by a wall with shared bathrooms, and measurements indicated insufficient living space per resident. Despite this, residents and staff reported no significant issues with space or maneuverability. A room waiver was recommended by the Department.
The facility failed to meet the minimum space requirement of 80 square feet per resident in 11 rooms. Despite staff and residents not reporting issues with maneuverability, measurements confirmed the deficiency, with some rooms providing only 72.5 square feet per resident.
The facility failed to provide accessible call light buttons for two residents, one with cardiomyopathy and dementia and another with atherosclerosis and dementia. The call light buttons were found in locations that were not within the residents' reach, making it difficult for them to call for help when needed. The DON and UM confirmed that the call light buttons should be accessible to ensure resident safety.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another to the floor. Resident 1, admitted in July 2024 with degenerative disorders of the nervous system and dementia, had a BIMS score of 11 indicating moderate cognitive impairment. Resident 2, admitted in October with Alzheimer's disease and dementia, had a BIMS score of 3 indicating severe cognitive impairment and was described by the DON as a wanderer who goes near others and does not understand boundaries. According to the Administrator, Resident 2's wandering behavior could be a danger to himself and others because he gets physically too close to others, which can be an annoyance. A progress note dated 3/22/26 at 10:15 p.m. documented that Resident 1 pushed Resident 2 to the floor in an unwitnessed altercation. Resident 1 stated she was tired of Resident 2 going into her room, that she pushed him as hard as she could, and that she hoped he learned his lesson. In a subsequent interview, Resident 1 reiterated that she did not like Resident 2 and wanted him to stay away from her, which was why she pushed him. The facility’s abuse prevention policy, revised 10/17, states that each resident has the right to be free from physical and other forms of abuse and that residents must not be subjected to abuse by anyone, including other residents. Despite this policy, the incident occurred, resulting in Resident 2 being pushed to the ground by Resident 1.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse when two residents were involved in separate resident-to-resident physical altercations. In the first incident, a resident with dementia and adjustment disorder but no documented memory impairment, and with a care plan noting trauma related to prior resident-to-resident abuse, was walking in a hallway when another resident approached from the opposite direction and swung her right arm, striking the resident in the stomach. The aggressor resident had dementia, anxiety, adjustment disorder with depressed mood, a BIMS score of 0 indicating severe memory impairment, and a care plan documenting a history of harm to others, poor impulse control, and prior hitting of another resident. Progress notes documented the altercation, and a CNA witness stated she saw the aggressor resident swing her arm and hit the other resident’s stomach; the victim resident reported being hit and experiencing pain at the time of the incident. In the second incident, a resident with Parkinson’s disease, dementia, Alzheimer’s disease, depression, moderate memory impairment, and a care plan noting trauma related to being a victim of resident-to-resident altercation was in bed when his roommate, who had Alzheimer’s disease, dementia, depression, anxiety, and severe memory impairment, hit him on the left shoulder. Progress notes for both residents documented that the roommate was witnessed hitting the resident’s left shoulder. A CNA reported hearing the resident yelling, entering the room, and observing the roommate hit the resident twice on the left shoulder. The DON acknowledged that residents have the right to be free from abuse and confirmed both incidents of one resident hitting another, despite the facility’s written policy on abuse prevention and reporting of alleged abuse and suspicion of crime intended to ensure residents’ rights are protected and to prevent any type of resident abuse.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care assistance to a resident, identified as Resident 16, who was observed with long, discolored nails with a brown substance underneath. Resident 16, who was readmitted to the facility in 2021, has a medical history that includes major depressive disorder, anxiety disorder, dementia, hepatitis C, nail dystrophy, and other nail disorders. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for assistance with personal hygiene and dressing. The care plan for Resident 16, revised in early 2025, stated that the resident was totally dependent on staff for personal hygiene and oral care. During observations and interviews conducted in February 2025, Resident 16 expressed a desire to have her nails trimmed. Nursing staff, including a Nursing Assistant and Unit Manager, confirmed the condition of the nails and acknowledged that they were long and had a brown substance underneath. The Certified Nursing Assistant (CNA) also confirmed the condition of the nails but could not recall the last time nail care was provided. The Director of Nursing (DON) agreed that the resident's nails should be clean and trimmed, especially given her medical condition. Despite requests, the facility's policy on nail care was not provided for review.
Infection Control Lapses During Norovirus Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control practices during a norovirus outbreak, as evidenced by the lack of training provided by the Infection Prevention nurse. Despite the outbreak affecting 15 residents with gastrointestinal symptoms, there was no documentation of preventive practices training or in-services conducted to protect patients and healthcare workers. Interviews with the Infection Prevention nurse, Director of Staff Development, and Director of Nursing confirmed the absence of such training, which was a critical oversight in managing the outbreak. Resident 335's care was compromised by several infection control lapses. The resident's urinary catheter drainage bag was found on the floor, contrary to proper infection control practices, which require it to be hung off the floor to prevent contamination. Additionally, the resident's intravenous tubing was not labeled with the date and time, a necessary step to ensure safe and effective IV therapy. The Unit Manager acknowledged the lack of labeling and the use of previously hung IV tubing, which was against facility policy. Further, a licensed nurse placed a dirty pillow under Resident 335's leg without cleaning or sanitizing it, despite the room not being cleaned after the previous resident's discharge. The housekeeping staff confirmed that the room had not been cleaned, highlighting a failure in communication and adherence to infection control protocols. The Director of Staff Development and Director of Nursing acknowledged the absence of specific training and checklists for these procedures, underscoring systemic issues in the facility's infection control practices.
Facility Exceeds Resident Room Capacity
Penalty
Summary
The facility failed to ensure that 13 of 32 resident rooms accommodated no more than four residents per room, as required by regulations. Observations during a facility tour revealed that these rooms were configured to house five residents each, with a solid wall dividing the space and a shared bathroom. The rooms had two beds on one side of the wall and three beds on the other, with privacy curtains separating the residents. Measurements taken during the survey indicated that the living space per resident was below the required standard, with one side of the room providing 117.5 square feet per resident and the other side providing only 88 square feet per resident. Interviews with residents and staff indicated that, despite the overcrowding, there were no significant complaints about space adequacy. Residents reported having enough space to move about and store personal belongings, while staff members, including a CNA and a licensed nurse, stated that they could maneuver residents and equipment without issues. The facility had requested a room waiver, and the Department recommended granting it, despite the potential for inadequate space for the provision of care.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 11 of 32 resident rooms met the minimum requirement of 80 square feet per resident. This deficiency was identified through observation, interviews, and record reviews. A facility letter dated 2/11/25 confirmed that these rooms measured less than the required space per resident. Despite this, the letter claimed that each resident had a reasonable amount of privacy and that the rooms provided sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During a tour and interviews with staff, it was observed that staff and residents could maneuver within the rooms without complaints. A Certified Nursing Assistant and a Licensed Nurse, both frequently assigned to the affected rooms, reported no issues with space or complaints from residents or families. The Assistant Administrator also confirmed no complaints had been received. However, a concurrent observation and interview with the Maintenance Supervisor and Assistant Administrator revealed that the living space per resident in one of the rooms was only 72.5 square feet, confirming the deficiency.
Inaccessible Call Light Buttons for Residents
Penalty
Summary
The facility failed to provide an accessible call system for two residents, resulting in a deficiency. Resident 1, who has cardiomyopathy and dementia, was unable to locate his call light button, which was found inside the top shelf of his bedside drawer, approximately 2 feet away from his bed. This placement made it difficult for Resident 1, who requires substantial assistance with various activities, to reach the call light button, especially in an emergency. The Certified Nurse Assistant (CNA) confirmed that the call light button should be within the resident's reach, but it was not in this case. Similarly, Resident 6, who has atherosclerosis and dementia, was also unable to locate her call light button, which was found on the bottom of her bed, touching the floor. Resident 6 requires substantial assistance with multiple activities and would not be able to reach the call light button in its current position. The CNA confirmed that the call light button should be next to the resident to ensure they can call for help when needed. The Director of Nursing (DON) and the Unit Manager (UM) acknowledged that the call light buttons should be accessible to residents. The facility's policy on resident rights emphasizes the importance of a safe and homelike environment, which includes having an accessible call system. The Centers for Medicare & Medicaid Services also require that the call system be accessible to residents while in their bed or other sleeping accommodations within the resident's room.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Folsom
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Healthcare Center | 5.1 mi | — | 22 | 0 |
| Citrus Heights Post Acute | 6 mi | — | 1 | 0 |
| Roseville Care Center | 6.4 mi | — | 2 | 0 |
| Pine Creek Care Center | 6.4 mi | — | 1 | 0 |
| Roseville Point Health & Wellness Center | 6.7 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.