Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Fairfield Post Acute Rehabilitation during CMS and state inspections, most recent first.
A resident with dysphagia and an order for a regular, easy-to-chew diet with thin liquids did not receive required quarterly nutritional assessments from the RD, who only documented assessments at admission and several months later, with no subsequent reviews. The resident reported being unable to eat spicy foods, relying on food brought from home, and not receiving help from dietary staff with food preferences, which the resident stated caused increased anxiety. A Dietary Aide stated they were unaware of the resident’s preferences until the RD recently updated the meal ticket, and the DON indicated the RD was expected to be proactive in meeting nutritional needs and quality of life, consistent with the facility’s dietitian job description.
A resident with metabolic encephalopathy and a burn injury did not receive weekly weights as ordered, with significant gaps in weight documentation and no follow-up on missed weights. The resident also had consistently low meal intake, but there was no evidence that LNs were notified of poor intake or meal refusals, despite facility expectations and care plan requirements.
A resident requiring continuous oxygen therapy due to respiratory failure and pneumonitis was transported to dialysis with an empty oxygen tank, resulting in the resident fainting upon arrival and requiring immediate intervention. Facility records confirmed the oxygen tank was not checked prior to transport, contrary to policy and physician orders.
The facility was found deficient in maintaining a sanitary environment for food storage and preparation. Ice packs for resident pain relief were improperly stored in a refrigerator meant for food. A dietary aide failed to correctly test sanitizer concentration, and a cook was unable to describe the proper cool-down process for food. These issues were confirmed by the Dietary Manager and Registered Dietitian.
The facility failed to maintain cleanliness in the trash area, potentially leading to vermin infestation. The trash area outside the kitchen had two dumpsters, with garbage found behind one and plastic bags shoved underneath. The Dietary Manager indicated the garbage came from a neighboring building and planned to have the waste company clean it. The facility's policy requires regular cleaning of the trash area to prevent vermin, but this was not followed.
The facility failed to maintain safe water temperatures in resident sinks, with temperatures reaching up to 121.8°F, causing fear and pain among residents. Staff interviews revealed inconsistent monitoring and a lack of policy on water temperatures. The Maintenance Supervisor was on vacation, and no alternative monitoring was arranged, leading to discrepancies in recorded temperatures.
The facility failed to provide adequate staffing, resulting in residents being left in urine or feces for extended periods. Staff confirmed short staffing issues, leading to delayed call light responses and compromised care quality. The facility lacked a specific staffing policy, relying instead on a Facility Assessment, which contributed to the deficiencies.
A resident on hospice care fell, resulting in a hematoma and a laceration, but the facility failed to initiate a care plan for these injuries. Despite physician orders to monitor the injuries, no treatment orders were made, and the care plan lacked focus areas for the wounds. The MDS Assistant and DON confirmed the absence of a care plan, which was against the facility's policy requiring comprehensive care plans for residents.
A facility failed to document the repositioning of a resident every two hours as required by their care plan, potentially delaying wound healing. Despite staff training on pressure ulcer prevention, record reviews showed gaps in documentation, indicating the care may not have been provided. Interviews with the DON, DSD, and nurses confirmed the importance of documentation, yet multiple instances lacked evidence of repositioning.
The facility failed to provide the required 80 square feet of living space per resident in multiple resident bedrooms. Observations revealed that rooms with three residents only offered 75.5 square feet per resident. Family members expressed concerns about the limited personal space available to residents.
Failure to Complete Quarterly Nutritional Assessments and Address Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when the Registered Dietician (RD) did not complete required quarterly nutritional assessments. The resident was admitted with diagnoses including dysphagia and had an order for a regular, easy-to-chew diet with thin liquids. Record review showed that the RD completed nutritional assessments only at admission in March 2025 and again in July 2025, with no further quarterly assessments documented thereafter. During a telephone interview, the RD acknowledged that subsequent quarterly nutritional assessments were not done and stated that the expectation was for timely assessments to monitor caloric needs, adverse weight changes, and changes to the diet plan. During an observation and interview, the resident reported being unable to eat spicy foods, that food was being brought in from home, and that dietary staff had not assisted with food preference requests, which the resident stated led to increased anxiety. In a separate interview, the Dietary Aide reported being unaware of the resident’s food preferences until recently, when the RD updated the resident’s meal ticket information, and acknowledged the importance of communication with residents and among staff to ensure meals match resident preferences. The DON stated that the RD was expected to be proactive in meeting residents’ nutritional needs and quality of life. The facility’s dietitian job description required informative dietary progress notes, periodic visits to evaluate meal quality and resident likes and dislikes, encouragement of resident/family participation, assistance with care plan scheduling, use of care plans in daily dietary services, review of nurses’ notes to determine if care plans were followed, and review of resident complaints and grievances.
Failure to Perform Weekly Weights and Notify Staff of Poor Intake
Penalty
Summary
The facility failed to perform weekly weights as ordered and per the care plan for one resident with significant medical conditions, including metabolic encephalopathy and a second-degree burn due to heatstroke. The resident was admitted with an order for weekly weights for four weeks, and the care plan also specified this intervention. However, documentation showed that weights were not consistently recorded on a weekly basis, with gaps of 8 to 18 days between some weight entries. There was no documented weight for one of the scheduled weeks, and no follow-up documentation was provided regarding the missed weight. Additionally, the resident's nutritional intake was below expectations, with meal consumption often at 26-50% for breakfast and lunch. Despite this, there was no evidence in the progress notes that licensed nurses were notified when meal intakes were low or when meals were refused, as required. Interviews with staff confirmed that the expectation was to follow orders and care plans, and to report changes in condition or poor intake, but there was no policy outlining the communication process between CNAs and licensed nurses for such concerns. The facility's own policy required weekly weights for four weeks upon admission, which was not followed in this case.
Failure to Ensure Oxygen Supply During Resident Transport to Dialysis
Penalty
Summary
A resident with diagnoses of respiratory failure and pneumonitis was admitted to the facility and required continuous oxygen therapy as per physician orders and care plan. The resident was scheduled for dialysis three times a week, with orders specifying continuous oxygen via nasal cannula at two liters per minute during all shifts, including transport to the dialysis center. On the day in question, the resident was transported to dialysis, but upon arrival, the transport driver and dialysis center staff discovered that the resident's oxygen tank was empty. The resident fainted in the transport van and required immediate oxygen upon entering the dialysis center. Facility documentation, including a late entry note and dialysis form, confirmed that the oxygen tank was empty upon arrival at the dialysis center. The facility administrator acknowledged that there was no documentation regarding the status of the oxygen tank prior to the resident leaving the facility, and stated that the expectation was for oxygen tanks to be checked before use. The facility's policy on oxygen therapy required safe administration of oxygen under physician's orders, but this was not followed in this instance.
Sanitation and Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary environment for food storage and preparation, as evidenced by several observations. Ice packs intended for resident pain relief were improperly stored in a refrigerator designated for resident food only. This was confirmed by the Dietary Manager and a Licensed Nurse, who acknowledged the ice packs were used for residents' pain relief, such as after knee replacement surgery. The Registered Dietitian also confirmed that ice packs should not be stored in a refrigerator meant for food. Additionally, a dietary aide did not correctly test the sanitizer bucket used for cleaning food preparation surfaces. The aide was unable to state the correct concentration for the sanitizer and had to consult the Dietary Manager. The facility's policy required the sanitizer concentration to be tested and maintained at a specific level. Furthermore, a cook was unable to accurately describe the cool-down process for food, specifically what to do if the food temperature was not at the required level. The Registered Dietitian noted that staff should be knowledgeable about these procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain cleanliness in the trash area, which could potentially lead to an infestation of rodents or other vermin. During an observation and interview, the Dietary Manager showed the surveyor the trash area outside the kitchen, which contained two dumpsters. One dumpster was designated for garbage and the other for recycling. Behind the garbage dumpster, a large container was found full of various pieces of garbage, including drink cups, napkins, and plastic bags. The Dietary Manager claimed that this garbage originated from the neighboring building. Additionally, the garbage dumpster was low to the ground, with approximately two inches of clearance, and plastic bags containing napkins, straw wrappers, and plastic utensils were shoved underneath it. The Dietary Manager stated that she would request the waste company to clean the area during their next visit, which was scheduled for 4 a.m. The facility's policy and procedure for the trash collection area, last revised in February 2023, mandates that the area must be swept and kept clean regularly to prevent it from becoming a feeding ground for vermin and rodents. However, the observation revealed that the facility did not adhere to this policy, as evidenced by the unclean trash area and the presence of garbage from an external source.
Unsafe Water Temperatures in Resident Sinks
Penalty
Summary
The facility failed to maintain safe water temperatures at resident sinks, resulting in water that was too hot to touch in 6 out of 22 resident bathroom sinks. This issue led to two residents expressing fear of burns and one resident experiencing pain when a hot washcloth was applied to her hands. Observations revealed that the water temperature in several sinks exceeded safe levels, with temperatures recorded as high as 121.8 degrees Fahrenheit. Interviews with staff, including the Environmental Services Supervisor, Maintenance Assistant, and CNAs, indicated a lack of consistent monitoring and awareness of the water temperature issue. The Maintenance Supervisor, who was responsible for checking water temperatures, was on vacation, and no alternative arrangements were made to ensure continued monitoring. Staff reported intermittent issues with hot water, but there was no clear protocol or policy in place to address these concerns promptly. The facility's Administrator acknowledged the absence of a specific policy on water temperatures for resident bathroom sinks and relied on guidance from an electronic log platform. However, discrepancies were noted between the temperatures recorded by the Maintenance Director and those observed by the surveyor and Maintenance Assistant, suggesting inconsistencies in monitoring and documentation. The lack of a systematic approach to managing water temperatures contributed to the deficiency, posing a risk of accidental burns to residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Multiple residents, including those with intact cognition and those requiring substantial assistance with toileting and personal hygiene, reported being left in their urine or feces for extended periods, sometimes over an hour. This lack of timely care led to feelings of frustration, humiliation, and fear among the residents, with one resident expressing concern about the risk of wound infection due to prolonged exposure to urine. Interviews with staff members, including a Licensed Nurse (LN), Staffing Coordinator (SC), and Director of Staff Development (DSD), confirmed the issue of short staffing. Staff reported that call lights were often not answered promptly, sometimes taking up to an hour, which was deemed unacceptable by the DSD. The SC noted that short staffing was often due to call-offs, leading to an increased workload for the remaining staff, which compromised the quality and safety of care provided to residents. The Director of Nursing (DON) acknowledged that staffing was based on various factors, including census and resident needs, but admitted that the facility lacked a specific staffing policy and procedure. The facility's policy on call lights required them to be answered within a reasonable time frame, but this was not consistently adhered to, contributing to the deficiencies observed. The absence of a formal staffing policy and the reliance on the Facility Assessment for staffing decisions further exacerbated the issue of inadequate staffing.
Failure to Initiate Care Plan for Resident's Fall Injuries
Penalty
Summary
The facility failed to initiate a care plan for a resident who experienced a fall, resulting in a hematoma on her forehead and a laceration on her right foot. Despite the fall occurring on 9/2/24, the care plan did not include focus areas for these injuries. The resident's physician orders included monitoring the injuries for signs of infection, but there were no treatment orders for the head and foot injuries. The resident was on hospice care, as indicated by the MDS dated 6/14/24. During observations and interviews, it was confirmed that there was no care plan for the resident's wounds. The MDS Assistant and the Director of Nursing both acknowledged the absence of a care plan and stated that it was the responsibility of the nurse assigned at the time of the fall to initiate it. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident based on their needs, but this was not done for the resident's injuries following the fall.
Failure to Document Repositioning of Resident
Penalty
Summary
The facility failed to implement all care measures specified in a resident's Comprehensive Care Plan, specifically the requirement to turn and reposition the resident every two hours. This deficiency was identified through interviews and record reviews, which revealed a lack of documented evidence that the resident was repositioned at the specified intervals on multiple dates. The resident, who was admitted with conditions including aftercare following joint replacement surgery and Down Syndrome, was totally dependent on staff for repositioning and turning in bed. The care plan highlighted the resident's potential for pressure ulcer development, necessitating regular repositioning as a preventive measure. Interviews with the Director of Nursing, Director of Staff Development, and licensed nurses confirmed that staff were trained to turn and reposition residents every two hours to prevent pressure ulcers. However, the documentation survey reports indicated gaps in the required care, with no records of repositioning on several occasions. The facility's policy and procedure for documentation emphasized the importance of accurate and chronological recording of resident care, yet the absence of documentation suggested that the care was not provided as required. This failure had the potential to delay wound healing for the resident.
Inadequate Living Space in Resident Bedrooms
Penalty
Summary
The facility failed to provide adequate living space in resident bedrooms, as required by regulations. During an observation, it was found that multiple resident bedrooms, each housing three residents, did not meet the minimum space requirement of 80 square feet per resident. Specifically, rooms 6, 7, and 8 were measured at 12 feet and 5 inches by 18 feet and 3 inches, resulting in only 75.5 square feet per resident after excluding the space occupied by movable wardrobes. This issue was consistent across 29 multiple resident bedrooms in the facility. Interviews with family members of residents occupying these rooms revealed concerns about the limited personal space available to the residents. Family members expressed that the space was tight and that residents needed more personal space to live comfortably.
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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 Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfield Care Center Of Fairfield | 0 mi | — | 30 | 0 |
| Emmanuel Care Center - Travis | 0 mi | — | 21 | 0 |
| Laurel Creek Health Center | 3.6 mi | — | 15 | 0 |
| Vacaville Ranch Post Acute | 7.3 mi | — | 0 | 0 |
| Vacaville Convalescent And Rehabilitation Center | 9 mi | — | 12 | 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.