Fairfield Post Acute Rehabilitation
Fairfield Post Acute Rehabilitation in Fairfield, CA — inspection on January 9, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 53's AR, the AR indicated Resident 53 was admitted in December 2025 with several diagnosis including severe protein calorie malnutrition.During a review of Resident 90's AR, the AR indicated Resident 90 was admitted in December 2025 with several diagnosis including acute respiratory failure with hypoxia (low levels of oxygen in tissues and organs).
During a review of Resident 7, Resident 32, Resident 53, and Resident 90 ?s clinical records, the clinical records did not have an advance directive or documentation that indicated an advance directive was offered.
During a concurrent interview and record review on 1/8/26 at 2:06 p.m. with Social Services Director (SSD), SSD confirmed Resident 7, Resident 32, Resident 53, and Resident 90 did not have an advance directive or documentation that indicated an advance directive was offered. SSD stated the expectation was for advance directives to be offered at admission. SSD further stated there should have been documentation that indicated an advance directive was offered if residents did not have an advance directive. SSD further stated there was a risk for residents' medical wishes to be unclear when an advance directive was not available.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives revised 2/25, the P&P indicated, .it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive Prior to, upon, or immediately after admission, the facility staff will ask residents, and/or their family members, about the existence of any advance directives.Should the resident indicate that he or she has issued advance directives about his/her care and treatment, the facility will require that a copy of such directives be included in the medical record.
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
During a review of Resident 9's physician's orders dated 11/7/25, the physician's orders indicated Resident 9 was prescribed quetiapine (a psychotropic medication that treats schizophrenia and bipolar disorder).During a review of Resident 9's Initial Psychology Evaluation dated 11/26/25, the Initial Psychology Evaluation did not include a review of quetiapine or address the reason for starting and continuing quetiapine.
During an interview with Neuropsychologist (NPSY) on 1/8/26 at 11:32 a.m., the NPSY confirmed she was the clinician that evaluated Resident 9 on 11/26/25.
The NPSY stated quetiapine was not reviewed during the Initial Psychology Evaluation.
The NPSY further stated I missed it (quetiapine) on the med (medication) list.
The NPSY confirmed Resident 9 did not have a diagnosis of schizophrenia or bipolar disorder.
During an interview on 1/9/25 at 10:20 a.m., with the Director of Nursing (DON), DON stated the expectation was for NPSY to review the quetiapine during the Initial Psychology Evaluation on 11/26/25. DON acknowledged the risk for mortality when Resident 9's quetiapine was not reviewed.During a review of the U.S.
Food, Drug and Administration (FDA) medication guide for quetiapine, revised 8/19, the FDA medication guide indicated quetiapine increased the risk of death in elderly people with dementia.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Use, revised 2/2025, the P&P indicated, .It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
Upon initial comprehensive assessment, SSD and/or nursing designee shall review new admissions for.physician's orders for psychotropic medications.
These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist.
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
Based on observation, interview, and record review, the facility failed to ensure medications were
packaging with clear plastic bubbles (blisters) holding individual pills) were found on the bottom of a drawer and in the back of the drawers for one out of five sampled medication carts.
These failures had the potential for medication error, misuse, or drug diversion.Findings: During an inspection of Medication Cart 5 on 1/6/26 at 12:20 p.m., one unlabeled loose pill and three labeled blister packs were found on the bottom of the drawer and behind the drawers in the back of medication cart 5.
During an interview on 1/6/26 at 9:48 a.m. with Nursing Supervisor (NS), NS removed the pill found on the bottom of the drawer and confirmed there was 1 loose pill. NS also confirmed there were three labeled blister packs found behind the drawer at the back of cart 5.
The NS stated the carts were cleaned regularly but admitted she did not think of looking behind the drawers.
The NS confirmed the loose pill or the misplaced medications in the back of the cart could have led to a mediation error.
During an interview on 1/6/26 at 1:29 p.m. with the Director of Nursing (DON), the DON confirmed medications should not be loose in the drawers and medications should not be at the back of the cart behind the drawers.
The DON stated, the medication carts should be checked thoroughly, and kept clean.
The DON stated the loose pill and medications in the back of the cart could lead to a medication error.During a review of the facility Policy and Procedure (P&P), titled, Storage of Medications, dated May 2022, the P&P indicated, Medications and biologicals are stored safely, securely, and properly .All medications. are stored in the container with the pharmacy label.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
serve food in accordance with professional standards.
pans and utensils in accordance with professional standards for food service safety when: Frying
in the drawer.These failures had potential to cause food-borne illnesses in a highly susceptible population of 97 residents who received food from the kitchen.Findings:During a concurrent initial tour observation and interview on 1/6/26 at 8:45 a.m. at the kitchen with the Certified Dietary Manager (CDM), several wet pans and ladles were stacked and stored at the clean and ready-to-use storage areas as indicated below:6 frying pans- different sizes6 ladles - various sizes1 cake slicerThe CDM confirmed that the 6 frying pans, 6 ladles, and 1 cake slicer were wet. CDM stated, the frying pans, ladles, and a cake slicer should have been completely air dried before being stored away.During an interview on 1/8/26 at 10 a.m. with Registered Dietician (RD), the RD stated, the expectation was: the frying pans and ladles including the cake slicer will be cleaned and air dried before it is stored away.During a review of an undated facility's policy and procedure titled, Dishwashing, indicated, .dishes are to be air dried in racks before stacking and storing.
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
soda stored past their use by date,Two bottles of opened salad dressings, and one fruit spread found
chowder with expired use by date.These failures had the potential to cause foodborne illnesses in a vulnerable resident population.
Findings:During a concurrent observation and interview on 1/8/26 at 10:30 a.m. with Certified Dietary Manager (CDM), several resident food items were found in the refrigerators for residents at Nursing Station 1 and Nursing Station 2.
The food items found were as follows:Nursing Station 1 refrigerator for residents:One opened bottle of soda stored past their use by date 12/27/25.Two opened salad dressings, and one fruit spread found unlabeled, undatedOpened Clam Chowder with use by date 1/7/26 and unlabeled.Nursing Station 2 refrigerator for residents:One bag of loaf of bread was unlabeled, undated, and expired.CDM confirmed the findings and stated her expectations were to have all residents' food be labelled. CDM further stated, . staff must check the resident refrigerators every night and discard anything that has expired or does not have any labels.
During an interview on 1/8/26 at 11 a.m. with the Registered Dietician (RD), RD stated, her expectations were for the staff to label the food received from home, the date, and the location of the resident. RD further stated perishable food that has been opened must be discarded after 3 days.During a review of the facility's policy and procedure titled, Foods Brought by Family or Visitor, revised 2/2025, indicated, .all foods shall be labeled with the resident name, location, and date.perishable prepared foods will be checked by nurse, dietary staff daily and discarded after 3 days of storage.
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
measures were implemented for a census of 97 when:One facility staff did not sanitize the blood
(Resident 2 and Resident 61).These failures had the potential to spread germs.Findings:A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with diagnosis that included Chronic Viral Hepatitis C (a long term viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), Immunodeficiency (the immune system can't effectively fight infections and diseases, leading to frequent, severe infections and potentially cancer), Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing).A review of Resident 61's clinical record indicated Resident 61 was admitted [DATE] with diagnosis that included Immunodeficiency, and Pneumonia (an infection/inflammation in the lungs).During a concurrent observation and interview on 1/6/26 at 8:47 a.m., 9:01 a.m., and 9:14 a.m., respectively with Licensed Nurse (LN)1, LN 1 did not sanitize the BP cuff before, after or in between taking the BP of Resident 2 and Resident 61. LN 1 stated, .we are supposed to sanitize the blood pressure cuff after each use, but I forgot. LN 1 stated not sanitizing the BP cuff could spread germs.
During an interview on 1/6/26 at 12 p.m. with the Nursing Supervisor (NS), the NS stated, the BP cuff and machine needed to be wiped down in between each resident use.
The NS stated that not sanitizing can lead to spreading germs.
During an interview on 1/6/26 at 1:29 p.m., with the Director of Nursing (DON), the DON stated the expectation was for the BP cuff to be sanitized in between each resident use to prevent the spread of germs.During a concurrent interview on 1/7/26 at 9:56 a.m. with the Infection Preventionist (IP) and Director of Staff Development IP Consultant (DSD IP), the IP and DSD IP stated the expectation for sanitizing the BP cuff was to sanitize the cuff in between each resident use.A review of the facility's policies and procedures (P&P) titled, Infection Control Program, revised 2/2025, indicated, .Patient-care equipment (e.g., blood pressure cuffs).clean and disinfect such equipment before use on another patient.
055014 01/09/2026
Fairfield Post Acute Rehabilitation 1255 Travis Blvd Fairfield, CA 94533
single resident rooms.
minimal harm NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms
following rooms were measured as:room [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personroom [ROOM NUMBER] at 75.5 sq. ft. per personThese failures had the potential to negatively affect the residents' quality of life and result in inadequate space for the provision of care.During observations made throughout the survey in the rooms with three resident occupancies, the space was adequate to store assistive devices in the rooms (such as wheelchairs and/or walkers) and to facilitate provision of care and needs.
During an interview on 1/7/26 at 8:22 a.m., a resident in room [ROOM NUMBER] stated he could get around his room without issues when wheelchair and trashcans were not blocking pathways to bathroom.
During an interview on 1/7/26 at 8:29 a.m., a resident in room [ROOM NUMBER] stated she had no concerns or issues with the size of the room.
During an interview on 1/8/26 at 12:59 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated there were no issues with room sizes.
LN 2 further stated there was enough room to do her job. LN 2 further stated wheelchairs and trash cans must be moved to accommodate a Hoyer lift while transferring residents.
During an interview on 1/8/26 at 1:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated if there was no clutter and resident items were organized, there was enough space in the rooms for her to do her job.During an interview on 1/8/26 at 1:25 p.m., a resident in room [ROOM NUMBER] stated she had no issues moving around in her room.The Department recommends continuation of the waiver for the above-mentioned rooms.