Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emmanuel Care Center - Travis during CMS and state inspections, most recent first.
A resident received an antihypertensive without the pharmacy hold parameter being followed, an LPN handled a hazardous med without gloves during preparation, and another resident with cerebrovascular disease and severe cognitive impairment had antihypertensives given without required VS checks or within hold limits. The same resident also missed scheduled evening meds when asleep and had a left elbow splint applied far less than the ordered 4 hours.
Fluid restriction was not followed for a resident with ESRD, dialysis dependence, a PEG tube, and CHF, as intake exceeded the ordered limit and staff acknowledged the overages were not consistently reported. In a separate issue, a cognitively intact resident with morbid obesity, DM, and HF had monthly weight refusals that were not fully documented in the chart, despite staff and policy expectations that refusals be recorded in the medical record.
The facility failed to ensure controlled substances were disposed of and reconciled according to policy and regulation. The DON described a destruction process conducted with the CP via Zoom, but the CP could not confirm witnessing all required steps and had no documentation of a current waiver for remote participation. In addition, a resident’s morphine dose was removed from the cart and recorded on the CDR, but the MAR and nursing notes did not document administration of that dose.
Food items in dry storage were inconsistently labeled, with bulk rice and barley lacking received and opened dates while showing far-future use-by dates. A chipped can opener tip and a deeply gouged blue cutting board used for fish and seafood were also observed, and the DSS acknowledged the conditions. Facility policy and FDA Food Code guidance reviewed during the survey required proper dating of stored food and good repair of food prep equipment and cutting surfaces.
Failure to Provide Ordered Podiatry Care: A resident with cerebrovascular disease, hemiplegia, dementia, and Type 2 DM had an order for podiatry care every 2 months as needed, but podiatry services were not provided after the initial visit. Facility podiatry lists did not include the resident, and during observation the resident’s toenails were found to be long. The DON confirmed there were no further podiatry visits after the first consult.
Inconsistent Documentation of PRN Oxygen Use: A resident with stroke-related hemiplegia and a G-tube had a PRN O2 order for SOB, O2 sats below 90%, or chest pain. Staff observed the resident on 2 L NC, and interviews confirmed oxygen was being used, but the MAR and O2 sat records did not consistently show the oxygen administration. The LPN and DON confirmed the PRN oxygen use was not consistently documented.
Inconsistent Pain Medication Administration: A cognitively intact resident with chronic pain from spinal stenosis and osteoarthritis received pain medications that did not match the documented pain scale. The MAR showed Tylenol given for pain levels documented as moderate and severe, and morphine given for pain levels of 5 and 10. An LPN acknowledged that the pain assessment did not correlate with the medication given, and the DON stated the Tylenol order had been incorrect.
Failure to Document Insulin Injection Site: A resident with ESRD, dialysis dependence, and DM received Humalog sliding scale insulin and Insulin Glargine, but the MAR did not consistently document the injection site for either insulin. The pharmacy consultant twice noted that the site of injection needed to be recorded with every dose, yet the DON confirmed the recommendation was not acted on timely and that documentation remained incomplete across multiple months.
A resident with a G-tube received medications through the tube without the ordered flush volume being used before administration. An LPN prepared crushed tablets and liquid meds, used a 5 mL flush instead of the ordered 30 mL flush, and later had to push the final sticky medication through the tube when it would not drain by gravity. The MAR, facility policy, and DON interview confirmed that the prescribed flush amounts were not followed.
An LN prepared hydralazine for a resident by removing it from a sealed blister pack, crushing it, and mixing it with applesauce. After the resident refused the dose, the LN labeled the medication cup, covered it with a tissue, and returned it to the med cart. The DON stated prepared medication should be discarded, and facility policy said medication mixed with applesauce should be thrown away and a new dose prepared when the resident is ready.
Missing Hospice Coordination Documents: The facility failed to maintain coordination of care with hospice for a resident with end stage heart failure and hospice orders. The resident’s chart and hospice binder did not contain the hospice POC, current CTI, accurate med list, visit notes, or a current visit schedule, and staff could not explain the communication process between the facility and hospice. The DON stated hospice residents should have current hospice documentation, while the SSD said she was not a clinical person to coordinate the resident’s care.
The facility failed to develop PIPs when high risk and problem-prone areas were identified during QAPI meetings for a census of 8. The ADM stated that monthly QAPI discussions included pressing issues such as kitchen management, but no PIPs were completed to address those concerns, despite the facility policy requiring PIPs when problems are identified and prioritization of quality issues based on risk and frequency.
Medication Administration and Restorative Care Errors
Penalty
Summary
Resident 1 received losartan 25 mg via PEG tube during a medication pass even though the medication label from the pharmacy included a hold parameter of hold for SBP less than 110. The nurse who administered the dose stated the resident’s BP was 108/69 after returning from dialysis, then confirmed the medication should have been held and that she gave it without clarifying the order with the prescriber. The DON reviewed the record and confirmed the losartan was administered without hold parameters on the day the resident returned from dialysis, and stated the nurse should have clarified the order because of the risk of hypotension following dialysis. Resident 3’s valproic acid, identified on the bag and bottle as a hazardous drug, was prepared without gloves. The nurse removed the bottle from the hazardous-drug bag with bare hands and poured the liquid medication into a medicine cup with bare hands before later donning gloves to enter the room and administer the medications. During interview, the nurse stated gloves must be worn, confirmed she did not wear gloves while preparing the hazardous medication, and stated she did not notice it was hazardous. The DON stated she expected the nurse to wear gloves because the medication may be absorbed into the skin. Resident 8 had multiple medication and restorative care issues. The resident had diagnoses including cerebrovascular disease, hemiplegia, hemiparesis, and severe cognitive impairment. Orders for hydralazine and lisinopril included hold parameters, but MAR review showed blood pressures and heart rates were not documented before administration as required, and lisinopril was given on occasions when the BP was below the ordered hold threshold. In addition, evening medications scheduled for 9 p.m. were not administered on several dates because the resident was asleep, with no documentation that the medications were offered again or that the physician was notified. Resident 8’s left elbow extension splint was also ordered for 4 hours or as tolerated, but the ADL task sheet showed it was applied for 15 minutes on multiple occasions instead of the ordered duration, and the DON confirmed there was no documented evidence that the resident did not tolerate the splint for the full ordered time.
Fluid Restriction Not Followed and Weight Refusals Not Documented
Penalty
Summary
The facility failed to ensure adequate hydration for a resident with ESRD, dialysis dependence, a gastrostomy tube, and CHF when the resident’s fluid restriction order was not followed. The resident had a physician order for 1300 ml per 24 hours, but the intake and output records showed intake above that limit from 8/17/25 through 12/2/25. During interviews, licensed nurses confirmed the resident had been on fluid restriction for some time, stated that intake over the ordered amount should be reported to the physician and dialysis clinic, and acknowledged that the resident’s total intake on 11/30, 12/1, and 12/2 exceeded 1300 ml. The RD also stated the resident was receiving more fluids than ordered, and the DON confirmed the intake was above the fluid restriction as ordered. The resident’s record also showed changes in the fluid restriction order over time, including 1000 ml, 1200 ml, and 1300 ml per 24 hours. Staff interviews indicated the PM shift nurse was expected to calculate the resident’s 24-hour fluid intake, and the DON stated licensed nurses were expected to follow the fluid restriction order and notify the physician and dialysis clinic if the resident received more fluids than ordered. The facility policy on fluid restrictions stated that prescribed fluid amounts should be documented in the medical record, a plan of care should reflect the restriction and how fluids would be provided, and resident compliance should be monitored and reported to the physician as needed. The facility also failed to document weight refusals for another resident who had diagnoses including chronic venous insufficiency, morbid obesity, diabetes, and heart failure. The resident had a monthly weight order, but the clinical record showed only two weights documented and no further weights recorded. Progress notes documented refusals in October and November, but the record did not show a refusal for September. The RD stated that if the resident refused to be weighed, it should be charted on the day of refusal, and confirmed there was no documentation of a September refusal. The DON and staff stated weights were to be obtained monthly, refusals should be documented in the progress notes, and the physician should be notified of the refusal. The facility’s policies stated that resident weights are to be monitored and recorded in the medical record, and that documentation should include whether the resident refused the procedure or treatment.
Controlled Substance Disposal and Documentation Errors
Penalty
Summary
The facility failed to develop a system to ensure the safe and secure disposal and reconciliation of controlled substances. During interview and record review, the Director of Nursing described the facility’s process for controlled substance destruction, stating that discontinued, expired, or no longer needed controlled medications were brought to her with the corresponding Controlled Drug Record, and that she documented receipt and completed the Narcotic Destruction Log with the transferring nurse. She also stated that the most recent destruction occurred with the consultant pharmacist viewing the process remotely via Zoom, and that the medications were placed into a bin with hot water and kitty litter. The consultant pharmacist confirmed by phone that the November destruction was conducted via Zoom with the DON and Unit Supervisor. He stated he believed this practice was acceptable because of a COVID-19-related waiver, but he could not provide documentation of a current waiver. He also stated that the facility’s process involved adding liquid to the bin containing the controlled substances, but when asked whether he witnessed that step, he said he believed they did but was not certain. The facility policy stated that the DON, in collaboration with the consultant pharmacist, is responsible for compliance with laws and regulations in handling controlled medications, and California regulations required destruction of Schedule II, III, or IV drugs in the presence of a pharmacist and a registered nurse employed by the facility. The facility also failed to accurately account for a controlled substance for one resident. The resident’s medication order included morphine 15 mg, to give 7.5 mg by mouth every 4 hours as needed for moderate to severe pain. The Controlled Drug Record showed morphine was removed from the medication cart, but the corresponding Medication Administration Record did not document administration of that dose, and the DON confirmed that the dose removed was not documented in the MAR or nursing notes. The facility’s medication administration policy stated that the individual administering the medication initials the resident’s MAR after giving each medication.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
Food was not stored and prepared in accordance with industry standards during the kitchen tour and record review. In the dry storage area, bulk food items were kept in large plastic containers with inconsistent labeling. One container of long grain rice had no received date or opened date and showed a use-by date of 5/22/35, and another container of barley also had no received date or opened date and showed a use-by date of 12-6-35. During interview, the Dietary Services Supervisor agreed the dates were close to 10 years away and said they may match manufacturer storage guidance, but could not produce the packaging to confirm it. The Dry Goods Storage Guide in the storage area stated opened barley should be discarded 6 months after opening and opened rice after a year, and the facility policy required food in storage to be labeled and dated with a received date and, when opened, an open date and use-by date. The can opener was observed with a chip on the cutting tip, and the Dietary Services Supervisor agreed it was chipped. One of six cutting boards, the blue board used for fish and seafood, was also observed with deep gouges on the cutting surfaces, and the Dietary Services Supervisor stated it should have been replaced because of the gouges. The facility policy and the FDA Food Code sections reviewed stated can opener cutting parts should be kept sharp and cutting boards with scratches or scoring should be resurfaced or discarded if they cannot be effectively cleaned and sanitized.
Failure to Provide Ordered Podiatry Care
Penalty
Summary
Proper foot care was not provided for one resident who was admitted with cerebrovascular disease, hemiplegia, hemiparesis, dementia, and Type 2 DM, and whose MDS indicated severe cognitive impairment. The resident had a physician order dated 1/29/25 for podiatry care every 2 months as needed for debridement of hypertrophic mycotic nails, corns, and/or callouses. Facility podiatry visit summaries dated 5/20/25, 8/21/25, and 10/24/25 did not include the resident, and the Social Services Designee confirmed the resident had only one podiatry visit on 3/18/25 with no visits afterward. During observation on 12/3/25, the resident’s toenails were noted to be long, with both big toenails measuring approximately 1 cm past the toe and the remaining toenails measuring approximately 0.5 cm past the toe. The DON confirmed there were no podiatry visits after 3/18/25 and that the resident was not on the podiatry consultation lists for May and August 2025.
Inconsistent Documentation of PRN Oxygen Use
Penalty
Summary
The facility failed to ensure oxygen use was documented consistently for one resident who was admitted with hemiplegia and hemiparesis following cerebral infarction and gastrostomy status. The resident had a physician order dated 10/8/25 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, oxygen saturation below 90%, or chest pain. Review of the resident’s oxygen saturation summary showed oxygen saturations were checked while the resident was on oxygen and were above 90%, with oxygen use recorded multiple times in October and November and three times in early December. However, review of the Medication Administration Record showed oxygen was documented only three times in October, three times in November, and not at all from 12/1 to 12/2/25. During observation on 12/2/25, the resident was in bed with oxygen at 2 liters per minute via nasal cannula and the head of bed elevated. Staff interviews confirmed the resident was on oxygen and that oxygen was used as needed when O2 sats were below 90%, but the licensed nurse stated the oxygen use was not consistently documented in the MAR and that the licensed nurse who started the oxygen should document it. The DON also confirmed the resident’s oxygen use was not consistently documented by the licensed nurses and stated that PRN oxygen should be documented in progress notes, MAR, and other applicable records.
Inconsistent Pain Medication Administration
Penalty
Summary
The facility failed to provide appropriate pain management for one resident with chronic pain. The resident was admitted with chronic venous insufficiency, lumbar spinal stenosis, and osteoarthritis of the left knee, ankle, and foot. The resident was cognitively intact with a BIMS score of 15 out of 15 and had a care plan addressing chronic pain related to spinal stenosis and arthritis, with interventions to administer Tylenol and morphine as ordered. The resident’s medication orders included morphine ER every 12 hours for pain management, morphine IR 7.5 mg every 4 hours as needed for severe pain, and Tylenol 325 mg tablets ordered separately for mild pain and moderate pain. The MAR showed that the resident received morphine for pain levels of 5 and 10, and Tylenol was administered multiple times for pain levels documented as 4, 5, 6, 7, and 8. The pain assessment scale in use defined 1 to 3 as mild, 4 to 6 as moderate, and 7 to 10 as severe. During interview and record review, the nurse acknowledged that the resident was receiving two Tylenol tablets for pain levels that indicated moderate pain even though the order indicated that dose for mild pain. The nurse also acknowledged that the pain level assessment did not correlate with the pain medication given. The DON stated the pharmacy consultant notified the facility that the Tylenol order in October was incorrect and that the pain level assessment needed to be changed from mild pain to moderate pain. The facility policy stated that pain interventions shall reflect the source, type, and severity of pain and that pain should be assessed using a consistent approach and standardized tool appropriate to the resident’s cognitive level.
Failure to Document Insulin Injection Site
Penalty
Summary
The facility failed to ensure that the pharmacy consultant’s medication regimen review recommendation was implemented for one resident receiving insulin. The resident was admitted with end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. Physician orders included Humalog subcutaneously every 6 hours per sliding scale and Insulin Glargine 16 units subcutaneously at bedtime. The medication regimen review dated 8/28/25 stated that insulin documentation should include the site of injection on the eMAR, and the 9/26/25 review repeated that the site of injection needed to be noted on the record with every dose for both Humalog and Glargine. During interview and record review with the DON, the MARs from 9/2025 through 12/2025 showed that the insulin injection site was inconsistently documented or not documented. Humalog injection site was documented once in September and once in October, while Glargine injection site was not documented in September, from 10/29 to 10/31/25, throughout November 2025, and from 12/1 to 12/4/25. The DON confirmed that the facility did not act on the pharmacy consultant’s recommendation timely and stated that licensed nurses were expected to enter insulin orders accurately, including the site of injection.
Failure to Flush G-Tube as Ordered During Medication Administration
Penalty
Summary
The facility failed to ensure one of eight sampled residents was free from a significant medication error when Resident 3’s gastrostomy tube was not flushed as ordered during medication administration. During observation, a nurse prepared seven medication preparations for the resident, including four crushed oral tablets, two liquid medications, and one liquid nutritional supplement. The nurse used a 5 mL flush before the first medication instead of the ordered 30 mL flush, then gave additional medications with small flushes between them. The final amber-colored liquid medication did not drain by gravity, and the nurse inserted the plunger and pushed the medication into the G-tube because it was too sticky. The resident’s MAR showed an enteral feed order dated 9/29/25 directing staff to flush the tube before and after medication administration with 30 cc. During interview, the nurse confirmed the 5 mL flush was given prior to the first medication rather than the ordered 30 mL flush and stated that flushing is important so the tube will not clog. The DON stated nurses are expected to follow physician orders for feeding tube medication administration, including prescribed flush volumes, and the facility’s policy required flushing the tube with 15 to 30 mL of water before and after medications. The facility’s policy also stated that medications should flow slowly through the tube by gravity.
Prepared medication returned to cart after resident refusal
Penalty
Summary
The facility failed to ensure that a prepared medication was not returned to the medication cart for one of eight sampled residents. During a medication pass observation with an LN, hydralazine 50 mg for Resident 8 was removed from a sealed, pharmacy-supplied blister pack, placed into a medication cup, put in a plastic bag to crush it, and then returned to the cup mixed with applesauce. The LN entered the resident’s room and explained the medication was for hypertension, but the resident refused the medication despite several offers. After the refusal, the LN returned to the medication cart and stated that the resident refused the medication. She then labeled the medication cup with the resident’s room number, covered it with a tissue, and placed it back in the medication cart. During follow-up interview, the LN confirmed that she labeled the cup, covered it with a tissue, and returned it to the cart. The DON stated that prepared medication should be thrown away, and the facility’s policy stated that contaminated or deteriorated medications, or medications without secure closures, are immediately removed from inventory. The administering medications policy also stated that if medication is mixed with applesauce, it should be discarded and a new set prepared when the resident is ready to take it.
Missing Hospice Coordination Documents
Penalty
Summary
The facility failed to ensure coordination of care between hospice and facility staff for one resident who was admitted with multiple diagnoses, including end stage heart failure, and had a physician order indicating hospice services. On review of the resident’s electronic record and the hospice binder at the nursing station, the resident’s hospice Plan of Care was not present. The record also did not contain the hospice medication list, physician orders, disciplines, frequencies, or visit schedule that were expected to be part of the hospice documentation. During interview and record review, a licensed nurse stated the resident had been receiving hospice services for a long time and that hospice documents were kept in a designated binder, but the binder did not contain the Plan of Care and only had an incomplete March 2025 visit calendar. The nurse also stated the visit notes were not available for review. The unit supervisor acknowledged the binder did not contain the current Plan of Care or the most current CTI, that there was no December visit calendar, and that the medication list in the binder was inaccurate and included medications the resident had not taken since May 2025. The DON stated hospice residents should have a current Plan of Care, visit schedule, sign-in sheet, and visit notes, and the social services designee stated she was not a clinical person to coordinate the resident’s care. The facility’s hospice agreement stated the designated interdisciplinary team member responsible for coordination must have a clinical background and obtain the most recent hospice Plan of Care, medication information, and physician orders.
Failure to Develop PIPs for Identified Quality Issues
Penalty
Summary
The facility failed to ensure performance improvement projects (PIPs) were developed when high risk or problem-prone areas were identified for a census of 8. During an interview, the Administrator stated that QAPI meetings were held monthly and that the QAPI members discussed the most pressing issues in the facility, including high risk and problem-prone areas such as kitchen management. The Administrator acknowledged that no PIPs were conducted to address the identified issues and stated that the QAPI team should have created a PIP based on the issues discussed during the QAPI meetings. Review of the facility’s QAPI policy showed that PIPs are initiated when problems are identified, involve systematically gathering information to clarify issues and intervene for improvements, and include prioritizing identified quality issues based on risk of harm and frequency of occurrence, as well as planning, conducting, and documenting PIPs.
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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 |
| Fairfield Post Acute Rehabilitation | 0 mi | ★★★★★ | 18 | 0 |
| Laurel Creek Health Center | 3.6 mi | ★★★★★ | 15 | 0 |
| Vacaville Ranch Post Acute | 7.3 mi | ★★★★★ | 3 | 0 |
| Vacaville Convalescent And Rehabilitation Center | 9 mi | ★★★★★ | 12 | 0 |
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