Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Laurel Creek Health Center during CMS and state inspections, most recent first.
Controlled Medication Disposition Log Missing Required Signatures and Date: The facility failed to ensure the controlled medication disposition record was completed accurately when the April log for five controlled med entries in a secure cabinet was missing the transferring LPN's signature and the date the meds were removed from the carts for storage before destruction. The DON confirmed the missing information was not the facility's standard process, and the facility policy required disposition records to include witness signatures.
Medication administration errors exceeded the allowed rate when two errors were found during observation. One LPN gave the wrong strength of eye drops, administering 5% Muro 128 instead of the ordered 2% strength, and another LPN did not follow the manufacturer’s MDI instructions for a resident receiving Fluticasone-Salmeterol, including proper breathing steps and holding the breath after the dose.
Improper Labeling and Storage of Medications: Opened glucose test strip bottles were found in medication carts without open-date labels, and an LPN could not determine their expiration dates. Two OTC eye drop bottles were also found on a resident’s bedside dresser without a physician order or self-administration assessment in the record, despite the resident having moderate cognitive impairment.
Food service safety standards were not followed when metal sheet pans and lids were stored wet and some were dusty and oily, scoops were kept inside bulk food bins, four open milk cartons in the pantry lacked open and use-by dates, and a breakfast meal cart was left open and unattended in the hallway. The CDM and RD confirmed these practices did not meet facility policy for safe food handling and food storage.
Improper storage of respiratory equipment and catheter tubing was observed for several residents. A resident with pneumonia had nasal cannula tubing on the floor, two residents had oxygen tubing on the floor with nebulizer or NC equipment left out without a bag, another resident’s nebulizer mask was not stored in a bag, and CPAP masks for two residents were hanging on shelves or hooks without bags. A resident with a Foley catheter also had catheter tubing on the floor. The IP stated the equipment should be stored in infection prevention pouches and that tubing should not be on the floor.
A facility failed to ensure that meal trays for multiple residents were checked by licensed nursing staff before delivery. During dining observation, a CNA was seen checking trays in the dining room and stated he was the only staff member doing so. The DON stated that an LN should check the meal ticket and tray before service, and the facility policy required CNAs to deliver trays only after licensed nursing had verified the diets.
A LTC facility was found to have a 10.34% medication error rate during a medication pass, exceeding the acceptable threshold. Errors included administering medication orally instead of via G-tube for a resident, giving two tablets of Acetaminophen instead of one, and administering Insulin Lispro without a meal. The errors were confirmed by the LN involved, and both the DON and Pharmacy Consultant stressed the importance of following physician orders.
The facility was found to have expired and improperly stored medications and supplies, including hydrogel dressings, Anasept gel, and COVID-19 test kits. Opened single-use vials were not discarded, and some medications lacked proper labeling. Ice buildup in a medication refrigerator was also noted, potentially affecting medication efficacy. These issues were confirmed by nursing staff and the DON.
The facility did not follow the prescribed menu for residents on a pureed diet, serving 1/4 cup of pureed chicken instead of the required 1/2 cup. This was confirmed by the Dietary Manager, who noted the use of an incorrect scoop size. The facility's policy mandates adherence to the menu to ensure proper nutrition.
The facility failed to maintain food safety standards, with an unclean ice machine, improperly labeled refrigerated food, and inadequate sanitizer concentration. These deficiencies were confirmed by dietary staff and posed a risk of food contamination.
The facility failed to maintain effective infection control, with issues such as unlabeled distilled water for CPAP machines, a coffee mug on a commode seat, and improper disinfection of blood pressure cuffs. Dust and stagnant water were found in the laundry area, and a resident with a pressure ulcer was not on Enhanced Barrier Precautions. These deficiencies highlight lapses in following infection control protocols.
A resident with multiple diagnoses, including Parkinson's and dementia, did not receive sufficient fluids to meet the RD's assessed needs. Despite being at risk for dehydration, the resident's fluid intake was consistently below the required amount, and water was often not within reach. Staff interviews revealed a lack of consistent monitoring and assistance, leading to the resident's increased risk of dehydration.
A resident's routine dose of Trazodone was not discontinued after being changed to a PRN order without a specified end date, leading to potential duplicate dosing. The resident had refused the routine dose and requested the medication later during the night shift. The facility's policy on PRN orders was not followed, increasing the risk of unnecessary medication and side effects.
A resident with Type 2 Diabetes Mellitus did not receive Insulin Lispro with meals as ordered by the physician, leading to a significant medication error. The insulin was administered by a licensed nurse without the presence of a meal, despite the facility's policies and the physician's specific instructions. The DON and Pharmacy Consultant confirmed the expectation to follow orders precisely.
A resident with difficulty swallowing and a history of pneumonia was served thin liquids instead of the prescribed nectar thickened liquids by a CNA, leading to coughing during a meal. The DON confirmed the expectation for adherence to diet orders, acknowledging the risk of aspiration. The facility's policy on therapeutic diets emphasizes the importance of following physician-ordered diets.
A resident developed a stage 2 pressure ulcer due to the facility's failure to follow its policy for pressure injury prevention, including daily skin inspections, regular Braden Scale assessments, and consistent turning and repositioning every two hours.
The facility failed to ensure nursing staff were competent and adhered to policies, resulting in missing narcotic tablets and unauthorized application of Baza Cream without a physician's order. These actions posed significant safety risks, including unauthorized access to the med cart and potential medication errors.
Controlled Medication Disposition Log Missing Required Signatures and Date
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not maintained when the facility failed to ensure the Controlled Medication Disposition Log was filled out and signed accurately for a census of 39. During inspection of the secure locked cabinet at Station 1, the April 2026 log contained five medication entries that matched the controlled medications in the bin, but the log was missing the transferring licensed nurse's signature and the date the medications were removed from the medication carts and stored in the secured locked cabinet before destruction. During interview, the DON confirmed the Controlled Medication Disposition Log for April 2026 was missing the transferring licensed nurse's signature and the date the transfer occurred, and stated this was not the standard process for the facility or pharmacy services. Review of the facility's Controlled Medication Disposition Log showed fields for resident name, medication number and pharmacy, medication and strength, quantity of medication, transferred by, received by, and date. Review of the facility policy titled Discarding and Destroying Medications, dated 6/2025, stated that medications not returned to the dispensing pharmacy are disposed of according to federal, state, and local regulations governing controlled substances and that the medication disposition records contain, at a minimum, the signature of witnesses.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 2 errors identified out of 34 opportunities for error during medication administration observations, resulting in a 5.88% error rate. One error involved a licensed nurse administering Muro 128 ophthalmic solution at 5% strength to a resident whose physician order specified Muro 128 2% eye drops, one drop in each eye daily for dry eyes. During interview, the nurse reviewed the resident’s current order and acknowledged that the 5% strength had been given instead of the ordered 2% strength, and the DON acknowledged the nurse should have followed the physician order. A second error involved another licensed nurse administering Fluticasone-Salmeterol via MDI to a resident without following the manufacturer’s instructions. The nurse instructed the resident to place their mouth around the device and breathe in and out while the medication was delivered, but did not direct the resident to exhale before administration, inhale deeply as the dose was released, or hold the breath for about 10 seconds afterward. The nurse stated she was not aware of the manufacturer’s post-administration guidance and confirmed those steps were not included in her instructions for the resident. The DON acknowledged the nurse should have followed the manufacturer’s instructions to administer the medication.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were properly labeled and stored in accordance with accepted standards of practice. During inspection of medication cart 2 at nursing station 2, two opened bottles of glucose test strips were found without open-date labels, and during inspection of medication cart 1 at nursing station 3, another opened bottle of glucose test strips was also found without an open-date label. The bottles’ manufacturer label stated the strips were to be used within 90 days, or 3 months, after opening. Licensed nurses were unable to determine the open dates or calculate the expiration dates, and both nurses stated the test strips should have been removed and discarded from the active medication area. The DON acknowledged that open dates were needed to document the expiration date. The facility policy required the date opened to be recorded on multi-dose containers. The facility also found two over-the-counter eye drop bottles on top of Resident 55’s bedside dresser. Resident 55 was admitted with diagnoses including wedge compression fracture of the lumbar vertebrae, and the MDS indicated moderate cognitive impairment. Resident 55 stated she used the two eye drops for dry eyes. When asked to locate a physician order and self-administration assessment, the LPN confirmed that neither was found in the resident’s electronic medical record. The LPN stated medications were expected to be kept in the medication cart for safe storage, and the facility policy stated medications are to be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems, with each resident’s medications assigned to an individual cubicle or drawer.
Food items and meal cart were improperly stored and left unattended
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 39 out of 39 residents. During a kitchen tour, several metal sheet pans and lids in clean and ready-to-use storage areas were observed stacked while wet, and some were dusty and oily. The Certified Dietary Manager confirmed the pans and lids were wet, dusty, and oily, and stated that dishes must be fully dry before stacking and that trays must be kept clean in the ready-to-use storage area. The Registered Dietician stated that dishes, trays, and tray covers must be fully air dried before stacking and storage, and that metal trays and lids need to be properly cleaned before storage in the ready-to-use area. Additional observations showed three large food storage bins with plastic containers inside being used as scoops, four open milk cartons in the pantry without open and use-by dates written, and a breakfast meal cart left wide open and unattended in the hallway with 10 trays. The Certified Dietary Manager confirmed the containers inside the food bins and the unlabeled milk cartons, and stated the milk cartons must have an open and use-by date. The CNA confirmed the open cart was unattended, and stated that when a food cart is left open it may be accessed by others and the food could become cold and exposed to contamination. The Registered Dietician stated food cart doors should be kept closed and monitored at all times, and that food may be accessed by others, including residents with dietary restrictions or modified diets.
Improper Storage of Respiratory Equipment and Catheter Tubing
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented for multiple residents using respiratory equipment and a urinary catheter. Resident 1, who had diagnoses including bacterial pneumonia, pleural effusion, interstitial pulmonary disease, and pulmonary candidiasis, was observed with nasal cannula tubing on the floor between the nightstand and garbage can. A nurse confirmed the tubing should not be on the floor because of the risk of bacterial contamination, and the Infection Preventionist stated the tubing should be stored in an infection prevention pouch after cleaning and drying. Resident 10, who had COPD and bacterial pneumonia, had an order for continuous oxygen via nasal cannula and nebulizer treatments. Resident 56, who had diagnoses including malignant neoplasm of the tongue and a gastrostomy tube, had an order for oxygen via nasal cannula. During observation, Resident 10’s nebulizer mask was found on top of the bedside dresser without a storage bag and the oxygen tubing was on the floor. Resident 56’s nasal cannula was also on top of the bedside dresser without a storage bag and the oxygen tubing was on the floor. An LN confirmed the tubing and equipment were not stored in bags and stated he did not store it in a bag. The Infection Preventionist stated nasal cannula tubing and nebulizer tubing should be stored in an infection prevention pouch after cleaning and drying, and that licensed nursing staff were responsible for ensuring proper storage. Resident 25, who had OSA and bronchiectasis, had an order for nebulizer solution as needed, and his nebulizer mask was observed stored upright and hooked to the side of the nebulizer machine rather than in a bag. Resident 19, who had OSA and used CPAP at bedtime, had a CPAP mask hanging on an open shelf and not stored in a bag. Resident 4, who had benign prostatic hyperplasia, urinary retention, OSA, and a Foley catheter for urinary retention, was observed with catheter tubing on the floor and a CPAP mask hanging on a wall hook without a bag. The Infection Preventionist stated CPAP masks should be stored in an infection prevention pouch and that catheter tubing should not be on the floor due to the risk of infection. The facility’s policy for respiratory infection prevention also stated oxygen cannulae and tubing used as needed should be kept in a plastic bag when not in use, and nebulizer circuits should be stored in a plastic bag between uses.
Meal trays checked by CNA instead of licensed nurse
Penalty
Summary
The facility failed to ensure that residents received appropriate meals and diets for 12 of 39 sampled residents, including Residents 3, 4, 16, 22, 23, 25, 26, 27, 28, 37, 39, and 43, when meal trays were checked by unlicensed staff before delivery. During a dining room observation, multiple residents were seated and waiting for lunch to be served, and a CNA was observed checking the meal trays prior to serving them. The CNA stated he was the only staff member checking the meal trays and that they were not checked before coming to the dining room. The DON stated that a licensed nurse should check the meal ticket and tray before the meal is served to the resident, and that a CNA could miss a change in a resident's diet. The facility policy titled Menu Planning stated that CNAs deliver trays after licensed nursing has checked the trays according to the Verification of Diets served by nursing policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 10.34% during a medication pass, exceeding the acceptable threshold of 5%. This was observed when three medication errors occurred out of 29 opportunities for two residents. For Resident 4, a medication intended to be administered via G-tube was given orally, contrary to the physician's order. This error was confirmed by the Licensed Nurse (LN) involved, who acknowledged the importance of following the prescribed method of administration to ensure proper medication efficacy. For Resident 34, two separate medication errors were identified. The first involved administering two tablets of Acetaminophen instead of the prescribed one tablet. The second error occurred when Insulin Lispro was administered without a meal, despite the physician's order specifying it should be given with meals. The LN confirmed these discrepancies during interviews and record reviews. The Director of Nursing and the Pharmacy Consultant both emphasized the necessity of adhering to physician orders and the facility's policy, which mandates that medications be administered as prescribed and within the required time frame.
Expired Medications and Improper Storage Found in Facility
Penalty
Summary
The facility failed to ensure that expired and discontinued medications and medical supplies were not available for resident use. During inspections of various medication storage areas, numerous expired items were found, including hydrogel absorbent sheet wound dressings, Anasept gel, enteral feeding bags, bleach germicidal wipes, Bisacodyl suppositories, Debrox earwax removal aid, Miralax, and arginaid arginine powder. These items were confirmed by nursing staff to be expired and should have been removed from the facility's stock. Additionally, expired COVID-19 test kits were found in the facility. A box of BinaxNOW test kits had a handwritten expiration date that did not match the extended expiration dates provided by the Infection Preventionist. The Director of Nursing and other staff confirmed that expired test kits should not be kept as they risk providing incorrect results. The facility's policy indicated that expired medications and supplies should be immediately removed from inventory and destroyed. The facility also failed to ensure that opened single-use vials were discarded after use and that medications were appropriately labeled. An undated open single-dose sterile water vial was found in the medication refrigerator, and several medication boxes had peeled labels, making it impossible to identify the intended resident. Furthermore, the medication refrigerator was not maintained in proper working condition, as ice buildup was observed, which could affect the temperature and efficacy of stored medications. These deficiencies were confirmed by the Director of Nursing and other staff members.
Failure to Follow Prescribed Pureed Diet Portions
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a therapeutic pureed diet during a lunch meal service. On the specified date, four residents who required a pureed diet due to difficulties with chewing or swallowing received only 1/4 cup of pureed chicken instead of the 1/2 cup portion indicated on the menu. This discrepancy was observed during the lunch service and confirmed by the Dietary Manager, who acknowledged that the blue scoop used was equivalent to 1/4 cup. The facility's policy on food preparation emphasizes the importance of following the menu to ensure adequate nutrient provision, which was not adhered to in this instance.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. An ice machine was found to be unclean, with dark stains resembling rust, white matter on its exterior, and debris in the ice scoop container. The Director of Dietary Services and the Dietary Manager confirmed these observations, acknowledging that the facility staff were responsible for weekly cleaning of the ice machine, while an outside vendor serviced it every six months. The facility's policy indicated that the ice scoop should be protected from contamination, yet this was not adhered to. Additionally, the facility did not properly label refrigerated food items, including an open tray of pasteurized eggs, dessert plates, and a nutritional shake, with received, opened, or use-by dates. This lack of labeling was confirmed by the Dietary Supervisor, Licensed Nurse 3, and Licensed Nurse 1, who acknowledged the risk of serving expired food to residents. Furthermore, the concentration of the sanitizer solution in a sanitation bucket was found to be below the required 200 ppm, as confirmed by the Dietary Manager and a cook. The facility's policy required the sanitizer to be at a high concentration, but this was not maintained, posing a risk for food contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. In one instance, an unlabeled and undated jug of distilled water used for a CPAP machine was found on the floor at a resident's bedside. The resident, who had a history of sepsis and obstructive sleep apnea, could not recall the last time the CPAP was used. Staff confirmed that distilled water jugs should be labeled with the resident's name and the date of opening to ensure proper usage and prevent contamination. Another deficiency was observed when a coffee mug was left on a commode seat in a resident's bathroom. The CNA responsible admitted to placing it there and forgetting to remove it, acknowledging the hygiene risk. The Infection Preventionist confirmed that such practices are unacceptable and pose a contamination hazard. Additionally, blood pressure cuffs were not disinfected between uses on different residents, increasing the risk of cross-contamination. Staff interviews revealed that proper disinfection protocols were not followed, and the use of incorrect disinfectant wipes was noted. Further issues included dust accumulation on the exhaust in the clean linen room and stagnant water in the laundry area, both of which were confirmed by staff as needing attention. A resident with a chronic pressure ulcer was not placed on Enhanced Barrier Precautions, which are necessary to prevent infection spread. The facility's policies and procedures were not adhered to, leading to these deficiencies in infection control practices.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure that a resident received sufficient fluids to maintain adequate hydration as per the resident's care plan and the Registered Dietitian's (RD) assessment. The resident, who was admitted with multiple diagnoses including Parkinson's disease, dementia, and constipation, was at risk for dehydration. The care plan indicated that the resident required assistance with eating and was at risk for dehydration related to constipation. The RD assessed the resident's fluid needs to be 1300 milliliters per day, but the resident's intake records showed an average daily intake significantly below this requirement. Observations and interviews revealed that the resident often did not have water within reach and was not consistently offered fluids between meals. The resident, who had moderate cognitive impairment and significant hand tremors, required assistance to drink and often called for help when thirsty. However, staff did not consistently respond to these calls, and the resident's fluid intake was not adequately monitored or documented to ensure it met the RD's recommendations. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed that the resident's fluid needs were not being met and that the facility lacked a system to monitor and address these needs effectively. The DON acknowledged that the resident's fluid intake was below the RD's recommendations and that this was not addressed in interdisciplinary meetings. The facility's policy on hydration was not followed, leading to the resident being at risk for dehydration and related health issues.
Failure to Discontinue Routine Dose After PRN Change for Antidepressant
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications. The resident, who was admitted with diagnoses of insomnia and depression, had a routine order for Trazodone, an antidepressant, which was changed to a PRN order without a specified end date. Despite the change to PRN, the routine dose was not discontinued immediately, leading to the potential for duplicate dosing. The resident had refused the routine dose multiple times and requested the medication later during the night shift, prompting a request to change the order to PRN. The Director of Nursing confirmed that the routine order was only discontinued after the PRN order was initiated, and the Pharmacy Consultant acknowledged the oversight in not discontinuing the routine dose immediately. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless extended with documented rationale, which was not adhered to in this case. This oversight had the potential to result in unnecessary medication for the resident, increasing the risk of side effects associated with psychotropic medications.
Insulin Administration Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when Insulin Lispro was not administered with meals as ordered by the physician. The resident, who was admitted with Type 2 Diabetes Mellitus, had a physician's order to receive Insulin Lispro subcutaneously with meals three times a day. However, during a medication administration observation, a licensed nurse administered the insulin without the presence of a meal, contrary to the physician's order. The licensed nurse confirmed that the insulin was given without a meal and acknowledged the physician's order to administer it with meals. The Director of Nursing and the Pharmacy Consultant both emphasized the importance of following physician orders precisely. The facility's policies on medication administration and insulin administration also highlighted the need for medications to be given as prescribed, including any required time frames. Despite these guidelines, the insulin was administered incorrectly, leading to a significant medication error.
Failure to Provide Nectar Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that a resident received nectar thickened liquids as ordered by the physician. This deficiency was observed when a Certified Nursing Assistant (CNA 2) served the resident thin liquids instead of the prescribed nectar thickened liquids. The resident, who had difficulty swallowing and was on a mechanically altered diet, was seen drinking regular water and coughing between sips during lunch in the main dining hall. The tray ticket indicated that the resident was on a pureed diet with nectar thickened liquids, but CNA 2 admitted to forgetting to remove the regular water after placing it at each station. The resident, identified as having been admitted with multiple diagnoses including pneumonia, was at nutritional risk according to their care plan. The Director of Nursing (DON) confirmed that the expectation was for all diet orders, including therapeutic and textured diets, to be followed. The facility's policy on therapeutic diets, revised in October 2017, stated that such diets are ordered by a physician as part of treatment for a disease or clinical condition, including altered consistency diets. The DON acknowledged the risk of aspiration if textured diet orders were not adhered to.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident did not develop a pressure ulcer by not following their policy and procedure for the prevention of pressure injuries. The facility did not inspect the resident's skin daily when performing or assisting with personal care or activities of daily living, did not continually evaluate the resident's potential for skin breakdown per the physician's order, and did not request a preventative treatment prescribed by the physician once the resident became incontinent of both bladder and bowel function. These failures resulted in the resident acquiring a stage 2 pressure ulcer on the left buttock. The resident was admitted with diagnoses of essential hypertension, hyperlipidemia, and type 2 diabetes mellitus. The resident's Minimum Data Sheet Assessment indicated short-term and long-term memory impairment and constant incontinence of both bladder and bowel. Upon admission, the resident's skin was intact, but a stage 2 pressure ulcer was noted on the left buttock within a few weeks. The facility's records showed that the Braden Scale Skin Assessment was only completed once, despite the physician's order to complete it weekly for four weeks. Additionally, there was no documentation indicating that the resident was being turned and repositioned every two hours or offered toileting or incontinence care every two hours. Interviews with various staff members, including unlicensed staff, licensed staff, the MDS coordinator, and the Director of Nursing, confirmed that the facility's policy required turning and repositioning residents every two hours, providing incontinence care every two hours, and using barrier cream for incontinent residents. However, these practices were not consistently followed for the resident in question. The Director of Nursing acknowledged that the resident's pressure ulcer developed while at the facility and that the Braden Scale Skin Assessments were not completed as required, potentially leading to missed risk factors and skin issues.
Nursing Staff Competency and Policy Adherence Issues
Penalty
Summary
The facility failed to ensure nursing staff were competent and had the necessary skills to provide nursing and related services to assure resident safety. Specifically, nurses did not follow the facility's policy and procedure on narcotic count reconciliation, left the medicine cart keys unattended on top of the med cart, and were unaware that Baza Cream requires a physician's order before application on a resident's skin. These failures resulted in missing and unaccounted narcotic tablets for one resident and posed significant safety risks, including unauthorized access to the med cart and potential medication errors. Resident 2, who was admitted with diagnoses of Parkinson's Disease, Dysphagia, and Hyperlipidemia, had a physician's order for Percocet for pain management. However, an investigation revealed that three tablets of Percocet were missing and unaccounted for. Interviews with various staff members, including the Director of Nursing (DON), Licensed Staff B, C, E, F, and G, and the MDS Coordinator, confirmed that the facility's policy for narcotic count reconciliation was not followed. Staff admitted to not completing the narcotic count reconciliation with incoming and outgoing nurses and leaving the med cart keys unattended on top of the med cart. Additionally, the facility's staff were found to be applying Baza Cream on residents without a physician's order, which is beyond their scope of practice. Interviews with the DON, Licensed Staff E, F, and the MDS Coordinator revealed that the facility did not have a specific policy for Baza Cream usage, and staff were unaware that it required a physician's order. This lack of knowledge and adherence to policy posed risks of allergies, worsening skin issues, and development of skin rashes for the residents.
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Illustrative
What surveyors actually found near you
We read the 338 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 3.6 mi | — | 30 | 0 |
| Emmanuel Care Center - Travis | 3.6 mi | — | 21 | 0 |
| Fairfield Post Acute Rehabilitation | 3.6 mi | ★★★★★ | 17 | 0 |
| Vacaville Ranch Post Acute | 3.8 mi | ★★★★★ | 14 | 0 |
| Vacaville Convalescent And Rehabilitation Center | 5.7 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 June 2026) and official state health department websites.