Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Vacaville Convalescent And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with vascular dementia, fall risk, and impaired decision-making was placed in a W/C and secured with a bedsheet that was wrapped under the arms and tied behind the chair, preventing independent release. Staff documented that the resident used a W/C and had a history of falls, and assessments showed significant cognitive and communication impairments, yet there was no MD order for restraints. Video reviewed by the ADM and statements from the DON, DSD, and a CNA confirmed that the sheet was tied in a way the resident could not remove, and staff acknowledged that using a bedsheet in this manner was considered a restraint and contrary to facility policy, which defines restraints as devices the resident cannot easily remove and requires a physician’s order.
Wound care orders were not followed as written for two residents. One resident with chronic osteomyelitis and polyneuropathy had a wound care plan and treatment order that did not match the care being provided, and staff acknowledged the orders had not been updated after wound rounds. Another resident with bladder cancer and anemia received zinc oxide mixed with A&D ointment for a tailbone wound even though the MAR showed zinc oxide only and no written order for the mixture was found; staff said a verbal order may have been discussed, but it was not documented.
Open and Uncovered Dumpsters: The facility failed to keep two of two dumpsters closed and covered, with one dumpster containing garbage and refuse and the other containing cardboard for recycling. The RD and DSS confirmed the lids needed to be closed to keep rodents away, and the Admin acknowledged the lids were difficult to close, remained open and uncovered throughout the survey, and that no policy and procedure existed for garbage and refuse container containment and disposal.
A resident with anxiety disorder was prescribed PRN lorazepam for anxiety/muscle spasms with no end date, and the MAR showed it was given 25 times after the medication review date. LN and the DON confirmed the PRN psychotropic order should have had a 14-day limit, and the facility policy required PRN psychotropics to be limited to 14 days unless the prescriber documented a rationale and duration.
Infection Control Breach With Treatment Cart Supplies: A treatment nurse brought a hand sanitizer bottle, a cream tube, and a box of plastic wrap into two residents' rooms during wound care, then returned those items to the clean treatment cart and stored them with other creams and supplies. The nurse confirmed the items had been placed on room surfaces and taken back to the cart, and the IP confirmed this created a risk of cross-contamination and spread of infections among residents.
Unsecured Housekeeping Closet Contained Cleaning Chemicals: An unattended housekeeping closet had the key hanging on the wall next to the door, allowing access to bleach and other cleaning chemicals inside. The Admin observed the closet during a hallway check and confirmed that leaving the key out increased the risk of unauthorized access, including by confused residents. Facility policy stated hazardous chemicals must be stored in a locked closet with access limited to authorized and qualified personnel.
The facility failed to store medications properly, with loose pills found in a medication cart and issues with medication refrigerators, including ice buildup and incorrect temperatures. These deficiencies were confirmed by nursing staff, who acknowledged the potential for compromised medications. The facility's policy requires proper storage and maintenance of medication areas.
The facility failed to maintain infection control practices, as the wound treatment nurse did not sanitize equipment or label wound dressings, and housekeeping staff used the same mop and solution for multiple rooms without hand hygiene. Enhanced Barrier Precautions were not applied for residents with wounds and indwelling devices, contrary to facility policy.
The facility failed to provide mandatory abuse prevention training to CNAs on the night (NOC) shift, as required by policy. The Director of Staff Development (DSD) did not conduct in-services for the NOC shift, resulting in a lack of documentation for 13 CNAs. This deficiency had the potential to affect all 82 residents, exposing them to risks of harm.
A facility failed to implement a baseline care plan within 48 hours for a resident prescribed Divalproex Sodium for seizure prevention. Despite the medication being administered, there were no orders for seizure monitoring or a seizure-specific care plan. This was confirmed by a Licensed Nurse and the DON, who acknowledged the absence of necessary monitoring and care planning, contrary to facility policy.
A resident with a history of pulmonary embolism and thrombosis was receiving apixaban without an anticoagulant monitoring care plan in place. The facility's policies required monitoring for side effects, but interviews with staff confirmed the absence of necessary orders and care plans, potentially putting the resident at risk.
A resident with respiratory failure and hypoxia did not receive respiratory care consistent with facility policy. The nasal cannula was unlabeled, and the humidifier bottle was incorrectly labeled, contrary to the facility's policy requiring changes every 24 hours for the bottle and every seven days for the cannula. Observations and interviews revealed discrepancies in staff practices and understanding of the policy, increasing the risk of respiratory infections.
A resident with dementia was admitted to the facility without a comprehensive dementia care plan, despite having moderate cognitive impairment and non-Alzheimer's dementia. This deficiency was confirmed by a nurse and the DON, who acknowledged the importance of such a plan for proper assessment, staff interaction, and intervention. The facility's policy requires care plans to meet residents' psychosocial and functional needs.
The facility did not display complete nurse staffing data, omitting actual hours worked by LNs and CNAs, potentially misleading residents and visitors. The Medical Records Director and Administrator confirmed the omission, which contradicted the facility's policy requiring the posting of actual hours worked.
A resident with dementia was slapped on the back by another resident, who was frustrated by sleep disturbances caused by the former's behavior. The incident was witnessed by CNAs, and the facility's abuse prevention policy was not followed, increasing the affected resident's potential for social withdrawal and fear for his safety.
Improper Use of Bedsheet as Physical Restraint in Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when a bedsheet was used to secure the resident to a wheelchair without a physician’s order. The resident, admitted in the spring of 2026, had vascular dementia with behavioral disturbance, a history of falls, was cognitively impaired, rarely or never understood, had memory problems, and was moderately impaired in decision-making. The baseline care plan documented wheelchair use and fall history, and the history and physical identified the resident as a fall risk with no capacity for decision making. Despite this, there was no physician’s order for restraints in the resident’s record as of late April. According to the plan of care note and staff interviews, during a night shift shortly after admission, a licensed nurse placed a sheet under the resident’s arms and tied it behind the wheelchair after the resident, identified as a fall risk, was standing at the nurse’s station and was hard to get to cooperate with sitting. Video reviewed by the administrator showed the sheet tied at the back of the wheelchair, and the DON confirmed the resident was unable to release the sheet. Staff, including the DSD and a CNA, acknowledged that using a bedsheet in this manner constituted a restraint and that staff had been instructed not to use bedsheets as restraints. The facility’s physical restraint policy defined a physical restraint as any manual method or device attached to the body that the individual cannot easily remove and that restricts freedom of movement, and required verification of a physician’s order for restraint use, which was not present in this case.
Wound care orders not followed as written
Penalty
Summary
The facility failed to provide wound care in accordance with professional standards for two residents. One resident was admitted with chronic osteomyelitis of the right arm and polyneuropathy. The resident’s wound care plan dated 3/2/26 directed cleansing with normal saline, skin prep to the periwound, collagenase, alginate, packing with 1/2 inch iodoform packing per surgeon, and covering with dry sterile foam dressing. During observation, the treatment nurse described a different sequence of wound care than what was written, and the treatment order dated 2/23/26 also differed from the wound care plan. Staff acknowledged that the wound care orders had not been updated after wound rounds and that the care provided since 3/2/26 was incorrect. A second resident, admitted with bladder cancer and anemia, had a tailbone wound treated by a treatment nurse who mixed zinc oxide with A&D ointment in approximately equal proportions and applied the mixture to the wound. The resident’s MAR showed an order for zinc oxide only, and no order was found for mixing A&D ointment with zinc oxide. A nurse stated the resident probably had a verbal order to mix the ointments, but it had not been updated in the system. The medical doctor confirmed that mixing zinc oxide and A&D ointments had been discussed. On review of the original treatment order dated 2/27/26, the order remained zinc oxide treatment only, and nursing staff confirmed that the treatment nurse was not following the order as written. Facility policies required medication and treatment orders to be written and verbal orders to be recorded immediately in the chart, and staff stated nurses were expected to follow physician orders as written. The report documents that wound care orders were not updated and implemented as written for one resident and were not updated and implemented per the physician’s verbal order for the other resident.
Open and Uncovered Dumpsters
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained when two of two dumpsters were left open and uncovered for a census of 87. During an observation on 3/3/26 at 7:33 a.m. in the small parking lot adjacent to the kitchen, a gray metal dumpster was observed with its lid open. During a concurrent observation and interview on 3/3/26 at 8:35 a.m. with the RD and DSS, two large dumpsters were observed uncovered; one contained garbage and refuse and the other contained cardboard for recycling. The RD and DSS confirmed the dumpster lids needed to be closed to keep rodents away. During an interview on 3/6/26 at 1:04 p.m. with the Administrator, the Administrator acknowledged the dumpster lids were difficult to close and remained open and uncovered throughout the survey, and confirmed the lids should be closed to keep pests away. The Administrator also acknowledged the facility did not have a policy and procedure for the containment and disposal of garbage and refuse containers.
Unnecessary PRN psychotropic medication without required end date
Penalty
Summary
The facility failed to ensure one of 24 sampled residents, Resident 42, was free from unnecessary medications when she was prescribed a psychotropic medication without adequate indications. Resident 42 was admitted in late 2024 with a diagnosis that included anxiety disorder, and her medication review report dated 12/27/24 indicated she had the capacity to make medical decisions. A medication review report dated 12/22/25 showed an order for lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety/muscle spasms manifested by fearful feelings affecting quality of life, and the order had no end date and was indefinite. The MAR showed the lorazepam 0.5 mg was administered 25 times after the medication review date of 1/5/26. During interview and record review, LN 3 confirmed the order should have been reviewed and could have been ineffective or could cause adverse effects, and the DON confirmed PRN psychotropic medications needed a 14-day end date and that Resident 42's lorazepam did not have one. The facility policy stated PRN psychotropic medications are limited to 14 days unless the prescriber documents the rationale for extending use and the duration of the PRN order.
Infection Control Breach With Treatment Cart Supplies
Penalty
Summary
The facility failed to implement infection control and prevention practices when items that had contact with resident room surfaces were brought back to the clean treatment cart. During an observation in Resident 124's room, the treatment nurse prepared wound care supplies at the cart outside the room, brought a hand sanitizer bottle to the bedside table inside the room, and after completing wound treatment moved the bottle from the bedside table to the table by the sink and then back to the top of the treatment cart. The cart surface was wiped with sanitizing wipes, and the hand sanitizer bottle was then placed on the cart. During another observation, the same nurse provided wound treatment to Resident 129, who had diagnoses including DM and ESRD. The nurse carried a tube of 2.5% lidocaine & 2.5% prilocaine cream and a box of plastic food wrap film into the room, set them on the blanket at the foot of the bed, applied cream to the left arm, and wrapped the area with plastic wrap taken from the box. After completing treatment, the nurse carried the cream tube and plastic wrap box back to the treatment cart and placed them in drawers with other creams and clean supplies used for other residents. The nurse confirmed these actions, and the Infection Preventionist confirmed that bringing these items from resident rooms back to the clean treatment cart presented a risk of cross-contamination and spread of infections among residents.
Unsecured Housekeeping Closet Contained Cleaning Chemicals
Penalty
Summary
The facility failed to ensure hazardous chemicals were secured and inaccessible to residents when a housekeeping closet containing cleaning chemicals was left unattended with the key hanging on the wall next to the door. During a concurrent observation and interview in the hallway near room [ROOM NUMBER], the Administrator observed the unattended closet, opened it with the key on the wall, and found bleach and other cleaning chemicals inside. The Administrator confirmed that leaving the key out increased the risk of unauthorized access to the chemicals, including confused residents who may be harmed by misuse of these chemicals. The facility policy titled Hazardous Materials Management Program stated that hazardous chemicals are to be stored in a locked closet with only authorized and qualified personnel having access.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during a survey. Loose pills were found in the bottom of a medication cart drawer, which was confirmed by a licensed nurse who acknowledged the risk of these pills being accidentally administered to residents. Additionally, the medication refrigerator in the north station was found to have significant ice buildup, preventing the freezer door from opening, and puddles of water were present at the bottom and on the shelving. The external areas of the fridge were also damaged. A licensed nurse confirmed that improper maintenance of the fridge could compromise the medications stored within, potentially leading to residents receiving ineffective medications. Further observations revealed that the medication fridge in the south station had a temperature of 24°F, which is outside the expected range of 36-46°F. This discrepancy was confirmed by another licensed nurse, who stated that such a temperature could damage the medications, rendering them ineffective. The Director of Nursing acknowledged that loose pills should not be present in the cart and should be disposed of properly. The facility's policy, dated 2001, requires medications to be stored under proper temperature conditions and mandates that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations and interviews. The wound treatment nurse (TN) was observed taking a container of medication from a resident's room and placing it back in the clean supply cart without proper sanitization. Additionally, the TN did not sanitize equipment between uses for different residents and failed to label wound dressings with dates or initials. These actions were confirmed by the TN and the Director of Nursing (DON), who acknowledged the breach in protocol. Housekeeping staff also did not adhere to infection control practices. Observations revealed that housekeepers did not perform hand hygiene between cleaning different resident rooms and used the same mop and sanitizing solution for multiple rooms. Interviews with housekeeping staff confirmed these practices, which were contrary to the facility's policy that required changing mop solutions every three rooms and performing hand hygiene after removing gloves. Furthermore, Enhanced Barrier Precautions (EBP) were not applied for residents with wounds and indwelling medical devices. The Infection Preventionist and a Licensed Nurse (LN) indicated that EBP was only used for residents with a history of multidrug-resistant organisms (MDROs), not for those with wounds or indwelling devices. The DON confirmed that EBP should have been implemented for these residents, as per the facility's policy, but was not done so, leading to potential risks of infection spread among the residents.
Failure to Provide Mandatory Abuse Training to NOC Shift CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received mandatory abuse prevention training, as required by their policy and procedure. Specifically, documentation for the required training was unavailable for the 13 CNAs assigned to the night (NOC) shift. This deficiency was identified through interviews and record reviews, revealing that the Director of Staff Development (DSD) did not provide in-services to the NOC shift staff. The DSD confirmed that the mandatory abuse prevention training had not been provided during 2024, and there was no documentation of NOC shift staff participation in the training. The facility's policy, revised in August 2022, mandates that all nurse aide personnel participate in regular in-service education, including training on abuse, neglect, and exploitation of residents. The DSD stated that in-services were scheduled twice a week, but these sessions did not accommodate the NOC shift staff. The DSD admitted to not providing in-person in-services to the NOC shift, instead claiming to ensure they received the information without requiring attendance or signatures on a sign-in sheet. This lack of training documentation and participation had the potential to affect all 82 residents in the facility, exposing them to risks of physical, mental, or psychosocial harm.
Failure to Implement Baseline Care Plan for Seizure Monitoring
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 238, who was prescribed anti-seizure medication, Divalproex Sodium, for seizure prevention. Despite the medication being administered as ordered, there were no corresponding orders for monitoring seizure symptoms, nor was there a seizure-specific care plan in place. This oversight was confirmed during a review of Resident 238's records and through interviews with the Licensed Nurse (LN 3) and the Director of Nursing (DON), both of whom acknowledged the absence of necessary seizure monitoring and care planning. Resident 238 was admitted with diagnoses including a fracture of the left femur and a fall, and was prescribed Divalproex Sodium to prevent seizures. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including necessary instructions for effective, person-centered care. However, the facility did not adhere to this policy, as evidenced by the lack of a seizure monitoring plan and care plan for Resident 238, which was contrary to the facility's established protocols for managing residents on anti-seizure medications.
Failure to Implement Anticoagulant Monitoring
Penalty
Summary
The facility failed to provide services according to professional standards by not implementing anticoagulant monitoring for a resident. The resident, admitted in February 2023, had diagnoses including pulmonary embolism and thrombosis of the left leg and was receiving apixaban, a medication that decreases blood clotting. However, the Medication Administration Record did not include an order to monitor for side effects such as excessive bleeding or bruising. Additionally, the resident's Care Plan lacked an anticoagulant monitoring care plan. Interviews with Licensed Nurse 1 and the Director of Nursing confirmed the absence of orders or a care plan for anticoagulant monitoring. The Director of Nursing stated that her expectations were for all residents on anticoagulants to have orders to monitor side effects and an anticoagulant monitoring care plan. The facility's policy on anticoagulation, dated 2001, and the policy on comprehensive person-centered care plans, revised in March 2022, both indicated the need for monitoring and establishing measurable objectives and expected outcomes of care.
Inconsistent Respiratory Care Practices for a Resident
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards and facility policy for Resident 240, who was admitted with respiratory failure and hypoxia. The resident's nasal cannula (NC) was not labeled with a date indicating when it was last changed, and the humidifier bottle was labeled with a date that did not align with the facility's policy. The facility's orders required the humidifier bottle and NC to be changed every five days, but the facility's policy stated that the humidifier bottle should be changed every 24 hours and the NC every seven days. Observations and interviews revealed discrepancies in the facility's practices and policies. The Infection Preventionist confirmed the lack of labeling on the NC and the incorrect labeling of the humidifier bottle. Licensed nurses provided conflicting information about the frequency of changes and labeling practices. The Director of Nursing acknowledged that the facility's practice of changing the bottle and tubing as one unit was not in agreement with the policy. These inconsistencies increased the risk of respiratory infections for Resident 240.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for a resident diagnosed with dementia, identified as Resident 57. The resident was admitted to the facility in October 2024 with diagnoses including senile degeneration of the brain and dementia. A review of the resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and non-Alzheimer's dementia. Despite these diagnoses, there was no dementia care plan in place for Resident 57, as confirmed by Licensed Nurse 1 during a record review and interview. The absence of a dementia care plan was acknowledged by both Licensed Nurse 1 and the Director of Nursing (DON), who stated that such a plan is crucial for assessing the resident properly, guiding staff interactions, monitoring behaviors, and implementing appropriate interventions. The facility's policy on comprehensive person-centered care plans, revised in March 2022, emphasizes the importance of including measurable objectives and timetables to meet the resident's psychosocial and functional needs. The lack of a care plan for Resident 57 had the potential to delay necessary dementia treatments and services.
Incomplete Nurse Staffing Data Displayed
Penalty
Summary
The facility failed to ensure that complete nurse staffing data was displayed and accessible for residents and visitors. During an observation at the North Nursing station, the Daily Staffing form was found to include the number of Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) scheduled for each shift, but it did not include the actual hours worked by these staff members. This omission was confirmed during an interview with the Medical Records Director (MRD), who acknowledged that the actual hours worked had never been posted since they began working at the facility. Further review with the Administrator (ADM) confirmed that the daily Staffing form lacked the actual hours worked per shift for LNs and CNAs. The facility's policy and procedure, titled 'Posting Direct Care Daily Staffing Numbers,' revised in August 2022, requires that the actual time worked during each shift for each category and type of nursing staff be recorded and posted. The failure to include this information had the potential to mislead residents and visitors about the actual hours worked by staff responsible for providing direct care.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident slapped him on the back. Resident 1, who was admitted in 2023 with diagnoses including syncope and dementia, was involved in an incident where Resident 2, admitted in 2022 with orthopedic aftercare and hypertension, exhibited aggressive behavior. Resident 2, who had a BIMS score of 14, indicating relatively intact cognition, became frustrated with Resident 1's behavior, which he found disturbing to his sleep. This led to Resident 2 slapping Resident 1 on the back, an act witnessed by two CNAs. The incident occurred when Resident 1 was being assisted by CNAs after Resident 2 complained about sleep disturbances. Despite attempts to redirect Resident 1 back to bed, Resident 2, who was angry and frustrated, got out of his wheelchair and hit Resident 1. The facility's policy on abuse prevention, which states that residents must not be subjected to abuse by anyone, including other residents, was not adhered to in this situation. This failure increased Resident 1's potential for social withdrawal and fear for his safety.
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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 Vacaville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vacaville Ranch Post Acute | 2.7 mi | ★★★★★ | 3 | 0 |
| Laurel Creek Health Center | 5.7 mi | ★★★★★ | 15 | 0 |
| Greenfield Care Center Of Fairfield | 9 mi | — | 30 | 0 |
| Emmanuel Care Center - Travis | 9 mi | — | 21 | 0 |
| Fairfield Post Acute Rehabilitation | 9 mi | ★★★★★ | 18 | 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 July 2026) and official state health department websites.