Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Lodi Creek Post Acute during CMS and state inspections, most recent first.
A resident with dementia and a history of aggressive behavior, care planned for line-of-sight monitoring during ambulation and proximity to others, was not consistently supervised in the hallway or near other residents. During one episode, this resident exited her room while CNAs assisted another resident in a wheelchair, perceived a response as disrespectful, and struck the resident’s face and chest; the physician was not notified until several hours later, delaying behavioral assessment. Later that evening, the same resident, left without close monitoring, approached another resident in a wheelchair at the nurse’s station, pulled the wheelchair backward, and struck the back of the resident’s head and upper back, causing head pain. Despite these incidents and the aggressive resident’s confusion and belief that the unit was her house, the facility continued to allow the two involved residents to share an unsupervised connecting bathroom, permitting ongoing unsupervised interaction and conflicting with facility policies on behavior management, resident rights, and abuse prevention.
A resident with diabetes, hemiplegia, and generalized muscle weakness was scheduled for twice-weekly PM showers, but EMR review showed almost all bathing entries coded as "response not required," with only two bed baths documented for the month. The resident reported routinely refusing showers and preferring bed baths, and CNAs stated they provided bed baths, notified an LN of refusals, and were responsible for documenting showers, bed baths, and refusals. However, staff frequently used incorrect EMR codes instead of documenting refusals or accurately recording provided bed baths, resulting in records that did not match the shower schedule or reported care. Nursing leadership and the DSD confirmed the inconsistency and stated that documentation should reflect actual showers, refusals, and reasons, in accordance with facility policy requiring date, time, and refusal details for bathing care.
A resident with chronic pain and depression did not receive scheduled pain and depression medications within the required time frame, with administration occurring one hour and 45 minutes late. The delay was not documented or explained, and a family member reported that this caused the resident distress and unmanaged pain. Facility policy requires medications to be given within one hour of the scheduled time.
Food service safety practices were not followed when an open bottle of vinegar and a partially exposed box of salt were stored in the kitchen, a melted fish spatula was found in the clean utensils box, canned goods were kept in dry storage without clear expiration or received-by dates, and multiple individuals entered or worked in the kitchen without proper hair restraints. The KS, DAS, and RD acknowledged the issues, and facility policy required food to be covered and stored appropriately, utensils to remain in good repair, and staff to wear hair restraints so hair does not contact food.
A resident with MRSA, osteomyelitis, and BKA wounds had contact precautions removed without physician involvement, and no isolation signage was posted at the room. Staff also failed to perform hand hygiene during resident care and medication pass, and an LPN did not sanitize a soiled med tray, BP cuff, or med cart between resident use. The DON and IP stated staff were expected to disinfect equipment and sanitize between residents.
A resident with cerebral infarction, epilepsy, and muscle weakness had the call light placed out of reach during observation. The resident could not extend the arm enough to access it, and an LPN confirmed the call light should always be within reach. The care plan identified fall risk and directed that the call light be within reach for assistance, while a CNA noted the resident preferred it positioned between the chest and stomach area with the phone charger.
A resident’s privacy curtain was found hanging down because several hooks were loose, and the resident said she had already told staff it needed to be fixed. An LPN confirmed the curtain was not working and had not been repaired, and a CNA stated the curtain was important during peri-care and brief changes to protect privacy, comfort, and dignity. The DON stated staff were expected to report the issue in the maintenance logbook and that the broken curtain put the resident at risk of not having privacy and dignity respected.
A resident with major depressive disorder and anxiety disorder had an active order for Prozac for depression, and the MAR showed it was administered during the assessment look-back period. However, the MDS Section N did not code the antidepressant, and the MDS Nurse confirmed the omission made the assessment inaccurate and could affect care planning, quality measures, and facility reporting.
Failure to Follow Dialysis Food and Weight Monitoring Care Plans: A resident with ESRD on dialysis did not receive the ordered sack lunch/brown bagged food before dialysis, despite the care plan and staff protocol requiring it. Two other residents with malnutrition, dysphagia, schizophrenia, and weight-related care plans had missed monthly weights documented as refusals, but the RN/LN and DON confirmed there was no documentation that the MD or RP/family were notified as required by the care plans.
Care Plan Not Updated After Contact Isolation Was Discontinued: A resident with MRSA and osteomyelitis was taken off contact isolation after completing antibiotics, but the comprehensive care plan was not revised to reflect the change. The care plan still referenced contact isolation and signage, while no isolation signage was present at the room door and the IP stated he was responsible for updating the care plan but had not actually done so.
Improper Urinary Catheter Bag Positioning: A resident with a urinary catheter and diagnoses including urinary retention and obstructive/reflux uropathy had the drainage bag observed on the upper bedside rail above bladder level. An LPN confirmed the bag should have been placed lower to prevent urine backflow, and the IP stated the bag must remain below the bladder so tubing stays unkinked and urine drains by gravity, consistent with the facility’s catheter care policy.
A resident with dysphagia and a gastrostomy tube was observed receiving tube feeding while the head of bed was almost flat, despite care plan and MD order instructions to keep the HOB elevated 30 to 45 degrees during feedings. A CNA confirmed the HOB was too low, and the DON acknowledged the positioning was incorrect.
A resident with ESRD and dependence on HD did not receive the ordered sack lunch or packed snacks for dialysis trips, and after returning from dialysis she was left without a meal tray and had to get food from family. Staff gave inconsistent accounts of who was responsible for early trays, packed food, and post-dialysis meals, while the DON confirmed the resident should have had food on return and noted that lack of food can lead to weight loss.
A resident with chronic respiratory failure, OSA, gait and mobility issues, and a need for assistance with personal care had saline nasal spray left accessible on an overbed table and was using it daily without a complete self-administration assessment or a physician order allowing self-administration. The LPN found the resident’s PRN order in the chart but was unaware of the resident’s routine use, and the DON stated that self-administration requires assessment, physician notification, and care plan documentation.
Inaccurate MAR Documentation for Two Residents: An LPN administered Tylenol to one resident and docusate to another resident, but the MARs did not accurately reflect the administrations. The LPNs confirmed the medications were given, while the DON and ADON verified the documentation errors and noted that medications must be documented at the time they are administered to prevent medication errors.
Failure to Administer Consented Vaccines: Two residents did not receive ordered/consented immunizations. One resident with acute respiratory failure, COPD, and chronic pulmonary edema did not receive the pneumococcal vaccine despite signed consent. Another resident with pleural effusion and atelectasis did not receive influenza, pneumococcal, or COVID-19 vaccines despite consent forms on file. The IP confirmed the missed vaccines and stated he was responsible for giving them but had not done so timely.
Rooms 2, 3, 4, 8, 41, 43, 44, 45, 46, 47, and 48 did not meet the required square footage per resident. During observation, the Maintenance Supervisor measured several 2- and 3-occupancy rooms below the required standard. Interviews with a resident, a family member, and a CNA described tight space in the room and the need to move furniture when using a Hoyer lift, while another resident and a housekeeper reported enough space to function and clean properly.
A resident was discharged without receiving a 30-day advance written notice, and the required Notice of Transfer or Discharge was not sent to the Ombudsman on the same day. Additionally, the discharge location listed on the notice did not match the physician's order, and staff confirmed these inconsistencies and failures to follow policy.
A resident with dementia and muscle weakness was not repositioned or assisted with care needs in a timely manner, despite being at risk for pressure injuries and skin breakdown. Observations and interviews revealed that the resident was not repositioned or taken to the bathroom during a family member's visit, and documentation for care was incomplete. Staff interviews indicated inconsistencies in care provision, and the Director of Nursing acknowledged the risk of skin breakdown and discomfort due to unmet care needs.
A resident with anoxic brain injury and bipolar disorder was physically abused by another resident with Alzheimer's disease in a shared bathroom. The aggressor, who believed she owned the facility, grabbed the other resident's arm, causing a scratch. The incident was unwitnessed, and staff interviews revealed the aggressor's history of territorial behavior. The facility's policies on abuse prevention were not effectively implemented to prevent this altercation.
The facility failed to log the use of two opened emergency kits (E-Kits) containing injectable medications, as confirmed by a licensed nurse and the ADON. The missing documentation and communication with the pharmacy were not completed, contrary to the facility's policy, increasing the risk of not having necessary medications during emergencies.
The facility failed to properly label, store, and dispose of medications, leading to several deficiencies. Expired medications were found in the medication cart and storage room, and several pharmaceutical products lacked opened or discard dates. Medications with torn labels were also found, violating labeling policies. Additionally, loose medications were found in a cart, and a powdered medication was left unattended at a resident's bedside, risking medication errors and resident safety.
The facility failed to accurately test sanitizing solutions in the kitchen, potentially exposing residents to foodborne illnesses. The dishwasher's sanitizing solution was not properly checked, with faded test strips and an unknown operational temperature. Additionally, the QAC solution used for dish and surface sanitation was tested at an incorrect temperature, below the manufacturer's recommendation, compromising the accuracy of the readings.
The facility failed to follow infection control practices, including improper hand hygiene by a laundry aide, delayed enhanced barrier precautions for a resident with medical devices, and lack of hand hygiene for a resident before meals. Additionally, the ice machine was found to be improperly cleaned, with blackish growth present.
The facility failed to ensure that call lights were within easy reach and operable for six residents, including those with Alzheimer's, dementia, and other conditions. Observations revealed broken or inaccessible call lights, confirmed by CNAs and the Maintenance Director. The Director of Nursing emphasized the importance of functional call lights, as per facility policy.
The facility failed to obtain and update informed consent for antipsychotic medications for two residents. One resident's consent was not updated every six months, while another was prescribed medication without any consent. Facility policy and regulations require informed consent before administering such medications, which was not followed in these cases.
A resident admitted with an indwelling urinary catheter (IUC) did not have the IUC included in their baseline care plan within 48 hours of admission, as required by facility policy. Staff interviews confirmed the expectation that the IUC should have been documented to guide care. The omission potentially placed the resident at risk for unmet care needs.
A resident with dementia, schizophrenia, and apraxia, who did not speak English, was not provided with an effective communication care plan. Staff relied on gestures and an unofficial interpreter, despite the availability of translation services and communication boards. The resident's care plan, last revised in 2020, failed to include these resources, contrary to facility policies.
The facility failed to adhere to professional standards for two residents. One resident's PICC IV flushes were improperly documented, with nurses not recording the procedure as required. Another resident's urinary drainage bag was improperly managed, being positioned higher than the bladder, not enclosed in a privacy bag, and with kinked tubing, obstructing urine flow. These deficiencies were confirmed by staff and did not align with facility policies.
A resident with a language barrier was not provided with adequate communication support, as staff failed to use a communication board or translator service, relying instead on gestures and the resident's son for translation. This was contrary to the facility's policy, which requires the use of communication aids for residents with limited English proficiency.
The facility failed to monitor VADs for two residents, risking infection. One resident with a Midline catheter for cellulitis treatment had nine out of 23 shifts without documented assessments. Another resident with a PICC line for multiple conditions had several shifts without documented assessments. Staff interviews confirmed the lack of documentation, increasing infection risk. Facility policies required consistent monitoring, which was not followed.
A facility failed to accurately measure and record the output of a resident with ESRD receiving hemodialysis, as required by physician orders. Instead of recording the output in milliliters, staff noted the number of times the resident urinated, despite the resident being continent. This oversight was confirmed by the DON, highlighting a deviation from the facility's policy and recognized standards of care.
A resident with depression and bipolar disorder was prescribed buspirone without proper documentation of diagnosis, manifestation, or side effect monitoring. The facility's policy requires these elements for psychotropic medication management, but they were not followed, as confirmed by interviews with the Medical Record Director and nursing staff.
The facility failed to maintain freezer number six in good working order, with an observed internal temperature of 10 degrees Fahrenheit and loose door seals causing frost buildup. The Certified Dietary Manager confirmed the freezer should be at 0 degrees Fahrenheit or lower, as per facility policy and FDA guidelines. This deficiency posed a risk of foodborne illnesses due to improper food storage conditions.
A resident in an LTC facility was hit in the face with a television remote control by another resident, resulting in a scratch and bruise. The incident was witnessed by a staff member who intervened after the first strike. The victim, who has a history of cerebrovascular accident, was sent to a hospital for evaluation and diagnosed with a subconjunctival hemorrhage. The facility's policy on abuse prevention was not followed, leading to this deficiency.
A resident with dementia and a history of aggression punched another resident in the memory care unit, causing injury. The altercation occurred after the second resident accidentally ran over the first resident's foot with a wheelchair. Staff interviews revealed that both residents have severe memory problems and behavioral issues, requiring close monitoring. However, there was a lack of supervision in the hallway at the time of the incident, leading to a failure in protecting residents from abuse.
A medication cart was left open and unattended in a hallway, with LN 1 unaware of its unlocked state while sitting at the nursing station. The DON confirmed that staff are expected to lock medication carts when not in use, as per the facility's policy. This incident posed a risk for medication misuse and drug diversion.
Failure to Prevent Resident-to-Resident Abuse and Provide Required Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to implement timely behavioral assessment and monitoring after resident-to-resident altercations. Resident 1, who had Alzheimer’s disease, dementia, mild neurocognitive disorder, major depressive disorder in remission, and unsteadiness of feet, had a BIMS score of 9 indicating moderately impaired cognition and a care plan focus on aggressive/physical behaviors toward peers with potential to escalate quickly. The care plan interventions included assigning CNA monitoring during ambulation or activities in proximity to other residents and ensuring line-of-sight supervision at all times, as well as proactively separating residents near identified triggers. Despite this, on the evening of 3/27/26 at approximately 8 PM, Resident 1 exited her room while CNAs were assisting Resident 2 in a wheelchair near Resident 1’s doorway, told staff to be quiet because her roommate was asleep, and then made brief open-hand contact to Resident 2’s left face and chest area after perceiving Resident 2’s unclear response as disrespectful. Staff separated the residents and redirected Resident 1, but the physician was not notified until 12:15 AM, about four hours after the incident, delaying assessment and management of Resident 1’s behavior. Following the first altercation, staff did not provide the close, line-of-sight monitoring required by Resident 1’s behavior care plan. CNA 1 later acknowledged being aware of Resident 1’s history of resident-to-resident altercations and the need for monitoring to prevent further incidents, yet stated that no staff were present in the hallway to monitor Resident 1 and that she did not know Resident 1’s whereabouts. On 4/20/26, surveyors observed Resident 1 ambulating independently in the hallway and from her room to the dining room without staff present, while the nurse’s station door was closed and three staff, including CNA 1, were inside. The ADON confirmed that CNAs were expected to provide line-of-sight monitoring of Resident 1 due to unpredictable aggressive behaviors and that without such monitoring, staff could not promptly de-escalate or intervene if Resident 1 became aggressive toward other residents. A second altercation occurred at approximately 8:50 PM on 3/27/26 involving Resident 1 and Resident 3. Resident 3 had dementia with agitation, a cognitive communication deficit, restlessness and agitation, and major depressive disorder, but an MDS BIMS score of 15 indicating intact cognition. Resident 3 used a wheelchair and typically required only set-up or clean-up assistance for toilet transfers. According to Resident 3’s SBAR and staff interviews, Resident 3 was in the nurse’s station with CNA 3 for snacks when Resident 1 approached from behind, stated it was her house, questioned Resident 3’s presence, pulled Resident 3’s wheelchair backward, and made brief open-hand contact to the back of Resident 3’s head and upper back, causing pain in the back of the head. CNA 2 reported that she had left Resident 1 without close monitoring in the hallway when she went to assist another resident and then saw Resident 1 enter the nurse’s station and strike Resident 3. CNA 2 stated the altercation could have been prevented with adequate staff monitoring and that Resident 1 and Resident 3 required consistent separation. The facility also failed to prevent ongoing risk of further resident-to-resident altercations between Resident 1 and Resident 3 by allowing them to continue sharing a bathroom between their adjacent rooms. Resident 3 reported that Resident 1 had struck her on the back of the head, causing pain, and that she feared Resident 1 and did not feel comfortable sharing the bathroom because Resident 1 might hurt her again. CNA 2 and the ADON acknowledged that Resident 1 and Resident 3 could access the shared bathroom without staff supervision, allowing unsupervised interaction despite Resident 1’s confusion, belief that the unit was her house, and unpredictable aggressive behaviors. The DON and ADON both recognized that Resident 1’s belief that the unit was her house contributed to the two altercations and that sharing a bathroom under these circumstances placed both residents at risk for further altercations. These actions and inactions conflicted with the facility’s policies on Behavioral Assessment, Intervention, and Monitoring, Resident Rights, and Abuse, Neglect, Exploitation and Misappropriation Prevention, which require immediate safety strategies to protect residents and a facility-wide commitment to protect residents from abuse by anyone, including other residents.
Inaccurate EMR Documentation of Resident Bathing and Shower Refusals
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for a resident whose bathing care was not properly recorded in the electronic medical record (EMR). The resident, admitted in 2022 with type 2 diabetes, right-sided hemiplegia/hemiparesis, and generalized muscle weakness, was scheduled to receive showers on Sunday and Wednesday during the PM shift. Review of the EMR bathing record for the month of January showed that "response not required" was documented for all shifts except for three entries: one notation of "resident not available" and two entries indicating bed baths on specific dates. This documentation did not align with the facility’s shower schedule or with staff reports of the resident’s actual bathing routine. Interviews with the resident and multiple CNAs revealed that the resident routinely refused showers and preferred bed baths, which staff reported were being provided, often on the morning shift instead of the scheduled PM shift. CNAs stated that they were responsible for completing shower sheets, obtaining nurse signatures, and documenting showers, bed baths, and refusals in the resident’s chart. They also stated that when a resident refused a scheduled shower, they would notify a licensed nurse and offer the shower multiple times during the shift, then document the refusal. However, review of the EMR showed that CNAs frequently used the code "response not required" instead of documenting refusals or accurately recording when bed baths were provided. Licensed nurses and facility leadership, including the Director of Staff Development and the Director of Nursing, confirmed that the EMR documentation for the resident’s showers and bed baths in January was inconsistent with expectations and the facility’s shower schedule. The DSD verified that only two bed baths were documented for the month, whereas at least eight showers should have been documented if the resident was receiving bathing twice weekly as scheduled. Both the DSD and DON stated that staff were expected to use correct coding, such as documenting refusals and appropriate reasons when showers did not occur, and confirmed that the existing charting did not meet these expectations. Review of the facility’s bath/shower policy indicated that staff were required to document the date and time of showers/tub baths and, if refused, the reasons and interventions taken, which was not consistently done for this resident.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), major depressive disorder, and osteoarthritis was admitted with a care plan identifying a risk for pain, depression, anxiety, and sleep problems related to unrelieved pain. The care plan included interventions such as administering medication as ordered. The resident was prescribed meloxicam for osteoarthritis pain, scheduled to be administered daily at 8:00 AM. On one occasion, the medication was administered at 9:46 AM, one hour and 45 minutes after the scheduled time, as confirmed by the medication administration record and interviews with facility staff. There was no documentation explaining the delay in administration. A family member reported that the late administration of the pain medication caused the resident distress and unmanaged pain. The Assistant Director of Nurses confirmed that medications are required to be administered within one hour before or after the scheduled time and that any delays should be communicated to the physician. The facility's policy also states that medications must be administered in a safe and timely manner, within one hour of the prescribed time, and based on resident need rather than staff convenience.
Food Storage, Utensil Condition, Labeling, and Hair Restraint Failures
Penalty
Summary
Food service safety practices were not followed when an open bottle of vinegar was observed stored under the kitchen steam table during the initial kitchen tour. The kitchen supervisor/manager stated the bottle had been covered but the cap had fallen off, and later explained that the vinegar had been stored there with other condiments because of limited kitchen space. The supervisor/manager also stated that leaving the bottle uncovered posed a risk of dust contamination, and the facility policy required liquids and food that are prepared and not served to be tightly covered and stored appropriately. An open box of salt was also observed in the kitchen with the mouth of the box taped, but with a visible gap that left the contents partially exposed to air. The kitchen supervisor/manager stated the box had been found under the steel kitchen worktable and acknowledged that leaving it partially open could attract insects. The facility policy and the cited Food Code provisions required food to be stored in covered containers or wrappings and protected from contamination, splash, dust, and other contamination. A fish spatula stored in the clean utensils box was observed with a melted middle section, and the kitchen supervisor/manager stated it should have already been discarded because it was not safe for cooking. Canned goods were also found in the dry storage room without expiration dates or received-by dates, and the dietary assistant supervisor/cook had assumed a printed marking on the cans was the expiration date. In addition, a delivery trainee entered the kitchen without a hairnet, the DON was observed exiting the kitchen without a hairnet while carrying resident snacks, and the dietary assistant supervisor/cook’s mustache was not fully covered by his beard-net while preparing pureed food. The kitchen supervisor/manager and RD stated that all hair, including facial hair, must be fully covered, and the facility policy required food and nutrition services staff to wear hair restraints so hair does not contact food.
Infection Control Failures With Isolation, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in several areas. Resident 7 was admitted with diagnoses including metabolic encephalopathy, osteomyelitis, MRSA infection, and acute kidney failure. The resident’s hospital discharge summary indicated contact isolation due to MRSA, and the facility’s order details placed the resident on contact precautions for MRSA-positive bilateral below-the-knee amputation wounds. The care plan also identified contact isolation as required for MRSA in bilateral BKA wounds. During observation and interview, no isolation signage was posted at Resident 7’s door. The Infection Preventionist stated the resident had been on contact precautions from 10/15/25 to 11/13/25 and that he removed the isolation signage after the resident completed Linezolid according to the physician’s signed admission order. The physician stated she did not receive documentation or text messages about discontinuing contact isolation and did not recall being asked to discontinue it. She further stated that, given the resident’s condition, it would have been better for staff to ask her to reassess the resident and consider whether Enhanced Barrier Precautions should have been implemented. The Infection Preventionist also stated the resident did not receive MRSA re-testing after antibiotics and that he did not document contacting the local health department for guidance. The facility also failed to maintain hand hygiene during resident care and failed to disinfect equipment between resident use. A housekeeper exited a resident room with trash, placed it outside the room, did not change gloves or sanitize hands, touched the door with dirty gloves, and re-entered the room. A CNA carried a trash bag containing a dirty urinal, placed it in a hallway trash bucket, removed one glove, and then touched a binder at the nursing station without hand hygiene. Another nurse entered and exited a resident room twice and then prepared and administered medication without sanitizing hands. During medication administration, an LPN exited a room on Enhanced Barrier Precautions, placed a soiled medication tray on the medication cart, removed gown and gloves, and did not sanitize hands or the tray before preparing medications for another resident. The same LPN also brought a blood pressure machine used in one resident’s room back to the medication cart and later did not sanitize the cart surface before placing medication cups on it. Facility staff, including the DON and Infection Preventionist, stated that staff were expected to disinfect equipment and sanitize between residents and during resident care.
Call Light Not Within Reach
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident 57 when the resident’s call light was not within reach. Resident 57 was admitted with diagnoses including cerebral infarction, epilepsy, and muscle weakness. During observation in the resident’s room, the call light was seen lying on the right lower leg area, and Resident 57 was unable to extend the left arm enough to reach it. When asked, Resident 57 indicated that having the call light within reach was important. A licensed nurse confirmed that Resident 57 was unable to reach the call light and stated it should always be within reach. The resident’s care plan identified a fall risk related to an unsteady gait and included the intervention that the resident’s call light be within reach and used for assistance. A CNA stated the resident preferred the call light positioned between the chest and stomach area with the phone charger, and the DON stated it was the expectation that the call light be placed within Resident 57’s reach at all times.
Broken Privacy Curtain Left Resident Without Proper Privacy
Penalty
Summary
The facility failed to maintain a safe and home-like environment for 1 of 22 sampled residents, Resident 108, when the resident’s privacy curtain was found not properly secured and functioning. During observation in the resident’s room, the window curtain was hanging down because three hooks were loose, and Resident 108 stated the curtain needed to be fixed and that she had already told staff about it. During interviews, LN 4 confirmed the curtain needed repair, and Resident 108 later stated that no one had come to fix it despite her reporting the issue. LN 1 also confirmed the curtain was not working and had not been repaired, stating it was a safety and privacy issue and could fall on the resident. CNA 8 stated the curtain was important during peri-care and brief changes because it protected the resident’s privacy, comfort, and dignity. The DON stated staff were expected to report the curtain problem in the maintenance logbook and that the broken curtain put Resident 108 at risk of not having privacy and dignity respected.
MDS Assessment Omitted Antidepressant Medication
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the MDS assessment for one sampled resident. Resident 59 was admitted with diagnoses including major depressive disorder and anxiety disorder, and the record showed an active physician order for Prozac 20 mg by mouth in the morning for depression. During a concurrent interview and record review, the MDS Nurse confirmed that Prozac was prescribed and that it was administered during September 2025 throughout the assessment timeframe. The MDS Nurse also confirmed that the completed MDS Section N did not code the antidepressant medication even though it was given during the look-back period. The MDS Nurse stated the medication should have been captured in the assessment and acknowledged that the omission resulted in an inaccurate assessment that could affect care planning, quality measures, and facility reporting. The DON stated that MDS Nurses must assess residents accurately and that capturing psychotropic medications in Section N is important for quarterly evaluations, care planning, quality measures, and facility reporting.
Failure to Follow Dialysis Food and Weight Monitoring Care Plans
Penalty
Summary
A care plan intervention for Resident 106 was not implemented as written. Resident 106 was admitted with ESRD, acute kidney failure, and dependence on renal dialysis. The record showed an order to provide a sack lunch per the resident’s dialysis schedule, and the care plan included providing brown bagged food while out for dialysis. During observation and interviews, Resident 106 stated she had requested packed snacks for dialysis because she might get hungry again and said the staff did not provide food the last time she went for dialysis. She later stated she left for dialysis and did not get the packed snacks, and staff did not provide them either. Interviews with CNA staff, the DSD, the Kitchen Supervisor, and the DON showed that the facility’s routine was for kitchen staff to prepare sack lunches for residents going to dialysis and for CNAs to pick them up and provide them before transport. The DON confirmed that residents on dialysis were supposed to have a sack lunch before leaving, that the care plan and order existed for Resident 106, and that the care plan and order were not followed. The DON stated the care plan was intended to reflect the resident’s plan of care and guide how care was to be provided. For Resident 10, the record showed diagnoses including moderate protein-calorie malnutrition, dysphagia, and adult failure to thrive. The care plan identified the resident as non-compliant with weights and included notifying the physician of difficulties and notifying the responsible party of refusal and/or non-compliance. Facility documents showed monthly weights marked RX3, but the weights and vitals summary indicated the last weight was taken on 06/01/2024. For Resident 3, the record showed diagnoses including schizophrenia, need for assistance with personal care, and dysphagia. The care plan identified the resident as non-compliant with weights and at nutritional risk related to intermittent weight measurement refusals, with interventions to notify the resident representative and notify the MD of significant weight changes. Facility documents showed RX3 on monthly weight sheets, but the weights and vitals summary indicated the last weight was taken on 09/02/2025, and staff interviews confirmed there was no documentation that the family or doctor were notified.
Care Plan Not Updated After Contact Isolation Was Discontinued
Penalty
Summary
The facility failed to revise Resident 7’s comprehensive care plan after contact isolation precautions were discontinued. Resident 7 was admitted with diagnoses including osteomyelitis and MRSA infection, and her BIMS score was 15 out of 15, indicating normal memory, thinking, and understanding abilities. Her order details showed contact precautions for MRSA-positive bilateral below-the-knee amputation wounds, and her care plan identified contact isolation as required, with signage to be placed near the room or doorway to alert staff and visitors. During observation on 11/20/25, no isolation signage was noted by Resident 7’s door, and the resident stated that staff had removed her isolation status because she finished her antibiotics. The Infection Preventionist stated that the contact isolation precaution had been removed after the antibiotic course was completed per facility policy and that he was responsible for updating the isolation care plan, but he believed he had updated it and apparently had not. The facility policy stated that care plans are revised when residents’ conditions change and are updated by the interdisciplinary team when there is a significant change in condition.
Improper Urinary Catheter Bag Positioning
Penalty
Summary
The facility failed to follow professional standards of practice for the use of an indwelling urinary catheter for one resident with a urinary catheter. During a concurrent observation and interview, the resident’s urinary catheter bag was observed positioned on the upper bedside rail above the resident’s bladder level. A licensed nurse confirmed that the bag should have been placed at the lower part of the bed to prevent urine backflow into the bladder and to help prevent a urinary infection. The resident was admitted in 2025 with diagnoses including retention of urine and obstructive and reflux uropathy. During interview, the Infection Preventionist stated that catheter drainage bags needed to be placed below the level of the bladder so tubing had no kinks, urine flowed by gravity, and fluid did not remain stagnant in the tubing. The facility policy titled Catheter Care, Urinary, revised August 2022, stated that the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
Improper Head-of-Bed Position During Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care for one resident who required tube feeding. The resident had diagnoses including dysphagia and a gastrostomy tube, and the clinical record showed orders and care plan instructions to keep the head of bed elevated during feedings, including elevating the head of bed 30 to 45 degrees when tube feeding was running and keeping it 30 to 40 degrees during feedings. During an observation in the resident’s room, the head of bed was noted to be almost flat while tube feeding was being administered. A CNA present during the observation confirmed that the head of bed was too low and should have been higher. The DON also acknowledged that the head of bed was too low and stated that it should have been between 30 and 45 degrees during tube feeding.
Missed Meals for Resident on Dialysis
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis received meals and snacks consistent with the resident’s dialysis schedule and the facility’s documented orders and care plan. Resident 106 was admitted with end stage renal disease, acute kidney failure, and dependence on renal dialysis. The resident’s order directed the facility to provide a sack lunch per schedule, and the care plan directed staff to provide brown bagged food while the resident was out for dialysis. During observation and interview, Resident 106 stated that after returning from a dialysis session, she did not have a meal tray left for her and her family had to buy food from outside because she was hungry. The resident also stated that she requested packed snacks for a later dialysis trip because staff had not provided food the prior time. Resident 106 later stated that she left for dialysis again and did not receive the packed snacks, and staff did not provide them. Staff interviews showed inconsistent understanding of responsibility for providing food to residents on dialysis. CNAs stated that residents should have packed food for dialysis, that early trays could be obtained before leaving, and that if residents returned after mealtimes they should be offered food or a new meal prepared. The DSD stated that staff were supposed to request early trays, leave trays warm if the resident had not returned, and offer food or snacks when the resident came back. The kitchen supervisor stated that dialysis residents should receive a sack lunch before leaving, that trays should be saved for up to 2 hours, and that snacks were available after kitchen hours. The DON confirmed that Resident 106 should have had food upon return from dialysis and stated that if the resident had no food, the resident would get hungry and it can lead to weight loss.
Unsafe Self-Administration of Nasal Spray
Penalty
Summary
Safe medication management was not ensured for one sampled resident when a bottle of saline nasal spray was left on the resident’s overbed table and was accessible without being secured. During observation, the resident stated that she used the spray when her nose got dry and reported using it every day, about 3 to 4 times a day or whenever needed. The resident’s record showed diagnoses including chronic respiratory failure, obstructive sleep apnea, abnormalities of gait and mobility, and need for assistance with personal care. A licensed nurse reviewed the record and found a physician’s order for Deep Sea Nasal Spray, 2 sprays in each nostril every 2 hours as needed for nasal dry membrane, but there was no complete self-administration assessment and no physician’s order authorizing self-administration of the saline nasal spray. The nurse stated she was unaware of the resident’s daily use of the spray. The DON stated that licensed nurses should assess whether a resident can self-administer medication, the IDT should notify the physician if the resident can safely self-administer, and the care plan should reflect the resident’s ability to self-administer medication.
Inaccurate MAR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate medication administration record (MAR) documentation for two sampled residents. For Resident 69, who had diagnoses including diastolic congestive heart failure, chronic respiratory failure, obstructive sleep apnea, essential hypertension, and acute kidney failure, LN 4 administered Tylenol 650 mg by mouth for pain during observation on 11/19/25 at 12:17 p.m. During later interview and record review, LN 4 confirmed the Tylenol was given but was not documented on the MAR. LN 4 stated it was important to document medication administration to prevent medication errors, and the DON and ADON confirmed there was no documentation of the acetaminophen dose on the MAR and that if it is not documented, another nurse could give the same medication again. For Resident 34, who had diagnoses including atherosclerotic heart disease of the coronary artery, hypotension, vascular disorder of the intestine, muscle weakness, and dysphagia, LN 5 administered the resident’s scheduled morning medications, including Docusate Sodium 250 mg, during observation on 11/20/25 at 9:24 a.m. However, the MAR for November 2025 documented the docusate as not given at 0800. During interview and record review, LN 5 stated she did give the docusate but documented it as not given, and the DON confirmed the medication was administered and incorrectly recorded on the MAR. The facility’s medication administration policy stated medications are to be administered in accordance with prescriber orders and that the individual administering the medication initials the MAR after giving each medication.
Failure to Administer Consented Vaccines
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two sampled residents and failed to administer the influenza, pneumococcal, and COVID-19 vaccines to one sampled resident after both residents had consented to receive the vaccines. Resident 7 was admitted with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. During interview and record review, the Infection Preventionist confirmed that Resident 7 did not receive the pneumococcal vaccine even though a consent form dated 10/15/25 showed consent had been given. Resident 105 was admitted with diagnoses including pleural effusion and atelectasis. During interview and record review, the Infection Preventionist confirmed that Resident 105 did not receive the influenza, pneumococcal, or COVID-19 vaccines despite signed consent forms for all three vaccines. The Infection Preventionist stated he was responsible for administering the vaccines but could not administer them timely because he was busy and was going to administer them that week. The Director of Nursing stated she expected residents to receive all vaccinations within 5 days of admission if they consent, and noted that it was flu season and residents should be offered and given the influenza vaccine along with other vaccines. The facility policies reviewed stated that residents admitted between October 1 and March 31 should be offered influenza vaccine within five working days, pneumococcal vaccination status should be assessed within five working days of admission, and COVID-19 vaccine should be offered unless medically contraindicated or the resident is fully vaccinated.
Insufficient Room Square Footage in Multiple Resident Rooms
Penalty
Summary
Rooms 2, 3, 4, 8, 41, 43, 44, 45, 46, 47, and 48 did not meet the required square footage per resident. During observation with the Maintenance Supervisor, the measured square footage in these rooms was below the required 80 square feet per resident for multiple-occupancy rooms, with several rooms housing 2 or 3 residents and actual measurements recorded below the required standard. The report also noted that the facility was seeking continuation of the room size waiver for these rooms based on the recertification survey findings. During interviews, one resident and a family member stated that the room was tight and that when staff needed to use a Hoyer lift for the resident or roommate, the family member had to go to the bathroom to give staff space. A CNA stated that when using the Hoyer lift in the room for residents on 8-A and 8-C, she had to move the chair and table to make room for the lift and that extra space was needed because the lift requires two people to assist the resident. Another resident and family member stated there was enough space in their room, and the resident said therapy was done in the rehab gym rather than in the room. A housekeeper stated she could still clean properly in smaller rooms even when there were 3 residents in the room.
Failure to Provide Proper Discharge Notice and Notification to Ombudsman
Penalty
Summary
The facility failed to provide a 30-day advance written notice of discharge to a resident, as required by both federal and state regulations. The resident, who had diagnoses including acute respiratory failure, influenza, and pneumonia, was verbally informed of the discharge on the same day the facility attempted to discharge him and received the discharge paperwork at that time. There was no evidence that the resident received any prior written notification about the impending discharge before that day, despite the facility's policy and regulatory requirements for advance notice. Additionally, the facility did not send a copy of the Notice of Transfer or Discharge to the Ombudsman's office on the same day the resident was served the notice. The resident contacted the Ombudsman independently and was informed that their office had not received the required notice from the facility. Interviews with facility staff confirmed that the notice was not sent to the Ombudsman, and there was a misunderstanding among staff regarding the timing and necessity of this notification, particularly for residents with Medi-Cal coverage. Furthermore, there was a discrepancy between the discharge location listed on the resident's Notice of Transfer or Discharge and the location specified in the physician's discharge order. The notice indicated one homeless shelter, while the physician's order specified a different shelter. Facility staff, including the Social Services Director, Case Manager, and ADON, acknowledged that the discharge locations should have matched and confirmed the inconsistency. The facility's own policy requires that the specific discharge location be accurately documented and communicated.
Failure to Reposition and Assist Resident Timely
Penalty
Summary
The facility failed to meet professional standards of care for a resident who was not repositioned or assisted with care needs in a timely manner. The resident, who was admitted with diagnoses including dementia and muscle weakness, was at risk for pressure injury development and skin breakdown due to immobility and incontinence. The care plan required turning and repositioning every two hours and as needed. However, observations and interviews revealed that the resident was not repositioned or taken to the bathroom during the family member's visit from 9:30 AM to 2:30 PM. The family member reported that the resident was never repositioned or provided incontinence care during these times, which was corroborated by the lack of documentation for turning, repositioning, and incontinence care after 6 AM on the day in question. Interviews with staff indicated inconsistencies in the care provided to the resident. CNA 2 stated that care was provided between 9 AM and 9:30 AM, but could not recall subsequent care times, while CNA 3 reported that care was last provided at 1 PM. The Health Information Manager confirmed that documentation for turning and repositioning was blank after 6 AM, and there was no documentation of incontinence care after 1:18 AM. The Director of Nursing stated that it was expected for residents to be repositioned every two hours and have their toileting needs met, acknowledging the risk of skin breakdown and discomfort if care was not provided. The facility's policy on Activities of Daily Living indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including mobility and toileting support.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident grabbed her arm, resulting in a scratch. The incident occurred in an adjoining bathroom shared by the two residents. The resident who was scratched had a history of anoxic brain injury and bipolar disorder but was cognitively intact, while the aggressor had Alzheimer's disease and moderate cognitive impairment. The altercation was unwitnessed by staff, and the residents were separated immediately after the incident. The resident who was scratched reported feeling unsafe in her room following the incident. She described the aggressor entering the bathroom, grabbing her arm, and claiming ownership of the bathroom. The aggressor, who believed she owned the facility, expressed fear of harm and did not recall grabbing the other resident's arm. Staff interviews revealed that the aggressor often believed the facility was her home and did not like others in her space, which may have contributed to the altercation. The facility's policies on abuse prevention and resident-to-resident altercations were reviewed, indicating a commitment to protecting residents from abuse and investigating all altercations. However, the incident highlighted a failure to prevent resident-to-resident abuse, as the aggressor's behavior was not adequately managed to prevent the altercation. The facility's policy required reporting and investigating such incidents, but the deficiency occurred due to the lack of effective measures to prevent the altercation.
Failure to Log Emergency Kit Usage
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of its residents by not properly logging the use of emergency kits (E-Kits). During an observation and interview, it was found that two out of three E-Kits with injectable medications were opened but not logged in the E-Kit log. Licensed Nurse 3 (LN 3) confirmed the oversight and stated that the yellow forms, which should have been filled out and faxed to the pharmacy, were missing from the binder. This indicates that the necessary documentation and communication with the pharmacy were not completed as required. The Assistant Director of Nursing (ADON) verified the lack of logging for the two opened E-Kits, and the Director of Nursing (DON) expressed that staff were expected to fill out the E-Kit log form immediately upon medication removal. The facility's policy from 2007 outlines that upon removal of any medication from the E-Kit, the nurse must document the usage on an emergency kit log and fax a copy to the pharmacy. The failure to adhere to this policy increased the potential risk of not having the necessary medications available during emergencies, which could jeopardize residents' health and safety.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications, leading to several deficiencies. Expired medications, such as pantoprazole suspension and regular insulin, were found in the medication cart and storage room, despite being past their discard dates. Licensed nurses confirmed these medications should have been discarded, as per the facility's policy, which mandates that multi-dose vials be dated and discarded within 28 days unless otherwise specified by the manufacturer. Additionally, several pharmaceutical products were found without opened or discard dates, including a vial of tuberculin purified protein derivative, an umeclidinium inhaler, a fluticasone furoate/vilanterol inhaler, a bottle of valproic acid oral solution, and a bottle of lactulose solution. The facility's policy requires that the date of opening be recorded on multi-dose containers, which was not adhered to in these instances. Furthermore, medications with torn and unclear labels, such as an albuterol sulfate inhaler and a budesonide and formoterol fumarate dihydrate inhaler, were found, violating the policy that requires clear labeling consistent with federal and state requirements. The facility also failed to maintain safe medication storage practices. Loose medications were found in a medication cup within a cart, and a white powdered medication was left unattended at a resident's bedside. The Director of Nursing confirmed that loose pills should be disposed of immediately and that medications should be stored in locked compartments to prevent access by wandering residents. These lapses in medication management could potentially lead to medication administration errors and jeopardize residents' health and safety.
Inaccurate Sanitizing Solution Testing in Kitchen
Penalty
Summary
The facility failed to accurately check and test sanitizing solutions in the kitchen, which could potentially expose residents to foodborne illnesses. During an observation and interview, it was found that the dishwasher sanitizing solution was not accurately checked for effectiveness. The Dietary Aide (DA 1) was unaware of the minimum operational temperature for the low-temperature dishwashing machine, which was observed to be operating at 110 degrees Fahrenheit. The sanitizing solution used was Chlorine, and the test strips used to check its concentration were faded and hard to read, with an expiration date that was not visible. This made it difficult to verify the accuracy of the Chlorine test readings. Additionally, the Quatenary Ammonium Compound (QAC) used for sanitizing dishes and kitchen surfaces was not tested at the correct temperature. DA 1 demonstrated the testing process and found the QAC solution to be at 400 ppm, but the solution was tested in cold water at 63 degrees Fahrenheit, below the manufacturer's recommended temperature range of 65 to 75 degrees Fahrenheit. The Registered Dietitian confirmed that the QAC testing result was at 400 ppm and emphasized the importance of following the manufacturer's recommendations to ensure accurate readings. The FDA Food Code highlights the necessity of accurate chemical sanitizer concentration testing to ensure effective sanitization.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices in several instances, as observed during a survey. A laundry aide was seen handling clean and soiled linen without performing necessary hand hygiene before and after glove use, which could lead to cross-contamination. The facility's policy requires handwashing after handling soiled linen and before handling clean linen, but this was not followed, as confirmed by the laundry aide and the infection preventionist. In another instance, enhanced barrier precautions (EBP) were not initiated in a timely manner for a resident with indwelling medical devices, such as a urinary catheter and a PICC line. The resident had been in the facility for over two weeks before EBP was implemented, despite the facility's policy indicating that EBP should be used for residents with such devices. This delay in implementing EBP was acknowledged by the infection preventionist, who confirmed that the best practice is to initiate EBP as soon as possible to prevent the spread of infection. Additionally, staff failed to ensure a resident performed hand hygiene before being served lunch. The resident, who required assistance with personal hygiene, was not offered hand sanitizer upon returning to the dining room, contrary to the facility's policy. Staff members acknowledged the oversight and confirmed that residents should be offered hand hygiene before meals. Furthermore, the facility's ice machine was found to be improperly cleaned, with blackish growth observed on the machine, indicating a lack of adherence to the facility's cleaning procedures.
Inoperable Call Lights in Resident Rooms
Penalty
Summary
The facility failed to ensure that call lights were within easy reach and operable for six residents, which could prevent them from contacting nursing staff when needed. Resident 51, who was admitted with Alzheimer's disease and dementia, had a call light that was broken and out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who noted the button was missing. Resident 42, diagnosed with senile degeneration of the brain, had a call light cord wrapped around the bed rail and hanging close to the floor, making it inaccessible. The CNA confirmed the call light was not within reach. Resident 14, with hemiplegia and epilepsy, was unable to locate the call light due to contractures in the right hand. A CNA had to search under pillows to find it, acknowledging the need for the call light to be closer to the resident's left hand. Resident 38, with encephalopathy and COPD, did not have a call light available, which was confirmed by the Maintenance Director. The director stated that non-working call lights should be reported immediately. Resident 30, with COPD and diabetes mellitus type 2, had a broken and inoperable call light, confirmed by a CNA. Resident 26, diagnosed with Huntington's disease and schizophrenia, also had a broken call light, as confirmed by the Maintenance Director. The Director of Nursing stated that call lights are expected to be within easy reach and functional, as per the facility's policy. The facility's policy requires that call lights remain functional and accessible at all times, and any defects should be reported promptly.
Failure to Obtain Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure informed consent for the use of antipsychotic medications for two residents, Resident 11 and Resident 20. Resident 11, who was admitted in 2021 with diagnoses of depression and bipolar disorder, had an informed consent for antipsychotic medication aripiprazole that was not updated every six months as required. The Director of Nursing (DON) confirmed that the informed consents for Resident 11's psychotropic medications were last obtained in 2021 and acknowledged the need for updates every six months. Resident 20, admitted in October 2023 with dementia, psychotic disturbance, and schizophrenia, was prescribed quetiapine fumarate for schizophrenia without an informed consent being completed. Despite being on the medication since December 2023, there was no documentation of informed consent in Resident 20's medical records. Interviews with the DON and Licensed Nurse 5 (LN 5) revealed that the facility's practice required the physician to obtain informed consent before starting antipsychotic medications, which was not adhered to in this case. The facility's policy, revised in June 2021, mandates that informed consent must be obtained and verified before the administration of psychotherapeutic drugs. Additionally, an All Facilities Letter (AFL) effective January 2024, reinforced the requirement for informed written consent before prescribing psychotherapeutic drugs, with renewals every six months. The failure to obtain and verify informed consent for Residents 11 and 20 highlights a significant deficiency in the facility's adherence to these policies and regulations.
Failure to Include IUC in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was developed within 48 hours of admission for a resident who had an indwelling urinary catheter (IUC). The resident, admitted in August 2024 with diagnoses including urinary tract infection, sepsis, and chronic kidney disease, did not have the IUC included in their baseline care plan. This omission was observed during a room visit where the resident was seen using a walker with an IUC drainage bag attached. The resident's order summary confirmed the presence of an active order for the IUC, which was initiated on the day of admission. Interviews with facility staff, including a licensed nurse, the Director of Staff Development, and the Assistant Director of Nursing, revealed that the care plan should have included the IUC to ensure staff were aware of the necessary care requirements. The facility's policy on baseline care plans, dated March 2022, mandates that such plans include physician orders and are developed within 48 hours to meet immediate health and safety needs. The failure to include the IUC in the baseline care plan potentially placed the resident at risk for unmet care needs.
Failure to Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to revise and implement an effective communication care plan for a resident who did not speak English, increasing the potential for inadequate and inaccurate care. The resident, who was admitted with diagnoses of dementia, schizophrenia, and apraxia, communicated in a language not understood by the staff. Observations revealed that the resident was communicating in a different language without the aid of a communication board in her room. Interviews with staff, including a CNA and a licensed nurse, confirmed that they were unaware of the specific language spoken by the resident and relied on gestures for communication. They also mentioned the presence of a relative working in the dietary department who occasionally helped with interpretation, although this person was not an official interpreter. Further investigation revealed that the facility had language communication resources, such as a communication board and 24/7 phone translation services, which were not utilized for the resident. The resident's care plan, last revised in 2020, did not include these interpreter services as interventions. The Director of Nursing acknowledged the oversight and confirmed that the care plan should have included these services. The facility's policies on translation and care plans emphasized the importance of providing meaningful access to services for individuals with limited English proficiency, which was not adhered to in this case.
Deficiencies in Documentation and Catheter Management
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. For Resident 331, the deficiency involved improper documentation of PICC IV flushes. The resident was admitted with conditions including a urinary tract infection, sepsis, and chronic kidney disease, and had an order for PICC IV flushes every shift. However, the documentation for these flushes was not completed by the nurse who performed the procedure, as required by professional standards and facility policy. Instead, nurses documented that another nurse had performed or would perform the flush, which was confirmed by the Director of Staff Development and the Assistant Director of Nursing as not aligning with facility expectations. For Resident 135, the deficiency involved improper management of a urinary drainage bag. The resident, admitted with pneumonia, urinary retention, and a urine catheter, was observed with a drainage bag positioned higher than the bladder, preventing optimal urine flow. Additionally, the drainage bag was not enclosed in a privacy bag, and the collection tubing was kinked, further obstructing urine flow. These observations were confirmed by a Certified Nurse Assistant and the Director of Nursing, who stated that the drainage bag should be positioned lower than the bladder, free of kinks, and enclosed in a privacy bag, as per facility policy. These failures in documentation and catheter management decreased the facility's potential to prevent worsening of the residents' clinical conditions. The facility's policies on medication administration and catheter care were not adhered to, leading to these deficiencies in care for Residents 331 and 135.
Failure to Provide Adequate Communication Support for Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident with a language barrier, which hindered the resident's ability to communicate basic needs. The resident, who was admitted in 2022 with a diagnosis of depression, primarily spoke Portuguese. The care plan for the resident included interventions such as providing a communication board and utilizing a translator or interpreter. However, these interventions were not implemented by the staff. During observations and interviews, it was confirmed that the staff, including a Certified Nursing Assistant and a Licensed Nurse, did not use the communication board or a translator service. Instead, they relied on body language, gestures, and the resident's son for translation, which was against the facility's policy. The Director of Nursing acknowledged that the staff should have used the communication board or phone translator as per the facility's policy, which aims to ensure meaningful access to information and services for individuals with limited English proficiency.
Failure to Monitor Vascular Access Devices
Penalty
Summary
The facility failed to ensure proper monitoring of Vascular Access Devices (VADs) for two residents, leading to potential risks of infection. Resident 282, who was admitted with cellulitis of the left lower limb, had a Midline catheter for IV antibiotics. The facility's records indicated that the midline site was to be assessed for signs of infection every shift. However, out of 23 shifts, nine shifts were not signed off as completed, indicating a lack of monitoring. Interviews with the Licensed Nurse and Director of Nursing confirmed the absence of documentation, and the Infection Preventionist emphasized the importance of monitoring to prevent infections. Similarly, Resident 331, admitted with diagnoses including urinary tract infection, sepsis, and chronic kidney disease, had a peripherally inserted central catheter (PICC) line. The order summary required the PICC line to be assessed for infection signs every shift. However, the August Medication Administration Record (MAR) showed multiple instances where the assessments were not documented, suggesting they were not performed. Interviews with nursing staff and the Director of Staff Development confirmed the lack of documentation, and the Assistant Director of Nursing acknowledged the increased infection risk due to missed assessments. The facility's policies on care plans and central venous catheter care emphasized the need for consistent monitoring and documentation to prevent complications such as infections. Despite these policies, the facility did not adhere to the required procedures, as evidenced by the missing documentation and interviews with staff. This oversight placed both residents at risk for VAD-related infections, highlighting a significant deficiency in the facility's care practices.
Failure to Accurately Measure Dialysis Patient's Output
Penalty
Summary
The facility failed to provide the necessary care and services for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, identified as Resident 281, was admitted with multiple diagnoses, including ESRD and fluid overload. The facility was required to monitor and record the resident's intake and output (I&O) in milliliters every shift as part of a fluid restriction order. However, the resident's output was inaccurately recorded as the number of times urinated rather than the actual amount in milliliters, as specified in the order. During interviews and record reviews, it was revealed that Licensed Nurse 6 (LN 6) recorded the number of times the resident used the toilet instead of measuring the output in milliliters, despite the resident being continent. The Director of Nursing (DON) confirmed that the staff should have recorded the output amount in milliliters according to the order. The facility's policy on measuring and recording output, as well as the care of residents with ESRD, required adherence to physician orders and recognized standards of care, which were not followed in this instance.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring of psychotropic medication for one resident, identified as Resident 11, out of a sample of 20 residents. Resident 11 was admitted to the facility in 2021 with diagnoses of depression and bipolar disorder. A review of the resident's Minimum Data Set (MDS) indicated mild cognitive impairment. The Order Summary Report showed that Resident 11 was prescribed buspirone, an antianxiety medication, without a documented diagnosis, manifestation, or side effect monitoring. This lack of documentation was confirmed during an interview with the Medical Record Director, who noted the absence of side effect monitoring in the Medication Administration Record. Further interviews with the Director of Nursing (DON) and Assistant DON (ADON) revealed that the psychotropic medication order was incomplete due to the missing diagnosis, manifested by, and informed consent. The ADON emphasized that without these elements, the resident or their family would not understand the reason for the medication. The facility's policy on psychotropic medication use, dated July 2022, requires indications for use and monitoring of behavior, as well as adequate monitoring for efficacy and adverse consequences, which were not adhered to in this case.
Freezer Temperature and Seal Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good working order, specifically freezer number six, which was observed to have an internal temperature of 10 degrees Fahrenheit. This was noted during an observation and interview with the Certified Dietary Manager (CDM) in the kitchen dry storage area. The CDM confirmed that the freezer's temperature should be kept at zero degrees Fahrenheit or lower. It was also noted that the freezer's door seals were not forming a tight seal, leading to an accumulation of frost inside the top part of the freezer. The CDM stated that a latch was needed to ensure the freezer door could be closed and locked properly to maintain a tight seal. The facility's policy on food storage, dated January 1, 2017, indicated that frozen foods should be stored in their frozen state unless being thawed according to the current Food Code. Additionally, a Food and Drug Administration article dated March 5, 2024, emphasized the importance of keeping freezer temperatures at 0 degrees Fahrenheit. The CDM acknowledged the loose seals and frost buildup, stating that she regularly removed the frost and that a new freezer was needed. This deficiency had the potential to cause foodborne illnesses among the residents due to improper food storage conditions.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident hit them in the face with a television remote control, resulting in a scratch on the nose and a bruise on the left eye. The incident occurred when the victim was resting in bed, and a staff member witnessed the perpetrator standing over the victim with the remote control in hand. The staff member intervened after the first strike but was unable to prevent the initial assault. The victim was subsequently sent to a local hospital for further evaluation, where they were diagnosed with a subconjunctival hemorrhage and a history of cerebrovascular accident with residual deficit. The facility's policy on abuse prevention, which states that residents have the right to be free from abuse, was not adhered to in this case. Interviews with various staff members, including the Director of Nursing and the Social Services Director, confirmed that the incident was recognized as inappropriate and that the victim was more agitated and traumatized following the event. The perpetrator admitted to hitting the victim due to noise caused by the victim shaking the bed siderail. The facility's failure to prevent this altercation highlights a deficiency in ensuring resident safety and protection from abuse.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents in the memory care unit. Resident 1, who has a history of dementia and traumatic brain injury, punched Resident 2 in the face, causing a bruise and a skin tear on Resident 2's right eye. This incident was witnessed by a Licensed Nurse (LN 1) who was nearby but not directly supervising the residents at the time. The altercation began when Resident 2, who also has dementia and delusional disorders, accidentally ran over Resident 1's foot with a wheelchair, prompting Resident 1 to react aggressively. The report highlights that both residents involved in the incident have severe memory problems and behavioral issues, necessitating close monitoring and supervision. Resident 1's care plan included interventions for comfort and safety, such as checking on him every two hours, but it appears that these measures were insufficient to prevent the altercation. Staff interviews revealed that Resident 1 is known to become agitated and aggressive, while Resident 2 can be verbally aggressive, indicating a need for heightened supervision in the memory care unit. The facility's policies on resident rights and abuse prevention emphasize the need for residents to be free from abuse and the importance of adequate staffing and oversight. However, during the incident, there was a lack of supervision in the hallway where the altercation took place. Staff members, including CNAs and the Director of Nursing, acknowledged that the incident could have been prevented with closer monitoring, underscoring a deficiency in the facility's ability to protect residents from abuse by other residents.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by a medication cart being left open and unattended in the hallway. This incident was observed during a survey when Licensed Nurse 1 (LN 1) was found sitting at the nursing station, on the phone, and unaware that Medication Cart 2 was unlocked. The cart was left open in a hallway where other residents in wheelchairs and staff were present, creating a potential risk for medication misuse and drug diversion. The Director of Nursing (DON) confirmed that the expectation is for staff to lock the medication cart when not in use or when they are not in close proximity to it. The facility's policy on Medication Labeling and Storage, dated February 2023, clearly states that all medications and biologicals must be stored in locked compartments when not in use. The Administrator (ADM) indicated that LN 1 would be asked to write a statement acknowledging awareness of the unlocked cart. This deficiency highlights a lapse in adherence to the facility's medication storage policy.
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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 Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Rehabilitation & Nursing Center | 1.6 mi | ★★★★★ | 22 | 0 |
| Fairmont Rehabilitation Hospital | 1.7 mi | ★★★★★ | 2 | 0 |
| Lodi Nursing & Rehabilitation | 2.1 mi | ★★★★★ | 20 | 0 |
| Vienna Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 27 | 0 |
| Rancho Seco Care Center | 7.3 mi | — | 25 | 1 |
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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.