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 Lodi Nursing & Rehabilitation during CMS and state inspections, most recent first.
Medication Refrigerator Not Maintained Within Required Range A medication refrigerator at Nurse Station 1 used to store insulins, tuberculin tests, eye drops, and an emergency kit had heavy frost buildup and a temperature of 24 degrees Fahrenheit, below the facility’s required range. LN staff, the IP Nurse, the PC, and the DON stated that refrigerated meds must be kept between 36 and 46 degrees Fahrenheit and that staff were expected to monitor temperature and frost buildup. The DON acknowledged the facility had no log or tracking system for routine cleaning and defrosting, and the policy did not identify who was responsible for maintaining and defrosting the refrigerator.
Improper Food Storage and Covered Transport of Meal Trays: Kitchen staff stored multiple utensils, pitchers, a blender, baking sheets, and plates while wet, and a bag of uncooked pasta was kept in a clear bag without a use by date. During meal delivery, a CNA transported lunch trays on an uncovered cart, and two meal plates were not fully covered. The DM, RD, DSD, and ADM confirmed the items and trays were not stored or transported in accordance with facility food safety standards.
Multiple infection control lapses were observed, including perishable food left at a resident’s bedside for an extended period, a single-use skin ointment packet left on an overbed table after incontinent care, a CNA entering a room on contact precautions without PPE, a nurse obtaining VS for a resident on EBP with ungloved hands and equipment placed on the bed, bloody linens left in use after Foley care, and a nurse using a resident’s tissue on a fingerstick puncture site instead of approved supplies.
A resident with major depressive disorder and anxiety disorder was observed in bed with a meal tray while wearing a clothing protector during meals despite stating she did not want to wear one. CNA confirmed the protector was used routinely to keep clothing clean and said a towel or cloth napkin could be used instead, while the DSD and DON stated residents should be asked their preference and their choice honored. The facility policy also stated to avoid using bibs or clothing protectors unless requested by the resident.
Two residents did not have their call lights within reach. One resident with breast cancer, dementia, and palliative care was seated in a wheelchair and could not locate or use the call light because it was placed on the opposite side of the bed. Another resident with difficulty walking, muscle weakness, pain, and kidney cancer had a call light stuck between the bed rail and bed frame and said staff had previously had to free it. The DON stated call lights must be within residents’ reach, and facility policy required call lights to be accessible while residents were in bed.
Failure to Provide Written Bed-Hold Notice: A resident with breast cancer, lung cancer, and palliative care was transferred to the hospital and later returned to the facility, but the RP did not receive a written Bed-Hold Notice. LN and the DON stated that the bed-hold option must be offered in writing to the resident or RP before transfer, and the facility policy required written notice of the bed-hold and return policy.
Failure to care plan and communicate an ordered q2h repositioning intervention for a resident with an existing pressure injury. The resident had impaired mobility, severe cognitive impairment, and was at risk for further skin breakdown; the LPN and CNA confirmed the order was not in the care plan or Kardex used for daily care, and the resident later developed a facility-acquired right heel DTI.
Incomplete Pharmacy Delivery Receipt Documentation: Pharmacy delivery manifests were not consistently signed and dated by licensed staff when medications were received at Nurse Station 1. LN staff confirmed that deliveries occurred on all shifts and included psychotropic meds and antibiotics, but multiple manifests were missing required signatures and dates. The receiving nurse was expected to verify the delivery, confirm the residents were still in the facility, and document receipt, but unsigned and undated manifests left the facility unable to verify whether meds were received, misplaced, or not delivered.
Medication administration errors exceeded the acceptable rate when surveyors observed 6 errors in 26 opportunities, resulting in a 23.08% error rate. A nurse administered a resident’s morning medications more than 3 hours late, including several time-sensitive orders such as a diuretic, antihypertensive, seizure medication, and psychotropic medications. The nurse, another RN, the pharmacy consultant, and the DON all confirmed medications were expected to be given within the ordered time window, and the facility policy required administration within 60 minutes of the scheduled time.
Failure to Continue Ordered PT and Restorative Services: A resident admitted with a femur fracture, left hip periprosthetic fracture, weakness, and difficulty walking had PT ordered to continue 5x/week for 8 weeks, but the therapy was discontinued and the resident reported no one was assisting with exercises. The DOR confirmed the extended PT order was not followed, the resident remained in the facility, and the resident was not enrolled in RNA/restorative services.
QAPI Committee Failed to Include Required Members at Quarterly Meetings: The facility's QAPI Committee did not meet quarterly with all required members present. The ADM confirmed the previous ADM missed the Q3 meeting and the MD did not attend any of the scheduled quarterly meetings. The DON stated the MD's attendance was needed to provide medical input, review trends, and support resident safety and quality of care, and the ADM stated all required committee members were expected to attend.
A facility failed to ensure a working call light system for two residents whose care plans required the call light to be within reach and answered promptly. One resident with mobility impairment, incontinence, and respiratory issues had a call light that only illuminated briefly before turning off, and staff said it had not worked properly for quite a while; the resident also reported the backup call bell was faint and hard for staff to hear. Another resident with mobility deficit, incontinence, and a history of PE and DVT pressed the call light and it did not turn on, with no alternative device in the room, and she said she had to yell for staff assistance.
A resident was not given the required SNF ABN notification after their Medicare Part A skilled services ended and they remained in the facility as an LTC resident. Staff confirmed that the notice, which should inform the resident of changes in coverage and potential financial liability, was not provided as required by facility policy.
A resident with severe mobility impairments and high fall risk was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat, as recommended by therapy. The care plan was not updated with these critical rehabilitation instructions, and staff relied on verbal communication rather than documented interventions. This led to the resident falling from the wheelchair and sustaining a head injury.
The facility failed to maintain food safety and sanitation standards, with issues including an unclean ice machine, improper food handling without gloves, expired coffee machine water filter, damaged utensils, and unclean equipment. These deficiencies posed a risk of foodborne illness to residents.
The facility failed to ensure functional and accessible call lights for residents, affecting their ability to contact staff for assistance. Residents with various medical conditions were given ineffective alternatives like hand bells, leading to longer wait times. Observations revealed nonfunctional call lights and inadequate systems for notifying staff, with issues escalated but not resolved due to cost. Staff confirmed the importance of call lights being within reach, but this was not consistently practiced, resulting in deficiencies in resident care.
The facility failed to ensure proper food safety practices, as staff were observed handling food without gloves, posing a cross-contamination risk. Additionally, weekly thermometer calibrations were not completed as required, potentially affecting food safety. These deficiencies could expose residents to bacterial contamination and foodborne illnesses.
The facility failed to ensure pureed food was of acceptable texture and palatability for residents on a pureed diet. Observations revealed that the cook did not follow the recipe for dilled zucchini and carrots, resulting in discoloration due to overcooking. Additionally, a puree beef entree was too thin, posing a choking hazard. These issues affected six residents, potentially impacting their nutritional status.
The facility failed to provide snacks that met residents' preferences, as revealed by resident council meetings and interviews. Two residents reported not receiving preferred snacks, such as cheese and meat sandwiches, due to shortages. Staff interviews highlighted inconsistencies in snack availability, and the facility's policies on food preferences were not followed, potentially impacting residents' nutrition and health.
The facility failed to implement proper infection control measures, as a used urinal in a shared bathroom was not labeled, and shared medical devices like glucometers and blood pressure devices were not adequately cleaned between uses. Staff confirmed these lapses, which contradicted facility policies and CDC guidelines.
The facility failed to maintain the low-temperature dishwashing machine at the required 120 degrees Fahrenheit, operating instead at 90-100 degrees. The booster equipment was non-functional for a week, and staff confirmed the temperature should be higher to ensure sanitation. This failure posed a potential health risk to residents.
A resident with dysphagia and muscle weakness was not treated with dignity during meal assistance. A CNA stood over the resident while feeding him, contrary to policy requiring staff to be at eye level. The CNA also referred to residents needing meal assistance as 'feeders,' which violates the facility's dignity policy. The DON confirmed these actions were dignity issues.
A resident experienced a lack of privacy due to a non-functioning curtain in their room, which staff were unaware of. The resident, admitted with muscle weakness, expressed concerns about privacy, and interviews with a CNA and the Director of Maintenance confirmed the issue. The DON highlighted the importance of functioning curtains for resident dignity.
A resident with a history of neoplasm, anxiety, and heart failure was not provided with adequate nail care, resulting in long, thick, and discolored toenails causing discomfort. Despite being on a podiatry list, staff failed to trim the resident's nails, citing a lack of appropriate tools and misunderstanding of policy. Facility policies emphasize the importance of grooming and foot care, yet staff did not address the issue, impacting the resident's quality of life.
A resident with a history of femur fracture and mobility issues did not receive restorative nursing services after physical therapy was discontinued due to insurance limitations. Despite recommendations for a restorative nursing program to maintain the resident's functional status, these services were not provided, as confirmed by facility staff. The facility's policies indicate that such care should be provided to promote safety and independence.
A resident with an indwelling catheter was observed multiple times with their urinary collection bag positioned above bladder level, contrary to facility policy and professional standards. Staff confirmed the bag should be below the bladder to prevent infection. The resident's care plan highlighted the risk of complications, including UTIs, due to catheter use, yet the deficiency persisted.
The facility failed to ensure safe medication storage practices, as staff's personal belongings were found in a medication storage room, and loose pills were discovered on the floor and in a cabinet. The DON acknowledged these practices were unacceptable due to risks of cross-contamination and drug diversion.
A resident with dysphagia and no teeth was not provided with the recommended mechanical soft texture diet, receiving instead a regular texture meal that was difficult to chew. Despite the Registered Dietitian's recommendation, the facility failed to implement the appropriate diet, potentially impacting the resident's nutrition and leading to weight loss.
The facility failed to provide adequate hydration for two residents, as observed when one resident's water pitcher was empty and another resident had no water pitcher available, despite expressing thirst. A CNA confirmed the risk of dehydration due to the lack of water availability. Interviews with the RD and DON indicated that water should be readily available unless there are fluid restrictions, aligning with the facility's hydration policy.
Medication Refrigerator Not Maintained Within Required Temperature Range
Penalty
Summary
The facility failed to ensure safe medication storage in the medication refrigerator at Nurse Station 1. During observation, the refrigerator used to store insulins, tuberculin tests, eye drops, and the emergency kit had heavy frost buildup on the top section, and the temperature was observed at 24 degrees Fahrenheit, which was outside the facility’s required range. LN 2 acknowledged the findings and stated she was unsure who was responsible for defrosting the refrigerator. She also stated that refrigerated medications must be kept within a specific temperature range because improper temperatures could damage the medications and affect their effectiveness. LN 7 stated that nursing staff were required to check the medication refrigerator twice daily, during the morning and night shifts, to ensure the temperature remained within the acceptable range and to monitor for cleanliness and frost buildup. The Pharmacy Consultant stated that nursing staff should check refrigerator temperatures as required by facility policy, take corrective action when temperatures were outside the acceptable range, notify responsible personnel, and monitor for excessive frost buildup. The Infection Prevention Nurse stated that nursing staff were required to check the refrigerator temperature during the morning and night shifts, clean the refrigerator weekly, and visually monitor it for frost buildup that might require defrosting. The DON stated that medication refrigerator temperature should be maintained within the proper range and addressed immediately if found outside that range. The DON also stated that the refrigerator should be kept clean, routinely monitored for frost buildup, and defrosted monthly, but acknowledged that the facility had not implemented a log or tracking system for routine cleaning and defrosting. Review of the facility policy indicated that refrigerated medications should be kept between 36 and 46 degrees Fahrenheit, but the policy did not address who was responsible for maintaining and defrosting the refrigerator.
Improper Food Storage and Covered Transport of Meal Trays
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observation in the kitchen, two water pitchers were found stored wet on a shelf next to the hot water dispenser, and the Assistant Dietary Manager confirmed they should have been dried completely before storage. In the same kitchen area, multiple spoons and spatulas were stored wet in a dry utensil drawer, a blender was stored wet on the food preparation counter, two metal baking sheets were stacked wet in the dry pan storage area, and plates were stacked wet on the food preparation counter. The Assistant Dietary Manager confirmed these items were stored wet and stated they should have been dried completely before being stored. In the dry food storage area, a bag of uncooked pasta had been removed from its original package and placed in a clear plastic bag without a use by date. The Assistant Dietary Manager confirmed the pasta did not have a use by date and stated it should have been labeled once removed from its original package. The Assistant Dietary Manager also stated the food could have been expired and that food without expiration dates should not be used. During lunch delivery, a CNA was observed taking an uncovered lunch cart from the dining room and leaving it in the hallway outside a resident's room, and two lunch meal plates were not fully covered with plate covers. Another CNA was observed delivering lunch trays from the uncovered cart to residents' rooms. The Registered Dietitian, Director of Staff Development, and Administrator each stated the cart and plates should have been fully covered, and the Administrator stated the uncovered plates should have been discarded while the fully covered plates should have been served to residents.
Infection Control Failures During Resident Care and Isolation Precautions
Penalty
Summary
The facility failed to maintain infection prevention and control practices in multiple resident care situations. During observation, perishable food was found at a resident’s bedside with a date showing it had been in the room for two days, despite staff stating that perishable food left at room temperature should be discarded within two hours. The Infection Prevention Nurse and DON both stated that food left in the room beyond that time could allow bacterial growth, and the facility policy stated that perishable foods left at bedside for extended periods shall be discarded. An open, half-filled single-use skin guard ointment packet was observed on another resident’s overbed table after it had been used during incontinent care. The resident stated staff left it there after use, and a nurse confirmed it should have been discarded after use. The Infection Prevention Nurse and DON stated the packet was intended for single use and should be discarded immediately after use, and that leaving it on the overbed table created an infection control concern because it could contaminate surfaces used for eating. Additional infection control failures were observed with resident care and isolation precautions. A CNA entered a room under contact precautions for ESBL urinary infection without wearing the required PPE, despite the posted isolation sign and the resident’s orders for gloves and gown on room entry. A nurse obtained vital signs for a resident on enhanced barrier precautions while using ungloved hands and placing equipment directly on the bed linens, and the nurse acknowledged she should have worn PPE. Another nurse used the resident’s tissue to wipe and apply pressure to a fingerstick puncture site after blood glucose testing, rather than using alcohol prep pads or sterile gauze. In a separate event, a resident’s bed sheets and linens were observed with blood on them after a Foley catheter change, and staff confirmed the linens needed to be cleaned right away but had not been changed at the time of observation.
Clothing Protector Applied Against Resident’s Wishes
Penalty
Summary
The facility failed to ensure Resident 19 was treated with dignity and respect when a clothing protector was applied during mealtime against her wishes. Resident 19’s admission record showed diagnoses of major depressive disorder and anxiety disorder. During a concurrent observation and interview, Resident 19 was found in bed in a sitting position with a meal tray on the overbed table, and she stated that she did not want to wear a clothing protector. CNA 1 confirmed that Resident 19 was wearing a clothing protector during each mealtime to prevent her clothing from getting dirty and stated that if one was not available, a towel or cloth napkin would be used instead. CNA 1 acknowledged there was a potential risk that Resident 19 could feel left out or singled out when she was the only resident wearing a clothing protector during meals in her room. The DSD and DON both stated that residents should be asked their preference before a clothing protector is applied and that staff should honor a resident’s choice. The facility policy on Assistance with Meals stated residents should receive assistance in a manner that meets individual needs and should avoid the use of bibs or clothing protectors instead of napkins unless requested by the resident.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents when their call lights were not within reach. Resident 10 had diagnoses including breast cancer with palliative care, metastatic lung cancer, dementia, metabolic encephalopathy, anxiety disorder, and pain. During observation, Resident 10 was seated in a wheelchair next to the bed and stated she did not know where the call light was and could not use it if she needed help. The call light cord was observed wrapped around the opposite bed rail, and the Activity Director stated it was not within the resident’s reach because it was placed on the other side of the bed. Resident 83 had diagnoses including difficulty walking, muscle weakness, pain, and kidney cancer. During observation, Resident 83 was sitting upright in bed and tried to pull the call light out after it was stuck between the left bed rail and bed frame, but could not remove it. Resident 83 stated it had also been stuck during the previous shift and staff had to free it, and that she would ask her roommate to press the roommate’s call light to get staff assistance. A CNA confirmed the call light was not within Resident 83’s reach and stated it was a safety concern. The DON stated call lights must be within residents’ reach and answered promptly, and the facility policy stated staff should place call lights within reach and keep them accessible while residents are in bed.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that Resident 10 and her resident representative were fully informed in writing of the bed-hold process when the resident was transferred to the hospital on [DATE]. Resident 10’s admission record showed diagnoses including breast cancer, lung cancer, and palliative care, and identified a resident representative. Progress notes dated 12/1/25 indicated that Resident 10 transferred to [hospital] from a PCP appointment, and progress notes dated 12/8/25 indicated that Resident 10 returned to the facility via gurney. During a concurrent interview and record review on 3/5/26, LN 8 reviewed Resident 10’s admission record and electronic health record and stated that the resident’s RP had not received a written Bed-Hold Notice when the resident was transferred to the hospital. LN 9 stated that a bed hold must be offered to the resident or RP when a resident is transferred to the hospital and return is anticipated, and the DON stated that a written Bed-Hold Notice must be offered to the resident or RP to allow the option to hold the bed for up to seven days during hospitalization. The facility policy titled Bed-Holds and Returns stated that prior to transfers, residents or resident representatives will be informed in writing of the bed-hold and return policy.
Failure to Care Plan Ordered Repositioning for Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure that a physician-ordered intervention to prevent pressure injuries was included in the care plan and communicated to staff for one resident with an existing left buttock stage II pressure injury present on admission. The resident was admitted with multiple diagnoses including generalized muscle weakness, difficulty walking, bilateral shoulder osteoarthritis, right ankle contracture, major depressive disorder, dizziness, and severely impaired cognition, and the physician ordered turning and repositioning every 2 hours with wedges and pillows on 2/12/26. During record review and interviews, the licensed nurse stated the repositioning order needed to be in the care plan so it would trigger the Kardex used by CNAs, but the resident’s care plan did not include repositioning every 2 hours. A CNA stated the Kardex did not include the intervention and that, if it was not listed, the resident might not be repositioned every 2 hours. Additional records showed the resident was bed bound, confused, required dependent to moderate assistance with bed mobility, had a Braden score of 16 indicating pressure injury risk, and later developed a facility-acquired right heel suspected deep tissue injury that was documented as a right heel deep tissue pressure injury.
Incomplete Pharmacy Delivery Receipt Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services were provided with accountability for delivered medications because pharmacy delivery slips and manifests were not consistently signed and dated by licensed staff when medications were received from the delivery courier. Review of the pharmacy delivery receipt binder at Nurse Station 1 for the period from 2/3/26 to 3/3/26 showed that the consolidated delivery sheets were incomplete and did not consistently contain the required licensed nursing staff signatures and dates. The facility’s documents stated that authorized signatures only were required and that stamped signatures and dates were not acceptable. During a concurrent interview and record review on 3/3/26, LN 3 reviewed the binder and confirmed that multiple pharmacy delivery manifests dated 2/24/26, multiple manifests dated 2/25/26, and one manifest dated 3/1/26 were missing the required signatures and dates. LN 3 stated that pharmacy deliveries could occur on any shift, that the deliveries included medications such as psychotropic medications and antibiotics, and that the receiving nurse was responsible for verifying the residents listed on the manifest and signing and dating the delivery manifest. LN 3 also stated that a signed copy should be maintained in the binder and that when manifests were left unsigned and undated, the facility could not verify whether the medications were received, misplaced, or not delivered. LN 7 stated during interview on 3/4/26 that pharmacy deliveries occurred during all shifts and that the nurse at Nurse Station 1 typically received the medications, signed and dated the manifest, and printed their name to acknowledge receipt before a copy was placed in the binder. LN 7 stated that when delivery manifests were not signed and dated consistently, there was a possibility that medication could be diverted or lost. The Pharmacy Consultant stated that the receiving nurse should verify the medications listed on the manifest, confirm that the residents were still in the facility, and return medications for residents no longer in the facility at the time of delivery. The DON stated that licensed nursing staff were expected to reconcile medications with the delivery manifests and sign and date the receipts at the time of delivery, and that when this did not occur, there was a risk that received medications might not be appropriately reviewed.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices when its medication error rate exceeded 5 percent. Surveyors observed medication administration over multiple days and found 6 errors out of 26 opportunities, resulting in a facility-wide medication error rate of 23.08% in 1 of 9 residents observed during medication administration. For one resident with diagnoses including hypertension, seizure disorder, schizophrenia, anxiety disorder, and depression, a nurse prepared 12 medications during a morning medication pass but administered them more than three hours after the scheduled 8:00 a.m. time. The resident’s medication list included several time-sensitive medications ordered for 8:00 a.m., including furosemide, gabapentin, amlodipine, olanzapine, levetiracetam, and quetiapine. The nurse stated she was giving the morning medications late because she was running behind. During interviews, the nurse confirmed the medications were due at 8:00 a.m. and were given outside the acceptable window. Another nurse stated medications should be given at the prescribed time to prevent adverse reactions and maintain the resident’s condition. The pharmacy consultant stated medications were expected to be administered within the established time window, and the DON stated the five rights of medication administration included the right time and that delayed medications outside the acceptable timeframe should prompt physician notification. The facility policy stated medications are to be administered within 60 minutes of the scheduled time.
Failure to Continue Ordered PT and Restorative Services
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were continued for Resident 31 after a physician ordered skilled PT to be extended 5 times per week for 8 weeks for difficulty walking. Resident 31 was admitted with diagnoses including a left femur fracture, periprosthetic fracture around the left hip prosthesis, difficulty walking, muscle weakness, acute kidney failure, major depressive disorder, bone density and structure disorders, pain, and a history of falls. The PT evaluation described decline in overall mobility related to recent acute hospitalization, deconditioning, pain, generalized weakness, and decreased activity tolerance, and stated the resident required skilled PT to minimize falls and increase lower-extremity ROM and strength. The PT discharge summary indicated the resident was not medically safe and would need significant help at home, with discharge recommendations for home health PT and a wheelchair. However, during observation, the resident stated PT had been discontinued a couple of weeks earlier and that no one was assisting with exercises, leaving the resident sitting in a wheelchair and hoping to walk again. The DOR confirmed the physician’s order to extend PT was not followed, verified the resident did not receive PT services for the ordered 8-week extension, and stated the resident remained in the facility and could have been transitioned to the RNA program. RNA staff also confirmed the resident was not enrolled in the RNA program and was not receiving restorative nursing services.
QAPI Committee Failed to Include Required Members at Quarterly Meetings
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to meet quarterly with all required members present. During a concurrent interview and record review on 3/6/26, the Administrator confirmed that the previous Administrator did not attend the quarter 3 meeting on 11/7/25, and the Medical Director did not attend any of the scheduled quarterly meetings held on 4/10/25, 7/28/25, or 11/7/25. The report identified this as a failure of the facility's Quality Assurance Committee to include the required members and meet at least quarterly for a census of 69. During interviews, the DON stated that the Medical Director's attendance was important so he could provide medical input for resident safety and quality of care, discuss trends occurring in the facility, and help the committee develop plans for improvement. The DON also stated the Administrator played a vital role in conducting the quarterly QAPI meetings and following through to make sure the meetings occurred, and that both the Administrator and the Medical Director should have attended all regularly scheduled QAPI meetings. The Administrator similarly stated it was his expectation that all required committee members, including the Medical Director and Administrator, attend the QAPI meetings. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Committee stated the committee would include the Administrator and Medical Director and would meet at minimum quarterly at an appointed time.
Call Light System Not Functioning for Two Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents, both of whom had care plans that included keeping the call light within reach and answering the light promptly. Resident 61 was admitted with diagnoses including difficulty walking, muscle weakness, and acute respiratory failure with hypoxia, and his care plan addressed altered bladder elimination due to incontinence and high risk for falls and injury. During observation, he pressed his call light and it illuminated for only about two seconds before turning off automatically. He stated the system had been functioning this way for a long time, that the call bell provided was annoying to use, and that staff could not hear it well because his room was at the end of the hall. CNA 7 stated the call light system in his room had not been functioning properly for quite a while, and the DSD and DON stated the call light system should function properly and be audible to alert staff when assistance was needed. Resident 62 was admitted with diagnoses including difficulty walking, muscle weakness, chronic pulmonary embolism, and thrombosis of the deep veins of the right lower extremity. Her care plan addressed mobility deficit and altered bladder elimination due to incontinence, with interventions to keep the call light within reach and answer promptly. During observation, she pressed the call light and it did not turn on, and no call bell or whistle was present as an alternative method of notifying staff. She stated she had to yell and scream for staff to come assist her. CNA 2 stated she became upset when the call light was not answered in a timely manner, especially when she needed to use the restroom, and the DOM stated there was a visual screening system but not an auditory alert system at each nurses' station.
Failure to Provide SNF ABN Notification After End of Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident after the end of their Medicare Part A skilled services coverage. According to interviews and record reviews, the resident's Medicare Part A coverage ended, but the resident continued to stay in the facility as a long-term care resident. The Admissions Coordinator confirmed that the SNF ABN notice, which informs residents of changes to their Medicare coverage and potential financial liability, was not issued when the skilled services ended. The Social Services Director and Director of Nursing also confirmed that there was no documentation in the resident's medical record indicating that the SNF ABN was provided. Facility policy requires that Medicare beneficiaries be informed of their potential liability for payment and that the SNF ABN (Form CMS-10055) be issued before providing items or services not covered by Medicare. Staff interviews revealed that the SNF ABN should have been given three days before the last covered day to ensure the resident was aware of their rights and had the opportunity to appeal. The failure to provide this notice was acknowledged by facility staff, and it was confirmed that the resident did not receive the required notification.
Failure to Update Care Plan and Ensure Safe Wheelchair Use Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure an accident-free environment and provide adequate supervision to prevent accidents for a resident with significant mobility impairments. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, paraplegia, and contractures, was assessed as having a high risk for falls and was totally dependent on staff for transfers and mobility. The care plan did not include updated or specific instructions from the rehabilitation department regarding the use of a recliner wheelchair and a non-slip mat (Dycem), which were necessary to safely position the resident and prevent falls. On the day of the incident, nursing staff placed the resident in a regular upright wheelchair instead of the recommended recliner wheelchair with a Dycem. The staff relied on verbal communication and did not have access to therapy notes or updated care plan interventions. The resident was left in a 90-degree upright position in the wheelchair, became agitated, and attempted to push himself forward, resulting in a fall and a minor head laceration. Interviews with staff revealed that the specific rehabilitation instructions were not documented in the care plan, and staff were unaware of the need for a recliner wheelchair and Dycem for this resident. The facility's policies required that care plans be updated as residents' conditions changed and that interventions be clearly documented to prevent accidents. However, the care plan for this resident lacked the necessary details about the type of wheelchair, positioning, and supervision required, leading to a breakdown in communication between the rehabilitation and nursing departments. This omission directly contributed to the resident being placed in an unsafe position, resulting in a fall and injury.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and facility policy for food service, resulting in multiple deficiencies. The ice machine was not cleaned according to the manufacturer's guidelines and facility policy, with visible black and brown substances and debris found inside the machine. The Maintenance Director and Dietary Services Manager acknowledged the internal areas with debris, and the Registered Dietitian emphasized the risk of food-borne illnesses from dirty ice. The facility's policy required monthly cleaning of the ice machine, which was not followed. During a trayline observation, food handling practices were found to be unsanitary. Cooks and dietary aides were observed preparing and serving food without wearing gloves, and one cook placed a bare thumb inside a disposable dish. The Dietary Services Manager and Registered Dietitian both stated that gloves should be worn to prevent cross-contamination, aligning with the FDA Food Code that prohibits bare hand contact with ready-to-eat food. Additional deficiencies included an expired coffee machine water filter, damaged serving utensils, and unclean equipment. The coffee machine's water filter was expired by 18 months, contrary to the manufacturer's recommendation for annual replacement. Serving ladles and scoops had melted handles with grime, posing a risk of contamination. A griddle top collection tray was found with grime and food residue, and expired curry powder and discolored parsley were noted in storage. These issues collectively had the potential to cause widespread foodborne illness among the 61 residents consuming facility-prepared meals.
Deficiency in Call Light Functionality and Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of eight residents by not ensuring that their call lights were functional or within reach. Residents with various medical conditions, including ataxic gait, acute respiratory failure, epilepsy, and muscle weakness, were affected. The call lights for several residents were nonfunctional, and alternative means such as hand bells were provided, which were not effective in alerting staff promptly. This led to longer wait times for assistance, particularly for residents experiencing pain or needing to use the restroom. During observations, it was noted that call lights in multiple rooms were not working, and only one resident per room was given a hand bell to notify staff on behalf of others. This system was inadequate, especially when the resident with the hand bell had no visibility of their roommates. Staff confirmed that the call system had been down for 6-12 months, and the issue had been escalated to corporate, but repairs were denied due to costs. The facility's policies emphasized the importance of maintaining adaptive devices for residents, but these were not adhered to. Additionally, a resident's call light was found underneath the bed and out of reach, preventing them from contacting staff when needed. Staff interviews confirmed that call lights should be within reach to ensure residents can ask for help, and failure to do so increases the risk of unmet needs and falls. The facility's policy required call lights to be placed within reach before staff left the room, but this was not consistently practiced, leading to deficiencies in resident care.
Food Safety and Thermometer Calibration Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen staff adhered to proper food safety and sanitation practices, as observed during a tray line inspection. Two cooks and two dietary aides were seen handling food without wearing gloves, which is against the facility's policy and the FDA Food Code 2022. One cook was observed placing her bare thumb inside a foam container while serving meatloaf, and another was preparing dessert plates without washing her hands or wearing gloves. The dietary aides were also seen placing food trays onto carts without gloves. Interviews with the Dietary Services Manager and a Registered Dietitian confirmed that these practices posed a cross-contamination risk. Additionally, the facility did not complete weekly thermometer calibrations as required by their policy. A review of the WEEKLY THERMOMETER CALIBRATION CHART showed that calibrations were not performed weekly, with gaps of several weeks between calibrations. This was confirmed during an interview with a cook, who stated that calibrations depended on the cooks' schedules. The Dietary Services Manager acknowledged the failure to adhere to the weekly calibration schedule, which could result in food items not being at the correct temperatures. The facility's failure to follow proper food handling and thermometer calibration procedures had the potential to expose residents to bacterial contamination and foodborne illnesses. The facility's policies and the FDA Food Code emphasize the importance of wearing gloves during food preparation and maintaining accurate thermometer readings to ensure food safety. The census at the time of the survey was 61 residents, all of whom could be affected by these deficiencies.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that food served to residents on a pureed diet was of acceptable texture and palatability. During an observation, it was noted that the cook did not follow the pureed recipe as written for the preparation of dilled zucchini and carrots. The puree mixture was observed to have a dark brownish color, which was attributed to being kept in the oven for too long. The Dietary Services Manager (DSM) and Registered Dietitian (RD) confirmed that the oven's high temperature led to discoloration and potential loss of nutritional value. The facility's recipe for dilled carrots and zucchini specified simmering and steaming the vegetables until tender, which was not adhered to. Additionally, during a test tray observation, the puree of a beef entree was found to be too thin and not of the desired mashed potato consistency. The DSM confirmed that extra gravy was added, making the puree too watery, which could pose a choking hazard and aspiration risk. The facility's policy on food preparation emphasized using approved recipes and preparing foods close to serving time to preserve nutrition and prevent overcooking. These failures affected six residents on a pureed diet, potentially impacting their meal intake and nutritional status.
Failure to Meet Residents' Snack Preferences
Penalty
Summary
The facility failed to ensure that residents received snacks that met their preferences, as evidenced by observations, interviews, and record reviews. The resident council meeting minutes from April 2024 to October 2024 revealed ongoing concerns about the lack of regular snacks and nourishments. During a resident council meeting, residents expressed dissatisfaction with the availability and variety of snacks, noting that dietary preferences were not being met. This issue was further highlighted by the experiences of two unsampled residents, who reported not receiving snacks or alternative meals that aligned with their preferences. Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation, reported not receiving alternative meals and foods she liked, such as cottage cheese, oatmeal, and yogurt. Despite having an intact cognitive status, she had not communicated her food preferences to the Registered Dietitian. Similarly, Resident 63, with diagnoses including cellulitis, hyperlipidemia, hypertension, and constipation, expressed a preference for cheese and meat sandwiches and crisp rice cereal treats, but noted that the facility consistently ran out of these items. Interviews with staff members revealed inconsistencies in the availability and distribution of snacks, with some staff unaware of the residents' unmet needs. The facility's policies on food preferences and nourishment indicated that residents' food preferences should be adhered to and that suitable, nourishing alternative meals and snacks should be provided. However, interviews with the Administrator, Director of Nursing, Dietary Services Manager, and Registered Dietitian revealed a lack of awareness and communication regarding the residents' snack preferences and the facility's failure to consistently offer a variety of snacks. This deficiency had the potential to impact the residents' nutrition and health status, as the facility did not adhere to its policies and procedures regarding food preferences and nourishment.
Infection Control Lapses in Shared Equipment and Facilities
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, as observed during a survey. In one instance, a used urinal in a shared bathroom was not labeled with a resident identifier, which was confirmed by a Certified Nursing Assistant (CNA). The CNA acknowledged that the urinal should have been cleaned after use and labeled with a resident identifier to prevent cross-contamination among the three residents sharing the bathroom. The Infection Preventionist and the Director of Nursing also confirmed that the urinal should have been labeled to prevent potential cross-contamination. Additionally, the facility did not adhere to proper cleaning protocols for shared medical devices. Observations revealed that a Licensed Nurse (LN) used a glucometer and blood pressure device on multiple residents without adequately cleaning and disinfecting them between uses. The LN used a single wipe to quickly clean the glucometer's outer surface, contrary to the facility's policy and manufacturer's instructions, which require thorough cleaning and disinfection. The Director of Staff Development confirmed that the glucometer should be cleaned with a specific type of wipe and allowed to remain wet for a specified time to ensure proper disinfection. The facility's policies and procedures, as well as CDC guidelines, were not followed, leading to potential risks of infection spread among residents. The facility's policy required cleaning and disinfecting reusable items between residents, and the CDC guidelines emphasized the importance of cleaning and disinfecting glucometers between uses to prevent the spread of infectious agents. The failure to adhere to these protocols was acknowledged by the facility staff during interviews.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the kitchen equipment in a safe and operable manner, specifically the low-temperature dishwashing machine, which was not reaching the required wash temperature of 120 degrees Fahrenheit. During an observation, the dishwashing machine was found to be operating at temperatures between 90-100 degrees Fahrenheit. Dietary Aide 1 confirmed that the booster equipment, which is responsible for heating the water to the correct temperature, had been non-functional for a week. This issue was corroborated by the Maintenance Director and the Dish Machine Vendor Technician, both of whom stated that the wash temperature should be at least 120 degrees Fahrenheit. The Dietary Services Manager initially misunderstood the temperature requirements but later acknowledged the mistake, recognizing the potential health risks to residents if proper temperatures were not maintained. The Registered Dietitian also confirmed that the inadequate temperature could result in bacteria not being killed, posing a risk of illness to residents. The facility's policy and the FDA Food Code both specify the necessity of maintaining the dishwashing machine at the correct temperature to ensure sanitation and safety, which was not adhered to in this instance.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of Resident 10. Resident 10, who was admitted with diagnoses including dysphagia and muscle weakness, required supervision and assistance with eating. During an observation, CNA 1 was seen standing over Resident 10 while assisting him with his meal, which is contrary to the facility's policy that requires staff to be at eye level with residents during meal assistance. CNA 1 acknowledged that standing over a resident could make them feel uncomfortable and confirmed that she should have been sitting while assisting Resident 10. Additionally, CNA 1 referred to residents who needed assistance with meals as 'feeders,' which is against the facility's policy of addressing residents by their name of choice and not labeling them by their care needs. This was confirmed during an interview with the Director of Nursing, who stated that such terminology and actions were dignity issues. The facility's policies on assistance with meals and quality of life emphasize the importance of treating residents with dignity and respect, which was not adhered to in this instance.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to protect the privacy of a resident, identified as Resident 45, due to the absence of functioning privacy curtains in their room. Resident 45, who was admitted in the fall of 2023 with a diagnosis of muscle weakness, pointed out that the curtain in their room was unable to close completely, resulting in a lack of privacy since their admission. This issue was confirmed during an observation and interview with the resident, who expressed concerns about the lack of privacy. Further interviews with facility staff, including a CNA and the Director of Maintenance, revealed that the staff was unaware of the missing curtain. The CNA acknowledged that without the curtain, providing privacy during care would be challenging. The Director of Maintenance stated that residents could request curtain replacements, but was not aware of the issue in Resident 45's room. The Director of Nursing emphasized the expectation for complete and functioning curtains to maintain resident dignity and prevent embarrassment. The facility's policy on dignity and privacy was reviewed, indicating staff should promote and protect resident privacy during personal care and treatment procedures.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 43, who was admitted with diagnoses including neoplasm of the bladder, anxiety, and heart failure. The resident's Minimum Data Set indicated the need for supervision or assistance with personal hygiene. Despite this, the resident's toenails were observed to be long, thick, curved, and discolored, causing discomfort and pain. The resident reported that staff had not trimmed his toenails for months, despite multiple requests and being informed that he was on a podiatry list. Interviews with facility staff, including the Social Services Director, Licensed Nurse, and Director of Nursing, confirmed the resident's toenails were not trimmed and that he was not diabetic or suffering from vascular disease, which would necessitate podiatric intervention. The facility's policies on foot care and quality of life emphasize the importance of maintaining residents' mobility and dignity through proper grooming, including nail care. However, the staff acknowledged that the resident's toenails were not trimmed due to the lack of appropriate tools and the assumption that only a podiatrist could perform the task, despite the facility's policy allowing trained staff to provide routine foot care.
Failure to Provide Restorative Services Post-Physical Therapy
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as Resident 35, after the discontinuation of physical therapy. Resident 35 was admitted to the facility with diagnoses including a fracture of the lower end of the right femur, abnormalities of gait and mobility, and muscle weakness. The resident's care plan indicated a self-care deficit requiring extensive assistance with bed mobility, toileting, and personal hygiene. Despite recommendations for continued restorative nursing services following the end of physical therapy, these services were not provided. Resident 35's physical therapy was discontinued on December 21, 2023, due to insurance limitations, although the resident still required moderate assistance for mobility and self-care activities. The physical therapy discharge summary recommended a restorative nursing program to maintain the resident's current level of performance and prevent decline. However, the resident did not receive these services, as confirmed by interviews with the Restorative Nursing Assistant and the Director of Nursing. The facility's policies on restorative nursing and rehabilitation services indicate that residents should receive restorative care as needed to promote safety and independence, especially after discharge from rehabilitative care. Despite these policies, Resident 35 did not receive the recommended restorative nursing services, which could have helped maintain or improve her functional status. This oversight was acknowledged by the facility's Director of Nursing during the investigation.
Improper Positioning of Urinary Collection Bag for Resident with Catheter
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, as the urinary collection bag was repeatedly observed positioned above the resident's bladder level. This improper positioning was confirmed by multiple staff members, including CNAs and LNs, who acknowledged that the urinary collection bag should be kept below the bladder to ensure proper urine drainage and prevent infection. Despite the facility's policy and professional standards indicating the necessity of keeping the collection bag below the bladder, observations on multiple occasions showed the bag placed on the upper bed rail, above the bladder level. The resident involved had a history of obstructive uropathy and was at high risk for complications, including urinary tract infections, due to the use of a Foley catheter. The resident's care plan specifically noted the need to keep the drainage bag below the bladder level to mitigate these risks. Interviews with the Infection Preventionist and the Director of Nursing further confirmed the potential risks associated with improper catheter bag positioning, such as urinary retention and infection. Despite these guidelines and the resident's care plan, the deficiency persisted, as evidenced by repeated observations of the improper placement of the urinary collection bag.
Unsafe Medication Storage Practices Identified
Penalty
Summary
The facility failed to ensure safe medication storage practices for its residents, as observed during a survey. In one instance, staff's personal belongings, including a personal bag and an insulated water bottle, were found stored in the Station 2 medication storage room. The Licensed Nurse (LN) confirmed these items belonged to her and acknowledged that personal items should not be stored in the medication room. The Director of Nursing (DON) also confirmed that storing personal items in the medication storage room was unacceptable due to the risk of cross-contamination and drug diversion. In another instance, loose pills were found on the floor and at the bottom of the base cabinet in the Station 1 medication storage room. A total of five loose pills and one capsule were observed, and the LN confirmed their presence, stating they needed to be disposed of. The DON acknowledged that loose pills should not be on the floor or in the cabinet and should have been destroyed properly. The facility's policy on medication storage, revised in April 2007, indicates that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Provide Correct Diet Texture for Resident
Penalty
Summary
The facility failed to provide a diet in the correct texture to meet the needs of Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation. The resident's Nutrition Care Plan indicated impaired nutrition and hydration status related to osteoporosis and dysphagia, with a goal to maintain safe swallowing. Despite this, the active Physician Diet Order prescribed a regular consistency diet with thin liquids, which was inconsistent with the Registered Dietitian's recommendation for a dysphagia mechanical soft texture diet. Observations and interviews revealed that Resident 19, who is edentulous and rarely wears dentures, received a regular texture lunch meal that was difficult to chew. The resident expressed difficulty eating the hard noodles and vegetables and preferred soft and semi-soft foods. The Licensed Nurse confirmed that the resident was on a regular diet but preferred softer foods, and the Registered Dietitian acknowledged that the recommended diet texture was not implemented. The facility's policy required diet orders to be provided as prescribed by the physician, with any discrepancies clarified by the Food & Nutrition Services Director. However, the Registered Dietitian and Dietary Services Manager were unaware that the resident was not receiving the recommended mechanical soft texture diet. This oversight had the potential to negatively impact the resident's food intake, nutrition status, and lead to weight loss, as the resident had already lost weight over a short period.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, Resident 3 and Resident 36, as observed during a survey. On one occasion, Resident 36's water pitcher was found empty on the bedside table, and on another occasion, Resident 3 was observed without a water pitcher and expressed thirst. These observations were confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the absence of water pitchers could put residents at risk for dehydration. Interviews with facility staff, including a Registered Dietitian (RD) and the Director of Nursing (DON), revealed that it was the facility's expectation for water to be readily available to residents unless there were fluid restrictions. The facility's policy on Resident Hydration and Prevention of Dehydration, revised in October 2017, indicated that nurses' aides should provide and encourage fluid intake as part of daily care. The lack of water availability for Resident 3 and Resident 36 was contrary to these expectations and policies, potentially leading to health issues such as dehydration and urinary tract infections.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 484 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairmont Rehabilitation Hospital | 0.4 mi | ★★★★★ | 2 | 0 |
| Arbor Rehabilitation & Nursing Center | 0.7 mi | ★★★★★ | 22 | 0 |
| Vienna Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 27 | 0 |
| Lodi Creek Post Acute | 2.1 mi | ★★★★★ | 22 | 0 |
| Creekside Center | 6.2 mi | ★★★★★ | 14 | 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.