Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Vienna Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when surveyors observed discolored blenders, sheet trays with residue buildup, and scratched cutting boards in the food prep area, along with improperly labeled cheese stored in the walk-in refrigerator. The DM confirmed the equipment conditions and the unlabeled food items, and the RD stated that food items removed from original packaging should be labeled with the received date, open date, and use-by date. These findings showed that food-contact surfaces and refrigerated food items were not maintained in accordance with facility policy and food safety standards.
A CNA did not wear a gown while emptying a resident’s Foley catheter even though the resident was on EBP for an indwelling urinary catheter. Staff also failed to perform hand hygiene during meal tray service and between assisting two residents with tray setup. In addition, two residents on continuous oxygen did not have protective storage bags available at the bedside for their nasal cannula tubing, contrary to facility expectations and policy.
Failure to Maintain Dignity During Meal Assistance and Catheter Care: Staff were observed assisting a resident with lunch while standing instead of sitting at eye level, and a resident’s urinary catheter bag was left exposed without a dignity bag. The resident receiving meal assistance had significant neurologic and swallowing-related diagnoses, and the resident with the catheter bag had quadriplegia and mental health diagnoses. The CNA, DSD, and DON acknowledged the catheter bag should have been covered, and staff stated standing over a resident during meals was a dignity issue.
Call Lights Not Kept Within Reach: Two residents were observed in bed with call lights placed out of reach, including one on a storage unit near the feet and one hanging from a bed rail onto the floor. Both residents had care plans directing staff to keep the call light within reach, and one resident had diagnoses including dementia, encephalopathy, falls, and a lumbosacral/pelvic fracture while the other had dementia, palliative care, pain, polyneuropathy, and a bleeding disorder.
A resident with hemiplegia and depression, who was cognitively intact and preferred to wear his hair long, reported that a CNA cut a large portion of his hair without asking permission while assisting him in the morning. Staff interviews confirmed CNAs were not authorized to cut hair and that haircuts were to be handled through the salon, but the CNA trimmed the resident’s hair after saying it was getting caught in her gloves. The resident said he became upset, did not trust the CNA, and did not feel safe around her after the incident.
A resident with CHF, hypertensive heart failure, and hospice care had a POLST in the paper chart showing DNR status, but the EHR did not list the code status or contain a scanned copy of the POLST. LNs verified the missing EHR documentation, and the DON stated the code status needed to be readily available to honor the resident’s wishes and guide emergency care.
Hot Water Temperatures Below Required Range in Resident Bathrooms: Hot water in the bathrooms of two resident rooms was measured below the required 105 F to 120 F range, with readings of 102.6 F and 99.6 F. A resident stated the water was too cold to shower, and the IP and DON confirmed the expected temperature range for resident rooms. Facility policy required residents to be provided a safe, clean, comfortable, and homelike environment and for hot water temperatures to be checked monthly.
A resident with dementia, polyneuropathy, anxiety, pain, and a history of TIA/CVA was observed using a Geri chair that prevented the resident from getting up. The physician order did not include a medical indication for the chair, and the resident did not have informed consent or a care plan for Geri chair use. Staff and the DON stated the chair could function as a physical restraint when it restricted movement.
A resident with multiple diagnoses, including depression, diabetes, pain, and a prior cerebral infarction, was observed smoking in the designated smoking area without staff supervision. The resident’s quarterly smoking assessment was completed late, the rationale for allowing unsupervised smoking was left blank, and the record showed use of sedating medications including hydrocodone and sertraline. Staff confirmed there was no smoking care plan in place, and the DON stated timely smoking assessments were required to determine whether residents could smoke safely and independently.
Failure to assess and relieve pain promptly for a resident with chronic pain, B-cell lymphoma, osteoporosis, and depression. The resident reported severe back and leg pain and waited about 10 minutes to be transferred back to bed while moaning and yelling for help; staff did not provide comfort measures, notify the nurse, or reassess pain. Record review showed no recent pain medication administration, and an LPN stated pain should have been assessed at the start of the shift. The DON stated CNAs should check residents for pain every two hours, provide non-pharmacological interventions without delay, and report pain to the nurse.
A resident with Alzheimer’s disease, severe cognitive impairment, and dependence for bed mobility had both half side rails raised, but no bed rail assessment had been completed to determine whether the rails were needed or safe to use. A CNA stated the resident could not follow instructions to use the rails and that the rails were not needed, while an LPN confirmed the lack of assessment and noted the resident’s condition increased concern for injury and entrapment. The DON stated bed rail assessments were required quarterly.
Medication administration errors exceeded the allowed rate when surveyors found 3 errors in 28 opportunities. An LPN gave a resident vitamin B12 without a doctor’s order, failed to give another ordered medication, and gave carvedilol to a second resident without the ordered food. The DON and pharmacist consultant confirmed that medications must be administered as ordered.
Expired ocular vitamins were found in a medication room and a medication cart, and two pill cutters in separate medication carts had whitish and grayish residue. An LPN confirmed the vitamins were expired and the pill cutters should have been cleaned after each use; the DON also stated expired meds should not be available for use and pill cutters are expected to be cleaned between uses.
QAPI Committee Lacked Required IP Attendance: The facility's Resident Care/QAPI Committee did not meet with all required members when the IP missed the quarterly QAPI meeting. The DON confirmed the IP was expected to attend every quarterly meeting, and the IP stated she was on leave and had no replacement coverage at the time. The IP and ADM both confirmed the missed attendance, and the IP stated her input was needed to identify infection trends, review organisms, and support staff education.
Room size deficiency in multiple-occupancy rooms. Four rooms did not meet the required square footage per resident, with measured space below the 80 sq ft minimum for each resident in rooms with 4 beds. Resident interviews were mixed, with some stating the space was adequate and one resident stating the room was too narrow for the care needed. Staff noted that the rooms could feel crowded when fully occupied and that care and movement became more difficult with 4 residents in the room.
A resident with dementia was found with unexplained bruises on her neck and clavicle, which the facility failed to report to the Department in a timely manner. Despite internal investigations ruling out abuse, the facility's policy required reporting all injuries of unknown source within 24 hours, which was not adhered to.
The facility failed to maintain proper food storage and service standards, affecting the safety of meals for 139 residents. The cook's refrigerator had fluctuating temperatures above the recommended level, and the three-door freezer had ice buildup and exposed food. Additionally, cleanliness issues were noted, including dusty fan blades, rusted shelves, and stained cutting boards, all confirmed by the Dietary Services Supervisor.
The facility exhibited inconsistent guidance and practices regarding the storage of food brought in by family and visitors. Staff interviews revealed varying understandings of storage durations, with some stating food could be kept for 24 hours and others for three days. Observations of the resident refrigerator showed expired and unlabeled items, indicating a lack of adherence to expected procedures. A second policy review further highlighted discrepancies in storage durations, potentially leading to unsafe food handling.
Two residents experienced medication administration errors in an LTC facility. A nurse failed to wear gloves while administering Paroxetine to a resident, contrary to the physician's order. Another resident's Zolpidem was marked as administered despite being unavailable, as noted in the records. These actions violated the facility's medication administration policies.
A resident with a history of pulmonary embolism and atrial fibrillation refused to take Xarelto, a blood thinner, for five days due to fear of bleeding. The facility failed to notify the physician promptly, as required by policy, delaying communication until the fifth day of refusal.
Two residents in an LTC facility were at risk of developing pressure injuries due to the facility's failure to implement physician-ordered preventive measures. One resident lacked a foot cradle and sheepskin padding, while another had a foot cradle used incorrectly, with linens placed on top, causing pressure on the lower extremities. Staff acknowledged these deficiencies, which contradicted the facility's policy on skin care and wound management.
A resident with a history of stroke and right-sided weakness did not receive necessary interventions to prevent worsening of her right hand contracture. Despite being alert and cooperative, her clinical records lacked a care plan or preventative measures like a brace or splint. Staff confirmed the absence of assistive devices, and the DON acknowledged the lack of documentation addressing the contracture, focusing instead on lower extremity exercises.
A resident with COPD experienced improper storage and handling of respiratory equipment, including a nebulizer mask and tubing not stored in a labeled bag and outdated tubing. Additionally, the nasal cannula was incorrectly connected to a nebulizer machine instead of an oxygen concentrator, violating facility policies and posing infection control risks.
A resident with moderate cognitive impairment and specific pain management goals received Hydrocodone-Acetaminophen (Norco) for mild pain levels, contrary to physician orders for moderate to severe pain. Nursing staff inconsistently applied the pain scale, leading to unnecessary administration of narcotics, as confirmed by the DON.
The facility failed to provide the required 80 square feet per resident in rooms 24, 33, 43, and 68, with room sizes providing only 74, 71.5, 77.5, and 73.25 square feet per resident. Despite this, residents and staff reported adequate space and privacy, with no complaints about room size. The Department recommended continuing the room waiver.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and preparation and to maintain kitchen equipment and food-contact surfaces in accordance with professional standards for food safety for 133 residents who consumed facility-prepared meals. During the initial kitchen tour, surveyors observed three blenders in the food preparation area that were visibly discolored, five cooking sheet trays stored inside the hot box with dark brown residue buildup in the inside corners, and two cutting boards on a rack with significant scratches on both sides. The Dietary Manager confirmed each of these findings during the observation. During interviews, the Dietary Manager stated the blenders were old and in need of replacement, the sheet trays were old and had residue buildup from repeated cooking over time, and the cutting boards were old and would be replaced. The Dietary Assistant described the dishwashing process as removing food debris, spraying items with water, washing and sanitizing them in the dishwasher, and air drying them. The Dietary Manager later stated the blenders were discolored due to hard water buildup and frequent use despite repeated dishwashing, and that blenders, trays, and cutting boards with these conditions should be discarded because residue or food particles could remain on the items. Surveyors also observed a container of cheddar cheese and a container of mozzarella cheese stored in the walk-in refrigerator without clear identification of the received date, open date, or use-by date. The Dietary Manager confirmed the cheeses were not properly labeled and stated staff would not know how long they were safe for use without proper dating. The Registered Dietitian stated that once food items are removed from their original packaging, they should be labeled with the received date, opened date, and use-by date in accordance with the facility's food storage guidelines, and that this expectation was not met at the time of observation.
Infection Prevention Failures During Catheter Care, Meal Service, and Oxygen Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices during care for a resident with an indwelling Foley catheter who was on Enhanced Barrier Precautions (EBP). The resident’s record showed an order for a 16 French Foley catheter and EBP requiring gown and glove use for high-contact care, including urinary catheter device care. During observation, a CNA emptied the resident’s Foley catheter while wearing a mask and gloves, but not a gown. In interview, the CNA stated she only wore a gown when providing care for the resident’s roommates and believed the resident was not on precautions, so she did not need to wear a gown for the catheter care. Other staff, including another CNA, an LN, the IP, and the DON, confirmed the resident was on EBP and stated gown and gloves were expected for this type of care. The facility also failed to ensure hand hygiene was performed during meal tray service for multiple residents. During observation, a CNA picked up a meal tray from the cart and brought it into a resident room without doing hand hygiene, then assisted the resident with slicing food without performing hand hygiene first. In another observation, a CNA assisted one resident with lunch tray setup and then immediately assisted another resident with tray setup without performing hand hygiene between the two residents. The CNA acknowledged not performing hand hygiene between residents. The IP and DON stated staff were expected to perform hand hygiene before and after tray handling and between residents to prevent cross-contamination and spread of infection. The facility also failed to provide protective storage bags for oxygen tubing at the bedside of two residents receiving continuous oxygen. One resident had diagnoses including respiratory failure, COPD, asthma, heart failure, and palliative care, and another resident had diagnoses including heart failure, respiratory failure with hypoxia, pneumonia, and dependence on supplemental oxygen. During observations in both rooms, the residents had nasal cannula tubing in place connected to oxygen concentrators, and staff stated no protective storage bag was available at the bedside. The IP and DON stated a protective storage bag was expected to be available for oxygen tubing when not in use, and the facility policy stated oxygen supplies should be stored in a clean, dry area protected from dust and moisture.
Failure to Maintain Resident Dignity During Meal Assistance and Catheter Care
Penalty
Summary
The facility failed to ensure dignity and respect for two residents when staff assisted one resident with meals while standing at the side of the bed instead of positioning themselves at eye level. The resident had diagnoses including cerebrovascular disease, aphasia, dysphagia, hemiplegia and hemiparesis, depression, and pain. During a concurrent observation and interview, a CNA was seen assisting the resident with lunch while standing, and the LN stated staff were expected to sit at eye level when assisting residents with meals to promote comfort and respectful interaction. The CNA confirmed standing while assisting with meals and stated it was a dignity issue. The resident’s care plan indicated a functional abilities/self-care and mobility performance deficit and included a goal to maintain comfort and dignity, with an intervention for staff to assist the resident with utensils to bring food and/or liquid to the resident’s mouth. The DON stated staff were expected to engage with residents during meal assistance by maintaining eye-level interaction and not standing over the resident, and stated that standing over residents while assisting with meals created an intimidating environment and was a dignity and resident rights issue. The facility policy on Assistance with Meals also stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them. The facility also failed to ensure a resident’s urinary catheter bag was covered with a dignity bag. The resident had diagnoses including UTI, quadriplegia, depression, generalized anxiety disorder, and bipolar disorder. During observation, the resident’s urinary bag was hanging on the side of the bed without a dignity bag. A CNA stated the bag should have been covered, another CNA stated dignity bags were only used when the resident was in a wheelchair outside the room, and the resident stated she preferred the catheter bag covered at all times, including when in bed, and would feel embarrassed if it were exposed. The DSD and DON both stated the catheter bag should have been covered and that leaving it uncovered was a privacy and dignity issue. The facility’s dignity policy stated staff shall help residents keep urinary catheter bags covered.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to keep the call light within reach for two sampled residents. Resident 17 was admitted with diagnoses including unspecified dementia, encephalopathy, anxiety disorder, unspecified falls, and fracture of the lumbosacral spine and pelvis. During observation, Resident 17 was lying in bed and the call light was placed on top of a plastic storage unit beside the bed near the resident’s feet, rather than within reach. CNA 2 confirmed the placement, and LN 2 later reviewed the resident’s fall risk care plan, which directed staff to be sure the call light was within reach. LN 2 stated staff did not follow the care plan and that the call light should always be kept within the resident’s reach. Resident 147 was admitted with diagnoses including hereditary factor VIII deficiency, palliative care, unspecified dementia, a history of transient ischemic attack and cerebral infarction without residual deficits, anxiety disorder, pain, and polyneuropathy. During observation, Resident 147 was lying in bed and the call light was not within reach; LN 1 stated it was on the floor hanging from the right-side bed rail. LN 1 stated the resident was at risk for falls and unmet needs because the call light was not within reach. The resident’s care plan identified a moderate fall risk and directed staff to be sure the call light was within reach. The DON stated staff were expected to keep residents’ call lights within reach, and the facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Resident’s Hair Cut Without Consent
Penalty
Summary
The facility failed to promote and facilitate resident choice when a CNA cut a resident’s hair without his consent. The resident was admitted with diagnoses including hemiplegia and depression, and his MDS indicated a BIMS score of 13, showing he was cognitively intact. The resident stated he liked his hair long and said he had not consented to the haircut. He reported that the CNA cut a large portion of his hair while he was getting ready to get up from bed to his wheelchair, and that the CNA did not ask permission before using scissors on his hair. The resident told staff that the haircut happened during the morning while the CNA was helping him and teasing that she wanted to cut his hair. He stated the CNA held him down and cut his hair, that he was not scheduled for a haircut, and that only the facility’s beauty salon staff were supposed to provide haircuts. He also stated he became upset after the incident, did not trust the CNA anymore, did not feel safe around her, and did not want her assigned to him again. Staff interviews confirmed that CNA staff were not authorized to cut residents’ hair and that haircuts were to be done through the facility’s beauty salon. Multiple staff members stated that if a resident wanted a haircut, an appointment should have been made with the salon and the nurse should have been notified. The DSD, SSD, DON, and Administrator all stated the CNA should not have cut the resident’s hair and that the resident was alert and able to make his own needs known. The facility’s hair care policy stated that tangles should be worked out with a comb starting at the ends and that resident complaints related to the procedure should be documented. The resident’s hair was later described by salon staff as having one side cut shorter, and the resident reported that someone had cut a tangle in his hair.
Code Status Not Available in EHR
Penalty
Summary
The facility failed to ensure that Resident 6’s treatment choices were known and protected when his code status was not available in the EHR. Resident 6 was admitted with diagnoses including congestive heart failure, hypertensive heart failure, and palliative care. During record review, his EHR did not show a code status order, and a copy of his POLST was not found in the electronic record. Licensed nurses reviewing the EHR verified that the code status was not listed and that there was no MD order in place for it, requiring them to go to the physical chart to look for the information. When the physical chart was reviewed, Resident 6’s POLST showed DNR status, and the chart also showed an order for hospice care. The DON stated it was her expectation that the POLST be in the physical chart and scanned into the EHR, and that the code status needed to be in the chart to provide the right care and honor the resident’s wishes. The facility policy stated that each resident’s code status and treatment preferences were to be clearly documented and readily accessible to staff, with the POLST scanned/uploaded and filed in a rapid-access location.
Hot Water Temperatures Below Required Range in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment when hot water temperatures in the bathrooms of rooms A and B were below the required range of 105 F to 120 F. During a concurrent observation and interview, the Maintenance Supervisor measured the hot water temperature at 102.6 F at the bathroom sink in room B and 99.6 F at the bathroom sink in room A, and stated that the resident room hot water temperature should have been at least 105 F. The report identified six residents assigned to those rooms, including residents with anemia and Parkinson's disease, and noted that Resident 67 stated the water was too cold to shower. The Infection Preventionist stated the hot water temperature range should have been between 105 F and 120 F in resident rooms and that when the water was not within the appropriate range, elderly residents got cold easily and the low temperature might not have killed all bacteria when residents showered. The DON stated her expectation was for each resident room to have hot water within the acceptable range of 105 F to 120 F, and that if the minimum range was not reached, residents would not have been able to tolerate the water temperature, which could have affected hygiene. Facility policy required residents to be provided a safe, clean, comfortable, and homelike environment, and required monthly checks of hot water temperatures in random resident rooms.
Geri Chair Used Without Medical Indication, Consent, or Care Plan
Penalty
Summary
The facility failed to ensure that a Geri chair used for Resident 147 was safe to use and medically necessary as a physical restraint. Resident 147 was admitted with diagnoses including hereditary factor VIII deficiency, unspecified dementia, a history of transient ischemic attack and cerebral infarction without residual deficits, anxiety disorder, pain, and polyneuropathy. The resident also had documented mobility abilities, including walking with assistance, sitting up with supervision or touching assistance, and sit-to-stand with supervision or touching assistance. During observation, Resident 147 had a front wheel walker placed near the foot of the bed, and a CNA stated it was used for walking. Later, the resident attempted to get up from bed, and an LN told the resident not to get up because of fall risk. In a later observation, Resident 147 was seated in a Geri chair and attempted to get up, and an LN stated the chair prevented the resident from getting up. The physician order for the Geri chair stated the resident was able to get up to the Geri chair as tolerated, but the LN stated the order did not include a medical indication for the chair and that, without such documentation, the Geri chair could be a physical restraint. Record review showed Resident 147 did not have informed consent for the Geri chair and did not have a Geri chair care plan. The LN stated informed consent was required to explain the purpose and risks of the Geri chair and allow the resident's representative to make an informed decision, and that a care plan was required to outline safe use and appropriate interventions. The DON stated staff were expected to assess whether a Geri chair functioned as a physical restraint and ensure a medical indication, informed consent, and a care plan were in place. The facility's policies defined physical restraint as any device restricting freedom of movement and required physician order, medical symptom, informed consent, and care plan documentation for restraint use, including Geri chairs.
Late Smoking Assessment and No Smoking Care Plan for Resident Allowed to Smoke Unsupervised
Penalty
Summary
The facility failed to ensure an environment free of accident hazards and adequate supervision for one resident who smoked. Resident 131 was admitted with diagnoses including dysarthria following cerebral infarction, depression, type 2 diabetes mellitus, polyneuropathy, pain, a displaced comminuted fracture of the right tibia, anxiety disorder, and other stimulant abuse. During observation, the resident was seen smoking in the designated smoking area without staff supervision and stated that she smoked without supervision. The Medical Records Director confirmed this was a safety concern. Record review showed the resident’s quarterly smoking assessment was not completed until two months after the required due date. The assessment indicated the resident was not free of sedating medications, but the section requiring the interdisciplinary team’s rationale for allowing unsupervised smoking was left blank. Licensed Nurse 2 confirmed the assessment was late and stated the delay increased the resident’s safety risk. Review of the care plan showed there was no smoking care plan in place, and the nurse confirmed this left no interventions for safe smoking. The resident’s medication record showed ongoing administration of insulin, hydrocodone, and sertraline. The DON stated residents who smoked were required to have a timely smoking assessment to determine whether they could smoke safely and independently, and that residents taking sedating medications were not safe to smoke without supervision.
Failure to Assess and Relieve Resident Pain Promptly
Penalty
Summary
The facility failed to assess pain and provide timely pain relief for one resident with diagnoses including unspecified B-Cell lymphoma, depression, age-related osteoporosis, and pain. The resident’s pain assessment documented chronic pain relieved by repositioning and pain pills, and the care plan directed staff to evaluate the effectiveness of pain interventions, monitor and record pain complaints, give PRN analgesics for pain, and provide pillows to help maintain a comfortable position. During observation, the resident was seated in a wheelchair next to the bed and stated that her back and legs were hurting badly and requested to be transferred back to bed. A CNA stated the resident had to wait to be transferred back to bed, and the CNA remained in the hallway while the resident moaned and yelled for help. Ten minutes later, two CNAs entered the room and transferred the resident back to bed using a standing transfer lift. One CNA later stated the resident complained of moderate pain during the transfer and that repositioning helped relieve her pain, while another CNA stated the resident waited approximately 10 minutes, did not receive comfort measures, and was not reported to the nurse. Record review and interviews showed the resident had chronic pain and had not received pain medication during the period reviewed, with the last documented acetaminophen dose given two days earlier. A nurse stated she had not assessed the resident for pain and should have done so at the beginning of her shift. The DON stated CNAs were expected to check residents every two hours, ask about pain, provide non-pharmacological interventions without delay, and report pain to the nurse, and stated nurses were expected to assess pain right away and residents should not have to wait for pain relief. The facility’s pain policy stated the pain management program is based on resident comfort, asks staff to ask if the resident is experiencing pain, and notes that non-pharmacological and pharmacological interventions may be used.
Missing Bed Rail Assessment for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to assess the safe use of bed rails for one resident who had a physician order allowing the use of bed handrails to support bed mobility and transfers. The resident was admitted with diagnoses including Alzheimer's disease, hyperosmolality and hypernatremia, anxiety disorder, depression, metabolic encephalopathy, and anemia. The resident's MDS showed short-term and long-term memory problems, impaired recall, severely impaired cognitive skills for daily decision making, limited range of motion, impairments in both upper and lower extremities on both sides of the body, and dependence on staff for rolling, sitting to lying, lying to sitting, and transfers. During observation, the resident was in bed with the left and right half side rails raised. A CNA stated the resident was totally dependent on staff for bed mobility and repositioning and could not follow instructions to hold or use the side rails, and also stated both side rails were not needed and could increase the risk for injury including entrapment. A nurse reviewed the bed rail assessment and stated no bed rail assessment had been completed for the resident, despite the resident's severe cognitive impairment and inability to follow instructions to use the side rails. The DON stated bed rail assessments were required quarterly and that when they were not completed, residents were at risk for safety concerns including falls, strangulations, entrapment, and the use of bed rails could function as a physical restraint.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent during medication administration observations. Surveyors identified 3 errors out of 28 opportunities, resulting in a facility-wide medication error rate of 10.71 percent. The errors were identified during observations of medication administration for 2 residents out of 8 residents observed. For one resident, a nurse prepared and administered seven pills, including two tablets of vitamin B12, even though the resident's Order Summary Report did not contain any doctor's order for vitamin B12. The nurse later confirmed that the vitamin B12 had been given without an order and stated that she needed to have a better eye for detail. The DON and the pharmacist consultant both stated that medications should not be given without a doctor's order. For the same resident, the record showed an order for cholecalciferol 1000 units, 2 tablets by mouth daily for supplement, but the nurse did not give the ordered medication. For another resident, the record showed an order for carvedilol 3.125 mg, 1 tablet by mouth twice daily for hypertension, to be administered with food, but the nurse gave the medication without any food. The nurse confirmed the omission of food, and the DON and pharmacist consultant stated that staff were expected to follow the prescriber’s orders as written.
Expired Medications and Dirty Pill Cutters Found in Medication Storage Areas
Penalty
Summary
Safe medication storage and labeling practices were not maintained in one of two medication rooms and two of three medication carts. During observation of the Station 2 medication storage room, an expired bottle of ocular vitamins with an expiration date of 11/25 was found in the active use area, and a Licensed Nurse confirmed it was expired and should not have been available for use. During observation of Station 1 Medication Cart 3, another expired bottle of ocular vitamins with the same expiration date was found stored in the cart, and the Licensed Nurse confirmed it was expired and stated it would not be as effective and could harm residents if given. Two pill cutters were also observed with whitish and grayish residue in Medication Cart 5 and Medication Cart 3. The Licensed Nurses confirmed the pill cutters were dirty and should have been cleaned after each use, and stated residue could lead to cross-contamination and possible allergic reactions. The DON stated expired medications should not have been available to use and that pill cutters were expected to be cleaned after each use. The facility policy stated outdated medications are to be removed from active supply and destroyed, and that tablet splitters are to be cleaned before and after each use.
QAPI Committee Lacked Required IP Attendance
Penalty
Summary
The facility's Resident Care/Quality Assurance Committee failed to meet quarterly with all required members when the Infection Preventionist did not attend the QAPI quarter 2 meeting scheduled on 4/24/25. During a concurrent interview and record review on 2/20/26, the DON reviewed the 2025 QAPI binder and confirmed that the IP was absent from that quarterly meeting. The DON stated that the IP was expected to attend every quarterly QAPI meeting because of the IP's role in identifying infection-related issues and educating staff members. During interviews on 2/20/26, the IP stated that she had been sick and on leave for a while in 2025 and was unable to attend the quarter 2 QAPI meeting. The IP confirmed that she did not have a replacement to cover for her at that time and stated that her input was important so trends and organisms could be identified and reviewed. The IP also stated that it was important to educate staff and follow up on recommendations from other departments to work together effectively as a team. The Administrator confirmed that the IP did not attend the meeting and stated that it was a struggle to find an IP nurse during the months the IP was not available.
Room Size Deficiency in Multiple-Occupancy Rooms
Penalty
Summary
Rooms 24, 33, 43, and 68 did not meet the required square footage of at least 80 square feet per resident in multiple-occupancy rooms. The report states that these rooms each had 4 beds, with required square footage of 320 square feet, but the actual measured square footage per resident was below the required amount in each room. During the survey, the Maintenance Supervisor measured one room at 13 feet by 23 feet and confirmed that rooms 24, 33, 43, and 68 each had 4 beds, with one room occupied by 4 residents at the time and another typically occupied by 3 residents because one bed was not occupied. Resident interviews reflected mixed views about the room space. One resident stated the room was okay and that there was good space, while another resident stated the space was good and that there was enough privacy and comfort, despite using a walker and wheelchair. Another resident stated the room was too narrow and that the space was not enough for the care needed. Staff interviews also reflected that the rooms could feel crowded when all four beds were occupied, with a CNA stating that moving around and providing care became more difficult when the room had four residents. The report concludes that the Department recommended continuation of the room size waiver for rooms 24, 33, 43, and 68.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source for a resident who had a bruise on the right side of her neck and left clavicle. These injuries were identified on consecutive days, but the facility did not report them to the Department until a week later. The resident, who was admitted with dementia and had severe impairments in daily decision-making, was unable to explain the cause of the bruises. The facility's delay in reporting resulted in a delay in the Department's investigation into the potential occurrence of abuse. The facility's policy required all injuries of unknown source to be reported to appropriate agencies within 24 hours. Despite this, the Administrator reported the bruises only after the resident's family requested an investigation. The Director of Nursing stated that the facility had investigated and ruled out abuse, which they believed negated the need for reporting. However, the facility's policy clearly mandated reporting all such incidents, regardless of internal findings, to ensure proper oversight and investigation by external authorities.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and service standards, affecting the safety of meals prepared for 139 residents. During an initial kitchen tour, the cook's refrigerator was found with fluctuating temperatures between 42 and 50 degrees Fahrenheit, exceeding the recommended 41 degrees Fahrenheit or lower. This issue persisted over several days, with internal temperatures remaining too high, leading to the disposal of potentially unsafe food items. Additionally, the three-door freezer used for meats had significant ice buildup, which can compromise the freezer's efficiency and the integrity of stored food. An open box of vegetarian meatballs was also found exposed to air, showing signs of freezer burn, indicating improper storage practices. The facility's kitchen was observed to have several cleanliness and maintenance issues. Three fans in various areas, including the tray preparation room and dish room, were found with discolored and dusty blades, posing a risk of contamination to clean trays and utensils. Furthermore, two metal shelves in the cook's preparation area were noted to have rusted surfaces, which can interfere with proper cleaning and sanitization, potentially leading to cross-contamination of food. These observations were confirmed by the Dietary Services Supervisor (DSS), who acknowledged the maintenance lapses. Additionally, four cutting boards were found with black staining and deep grooves, making them difficult to clean and sanitize effectively. This condition can lead to the accumulation of pathogenic microorganisms, which may be transferred to food prepared on these surfaces. The facility's policies and procedures, as well as the US FDA Food Code, emphasize the importance of maintaining equipment and surfaces in good repair to prevent contamination and ensure food safety. The deficiencies observed in the facility's kitchen practices highlight a failure to adhere to these standards, potentially compromising the health of the residents consuming the meals.
Inconsistent Food Storage Practices
Penalty
Summary
The facility failed to provide consistent guidance to staff regarding the handling and storage of food brought to residents by family and other visitors. The policy titled 'Food Brought To Resident By Family/Friends/Activity Department' indicated that cooked leftover food should be discarded after two hours at the bedside, but did not include procedures for storing food for residents. Interviews with staff revealed inconsistencies in the understanding and implementation of food storage procedures. The QA nurse mentioned that food brought in by family would be stored in the resident refrigerator and labeled with the resident's name and date, with perishable foods discarded after three days. However, Licensed Nurse 6 stated that food could be kept for 24 hours, while a Certified Nursing Assistant mentioned a three-day storage period. Observations of the resident refrigerator revealed expired and unlabeled food items, including yogurts, kimchi, a medication drink, and various other food items without proper labeling or dates. The Director of Nursing confirmed that housekeeping was responsible for discarding expired or unlabeled items, but the presence of such items indicated a lack of adherence to this expectation. A second policy review showed further discrepancies, allowing food to be kept for different durations than initially stated. These inconsistencies in policy and practice could lead to unsafe food handling, posing risks to the residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of medications for two residents. For Resident 114, a licensed nurse (LN 3) did not wear gloves while administering Paroxetine, a medication prescribed for depression, despite the physician's order specifying the use of gloves. This oversight was observed during a medication pass, and LN 3 acknowledged the error upon reviewing the physician's order. The facility's policy mandates that medications be administered as prescribed, and the NIOSH list identifies Paroxetine as a hazardous drug requiring special handling. For Resident 70, there was a discrepancy in the medication administration records. The resident was prescribed Zolpidem for insomnia, but the medication was signed as administered on the Medication Administration Record (MAR) despite the Controlled Drug Record (CDR) indicating it was not given. The Medication Administration Note stated that the medication was awaiting pharmacy delivery, suggesting it was not available at the time of administration. The Director of Nursing confirmed the inconsistency and noted that the MAR was incorrectly coded, highlighting a lapse in the medication administration process. These deficiencies demonstrate a failure to follow prescribed orders and document medication administration accurately, as required by the facility's policies and the Nursing Practice Act. The errors in handling and documenting medication administration could lead to potential health risks for the residents involved.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a resident's refusal to take prescribed medication, Xarelto, which is a blood thinner used to treat or prevent blood clots. Resident 12, who was admitted with diagnoses including pulmonary embolism and atrial fibrillation, had a physician order for Xarelto to be administered daily. The medication was on hold for a week due to heavy vaginal bleeding and was supposed to be resumed on October 10, 2024. However, the resident refused to take the medication from October 10 to October 14, 2024, expressing fear of bleeding and a desire to consult with the physician before resuming the medication. The Director of Nursing (DON) confirmed that the resident's refusal was not communicated to the physician until October 15, 2024, five days after the initial refusal. The facility's policy requires that refusals of medication be documented and the prescriber notified promptly. The DON acknowledged that the expectation was for licensed nurses to inform the physician on the first day of refusal, but there was no documentation found indicating that the primary care physician was notified during the period of refusal.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention measures for two residents, leading to potential risks of developing pressure injuries. Resident 3, who was admitted with dementia and had a care plan indicating a higher potential for skin impairment, did not have a foot cradle or sheepskin padding in place as ordered by the physician. Observations revealed that Resident 3 was without these protective devices, despite having orders for them to prevent pressure on the toes and protect the skin. Staff interviews confirmed the absence of these devices, and the Director of Nursing acknowledged the expectation for physician orders to be followed. Resident 37, admitted with dementia and diabetes, was identified as having severe cognitive impairment and a moderate risk for pressure sores. The resident's care plan included interventions to protect skin integrity, such as using a foot cradle. However, observations showed that the foot cradle was used incorrectly, with towels and linens placed on top, causing blankets to lay directly on the resident's lower extremities. Staff interviews confirmed the improper use of the foot cradle, acknowledging that it defeated its purpose of preventing pressure on the lower extremities. The facility's policy on skin care and wound management emphasized the importance of avoiding friction and shearing and using pressure redistributing devices to prevent skin breakdown. Despite this policy, the facility failed to implement the necessary preventive measures for Residents 3 and 37, as evidenced by the lack of proper use of foot cradles and sheepskin padding, which are critical in preventing pressure injuries.
Failure to Address Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as Resident 45, to maintain and/or improve her range of motion, specifically regarding her right hand contracture. Resident 45, who was admitted in 2016 with a history of hemiplegia and hemiparesis following a stroke, did not receive necessary interventions to prevent the worsening of her hand contracture. Despite being alert, oriented, and cooperative, the resident's clinical records lacked any documented evidence of a care plan or preventative measures, such as the use of a brace or hand splint, to address her right hand contracture. Observations and interviews with staff, including a CNA, LN, unit supervisor, PT, and the Director of Rehab, revealed that Resident 45's right hand was severely contracted, with fingers curled tightly into her palm, causing pain and difficulty in maintaining hygiene. The staff confirmed that they had not seen the resident using any assistive devices for her contracture, and there was no documentation of any assessment or intervention for her hand condition. The PT noted that the resident's right upper extremity was stiff and rigid during therapy sessions in 2016, indicating a risk for contractures if not treated, yet no follow-up measures were documented. The Director of Nursing acknowledged the absence of a care plan addressing the resident's hand contracture and stated that it was expected that such a plan should have been initiated upon admission and revised as needed. Despite the facility's policy on rehabilitative nursing care, which aims to assist residents in achieving and maintaining optimal levels of self-care and independence, the focus remained on the resident's lower extremities, neglecting her upper extremity needs. This oversight resulted in the resident experiencing a severe contracture in her right hand, with no documented efforts to prevent further deterioration.
Improper Storage and Handling of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage, usage, handling, and labeling of respiratory care equipment for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and dependent on supplemental oxygen. The resident's physician orders required the nebulizer mask and tubing to be changed weekly and stored in a labeled bag. However, during an observation, the nebulizer mask and tubing were found on top of the nightstand without a storage bag, and the tubing was dated nearly a month old. The Licensed Nurse confirmed the improper storage and outdated tubing, acknowledging it as an infection control issue. Further investigation revealed that the facility's Infection Preventionist confirmed the non-compliance with the physician's order and facility policy, emphasizing the risk of infection due to improper storage and outdated equipment. The Director of Nursing also confirmed the expectation for the nebulizer mask and tubing to be stored in a labeled bag and changed as per the order, highlighting the infection control concerns associated with the observed practices. Additionally, the resident's nasal cannula, used for oxygen therapy, was found improperly stored and connected to a nebulizer machine instead of an oxygen concentrator. The Infection Preventionist and Director of Nursing both confirmed the incorrect setup, with the DON expressing disbelief at the error. The facility's policy on oxygen administration was not followed, as the nasal cannula was not connected to the appropriate oxygen device, further contributing to the deficiency.
Inappropriate Pain Management for a Resident
Penalty
Summary
The facility failed to provide pain management consistent with professional standards for a resident who was administered PRN pain medication without adequate indication. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and bone density disorders, had a pain management goal of 1 on a scale of 1-10. Despite this, the resident received Hydrocodone-Acetaminophen (Norco) for pain levels of 1 to 3, which are considered mild and not within the physician's order for moderate to severe pain. Interviews with nursing staff revealed inconsistencies in understanding and applying the pain scale, with some nurses administering Norco for pain levels as low as 1, contrary to the facility's pain management policy. The Director of Nursing confirmed that Norco was given without proper indication and acknowledged that the medication administration did not align with the physician's orders. The facility's policy requires medications to be administered as prescribed and pain to be assessed accurately using the pain scale embedded in the electronic Medication Administration Record (eMAR). However, the failure to adhere to these guidelines resulted in the unnecessary administration of narcotics, potentially increasing the resident's risk of side effects and dependence.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required 80 square feet of living space per resident in multiple resident rooms, specifically in rooms 24, 33, 43, and 68. The measurements of these rooms were found to be less than the required space, with room sizes providing only 74, 71.5, 77.5, and 73.25 square feet per resident, respectively. This deficiency was identified through a review of a facility request for a square footage room waiver and was confirmed by observations and interviews with residents and staff. Despite the deficiency, interviews with residents and staff indicated that the residents felt they had adequate space and privacy. Residents reported being comfortable and having enough room to maneuver, even with wheelchairs, and some mentioned signing waivers acknowledging the room conditions. Staff, including CNAs and a Unit Supervisor, also reported no complaints from residents regarding room size and stated that there was sufficient space to provide care. The Department recommended the continuation of the room waiver for the affected rooms.
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What surveyors actually found near you
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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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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 | 1.7 mi | ★★★★★ | 2 | 0 |
| Lodi Nursing & Rehabilitation | 1.8 mi | ★★★★★ | 20 | 0 |
| Arbor Rehabilitation & Nursing Center | 2.2 mi | ★★★★★ | 22 | 0 |
| Lodi Creek Post Acute | 2.5 mi | ★★★★★ | 22 | 0 |
| Creekside Center | 6.5 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.