Lodi Creek Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete the comprehensive admission assessment (a thorough health history and physical evaluation conducted when a resident enters a healthcare facility) for one of three sampled residents, (Resident 1) when Resident 1 was admitted to the facility on [DATE] and the admission comprehensive assessment was not completed within the required 14 calendar days after admission. This failure had the potential to delay the identification of Resident 1's care needs, completion of Care Area Assessments (CAAs - assessments used to identify care needs and guide care planning), and the development of an appropriate comprehensive care plan (an individualized plan of care that identifies problems, goals, and interventions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care to prevent worsening of an existing pressure injury (localized areas of skin and tissue damage caused by sustained pressure) on the right foot and/or prevent the development of new pressure injuries when Resident 3 was not turned in bed at least every two hours to relieve pressure on the body. This failure placed Resident 3 at risk for worsening of the existing pressure injury on the right foot and the development of additional pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents' rights to be free from abuse (physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment resulting in physical harm, pain, mental suffering, or deprivation by a care custodian of goods and services necessary to avoid harm) for 2 of 3 sampled residents (Resident 2 and Resident 3) when:Resident 1 made open hand contact to Resident 2's face and chest area on 8/27/25 at 8 PM, and the physician was not notified timely to evaluate and manage Resident 1's aggressive behavior; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1) when scheduled showers were not documented accurately in Resident 1's electronic medical record (EMR). This failure had the potential for the records not to fully reflect Resident 1's scheduled showers being provided that could impact his health, hygiene and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely pain management for one of three sampled residents (Resident 1) when Resident 1's scheduled pain medication was administered one hour and 45 minutes after its scheduled time. This failure had the potential to cause Resident 1 increased pain and psychosocial distress. A review of Resident 1's admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, long term lung disease that causes airflow blockage and shortness of breath) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the 82 residents who received facility prepared meals when:1. An open bottle of vinegar was observed under the food steam table; and,2. An open box of salt was stored where the mouth of the box was taped but a visible gap remained between the tape and the box, leaving the contents partially exposed; and,3. A fish [NAME] (spatula) was found in the clean utensils box with a melted middle section; and,4. Canned goods were found in the dry storage room without expiration dates or a received by dates; and,5. Vendors and Staff were not wearing hairnet/beard-net inside the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective Infection Prevention and Control Program for a census of 82 residents when:1. Resident 7's Contact Precautions (a set of measures used to prevent the spread of germs through direct or indirect physical contact) were discontinued without physician involvement, failing to apply Enhanced Barrier Precautions (EBP - Extra safety that healthcare workers take to prevent spreading infections) when indicated,2. Facility staff did not perform hand hygiene during resident care; and,3. Licensed Nurse (LN) 5 did not sanitize the medication tray and blood pressure cuff during medication administration in between resident use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 1 out of 22 sampled residents (Resident 57) when Resident 57's call light (device used to contact staff for assistance) was not within her reach. This deficient practice placed Resident 57 at increased risk for unmet care needs, delayed staff response, and potential for accidents or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and home-like environment for 1 out of 22 sampled residents (Resident 108) when Resident 108's privacy curtain was found not properly secured and functioning. This deficient practice had the potential to compromise Resident 108's privacy and dignity during care.

Inspectors wroteBased on interview, and record review, the facility failed to implement a care plan intervention for 2 out of 22 sampled residents when:1. A care plan intervention of providing food to resident during and after the dialysis session was not implemented for Resident 106; and2. Weights were not checked monthly for Resident 3 and Resident 10 and the MD (medical doctor) and RP (responsible party) were not notified. These failures has the potential to place Resident 106 at risk for weight loss, Resident 3, and Resident 10 at risk for undetected weight loss, and for not receiving effective and person-centered care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 7) comprehensive care plan was revised when Resident 7 was taken off of contact isolation precautions (infection control measures such as hand washing and wearing gloves, gowns, and masks used in healthcare when caring for a resident to prevent the spread of germs), but her comprehensive care plan was not updated to reflect the change. This failure placed Resident 7 at risk for staff providing care based on inaccurate information, inconsistent implementation of interventions, miscommunication across shifts and disciplines, and potential errors during emergency care, due to the care plan not reflecting the resident's current condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for the use of an indwelling urinary catheter (a thin, flexible tube left inside the bladder for continuous urine drainage into a bag, held in place by a small, water-filled balloon at the tip, allowing for long-term or short-term use) for 1 of 7 residents with an urinary catheter (Resident 1) when Resident 1's urinary bag was positioned improperly. This failure had the potential to cause Resident 1 to have complications related to the use of an indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care for one of one resident (Resident # 6) requiring tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) when Resident 6's head of bed was not at the prescribed elevated angle. This failure had the potential for Resident 6 to have complications related to tube feedings such as aspiration (when food goes into the lungs instead of the stomach), pneumonia (infection of the lungs), and possible hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 106) who required hemodialysis (HD/dialysis, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), received services consistent with professional standards of practice when Resident 106 was not provided meals during and after dialysis sessions. This failure has the potential to cause complications including weight loss for residents on dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication management for 1 out of 22 sampled residents (Resident 21) when Resident 21's saline nasal spray was allowed to remain at Resident 21's overbed table without a physician's order for self-administration and without completion of a self-administration assessment. This deficient practice had the potential to result in Resident 21's unsupervised medication use, improper administration, and safety risks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 69, Resident 34) medication administration record (MAR) maintained accurate documentation when:1. Licensed Nurse (LN) 4 administered Resident 69's Tylenol and did not document administration in Resident 69's Medication Administration Record (MAR); and2. LN 5 administered Resident 34's Docusate (medication used to relieve occasional constipation, usually helps produce a bowel movement in 12 to 72 hours), but was documented as not given on the MAR.This failure had the potential for residents at risk for medication errors, by getting a double dose of the same medication, risk for injury, and possible hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine to two out of five sampled residents (Resident 7 and Resident 105) and the influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and covid-19 (an infectious respiratory disease caused by the SARS-CoV-2 virus) vaccine to one out of five sampled residents (Resident 105) when:1. Resident 7 was not given the pneumococcal vaccine after consenting to receive it.2. Resident 105 was not given the influenza, pneumococcal and covid-19 vaccines after consenting to receive them. [...]

Inspectors wroteBased on observation and interview, eleven rooms (rooms 2, 3, 4, 8, 41, 43, 44, 45, 46, 47 and 48) in the facility did not meet the required 80 square feet per resident. This failure placed the residents in rooms 2, 3, 4, 8, 41, 43, 44, 45, 46, 47 and 48 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage.

Inspectors wroteBased on interview, and record review, the facility failed to implement their infection control policy and procedure by failing to ensure that two of six sampled residents (Resident 1 and Resident 4) were tested for COVID-19 after being exposed to a COVID-19 (a contagious disease) positive resident. This deficient practice had the potential to place residents, staff members, and visitors at risk for spreading infection. There was also the potential to cause further delay in the treatment for Resident 1 and Resident 4.

Inspectors wroteBased on interview, and record review, the facility failed to provide the proper notice for discharge for Resident 1 when: 1. Resident 1 was not given a 30-day advance written notice of the impending transfer or discharge from the facility, 2. The facility did not notify or send Resident 1's Notice of Transfer or Discharge form to the Ombudsman's office (a government appointed person who actively supports the rights of the residents) on the same day that Resident 1 was served the notice; and, 3. The location listed on Resident 1's Notice of Transfer or Discharge (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another location) did not match the location listed on Resident 1's discharge order location. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents, (Resident 1) when Resident 1 was not repositioned or assisted with care needs in a timely manner. This failure put Resident 1 at risk of discomfort and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 6 sampled residents (Resident 1) from physical abuse when Resident 1's arm was grabbed by Resident 2. This failure resulted in Resident 1 sustaining a scratch to her arm and felt unsafe in her room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of a census of 81 residents, when the emergency Kit (E-Kit, limited number of medications for use in an emergency) log was not filled out for two opened E-Kits. This failure increased the potential for the facility to not have the needed medications available during emergencies that could jeopardize residents' health and safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 81, when: 1. Expired medications were not removed from the medication cart and the medication storage room; 2. Pharmaceutical products were found in the medication storage room and the medication cart without an opened date; 3. Pharmaceutical products with an unclear and torn label was found in a medication cart; 4. Loose medications were found in a medication cup in the first drawer of the medication cart; and, 5. A white powdered medication in medication cups were left unattended at the resident's bedside. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to accurately check and test sanitizing solutions in the kitchen for a census of 81, when: 1. The dishwasher sanitizing solution was not accurately checked for effectiveness; and, 2. The Quatenary Ammonium Compound (QAC; a type of chemical that is used to kill bacteria, viruses, and mold) was not tested at the right temperature and concentration. These failures had the potential to expose residents to foodborne illnesses from improperly sanitized eating utensils served with the residents' meals.

Inspectors wrote2. A review of Resident 331's admission record, indicated Resident 331 was admitted to the facility in August of 2024 with diagnoses that included, urinary tract infection (UTI; when bacteria multiply in the urinary organs), sepsis (a severe response to infection which can lead to organ damage), and chronic kidney disease (when kidneys are damaged and can't filter blood properly). A review of Resident 331's Order Summary Report, dated 9/4/24, indicated Resident 331 had an active order that started on 8/19/24 for an indwelling urinary catheter (IUC: a medical device that drains and collects urine from the bladder) and a peripherally inserted central catheter intravenous line (PICC IV: a long thin tube put into a vein used to deliver medications over a long period of time). During an interview on 9/4/24 at 1:52 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure six residents (Resident 14, 26, 30, 38, 42, and 51) out of 20 sampled residents had call lights (equipment used by a patient to alert or communicate with a caregiver) within easy reach or call lights that were operable. This failure had the potential for residents to be unable to contact nursing staff when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 20 sampled residents (Resident 11 and Resident 20) had an informed consent for the use of antipsychotic medications (drugs that mainly treat psychosis-related conditions and symptoms), when: 1. Resident 11's antipsychotic informed consent was not updated every six months; and, 2. Resident 20 had no informed consent for an antipsychotic. This failure decreased the facility's potential to ensure residents or their responsible person(s) were fully informed of the risks, benefits, and alternative treatment options prior to the use of an antipsychotic medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a baseline care plan (instructions needed to provide effective and person-centered care for the resident developed within 48 hours of admission) for one of 20 sampled residents (Resident 331), when Resident 331's baseline care plan did not include an indwelling urinary catheter (IUC; a medical device that drains and collects urine from the bladder). This failure had the potential to place Resident 331 at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to revise and implement a communication care plan for one of 20 sampled Residents (Resident 20) who did not speak English. This failure increased Resident 20's potential to receive inadequate and inaccurate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 20 sampled residents (Resident 331 and Resident 135) when: 1. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: used to deliver medications into a vein over a long period of time) flushes (a procedure that uses a mixture of salt and water to clear an IV line and reduce the risk of infection) were not documented in accordance with professional standards; and, 2. Resident 135's urinary drainage bag was not enclosed in a privacy bag, the urinary drainage bag collection tube was not kept properly positioned and kept free from kinks for optimal drainage. These failures decreased the facility's potential to prevent worsening of the residents' clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication board or use translator during assisting care for one resident (Resident 1) of 20 sampled residents. This failure decreased the facility's potential to meet Resident 1's ability to communicate her basic needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 20 sampled residents (Resident 282 and Resident 331) who had Vascular Access Devices (VAD, thin flexible tube that provides access to veins for the delivery of IV [Intravenous, administered into a vein] medications) received the necessary care and services when: 1. Resident 282's Midline catheter (a type of VAD used for intravenous treatments of more than six days) was not monitored for signs and symptoms of infection every shift as ordered; and, 2. Resident 331's peripherally inserted central catheter intravenous line (PICC IV: a type of VAD used to deliver medications into a vein over a long period of time) was not monitored for signs and symptoms of infection every shift as ordered. These failures placed the residents at risk for VAD related infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for one of 20 sampled residents (Resident 281) who received hemodialysis (HD, a medical procedure that helps remove waste and excess fluid from the blood when the kidneys are unable to perform this function), when her output was not accurately measured as ordered. This failure increased Resident 281's risk in developing fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 11) out of 20 sampled residents received proper monitoring for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) when there was no manifestation, no diagnosis identified, and no side effect monitoring for Resident 11's buspirone (an antianxiety medication). These failures placed Resident 11 at risk for unnecessary psychotropic medication use side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an essential kitchen equipment in good working order and repair for a census of 81, when freezer number (#) six was observed to have an internal temperature of 10 degrees Fahrenheit (a unit of measure for temperature) and was not in good repair. This failure had the potential for residents to become sick from food borne illnesess.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the right to be free from abuse for 1 of two sampled residents (Resident 1) when Resident 1 was hit in the face by Resident 2 causing a scratch to the bridge of the nose and bruise to the left eye. This failure to protect Resident 1 resulted in a scratch to his nose and a bad bruise to the left eye.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the rights to be free from abuse for 1 of 3 sampled residents (Resident 2) when staff witnessed Resident 1 punched Resident 2 in the face during an altercation causing Resident 2's eyes to bleed. This failure resulted in Resident 2 abused by Resident 1 and sustaining a bruise and a skin tear on the right eye.

Inspectors wroteBased on observation, interview, and policy record review, the facility failed to ensure medications were stored locked for the census of 82, when a medication cart (Med Cart 2) was left open and unattended in the hallway. This failure had the potential for medication misuse and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure complaints and grievances were documented as directed by their grievance policy and procedure for one of 3 sampled residents (Resident 1). This failure had the potential for Resident 1's concerns not to be thoroughly investigated and resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% when: 1. Resident 60 was administered crushed metoprolol (a medication to treat high blood pressure) XR [extended release] and omitted a dose of aspirin; and, 2. Resident 45 was administered isophane insulin (an intermediate-acting medication to lower blood sugar levels) without being rolled prior to administration. These failures resulted in two medication errors and one omitted dose being identified out of 29 opportunities during an observation of medication administration which resulted a medication error rate of 10.34%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 81 when: 1. One of three medication carts was left unlocked; 2. Loose pills were found in two of two medication carts; and, 3. Outdated medication was found in two of two medication carts. These failures had the potential to contribute to medication error, unsafe medication use and storage, and diversion.

Inspectors wroteBased on interview and record review, the facility failed to maintain confidential information when resident meal tickets were thrown in the regular trash. These failures decreased the facility's potential to prevent resident-identifiable information being accessible to the public.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain infection control practices designed to provide a safe and sanitary environment and help prevent the transmission of diseases and infections for a census of 81 when: 1. The Dietary Assistant (DA) used a gloved hand to rub her nose and continued to prepare lunch plates without washing her hands or putting on new gloves; 2. The Dietary Services Supervisor (DSS) refilled fresh butter sauce into a bottle with older butter sauce which had initially been filled 11 days prior; 3. Staff members did not use hand hygiene before and after providing resident care or during medications administration; 4. A juice dispensing machine spike was left uncovered; 5. The dry storage room was not maintained in a clean and sanitary manner; 6. The base of the bench can opener was not clean; and, 7. [...]

Inspectors wroteBased on observation and record review the facility failed to maintain essential kitchen equipment in good working order and repair when: 1. The beverage dispensing machine was not kept in a sanitary condition; 2. The ice machine was not cleaned and sanitized; and, 3. The kitchen equipment cleaning schedule was not followed. These failures had the potential for residents to become sick.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards when: Staff did not follow physician orders when they cleaned Resident 16's indwelling catheter (a tubing that collects urine attached to a drainage bag). This failure decreased the potential to provide effective care and services that meet the nursing standards of quality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order to clean an indwelling catheter (a tubing that collects urine attached to a drainage bag) for one resident (Resident 16) of 23 sampled residents for a census of 81. This failure reduced the facility's potential to prevent urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident 59, Resident 11, and Resident 21) out of 23 sampled residents received proper monitoring for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) when: 1. Resident 59 did not have orders to monitor behavior and side effects; and 2. Resident 21 was prescribed quetiapine (a psychotropic medication that affects the brain associated with mental processes and behavior) without appropriate indications for use, behavior, and medication side effects monitoring. These failures placed the residents at risk for unnecessary psychotropic medication use.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in 11 shared rooms. This failure had the potential to limit the personal belongings of each resident and compromise their ability to safely move freely in their rooms.