Lodi Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for one of one sampled resident (Resident 1), when staff did not perform hand hygiene and change their gloves during a nephrostomy tube (a tube that drains urine directly from the kidney) dressing change for Resident 1 who was on Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes that requires use of gowns and gloves during high-contact care activities to reduce the transmission of germs and bacteria). This failure increased the risk for infection to Resident 1 and had the potential to spread infection and cause health problems for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage in the medication refrigerator located at Nurse Station 1 for a census of 69 residents when:1. The medication refrigerator was observed with extensive frost buildup and temperature outside the facility's required range per policy; and,2. The facility had not implemented a log or tracking system for routine cleaning and defrosting of the medication refrigerator. These failures had the potential to contribute to unsafe medication storage and use, which could affect the health and well-being of vulnerable elderly residents.

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 when:1. Two water pitchers, multiple spoons, spatulas, a blender, two metal baking sheets, and plates were stored wet, 2. A bag of uncooked pasta did not have a use by date; and, 3. A lunch cart did not have a cover, and two lunch plates in the food delivery cart were not fully covered. These failures had the potential of leading to a food-borne illness (an illness that comes from eating contaminated food) for all 69 residents receiving facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 69, when:Resident 86 had perishable food at the bedside that was not consumed or discarded two days after the date,An opened and half-filled single-use skin ointment packet was left on Resident 85's overbed table after being used during incontinent care,Certified Nursing Assistant (CNA) 6 did not wear personal protective equipment (PPE- equipment such as protective clothing, gloves, masks or other garments used to prevent or minimize exposure to hazards) when assisting Resident 93 who was on contact precautions (infection control steps used in a healthcare setting to prevent the spread of germs that are passed by direct contact with a patient or their environment),Resident 1's linens were not changed in a timely manner after blood was [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 19) was treated with dignity and respect when a clothing protector (adult bib) was applied during mealtime against the resident's wishes. This failure violated Resident 19's right to dignity with the potential to negatively impact Resident 19's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of two of 23 sampled residents (Resident 10 and Resident 83) when,1. Resident 10'a call lights (devices used to contact staff for assistance) was not within their reach. 2. Resident 83's call light was not within reach. This failure placed Resident 10 and Resident 83 at increased risk for unmet care needs, delayed staff response, falls, and potential for accidents or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be fully informed of the Bed-Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) process for 1of 23 sampled residents (Residents 10) when the facility failed to provide a written Bed-Hold Notice to Resident 10 and her RP when transferred to the hospital on [DATE]. This failure placed Residents 10 and her RP at risk for emotional distress (mental or emotional harm) and deprived Resident 10 and her RP of the option and information to keep the resident's bed during hospitalization (bed-hold).

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of the nursing interventions to prevent the development or worsening of pressure injuries (pressure ulcers) for one of 23 residents (Resident 48) was care planned and communicated to staff when a physician ordered repositioning every two hours for Resident 48 for pressure injury prevention on 2/12/26, and the intervention was not included in the care plan or the Kardex (a quick reference care sheet used by Certified Nursing Assistants [CNAs] to guide daily care). This failure created the potential for unmet pressure injury prevention needs for Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe pharmaceutical services were provided with the accountability of delivered medications based on standards of practice for a resident census of 69 when medication delivery slips and manifests from the pharmacy provider were not consistently signed and dated by licensed staff upon receipt from delivery courier for accuracy and accountability of prescription medication received. This failure had the potential to result in drug diversion (illegal use of drugs), medication error, misuse, unaccounted-for and missing resident medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices were followed when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 69 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 6 errors out of 26 opportunities which resulted in a facility wide medication error rate of 23.08 % in 1 out of 9 residents (Resident 6) during medication administration observation. These failures had the potential to result in unsafe medication use, medication errors, and noncompliance with the physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to maintain and prevent decline in functional ability (the resident's ability to move and perform daily activities) for one of 23 sampled residents (Resident 31) when Resident 31's physical therapy (PT: a healthcare specialty service focused on improving movement, reducing pain, and restoring physical function through tailored exercises, manual techniques, and education) was discontinued despite a physician's order to extend physical therapy and without a plan to maintain or prevent decline in functional abilities through restorative nursing assistant (RNA - a program where trained staff help residents practice exercises and daily activities to maintain strength and mobility) services. [...]

Inspectors wroteBased on interview, and record review, the facility's Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members, when the Administrator (ADM) and the Medical Director (MD) did not attend the scheduled quarterly meetings as required. This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents for a census of 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system (system/device used by residents to call staff for assistance) was in place for 2 of 23 sampled residents (Resident 61 and Resident 62) when Resident 61 and Resident 62's call light was not working. This failure had the potential to result in Resident 61 and Resident 62 being unable to call staff for help when needed and their needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: a notice that informs residents of changes to their Medicare Part A coverage for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay) to one of one sampled resident (Resident 2) reviewed for Medicare benefit notification after skilled services ended. This failure had the potential for Resident 2 not to be able to make informed decisions about his care and finances, being unaware of his right to appeal and placed him at risk for unexpected medical bills. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an accident-free environment when necessary rehabilitation care instructions for nursing staff were not updated in the care plan for one of three sampled residents (Resident 1) when Resident 1 was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat. This failure resulted in Resident 1 falling out of the wheelchair and hitting his head on the floor on 7/27/25.

Inspectors wroteThe facility failed to store, prepare, distribute and serve food in accordance with professional standards and facility policy for food service when: 1. An Ice machine was not cleaned per manufacturer's guidelines and facility policy. 2. Lunch meal foods were not handled and served safely under sanitary conditions during a trayline observation. 3. Coffee machine water filter was expired for more than 1.5 years. 4. Serving ladles and scoop handles were damaged and not maintained in food safe manner. 5. A Griddle top collection tray cup had black sticky grime, brown stains and food residue inside of it. 6. Curry powder seasoning was out of date and code. 7. Parsley was found to be discolored with a tannish brown color on the leaves and stems. These failures had the potential to cause widespread foodborne illness in the 61 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure needs were accommodated for 8 of 21 sampled residents (Resident 36, Residents 40, Resident 21, Resident 38, Resident 1, Resident 23, Resident 50, and Resident 39), when: 1. Residents 40, Resident 21, Resident 38, Resident 1, and Resident 39 call light did not work and were not provided alternative means to contact staff, and for Resident 23 and Resident 50 staff did not respond timely to calls made by Resident 23 and Resident 50 who were given and alternative means to contact staff; and 2. Resident 36's call light (device used to contact staff for assistance) was not within reach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks and two Dietary Aides did not use proper food safety and sanitation practices to prevent cross-contamination; and 2. Weekly thermometer temperature calibrations were not completed by kitchen staff per facility policy. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was served at an acceptable texture and palatability (taste) for six of six residents (Resident 12, Resident 55, Resident 22, Resident 26, Reisdent 16, and Resident 25) on a pureed (to blend, chop, mash, or strain a food until it reaches this soft consistency) diet when; 1. The cook did not follow a pureed recipe as written for the preparation of dilled zucchini and carrots; and 2. Pureed food items were not of correct texture and consistency. These failures had the potential to affect meal and food intake which could impair the nutrition status for the six residents on a pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received snack foods that met their preferences, including two unsampled residents (Resident 19 and Resident 63), based on facility policy. This failure had the potential to lead to decreased food intake which could impair the resident's nutrition and health status. The facility census was 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 61, when: 1. A used urinal (a container used to collect urine) in Resident 51's shared bathroom was not labeled with a resident identifier; and, 2. The shared glucometer (a device used to measure blood sugar) and blood pressure device (BP device, measures the pressure of blood pushing against the walls of arteries) were not cleaned and sanitized in-between resident care based on manufacturer's recommendation and standards of practice. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained in a safe, operating, and fully functioning manner, when a low-temperature dishwashing machine was not maintaining the correct wash temperature, per manufacturer specifications and facility policy. This failure had the potential to impact the ability of dietary staff to prepare and serve food in a safe and sanitary manner. The facility census was 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of twenty-one sampled residents (Resident 10) when: 1. Certified Nursing Assistant (CNA) 1 stood over Resident 10 while assisting him with his meals; and, 2. CNA 1 called residents feeders who needed assistance with meals. This failure resulted in Resident 10 not being provided with a respectful and dignified dining experience, which could further impact Resident 10's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the right for privacy of one of twenty-one sampled residents (Resident 45) when Resident 45 had no privacy curtains (cloth that separates residents and provides them with privacy). This failure had the potential to negatively impact Resident 45's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-one sampled residents (Resident 43) was assisted with nail care as a part of Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) when staff did not trim Resident 43's long, thick, and discolored toenails. This failure had the potential for Resident 43 to sustain injury and/or to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to one of twenty-one sampled residents (Resident 35) when physical therapy was discontinued and further services by Restorative Nursing Assistant were not provided. This failure had the potential to cause a decline in Resident 35's optimal level of function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 27) with an indwelling catheter (foley catheter-a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services consistent with professional standard of care, when Resident 27's urinary collection bag was not positioned lower than his bladder (body organ where urine is collected). This deficient practice had the potential to result in urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder, and urethra) for Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 61 residents when: 1. Staff's personal belongings were stored in one of two medication storage rooms; and, 2. Loose pills were found on the floor and at the bottom of the base cabinet in the medication storage room. These failures had the potential to contribute to unsafe medication storage and diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a diet in the correct texture to meet the needs of an unsampled resident, (Resident 19), according to facility policy. This failure had the potential to negatively impact Resident 19's food intake which could further impair nutrition status and lead to weight loss. The facility census was 61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs of two of twenty-one sampled residents (Resident 3 and Resident 36) accommodated when water pitchers were not available or empty at the bedside. These failures had the potential to result in potential health problems related to dehydration (A condition that occurs when the body loses too much water and other fluids that it needs to work normally.) for Resident 3 and Resident 36.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the usual body weight of one resident (Resident 28) who experienced an unplanned 19 pound (lb)/14.8% weight loss over 9 months. This had the potential of decreased immune function, decreased muscle mass, and loss of independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%) for three out of four sampled residents (Resident 50, Resident 23, and Resident 7) when: 1. Licensed Nurse (LN) 1 did not follow the physician's order in administering Resident 50's prescribed medication; 2. LN 2 administered Resident 23's prescribed medication with a wrong dosage (strength of a medication); and 3. LN 2 did not administer a prescribed medication for Resident 7 which was due as ordered. These failures resulted in three medication errors identified out of 30 opportunities during the observation of medication administration; the facility medication error rate was 10%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and properly stored in accordance with manufacturer guidelines, the facility's policies and procedures, and accepted professional principles for a census of 59 when: 1. Three loose pills and a medication bag with prescription label were found on the bottom of medication cart two; 2. A used insulin medication (a medication used to treat high blood glucose) vial (a glass container used for holding liquid medicines) was found in the medication cart two without a resident label; and, 3. An expired vial of an opened insulin medication was found in medication cart two. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food to accommodate resident allergies, intolerances, and preferences for three out of 59 residents (residents 3, 12, and 38). These failures had the potential for allergic reactions, food intolerance and weight loss for these three residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored and prepared under sanitary conditions for a census of 59 when: 1. Items stored in the reach-in-refrigerator and walk-in-freezer were not properly dated; 2. The can opener tip was found chipped and with brown markings; 3. The steam table-pans were stored wet as well as the blender; 4. Uncooked bacon stored over hard cooked eggs; and, 5. [NAME] streaks were observed running down the sides of the kitchen stove, which were also rusted. The pipes behind the kitchen stove were rusted and covered in a dark fuzzy substance. These failures had the potential to cause foodborne illness (illness caused by consuming contaminated food) to residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed follow and maintain an effective infection prevention and control program for a census of 59 when: 1. Residents' non-pharmaceutical personal belongings were found stored in the medication carts with pharmaceutical products; 2. Resident 38's used oxygen masks and tubing (used to deliver oxygen to patients who need supplemental oxygen) and nebulizer (device used to deliver medicine to lungs) masks were not properly stored; and, 3. There was an unsanitary condition in the laundry room. These failures had the potential to spread germs and cause infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat their residents with respect and dignity for one of 20 sampled residents when (Resident 8) was not dressed in her own clothing and was left in a hospital gown. This failure had the potential to impact Resident 8's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment tool) assessment was conducted for one of twenty sampled residents (Resident 57) when a discharge MDS assessment was not done for Resident 57. This failure resulted in Resident 57 to have an incomplete clinical record to reflect his condition upon discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication needs were met for two of twenty sampled residents (Resident 3 and Resident 327) when: 1. Resident 3's communication care plan was not followed; and 2. Resident 327 had no care plan for her communication needs. This failure had the potential to negatively impact these resident's ability to communicate their needs to the staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities were provided for Resident 29 and Resident 18 for a census of 59. These failures increased Resident 29 and Resident 18's risk for physical and psychosocial isolation.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 66) received necessary treatment to promote healing of her left heel wound when a treatment order was not initiated as ordered. This failure placed Resident 66 at increased risk for delayed wound healing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accurate pharmaceutical services when Resident 73's full antibiotic course was not fully administered. This failure had the potential for Resident 73's infection to not be fully treated or possibly get worse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary condition was maintained when there was pool of water and water damage in the laundry room, for a census of 59 residents. These failures increased the potential to cause major damage to the walls and ceiling and the growth of mold and bacteria.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for 1 of 3 sampled residents (Resident 1), when he eloped from the facility unaccompanied and when the Licensed Nurses (LNs) failed to check and document the wanderguard (a door alarming device placed on the ankle) placement consistently every shift as per the care plan. This failure placed Resident 1's life in danger when he left the facility unaccompanied and walked over a mile on a busy street to his friend's house.