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The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 August 2026) and official state health department websites.