Cycle 1
Health 2025-01-16 · Fire 2025-01-16
14 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Lodi, CA
Fairmont Rehabilitation Hospital
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
950 S. Fairmont Avenue, Lodi, CA
(209) 368-0693
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing
LPN hours / resident day
1.49
Licensed practical nurse staffing
Aide hours / resident day
2.67
Nurse aide staffing
Weekend hours
4.10
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.3
1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
1.6%
3.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 13.0% |
6.8%
6.2 pts worse
|
11.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
13.7%
6.9 pts worse
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
14.2%
6.5 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.5% |
11.0%
2.5 pts worse
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
10.7%
3.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.0%
About the same
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
10.9%
15.8 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.7%
2.1 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.0%
5.7 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.2%
4.8 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
93.2%
5.5 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
23.2%
10.6 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-12 · Fire 2024-01-12
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-16
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-12
C · Minimal harm
2025-01-16
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-02-12
C · Minimal harm
2025-01-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-12
C · Minimal harm
2025-01-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-12
C · Minimal harm
2025-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-12
F · Potential for more than minimal harm
2024-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-05
F · Potential for more than minimal harm
2024-01-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-05
F · Potential for more than minimal harm
2024-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-05
F · Potential for more than minimal harm
2024-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-05
E · Potential for more than minimal harm
2024-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-12
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-05
E · Potential for more than minimal harm
2022-04-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-03
E · Potential for more than minimal harm
2022-04-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2026-01-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Not marked corrected
F · Potential for more than minimal harm
2025-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-08
D · Potential for more than minimal harm
2025-06-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-05-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-01-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-02
E · Potential for more than minimal harm
2024-01-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-02
E · Potential for more than minimal harm
2024-01-12
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-02
F · Potential for more than minimal harm
2022-04-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-04
E · Potential for more than minimal harm
2022-04-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-04
E · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-04
D · Potential for more than minimal harm
2022-04-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-04
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Buhari, Shiraz
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Monette, Cory
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Tu, Randy
Operational/Managerial Control · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
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Lodi Nursing & Rehabilitation
Lodi, CA
4-star overall rating with 3-star inspections with 17 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Arbor Rehabilitation & Nursing Center
Lodi, CA
2-star overall rating with 2-star inspections with 21 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Vienna Nursing And Rehabilitation Center
Lodi, CA
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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