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
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
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
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.56
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.49
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.72
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.10
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
2,735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0017
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.03
Baseline 20.82% · Performance 20.49% · Measure score 2.03 · Achievement 2.03 · Improvement 0.36
Healthcare-associated infections
4.23
Baseline 5.91% · Performance 6.57% · Measure score 4.23 · Achievement 4.23 · Improvement 0
Total nurse turnover
9.08
Baseline 47.22% · Performance 26.56% · Measure score 9.08 · Achievement 9.08 · Improvement 8.74
Adjusted total nurse staffing
3.89
Baseline 4.68 hours · Performance 4.18 hours · Measure score 3.89 · Achievement 3.89 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.4% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 318 · Observed rate 10.69% · Lower 95% interval 9.18% |
| Discharge to community | 62.09% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 337 · Observed rate 58.75% · Lower 95% interval 56.85% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.52% |
95.27%
4.2 pts better
|
Numerator 208 · Denominator 209 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 209 |
| Discharge self-care score | 57.76% |
53.69%
4.1 pts better
|
Numerator 93 · Denominator 161 |
| Discharge mobility score | 47.2% |
50.94%
3.7 pts worse
|
Numerator 76 · Denominator 161 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 209 · Adjusted rate 0.84% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 5.74% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 7.94% |
8.2%
0.3 pts worse
|
Numerator 10 · Denominator 126 |
| Staff flu vaccination coverage | 68.09% |
42%
26.1 pts better
|
Numerator 96 · Denominator 141 |
| Discharge function score | 52.8% |
56.45%
3.7 pts worse
|
Numerator 85 · Denominator 161 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 178 · Denominator 178 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.93% |
25.2%
16.3 pts worse
|
Numerator 10 · Denominator 112 |
Quality measures
| 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 · Adjusted 1.3 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| 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 · Adjusted 1.5 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 0.0% · Q2 3.2% · Q3 6.5% · Q4 9.1% · 4Q avg 4.9% · Used in QM five-star |
| 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 · Q1 11.5% · Q2 16.7% · Q3 6.9% · Q4 16.7% · 4Q avg 13.0% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 3.8% · 4Q avg 2.1% |
| 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 · Q1 16.0% · Q2 16.0% · Q3 23.1% · Q4 26.9% · 4Q avg 20.6% |
| 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 · Q3 4.8% · Q4 0.0% · 4Q avg 7.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 13.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 11.5% · Q4 16.0% · 4Q avg 7.1% · Used in QM five-star |
| 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 · Q1 4.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 36.1% · Q2 21.3% · Q3 21.2% · Q4 29.0% · 4Q avg 26.7% |
| 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 · Q1 4.3% · Q2 7.2% · Q3 6.8% · Q4 8.5% · 4Q avg 6.8% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 99.3% · Q3 100.0% · Q4 99.4% · 4Q avg 99.7% |
| 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 · Adjusted 16.0% · Observed 14.8% · Expected 10.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · Used in QM five-star |
| 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 · 4Q avg 98.7% |
| 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 · Adjusted 12.6% · Observed 11.5% · Expected 21.8% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-12
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-02-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-12
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-12
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-02-12
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-05
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-02-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-05
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-03
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-03
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-05-03
Fire Safety
Develop a communication plan.
Corrected 2022-05-03
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-05-03
Fire Safety
Establish methods for sharing information.
Corrected 2022-05-03
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-05-03
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-05-03
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-05-03
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-05-03
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-05-03
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-05-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-03
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-05-03
Inspection history
Health
Respond appropriately to all alleged violations.
Not marked corrected
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
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-14
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
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
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-14
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
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-14
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-14
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
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
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-14
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-02
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
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-02-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-02
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-04
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-04
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-04
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
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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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