Other·October 31, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00539614. Representing the Department of Public Health: HFEN, 36681 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F157 SS=D NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 12/15/2017 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555049 (X3) DATE SURVEY COMPLETED 11/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI NURSING & REHABILITATION 1334 S. Ham Lane Lodi, CA 95242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to notify the physician when there was a change in the discharge plan for 1 of 3 sampled residents (Resident 1). This failure had the potential to result in an unsafe discharge. Findings: Resident 1's diagnoses included bipolar disorder (a chronic mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly) and schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555049 (X3) DATE SURVEY COMPLETED 11/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI NURSING & REHABILITATION 1334 S. Ham Lane Lodi, CA 95242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE is real). A telephone order dated 6/6/17 indicated, "Please discharge resident home with Sister, HH RN [home health registered nurse], PT [physical therapy], OT [occupational therapy], ST [speech therapy], MSW [medical social worker] on 6/7/17..." A Social Services Note dated 6/7/17 indicated, "...resident was transported via facility provided transportation and discharged to [a local motel] room 5 with no HH services." Resident 1's clinical records did not indicate the physician was notified regarding the change in the discharge plan and there was no physician's order to discharge the resident to a facility with no medical care available. A telephone interview was conducted with the Social Service Director (SSD) on 8/9/17 at 1:30 p.m. The SSD stated she could not find any documentation of Resident 1's physician being notified of the changes in the discharge plan.

F201 SS=D REASONS FOR TRANSFER/DISCHARGE OF F201 RESIDENT CFR(s): 483.15(c)(1)(i)(ii) 12/15/2017 (c) Transfer and discharge (1) Facility requirements (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555049 (X3) DATE SURVEY COMPLETED 11/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI NURSING & REHABILITATION 1334 S. Ham Lane Lodi, CA 95242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555049 (X3) DATE SURVEY COMPLETED 11/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI NURSING & REHABILITATION 1334 S. Ham Lane Lodi, CA 95242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview, and document review, the facility failed to ensure the discharge plan was followed for 1 of 3 sampled residents (Resident 1). This failure increased the potential for an unsafe discharge. Findings: Resident 1's diagnoses included bipolar disorder (a chronic mental illness that causes dramatic shifts in a person's mood, energy and ability to think clearly) and schizophrenia (a mental disorder characterized by abnormal social behavior and failure to understand what is real). Resident 1's physician's order dated 6/6/17 indicated, "please discharge Resident home with Sister, HH RN [home health registered nurse], PT [physical therapist], OT [occupational therapy], ST [speech therapy], MSW [medical social worker] on 6/7/17..." A document titled "Notice of Transfer or Discharge" dated 6/5/17 indicated, "...(name of resident) will be transferred/discharged to Salvation Army, [Address], [City/State/Zip] on 6/7/17..." This documentation was not accurate as to where the resident was discharged. A Social Services Note dated 6/7/17 indicated, "...Resident was transported via facility provided transportation and discharged to [a local motel] 5 with no HH [home health] services..." A telephone interview with the Social Service Director (SSD) was conducted on 8/1/17 at 1:30 p.m. The SSD stated she personally informed the physician about Resident 1's change in the discharge plan the day after she was discharged from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555049 (X3) DATE SURVEY COMPLETED 11/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI NURSING & REHABILITATION 1334 S. Ham Lane Lodi, CA 95242 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A policy titled "Notice of Transfer and Discharge" dated 07/2012 indicated, "...2. A transfer or discharge notice will include the following:...c. The location to which the resident is transferred or discharged..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NVRA11 Facility ID: CA030000040 If continuation sheet 6 of 6