Other·November 15, 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 #CA00617856. Representing the Department of Public Health: HFEN, 40401 HFEN, 36738 HFEN, 39797 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 11/21/2019 §483.10(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 (D) A decision to transfer or discharge the resident from the facility as specified in 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: XM8J11 Facility ID: CA030000040 If continuation sheet 1 of 16 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 11/08/2019 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 §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). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure appropriate notification was provided for 1 of 3 sampled residents (Resident 1), when: 1) Resident 1's Physician was not notified of Resident 1's elevated blood sugars, which were above 180 for 9 days (from 11/11/18 11/19/18), in order to obtain treatment orders; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 2 of 16 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 11/08/2019 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 2) Resident 1's responsible party (RP) was not notified immediately when Resident 1 had a fall with injuries. These failures resulted in a lack of treatment for Resident 1's elevated blood sugars, that ranged from 198 to 430 for 9 days, which led to Resident 1 experiencing symptoms of confusion with the potential for worsening symptoms of hyperglycemia. Resident 1's responsible party was not notified timely of a fall with injuries which resulted in the responsible party not being informed in order to make choices for further treatment and care. Findings: 1) According to an undated Hospice Service Agency (HA 1) document titled, "[HA 1] Hospice Care Services," Resident 1 was admitted to the facility on 11/10/18 with diagnoses which included Alzheimer's Disease (an illness that impairs memory and functioning), Diabetes (a disease where the body is unable to properly use sugars), and repeated falls. Review of Resident 1's Minimum Data Set (an assessment tool), dated 11/16/18, indicated Resident 1 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS, a tool to measure cognitive capacity) score of 11 (on a scale from 0 to 15, with 0 being the lowest and 15 being the highest). Review of Resident 1's HA 1 "Plan of Care," dated 11/10/18, indicated a Diabetes treatment plan for, "Optimal blood sugar management for pt.[patient] comfort." The interventions included, "Monitor/assess effectiveness of current and new medication/treatment..." Review of Resident 1's facility medical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 3 of 16 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 11/08/2019 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 indicated a Physician's Order, dated 11/10/18, for NPH Insulin (a glucose [blood sugar] lowering medication), 25 units, once daily; it specified it was not to be given if the resident's blood sugar was under 100, but did not list instructions for elevated blood sugars or a sliding scale (an individualized scale ordered by a Physician to indicate how much insulin should be given for specific blood sugars). Review of an HA 1 document titled, "Staff Care Coordination," dated 11/10/18, indicated the facility was "...instructed to call [HA 1] 24/7 [24 hours a day/7 days a week] for change of condition, refill, concerns." Review of Resident 1's Nursing Care Plan, dated 11/10/18, indicated, "Facility staff will cowork & closely communicate with hospice staff in order to provide comfort care for the resident..." Review of Resident 1's Nursing Care Plan, dated 11/10/18, indicated, "At risk for hypoglycemia [low blood sugar] and hyperglycemia [high blood sugar]...Observe/report signs and symptoms of hypoglycemia...hyperglycemia...to MD [Medical Doctor] promptly...Report unstable and fluctuating blood sugar to MD promptly." According to the American Diabetes Association, it suggests the following target ranges (normal ranges) for nonpregnant adults with diabetes, "Before a meal: 80-130 mg/dl [mg/dl, or milligrams per deciliter, is a measurement that indicates the amount of a particular substance (such as glucose) in a specific amount of blood]" and "1-2 hours after the beginning of the meal: less than 180 mg/dl'. (Retrieved 10/25/19 from the ADA website: https://www.diabetes.org/diabetes/medicationFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 4 of 16 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 11/08/2019 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 management/blood-glucose-testing-andcontrol/checking-your-blood-glucose). Review of Resident 1's clinical record indicated the following blood sugars: - 205 on 11/11/18 at 8:00 a.m. - 234 on 11/12/18 at 8:00 a.m. - 333 on 11/13/18 at 8:00 a.m. - 198 on 11/14/18 at 8:00 a.m. - 347 on 11/15/18 at 8:00 a.m. - 398 on 11/16/18 at 8:00 a.m. - 350 on 11/17/18 at 8:00 a.m. - 400 on 11/18/18 at 8:00 a.m. - 378 on 11/19/18 at 8:00 a.m. - 430 on 11/19/18 at 1:30 a.m. - 430 on 11/19/18 at 1:46 a.m. According to the Mayo Clinic (2018), "...Several factors can contribute to hyperglycemia in people with diabetes, including...not taking enough glucose-lowering medication...It's important to treat hyperglycemia because if left untreated, hyperglycemia can become severe and lead to serious complications requiring emergency care...hyperglycemia, even if not severe, can lead to complications affecting your...heart...Hyperglycemia doesn't cause symptoms until glucose values are significantly elevated -- usually above 180 to 200 milligrams per deciliter [mg/dL, a unit of measurement]." Early signs and symptoms of hyperglycemia include frequent urination, increased thirst, blurred vision, fatigue, and headache. Late signs and symptoms include fruity breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion, coma, and abdominal pain. "Make an appointment with your doctor if...Your blood glucose is more than 240 mg/dL...even though you've taken your diabetes medication...Monitor your blood sugar...Careful monitoring is the only way to make sure that your blood sugar level remains within your target range" (Retrieved 6/20/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 5 of 16 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 11/08/2019 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 from the Mayo Clinic website: https://www.mayoclinic.org/diseasesconditions/hyperglycemia/symptomscauses/syc-20373631). Review of Resident 1's facility medical record indicated there were no Physician's Orders to perform blood sugar checks. Review of Resident 1's facility "Progress Notes," indicated a Nurses Note dated 11/18/18 at 6:04 p.m., which indicated Resident 1 was "not feeling to[sic] well...showing signs of disorientation as she attempts to get up unassisted multiple times and inability to make up mind when asked to make minute decisions..." Review of a facility "Incident Report," dated 11/19/18, indicated Resident 1 experienced an unwitnessed fall at 1:00 a.m. when trying to use the bathroom. Review of Resident 1's facility "Progress Notes," indicated a Nurses Note dated 11/19/18 at 1:46 a.m., which indicated Resident 1 experienced a fall and "...looks a little bit confused, and she was sweating. Check on her Blood sugar it was 430 and it was check twice [sic]...." Resident 1's "Post Fall Assessment," dated 11/19/18, indicated Resident 1 obtained a 4x2 cm contusion to the back of her head with 5/10 pain. The document indicated Resident 1's physician was notified of the fall at 3:20 a.m. on 11/19/18, but the "New Orders Received" box was left blank on the form. Review of Resident 1's medical record indicated no new Physician's treatment orders were written after Resident 1's fall on 11/19/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 6 of 16 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 11/08/2019 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 Review of a facility "Progress Note" dated 11/19/18 at 5:54 a.m., indicated Resident 1 was "still with pain at the back of her head..." Review of a facility "Progress Note" dated 11/19/18 at 2:05 p.m., indicated, "Resident is alert and responsive with episodes of confusion noted..." Review of a facility "Progress Note" dated 11/19/18 at 9:38 p.m., indicated Resident 1 was non-responsive during care and was "stoic with blank stare." Review of a facility "Progress Note" dated 11/20/18 at 5:09 a.m., indicated Resident 1 became unresponsive and was transported to the hospital. Review of an Emergency Department Physician (EDP) Note dated 11/20/18, indicated, "Patient...brought in from [facility] in cardiac arrest. She apparently fell...and was later found unresponsive...Disposition: Time 11/20/2018 05:50:00 [5:50 a.m.], Expired [died]." Review of Resident 1's clinical record indicated there was no evidence the facility contacted Resident 1's physician regarding Resident 1's elevated blood sugar levels until post-fall on 11/19/18; there was also no evidence the facility contacted the HA 1 regarding Resident 1's elevated blood sugar levels from 11/11/18 until post-fall on 11/19/18. During an interview with the Director of Nursing (DON) on 2/21/19 at 4:20 p.m., the DON reported, in response to the 11/18/18 Progress Note, the facility nurse should have monitored Resident 1 and called the hospice agency. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 7 of 16 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 11/08/2019 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 During a subsequent interview on 3/12/19 at 9:51 a.m., the DON confirmed disorientation and feeling unwell could be symptoms of hyperglycemia, and stated hyperglycemia should be reported if symptomatic. During an interview with the Licensed Hospice Nurse 1 (LHN 1) on 3/15/19 at 2:05 p.m., the LHN 1 stated she provided the facility with Resident 1's medication list for reconciliation. She reported she was not notified by the facility that Resident 1's insulin dosage was reduced from twice to once daily. The LHN 1 stated the target was to keep Resident 1's blood sugar below 200. She confirmed that disorientation and feeling unwell, as reported in the 11/18/18 Progress Note, could have been symptoms of hyperglycemia and stated the HA 1 should have been contacted if symptoms were present. The LHN 1 reported she did not receive any calls regarding Resident 1's hyperglycemia from the facility on 11/18/18. During an interview with the DON on 9/18/19 at 4:29 p.m., the DON confirmed there were no new Physician's Orders for treatment obtained for Resident 1 between the time of the fall on 11/19/18 and the order for transport to the hospital on 11/20/18. During an interview with the MD 1 on 9/18/19 at 4:40 p.m., the MD 1 stated he usually adjusts the insulin dosage for blood sugars of 400 or 500. The MD 1 stated staff should notify the MD of consistently elevated blood sugars, and should "definitely" notify the MD if blood sugars are over 300 for 3 or 4 days. The MD 1 explained the facility maintains the documentation regarding MD notifications, and stated if the facility does not have documentation that he was informed of Resident 1's elevated blood glucoses, then he does not believe any notification occurred. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 8 of 16 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 11/08/2019 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 Review of a fax correspondence from the DON, dated 9/19/19 at 4:38 p.m., indicated the facility did not have any documentation of "conversations with MD regarding blood sugar." Review of a facility policy titled, "Change in a Resident's condition or Status," revised May 2017, indicated, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status...The nurse will notify the resident's Attending Physician or physician on call when there has been a...need to alter the resident's medical treatment significantly..." Review of a facility policy titled, "Nursing Care of the Resident with Diabetes Mellitus," revised December 2015, indicated the policy's purpose was to "prevent recurrent hyperglycemia..." The policy indicated symptoms of hyperglycemia may include restlessness and increased urination. It defined blood sugar reference ranges as 80-130 before meals and less than 180 after meals, and indicated "Hyperglycemia is considered anything above target reference ranges...The nurse will closely monitor the diabetes management of cognitively impaired residents." Review of a facility policy titled, "Hospice Program," revised July 2017, indicated, "...it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include...Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 9 of 16 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 11/08/2019 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 care...Notifying the hospice about the following...Clinical complications that suggest a need to alter the plan of care..." 2) Review of a facility "Incident Report," dated 11/19/18, indicated Resident 1 experienced an unwitnessed fall at 1:00 a.m. when trying to use the bathroom. Review of Resident 1's "Post Fall Assessment," dated 11/19/18, indicated Resident 1 obtained a 4x2 centimeters (a unit of measurement) contusion to the back of her head with 5/10 pain (on a numeric rating scale where 0 is no pain and 10 is the worst pain). A review of Resident 1's facility "Progress Notes" indicated Resident 1's RP was notified of the fall on 11/19/18 at 5:54 a.m. During an interview with the DON on 3/12/19 at 9:51 a.m., the DON stated the fall occurred on 11/19/18 at 12:45 a.m. resulting in a 4x2 cm contusion to Resident 1's head. The DON confirmed the RP wasn't notified until 5:54 a.m. Review of a facility policy titled, "Change in a Resident's Condition or Status," dated May 2017, indicated, "Our facility shall promptly notify the...[resident's] representative...of changes in the resident's medical/mental condition and/or status...a nurse will notify the resident's representative when...the resident is involved in any accident or incident that results in an injury..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/21/2019 §483.25(d) Accidents. The facility must ensure that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 10 of 16 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 11/08/2019 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 §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facilty failed to ensure the health and safety of 1 of 66 residents (Resident 1) when Resident 1 was not screened for the use of 'Devices' or 'Side Rails' on admission, per facility policy. This failure had the potential for Resident 1 to experience a fall or injury. Findings: According to an undated Hospice Agency 1 (HA 1) document titled, "[Agency Name] Hospice Care Services," Resident 1 was admitted from home to the facility on 11/10/18 with diagnoses which included Diabetes, Alzheimer's Disease (an illness that impairs cognitive function), and repeated falls. Review of a facility document titled, "Side Rails Screening Tool," dated 11/10/18, indicated no reasons, benefits, risks, family education, or recommendations for the use of side rails; or signatures of completion were listed. Review of a facility document titled, "Device Evaluation Tool," dated 11/10/18, indicated no devices, benefits, risks, recommendations, or signatures of completion were listed. During an interview with the Director of Nursing (DON) on 2/21/19 at 4:20 p.m., the DON confirmed the "Side Rails Screening Tool" and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 11 of 16 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 11/08/2019 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 "Device Evaluation Tool" were not completed for Resident 1. During an interview with the DON on 4/10/19 at 9:36 a.m., the DON verified residents should be screened for the use of side rails and devices on admission per facility policy. Review of a facility policy titled, "Side Rail Screening," dated June 2017, indicated, "The resident will be screened for the use of side rail (s) by the Licensed Nurse on admission...to identify behavior(s) that affects the patient's/resident's mobility and safety which includes constant body movement, unsafe behavior getting in and out of bed unassisted." Review of a facility policy titled, "Device Evaluation," dated June 2017, indicated, "The resident will be screened for the use of device by the Licensed Nurse on admission...to identify behavior(s) that affects the patient's/resident's safety." The policy listed examples of possible safety devices including alarms and seatbelts to remind residents not to get up unassisted, and low beds and floor mats to reduce the impact of falls.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 11/21/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 12 of 16 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 11/08/2019 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 facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 13 of 16 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 11/08/2019 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 (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to maintain accurate medical records for 1 of 66 Residents (Resident 1), when 2 administered medications were not documented on the Medication Administration Record (MAR). This failure had the potential to result in medication errors. Findings: According to an undated Hospice Agency 1 (HA 1) document titled, "[HA 1] Hospice Care Services," Resident 1 was admitted to the facility in Fall 2018 with diagnoses which included Alzheimer's Disease (an illness that impairs memory and functioning), Diabetes (a disease that impairs the body's ability to process sugars), and repeated falls. Review of Resident 1's clinical record indicated: - A Physician's Order, dated 11/10/18, for Morphine Sulfate (narcotic pain medication) 0.25 milliliters (ml, a unit of measurement) every 4 hours as needed for breakthrough pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 14 of 16 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 11/08/2019 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 or shortness of breath; and - A Physician's Order, dated 11/10/18, for Tylenol 325 milligrams (mg, a unit of measurement), 2 tablets every 8 hours as needed for pain or fever. Review of an HA 1 "Visit Note," dated 11/19/18, indicated Resident 1 "...was medicated with Morphine" for 4 out of 10 pain after falling. Review of Resident 1's facility "Progress Notes," indicated a Nurses Note dated 11/19/18 at 2:05 p.m. which indicated Resident 1 complained of 2/10 pain (on a numeric pain scale where 0 is no pain and 10 is the worst pain) and Tylenol was given "with good effect." Review of Resident 1's "Medication Administration Record" (MAR) for November 2018, indicated Morphine and Tylenol were listed, but no administrations were documented. During an interview with the Director of Nursing (DON) on 3/12/19 at 9:51 a.m., the DON confirmed Tylenol and Morphine were given to Resident 1 per the Progress Notes and were not listed on the MAR. Review of the facility policy titled, "Administering Medications," revised December 2012, indicated, "The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XM8J11 Facility ID: CA030000040 If continuation sheet 15 of 16 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 11/08/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: XM8J11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000040 (X5) COMPLETE DATE If continuation sheet 16 of 16