Other·January 6, 2020

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 facility reported incident #CA00571529. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 29825 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 12/20/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: 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: JU4T11 Facility ID: CA030000040 If continuation sheet 1 of 7 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 12/13/2019 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 Based on interview and facility document review, the facility failed to follow their policy and procedure to prevent abuse when a staff member was not suspended immediately following an incident of alleged abuse towards 1 of 3 sampled residents (Resident 1). This failure potentially increased the risk for further harm to residents. Resident 1 was admitted to the facility with multiple diagnoses which included dementia (decline in memory, cognition, and decision making that interferes with ability to complete the activities of daily living), depression and a psychiatric disorder with mood swings. Resident 1's quarterly MDS (Minimum Data Set, an assessment tool), dated 1/18/18, indicated his cognition was severely impaired and he required limited to extensive assistance with his ADL's (Activities of Daily Living). There were no behaviors documented in the 7 day look back period. On 1/30/18 at 11:40 a.m., the Director of Staff Development (DSD) notified the Department of the alleged abuse. On 2/2/18 following an internal investigation, the Administrator notified the Department the allegation was substantiated and Certified Nurses Aid 3 (CNA 3) was terminated. Review of a letter, dated 2/7/18, sent to CNA 3 "RE: Termination of Employment" indicated, "...there has been an investigation regarding an incident between you and a resident [Resident 1] that occurred on 1/27/18 and 1/29/18. Through our investigation, this allegation was substantiated to have occurred...As a result, your employment is being terminated, effective immediately, February 7, 2018..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JU4T11 Facility ID: CA030000040 If continuation sheet 2 of 7 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 12/13/2019 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 an interview with the Director of Staff Development (DSD) on 2/13/18 at 11:40 a.m., she said "We have zero tolerance policy toward abuse. All staff have been educated to report abuse immediately." She verified 2 days passed before the alleged abuse was reported. During an interview on 2/13/18 at 11:43 a.m., with the Activities Assistant (AA), described the incidence which occurred on Saturday [1/27/18] around 8 a.m. "[Resident 1] said bad words [in Spanish] to the CNA [CNA 3, who was Spanish speaking]. She repeated the same words [back at him]. He stood up and acted like he was going to hit her and she put her hand back like she would hit him...She was mad...[CNA 3] worked Monday [1/29/18] and I overheard her say, 'No one cares about you. You have no family. That's why you're here.' I wasn't sure I should report it Saturday but when I felt she spoke down to him on Monday, I went to ask..." During an interview with the Administrator on 2/16/18 at 10:45 a.m., he said, "As soon as we became aware, we suspended her...We weren't aware [of the 1/27/18 incident] until Monday [1/29/18]." Review of the facility policy and procedure titled, ABUSE PREVENTION, revised 1/2013, indicated "IDENTIFICATION OF ABUSE 1. All alleged violations...are reported immediately to the administrator of the facility and to the officials in accordance with State law through established procedures...PROTECTION...2. If the suspected perpetrator is an employee: a. Remove employee immediately from the care or vicinity of the resident; b. Suspend employee during the investigation...REPORTING...2. First responder or staff member aware of suspected abuse incident will be responsible for informing immediate supervisor and initiating incident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JU4T11 Facility ID: CA030000040 If continuation sheet 3 of 7 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 12/13/2019 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 report..."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/20/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JU4T11 Facility ID: CA030000040 If continuation sheet 4 of 7 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 12/13/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to report alleged abuse immediately, or within 24 hours, when 1 of 3 sampled residents (Resident 1) was cursed at and verbally belittled on 2 different days before it was reported. This failure increased the potential risk for additional resident abuse. Findings: Resident 1 was admitted to the facility with multiple diagnoses which included dementia (decline in memory, cognition, and decision making that interferes with ability to complete the activities of daily living), depression and a psychiatric disorder with mood swings. Resident 1's quarterly MDS (Minimum Data Set, an assessment tool), dated 1/18/18, indicated his cognition was severely impaired and he required limited to extensive assistance with his ADL's (Activities of Daily Living). There were no behaviors documented in the 7 day look back period. On 1/30/18 at 11:40 a.m., the Director of Staff Development (DSD) notified the Department of the alleged abuse. On 2/2/18 following an internal investigation, the Administrator notified the Department the allegation was substantiated and Certified Nurses Aid 3 (CNA 3) was terminated. Review of a letter, dated 2/7/18, sent to CNA 3 "RE: Termination of Employment" indicated, "...there has been an investigation regarding an incident between you and a resident [Resident 1] that occurred on 1/27/18 and 1/29/18. Through our investigation, this allegation was substantiated to have occurred...As a result, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JU4T11 Facility ID: CA030000040 If continuation sheet 5 of 7 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 12/13/2019 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 your employment is being terminated, effective immediately, February 7, 2018..." During an interview with the DSD on 2/13/18 at 11:40 a.m., she said, "We have zero tolerance policy toward abuse. All staff have been educated to report abuse immediately." She verified 2 days passed before the alleged abuse was reported. During an interview on 2/13/18 at 11:43 a.m., with the Activities Assistant (AA), she said that on Saturday [1/27/18] around 8 a.m., "[Resident 1] said bad words [in Spanish] to the CNA [CNA 3, who was Spanish speaking]. She repeated the same words [back at him]. He stood up and acted like he was going to hit her and she put her hand back like she would hit him...She was mad...[CNA 3] worked Monday [1/29/18] and I overheard her say, 'No one cares about you. You have no family. That's why you're here.' I wasn't sure I should report it Saturday [1/27/18] but when I felt she [CNA 3] spoke down to him on Monday [1/29/18], I went to ask..." During an interview with the Administrator on 2/16/18 at 10:45 a.m., he said, "Per our policy, alleged abuse should be reported within 24 hours. [AA] came to me Monday afternoon [1/29/18]. It was 2 days before she reported it." Review of the facility policy and procedure titled, ABUSE PREVENTION, revised 1/2013, indicated, "IDENTIFICATION OF ABUSE 1. All alleged violations...are reported immediately to the administrator of the facility and to the officials in accordance with State law through established procedures...REPORTING...2. First responder or staff member aware of suspected abuse incident will be responsible for informing immediate supervisor and initiating incident report..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JU4T11 Facility ID: CA030000040 If continuation sheet 6 of 7 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 12/13/2019 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: JU4T11 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 7 of 7