Health inspection·September 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated .Resident noted with aggressive behavior towards another resident. Event was unwitnessed by staff. Residents were immediately separated. [Resident 2] was noted as the aggressor and sustained no injury .Per [Resident 1], [Resident 2] entered bathroom and grabbed arm . A review of Resident 2's Care Plan, initiated 2/28/24, indicated .Focus . Resident is making statements that this is her house .Interventions . Approach in a calm manner .Do not force resident to comply against his/her wishes . A review of Resident 2's Care Plan, initiated 9/18/24, indicated .Focus .Altercation .Interventions .Will redirect and remind resident that this facility is a home for all residents . During an interview on 9/20/24 at 11:27 a.m. with the Administrator (ADM) and the Infection Preventionist (IP), the ADM stated an unwitnessed incident occurred between Resident 1 and Resident 2 on 9/18/24. The ADM stated Resident 1 and Resident 2 were not in the same room but did share an adjoining bathroom. The ADM stated Resident 1 was in the bathroom and was scratched by Resident 2. The ADM stated Resident 2 thinks people are in her space and house and did not like that Resident 1 was in her space. Resident 1 had a scratch on left upper arm. During a concurrent observation and interview on 9/20/24 at 11:48 a.m. with Resident 1, observed an approximately one-inch red scratch on Resident 1's left upper arm. Resident 1 stated yesterday or the day before a man came into the bathroom when she was washing her hands or on the way out. Resident 1 stated, He grabbed my arm, said I couldn't use the bathroom, that it was his bathroom only. Resident 1 stated, Told them to let go. Resident 1 stated her arm bled at the time. Resident 1 stated, Felt violated in my own space. During an interview on 9/20/24 at 11:58 a.m. with Resident 2, Resident 2 stated, Know I own the place. Resident 2 stated she was in the bathroom; someone came in and wanted to kill her. Resident 2 stated, Don't like people doing things to harm me. I bought this home. No one else is supposed to use the bathroom. Don't remember grabbing anyone's arm. During an interview on 9/20/24 at 12:04 p.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated Resident 2 thinks she owns the whole place and doesn't like anyone in her room. CNA 1 stated that they have to get Resident 2's permission to have someone else in her room. During an interview on 9/20/24 at 12:11 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 scratched Resident 1's left arm on 9/18/24. LN 1 stated Resident 2 does not like anyone in her room and Resident 1 in the bathroom may have set her off. During a telephone interview on 9/20/24 at 12:30 p.m. with LN 2, LN 2 stated she was notified of the incident between Resident 1 and Resident 2 on 9/18/24. LN 2 stated Resident 1 had a scratch on left upper arm. LN 2 stated Resident 2 has dementia and believed she was in her own house and believed that Resident 1 was in her house unannounced. During a telephone interview on 9/20/24 at 12:42 p.m. with CNA 2, CNA 2 stated she heard commotion in Resident 1's room on 9/18/24. CNA 2 entered the adjoining bathroom, Resident 1 and Resident 2 were slapping at each others arms. CNA 2 stated Resident 2 was telling Resident 1, Get out of my house. CNA 2 stated Resident 2 does not want to share a bathroom. CNA 2 stated Resident 1 had a bleeding scratch on her arm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055289 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lodi Creek Post Acute 321 West Turner Road Lodi, CA 95240 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes but is not limited to freedom from physical abuse .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objective .Protect residents from abuse .by anyone including .other residents . Residents Affected - Few A review of the facility's P&P titled Resident-to-Resident Altercations, revised 9/22, indicated .All altercation, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Behaviors that may provoke a reaction by residents or others include .wandering into others rooms/space . A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 4/21, .All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies .and thoroughly investigated by facility management . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055289 If continuation sheet Page 3 of 3