Health inspection·May 8, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge notice for residents with Medi-Cal coverage because it was already discussed through the care conference meetings with the residents. The CM further stated Resident 1 received the Notice of Transfer or Discharge notice on 3/8/25 as part of the discharge paperwork. The CM stated the Notice of Transfer or Discharge would include the reason for discharge and resources on their right to file an appeal. Both the SSD and the CM confirmed Resident 1's Notice of Transfer or Discharge had a notification date of 3/4/25 but was signed by Resident 1 on 3/8/25. 2. During an interview on 5/8/25, at 9:43 a.m., with Resident 1, Resident 1 stated he called the Ombudsman's office on 3/8/25 when the facility was trying to discharge him and was told by the Ombudsman their office did not receive a copy of Resident 1's Notice of Transfer or Discharge. During an interview on 5/8/25, at 11:36 a.m., with the Ombudsman (OMB), the OMB stated Resident 1 called the Ombudsman's office on the after-hours line late in the afternoon on 3/8/25 to report the facility was discharging him. The OMB confirmed the Ombudsman's office did not receive Resident 1's Notice of Discharge or Transfer from the facility. The OMB stated their office usually received a 30-day notice prior to discharge from the facility so that the residents would be notified of their right to appeal and to have enough time to make arrangements for discharge. During a concurrent joint interview and record review on 5/8/25, at 12:42 p.m., with the SSD and the CM, the CM stated the Notice of Transfer or Discharge notice would be sent over to the Ombudsman's office on the discharge date via fax. The CM further stated Resident 1's Notice of Transfer or Discharge was not sent to the Ombudsman's office because the discharge did not happen. The CM stated the expectation was to send the Notice of Transfer or Discharge to the Ombudsman's office on the day of Resident 1's discharge. During an interview on 5/8/25, at 1:38 p.m., with the ADON, the ADON stated the Notice of Transfer or Discharge was usually sent out to the Ombudsman's office via fax on the day of resident's discharge. The ADON stated that the importance of sending Resident 1's Notice of Transfer or Discharge to the Ombudsman's office was for the Ombudsman to be aware that Resident 1 was discharging to the community and if there were follow-ups needed to be done on their end. 3. A review of Resident 1's medical record titled, Notice of Transfer/Discharge, indicated a notification date of 3/4/25 and was signed by Resident 1 on 3/8/25, with a discharge Transfer or Discharge location to [Name of Homeless Shelter 1]. A review of Resident 1's doctor's order, dated 2/27/25, indicated .MAY DISCHARGE TO [Name of Homeless Shelter 2] 03/08/25 WITH HOME HEALTH, RN, PT, OT, STANDARD WHEELCHAIR AND 7 DAYS MEDICATION SUPPLY . During an interview on 5/8/25, at 9:43 a.m., with Resident 1, Resident 1 stated that he was homeless and previously lived at Homeless Shelter 1 prior to being hospitalized . Resident 1 stated the facility planned the discharge on the discharge paperwork on 3/8/25 to be discharged to Homeless Shelter 2. During a concurrent interview and record review on 5/8/25, at 10:39 a.m., with the Licensed Nurse (LN), LN reviewed Resident 1's chart and confirmed Resident 1's discharge location was at Homeless Shelter 2. During an interview on 5/8/25, at 11:36 a.m., with the Ombudsman (OMB), the OMB stated she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055289 If continuation sheet Page 2 of 4 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 05/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few familiar with Homeless Shelter 2 and was told by the facility's SSD that Resident 1 was being discharged to a homeless shelter where he was originally from. The OMB further stated residents should not be discharged to a homeless shelter because the beds were not guaranteed. During a concurrent joint interview and record review on 5/8/25, at 12:42 p.m., with the SSD and the CM, Resident 1's Notice of Transfer or Discharge and discharge order were reviewed. The SSD and CM both confirmed that the discharge order dated 2/27/25 for Homeless Shelter 2 did not match the location listed on Resident 1's Notice of Transfer or Discharge. The SSD and CM both stated the discharge order location and Notice of Transfer or Discharge location should have matched. The SSD and the CM explained they were both responsible in ensuring the discharge orders and Notice of Transfer or Discharge matched. During a concurrent interview and record review on 5/8/25, at 1:38 p.m., with the ADON, the ADON reviewed Resident 1's discharge order dated 2/27/25 and Resident 1's Notice of Transfer or Discharge form. The ADON confirmed the discharge locations did not match and stated staff were expected to ensure that both locations listed matched. During an interview on 5/8/25, at 3:02 p.m., with the Administrator (ADM), the ADM stated it was his expectation for the facility staff to follow the facility's policy when providing residents with the Notice of Transfer or Discharge. The ADM stated that it was important to provide the Notice of Discharge or Transfer to Resident 1 to provide information on Resident 1's right on how to appeal the discharge. A review of the facility's policy titled, Transfer of Discharge, Facility-Initiated, dated 10/22, indicated .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer or Discharge (Planned) .1. Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .Notice of Transfer or Discharge (Emergent or Therapeutic Leave) .2. The resident and representative are notified in writing of the following information .The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged .3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .5. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge .b. The resident's health improves sufficiently to allow a more immediate transfer or discharge .6. Notice of transfer is provided to the resident and representative as soon as possible before the transfer and to the long-term care (LTC) ombudsman when practicable . A review of an online document published by the California Advocates for Nursing Home Reform (CANHR) titled, TRANSFER AND DISCHARGE RIGHTS, updated 9/4/24, indicated .Federal and California laws provide strong protections against evictions of nursing home residents. Residents have very specific rights that are intended to prevent inappropriate, unnecessary and untimely transfers and discharges .Written Notice .Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand. 42 CFR §483.15(c)(3)(i). The facility must send a copy of the notice to the long-term care ombudsman program. Except when specified below, the notice must be given at least 30 days before the resident is transferred or discharged (see the next section) .Exceptions to 30-Day Notice .As mentioned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055289 If continuation sheet Page 3 of 4 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 05/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few above, there are a few exceptions to the 30-day notice requirement. Federal regulations permit notice to be made as soon as practicable before transfer or discharge when: the health or safety of individuals in the facility would be endangered; the resident's urgent medical needs require a more immediate transfer; the resident's health has improved sufficiently to allow a more immediate transfer or discharge; or the resident has resided in the facility less than 30 days. 42 CFR §483.15(c)(4) .Even if an exception to the 30-day notice requirement is satisfied, the facility must nevertheless provide written notice in advance of a proposed transfer or discharge and an opportunity to appeal. A nursing home cannot transfer or discharge a resident while an appeal is pending, unless delay would endanger the health or safety of the resident or other individuals in the facility. 42 CFR §483.15(c)(1)(ii) .California law requires nursing homes to give reasonable advance notice in writing in all cases of transfer or discharge, unless there is an emergency. H&S Code §1599.78, 22 CCR §72527(a)(6) . https://canhr.org/transfer-and-discharge-rights/ FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055289 If continuation sheet Page 4 of 4