Health inspection·July 16, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to implement their infection control policy and procedure by failing to ensure that two of six sampled residents (Resident 1 and Resident 4) were tested for COVID-19 after being exposed to a COVID-19 (a contagious disease) positive resident.This deficient practice had the potential to place residents, staff members, and visitors at risk for spreading infection. There was also the potential to cause further delay in the treatment for Resident 1 and Resident 4.Findings:a. Resident 4's admission RECORD indicated Resident 4 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease (group of lung diseases that cause long-term breathing problems). A review of Resident 4's medical record titled, SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/14/25, indicated, .Pt [Patient] tested for COVID19 via rapid nasal swab with positive result.A review of Resident 3's medical record titled, SBAR [Situation Background Assessment Recommendation- communication form] & [and] INITIAL COC [Change of Condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/9/25, indicated, .Patient [Resident] tested positive for COVID 19 on rapid testing.During an interview on 7/15/25, at 2:38 PM, with License Nurse (LN) 1, LN 1 stated when a resident tested positive for COVID-19, the facility staff should have tested the roommate of the positive resident.During an interview on 7/15/25, at 2:53 PM, with Resident 3, Resident 3 stated she tested positive for COVID-19 on 7/9/25. Resident 3 further stated she was not moved to a different room when she tested positive for COVID-19, and her roommate (Resident 4) also remained in the same room.During a concurrent interview and record review on 7/15/25, at 3:49 PM, with the Infection Preventionist (IP), Resident 4's medical record was reviewed. The IP stated as a general practice, the facility staff swabbed the residents who had symptoms of COVID-19 and the residents who had been exposed to the virus. The IP further stated that exposed residents would have been tested on day 1, day 3, and day 5. The IP explained that the staff should have immediately tested the roommate of any COVID -19 positive resident. The IP confirmed the facility did not have documentation that Resident 4 (the roommate of Resident 3), was tested for COVID-19 on 7/10/25 and 7/12/25. The IP further confirmed there was no documentation for Resident 4 that testing was completed. b. Resident 1's admission RECORD indicated Resident 1 was admitted to the facility in 2019 with diagnoses including multiple sclerosis (a chronic neurological disorder affecting the brain and spinal cord).A review of Resident 1's Care Plan, initiated on 7/3/25, under the Focus section, indicated, .PERSON UNDER MONITORING: ASYMPTOMATIC [no symptoms] resident who is at risk for Respiratory Illness due to possible exposure to Covid-19. A review of Resident 2's medical record titled, SBAR & INITIAL COC/ALERT CHARTING & SKILLED DOCUMENTATION, dated 7/3/25, indicated, .Noted resident with a hoarse voice, c/o [complaint of] congestion and sore throat.Resident then swabbed via rapid COVID test, positive result.During a concurrent interview and record review on 7/16/25, at 11:50 AM, with the IP, Resident 1's medical record was reviewed. The IP stated as a facility practice, the facility waited for 24 hours before they tested asymptomatic residents that had a positive COVID-19 roommate, and if the resident Residents Affected - Few (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055289 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 07/16/2025 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)