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 Page 1 of 2 055289 055289 07/16/2025 Lodi Creek Post Acute 321 West Turner Road Lodi, CA 95240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was symptomatic, the staff immediately performed a COVID -19 test. The IP further stated it was important to test the roommate because there was a potential to spread the infection. The IP confirmed that Resident 1 did not have documentation of the COVID-19 test completed when her roommate (Resident 2) tested positive on 7/3/25. During a concurrent interview and record review on 7/16/25, at 1:53 PM, with the Director of Nursing (DON), Resident 4 and Resident 1's medical records were reviewed. The DON stated if the result of the first COVID-19 test was negative, the nursing staff should have continued with the testing for the third and fifth day of exposure. The DON further stated that when a resident tested positive for COVID-19, the nursing staff should have tested the roommate for COVID-19 within 24 hours. The DON stated she expected the nursing staff to document when a resident was tested for COVID-19 because if they did not document, it meant it was not done. The DON confirmed that Resident 4 had no documentation that she was tested for COVID-19 within 24 hours of exposure from her roommate Resident 3. The DON further confirmed that Resident 1 had no documentation that she was tested for COVID-19 within 24 hours of exposure from her roommate (Resident 2) or on the succeeding days. A review of undated facility document titled, Coronavirus Disease (COVID-19) -Infection Prevention and Control Measures, indicated, .The infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include.performing testing as recommended by current guidelines. According to the Centers for Disease Control and Prevention (CDC) publication titled, Infection Control Guidance: SARS-CoV-2, dated June 24, 2024, indicated, .Perform SARS-CoV-2 Viral Testing.Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. 055289 Page 2 of 2