Health inspection·November 1, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from verbal abuse by a staff member, by failing to ensure the facility's staff (FS 1), was not raising his voice, arguing with Resident 1, and calling the resident inappropriate names. This failure had the potential for Resident 1 to be fearful and to negatively affect her psychosocial well-being. Findings: A review of the admission record indicated the facility admitted Resident 1 with multiple diagnoses, including herpes viral encephalitis (a neurological disorder characterized by inflammation of the brain, which can lead to mental confusion) and depression. A review of Resident 1's ' Incident Note,' dated 10/19/23, at 11:06 a.m., indicated, Nursing staff reported to Administrator, witnessed incident between resident [Resident 1] and another staff member .Resident [1] saw staff member's lunch bag .opened lunch bag and took a bag of chips .and started to eat them .At 11:06 [a.m.] Staff member [FS 1] saw that his lunch bag had been opened and saw Resident [1] was holding the chips from his lunch box and was eating them. Per CNA [Certified Nursing Assistant], male staff member [FS 1] raised his voice and stated She [Resident 1] knows exactly what she's doing, she probably thinks this is a five-finger discount .Resident .with confusion per her norm [sic] .resident did not recall above incident .Offered activities .resident chooses not to participate at this time. The incident note further indicated that Resident 1 was unable to describe the incident due to her diagnoses of brain dysfunction. A review of the facility reported incident (FRI) investigation report sent to the Department on 10/20/23, at 11:44 a.m., indicated the incident in dining room between FS 1 and Resident 1 was witnessed by a few of the facility's staff. The investigation report contained the following witnesses' accounts of how the incident in the dining room unfolded: 1. FS 2 reported that as she was walking through the dining room, she heard FS 1 yelling at [Resident 1], saying that this was his lunch and not hers. He said you are nothing but a five-finger discount because .she [Resident 1] took his chips. FS 2 reported that she took Resident 1 and calmed her down. 2. FS 3 reported that when FS 1 noticed that his things had been looked through, [FS 1] then became furious .he snatched the item [chips] .that belonged to him and then proceeded to call the resident (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: 055481 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 055481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242 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)