Health inspection·February 7, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/30/24 at 11:05 a.m., the Laundry Staff (LS) explained that on 1/21/24 around 5:45 a.m., as she delivered linen to the hall, she observed Resident 2 standing in the hall by his room and screaming and shouting, threatening to hurt Resident 1. The LS stated that if she observed a resident to be aggressive, she would normally call the charge nurse for help, but there were several of the staff at the nursing station, close to Resident 2's room and she thought they would intervene. The LS stated that she had in the past witnessed Resident 2 being rude and verbally aggressive to staff. During an observation and interview on 1/30/24 at 11:20 a.m., Resident 1 was observed lying in his bed. Resident 1 stated he vividly remembered that morning when Resident 2 kicked his door open. Resident 1 explained, He [Resident 2] stood by the door, angry looking, puffing and huffing. This was not the first time that he yelled at me about the bathroom . Staff knows how inpatient he is .Unfortunately we are sharing a bathroom and he thinks he can control when I use the bathroom .I asked him, What's going on this time? He started screaming and yelling at me, calling me all kinds of names, cussing his head off. Resident 1 stated that he had not been to the bathroom that morning for more than 1 hour and 45 minutes. Resident 1 continued, .He grabbed my left foot and started to pull me out of bed. I managed somehow to escape his grip and got out on the other side of the bed. He .came around and started hitting me, beating the crap out of me .and then I went down. I was trying to defend myself, but he is stronger, and he easily overpowered me. He was .hitting me hard and kicking me. I was trying to cover my face and my head. Both of us were screaming and then the staff came in. During a continued interview on 1/30/24 at 11:20 a.m., Resident 1 stated that as a result of the altercation, he received small skin tears to his right arm, was hit on the face and pointed to the bridge of his nose where he had a small dry scab and got his eyeglasses messed up. Resident 1 pointed to his left shoulder and stated that the abrasion hurt for a while and he had to take pain medications. Resident 1 stated, Still scared of him, he's much stronger and tempered man. They moved him down the hall and I see him every time I go to gym .He's standing in the doorway watching .Gives me dirty looks .I feel safe as long as I don't see him. During an interview on 1/30/24 at 11:45 a.m., Resident 2 was sitting a wheelchair in his room. Resident 2 explained that a few nights ago, he woke up in the morning and needed to use the bathroom right away. Resident 2 stated when he saw the bathroom lights on, he assumed that next door resident was there. Resident 2 added, I was mad that I could not use it. Resident 2 stated he did not call staff before going to Resident 1's room and stated, I went to his room and tried to pull him out of his bed. Then I hit him 3 times. During a telephone interview on 2/7/24 at 2:50 p.m., Certified Nursing Assistant (CNA 1) stated on 1/30/24 around 6 a.m., she witnessed Resident 2 standing by the room entrance. CNA 1 stated Resident 2 was yelling and cursing everybody .his typical behavior. CNA 1 stated that Resident 2 yelled at her and used inappropriate words when she offered to weigh him. CNA 1 explained, I left .went looking for help . all happened so fast . we walked in [Resident 1] was sitting on the floor covering his head and [Resident 2] was kicking and hitting him. The other CNA .could not stop him hitting [Resident 1], he's a very tall and strong man. Then more staff . came and were able to separate them. CNA 1 stated she heard Resident 2 threatening to hurt Resident 1, saw him being verbally aggressive but had not seen him being physically aggressive. During an interview on 1/30/24 at 12:02 p.m., the Social Services Director (DSD) confirmed the incident when Resident 2 physically attacked Resident 1. The SSD stated, I know [Resident 2] has a difficult personality . he wants to be in control of everything. The SSD stated Resident 2 denied (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055481 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 055481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2024 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegations initially when she talked to him, but then he admitted that he hit Resident 1 because he was angry. The SSD stated Resident 2 was not violent and had not attacked anyone physically in the past. A review of the facility's Supervision of Resident Care, undated policy, indicated the purpose of the policy was to assure that the resident's safety and well being are maintained. The policy indicated, All residents receive adequate supervision. During a concurrent interview and record review on 2/7/24 at 3:33 p.m., the Director of Nursing (DON) validated that Resident 2 had a known history of verbal aggression. The DON was asked how the facility ensured that residents' safety was maintained and the residents were protected from verbal and physical abuse. The DON stated, Supervise environment. If we see/hear that a resident becomes aggressive verbally or physically staff intervenes immediately. Residents with dementia are unpredictable, one minute they are okay and the next they strike out. Need close supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055481 If continuation sheet Page 3 of 3