Other·August 9, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of entity reported incident #CA00539169. Representing the Department of Public Health: HFEN, 39060 HFEN, 26663 HFEN, 36524 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility.

F166 SS=D RIGHT TO PROMPT EFFORTS TO RESOLVE F166 GRIEVANCES CFR(s): 483.10(j)(2)-(4) 08/03/2017 (j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. (j)(3) The facility must make information on how to file a grievance or complaint available to the resident. (j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents’ rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident’s grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident’s concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents’ rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents’ rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on staff interview and facility record and policy review, the facility failed to ensure grievances were investigated and resolved promptly for 1 of 3 sampled residents (Resident 2) when Resident 2 reported missing a pair of blue jeans and it was not investigated. This failure had the potential to cause stress and affect the resident's trust of the staff in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Resident 2 was admitted to the facility with diagnoses which include dementia with behavioral disturbance and generalized anxiety disorder. The most recent Minimum Data Set (MDS, an assessment tool) dated 6/14/17, indicated Resident 2 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS). This indicated Resident 2 had no memory problems. A review of a facility undated document titled, "Resident Council Meeting," indicated "[room number of Resident 2] is missing a brand new pair of blue jeans, never been worn. Size 6." A review of the undated facility policy titled, "Theft and Loss; Safeguard of Resident's Belonging and Valuables," under the section, "B. Theft and Loss," indicated "The facility shall maintain a Theft and Loss Record with: resident name, article missing, current value, time and date of loss and action taken for follow up and outcome." In an interview with Social Services Director (SSD) on 6/21/17 at 2:30 p.m., SSD stated, he was not aware of the missing pair of blue jeans. The SSD further stated, the activities director who was present during resident council meeting should have filled out the theft and loss form and reported it to the SSD. In a phone interview with Activity Director (AD) on 6/28/17 at 3: p.m., AD acknowledged, Resident 1 reported missing a pair of brand new blue jeans on 5/8/17 during the resident council meeting. AD explained, she filled out an action plan form and gave it to laundry to locate the missing blue jeans. During a phone interview with the Laundry FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Manager (LM) on 6/28/17 at 3:20 p.m., LM does not remember receiving an action plan form regarding the missing blue jeans. LM further stated, she was first informed of the missing blue jeans on 6/21/17 by the SSD.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 08/03/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, and facility record and policy review the facility failed to report an alleged abuse for 1 of 3 sampled residents (Resident 1) within 24 hours as required, when certified nursing assistant 1 (CNA 1) witnessed CNA 2 strike Resident 1 on the face on 6/7/17. This failure potentially placed the residents of the facility at risk for abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Resident 1 was admitted to the facility in early 2012 with diagnoses which included dementia without behavioral disturbance. The most recent Minimum Data Set (MDS, an assessment tool) dated 3/11/17, indicated, Resident 1, "is rarely/never understood" and is "moderately impaired" in making decisions regarding tasks of daily life. A review of the nurses notes for Resident 1 dated 6/9/17 at 2:30 p.m., indicated, his/her responsible party was notified of the bruise on Resident 1's right eye, and the investigation into the cause. During an observation of Resident 1 with Licensed Nurse 1 (LN 1) on 6/21/17 at 2:30 p.m., Resident 1 was noted with skin discoloration of yellow to reddish-purple on her right lower eye. During an interview with LN 1 on 6/21/17 at 2:40 p.m., LN 1 stated, she first observed the skin discoloration of Resident 1 on 6/9/17. In an interview with CNA 3 on 6/21/17 at 2:45 p.m., CNA 3 stated, CNA 1 had told her on 6/8/17 that another CNA (CNA 2) had punched Resident 1 on the face. CNA 3 stated she had not witnessed the incident but had been aware and did not report it. In an interview with CNA 1 on 6/21/17 at 3:50 p.m., CNA 1 stated, "I witnessed [first name of CNA 2] punched [first name of Resident 1] on [the] face." CNA 1 stated, the incident happened on 6/7/17 between 9 p.m. to 9:30 p.m.. As she was walking down the hallway towards the nursing station she heard Resident 1 screaming and she peaked through Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1's door. CNA 1 described, the door was slightly opened and the privacy curtain drawn. When asked what Resident 1 and CNA 2 were doing in the room, CNA 1 stated, Resident 1 was on the sit-to-stand lift (a mechanical device use to assist in transfer) while CNA 2 was standing in front of Resident 1 trying to assist Resident 1 with transfer from her wheelchair to her bed. According to CNA 1, she observed Resident 1 trying to bite CNA 2 on his left arm and CNA 2 struck Resident 1 on the face with his right hand. CNA 1 stated she was scared to report the incident to the management but had mentioned the incident to another CNA (CNA 3) on 6/8/17. A review of the undated facility policy titled, "Abuse, Prevention Of," directed, "Administrator shall report all incidents of alleged abuse or suspected abuse to DHS [Department of Health Services] within 24 hours." In an interview with the Director of Nursing (DON) on 6/21/17 at 4:10 p.m., the DON explained all staff were mandated reporters and any suspected abuse should be reported within 24 hours to the state agency. The DON acknowledged the facility failed to report the abuse allegation within 24 hours as required, due to the failure of CNA 1 to notify the facility staff members.

F282 SS=D SERVICES BY QUALIFIED PERSONS/PER CARE PLAN CFR(s): 483.21(b)(3)(ii)

F282 08/03/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan, must(ii) Be provided by qualified persons in accordance with each resident's written plan of care. This REQUIREMENT is not met as evidenced by: Based on staff interview and facility record and policy review, the facility failed to ensure residents' care followed the care plan for 1 of 3 sampled residents (Resident 1) when certified nursing assistant 2 (CNA 2) assisted Resident 1 to transfer from wheelchair to bed with the use of sit-to-stand lift (a mechanical device used to assist in transfer) by himself despite the care plan directing 2 person transfer. This failure placed Resident 1 at risk for potential accident and physical injury. Findings: Resident 1 was admitted to the facility in early 2012 with diagnoses which included dementia without behavioral disturbance. The most recent Minimum Data Set (MDS, an assessment tool) dated 3/11/17, indicated Resident 1 required two or more staff members for transfer. A review of clinical record for Resident 1 titled, "ADL [Activities of Daily Living] Care Plan," dated 3/23/17, indicated Resident 1 required assistance by 2 staff members with transfer. During a phone interview with CNA 2 on 6/28/17 at 2:20 p.m., CNA 2 stated he assisted Resident 1 to transfer with the sit-to-stand lift from Resident 1's wheelchair to bed by himself on 6/7/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055289 (X3) DATE SURVEY COMPLETED 07/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LODI CREEK POST ACUTE 321 W. Turner Road Lodi, CA 95240 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the undated facility policy titled, "Hoyer Lifts, Stand Lifts," directed "there shall always 2 CNAs while performing any lift." In a phone interview on 6/28/17 at 10:10 a.m., the Director of Nursing (DON) stated, Resident 1 required 2 staff members for transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RUB211 Facility ID: CA030000029 If continuation sheet 10 of 10