Health inspection·September 8, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: a notice that informs residents of changes to their Medicare Part A coverage for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay) to one of one sampled resident (Resident 2) reviewed for Medicare benefit notification after skilled services ended.This failure had the potential for Resident 2 not to be able to make informed decisions about his care and finances, being unaware of his right to appeal and placed him at risk for unexpected medical bills.During a concurrent interview and record review on 8/6/25, at 2:48 PM, the Admissions Coordinator (AC) stated Resident 2's Medicare Part A skilled services coverage ended on 7/23/25. The AC stated Resident 2 continued to stay in the facility after his skilled care ended. The AC confirmed that Resident 2's Medicare eligibility benefits document indicated that Resident 2 had 46 Medicare days remaining. The AC stated the SNF ABN notice should have been issued to Resident 2 when his skilled services coverage ended on 7/23/25 and he continued to remain at the facility. The AC further stated that without the SNF ABN, the resident might not know his rights.During a concurrent interview and record review on 8/6/25, at 12:40 PM, the Social Services Director (SSD) confirmed that Resident 2 was discharged from Medicare Part A services on 7/23/25, but Resident 2 remained in the facility as a long term care resident. The SSD further confirmed there was no indication in Resident 2's medical record that the SNF ABN was provided to Resident 2.During a concurrent interview and record review on 8/6/25, at 1:13 PM, the Director of Nursing (DON) stated Resident 2 was scheduled for discharge on [DATE], but remained in the facility and transitioned to long term care. The DON stated further Resident 2's last Medicare-covered day was 7/23/25. The DON stated the SNF ABN notice should be given to residents three days before the last covered day, so the residents knew their rights and had a chance to appeal. The DON confirmed that the SNF ABN notice was not provided to Resident 2. The DON stated that not providing the SNF ABN could lead to unexpected billing for the residents.Review of an undated facility policy titled, Advance Beneficiary Notices, indicated, .The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides: (a.) An item or service that is usually paid for by Medicare .or (b.) Custodial Care .For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055. Residents Affected - Few Page 1 of 6 555049 555049 09/08/2025 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview, and record review, the facility failed to ensure an accident-free environment when necessary rehabilitation care instructions for nursing staff were not updated in the care plan for one of three sampled residents (Resident 1) when Resident 1 was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat.This failure resulted in Resident 1 falling out of the wheelchair and hitting his head on the floor on 7/27/25. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including hemiplegia (paralysis or weakness to one side of the body) and hemiparesis (one- sided muscle weakness) following cerebral infarction (also known as stroke, when blood flow to the brain is interrupted, leading to brain tissue damage) affecting right dominant side, difficulty in walking, and paraplegia (inability to voluntarily move the lower parts of the body).A review of Resident 1's Brief Interview for Mental Status (BIMS - a standardized assessment to quickly evaluate a resident's cognitive function by asking a series of questions related to attention, orientation, and memory recall, resulting in a total score ranging from 0-15) dated 6/16/25, indicated Resident 1 had a BIMS Score of 10 which indicated moderate impairment.A review of Resident 1's medical record titled, Morse Fall Risk Screen, (is a rapid and simple method of assessing a patient's likelihood of falling, score of 0-24 low risk, 25-44 moderate risk, and 45 and higher as high risk) dated 6/16/25, indicated Resident 1 had a score of 56 which categorized Resident 1 as a high risk for falling.A review of Resident 1's Minimum Data Set (MDS an assessment tool) Section GG (a standardized assessment in long-term care that measures a patient's ability to perform self-care and mobility activities, such as eating, bathing, and walking.) dated 6/19/25, indicated Resident 1 was, .Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).A review of Resident 1's Nurses Notes, dated 7/27/25, at 6:49 PM, indicated, .Resident under Palliative Care Services [provides symptom relief, comfort and support to people living with serious or chronic illnesses.] under [name of hospice provider].Resident have [sic] a baseline of refusing ADLs [activities of daily living] care, but despite refusals, nursing staff still continues to offer resident to get up in wheelchair as tolerated. Resident has AROM [active range of motion] of right and left upper extremities and is contracted of right and left lower extremities.Due to patient's multiple attempts to get out of wheelchair unassisted, 2 CNAs [certified nursing assistants] assisted patient back to room [Resident 1's room] to prepare for transfer back to bed.Resident repeatedly attempted to push himself onto the floor still while being assisted to room.Resident had 1 CNA supervising him while the other CNA got the Hoyer lift [a mechanical, portable hoist used to safely transfer people with limited mobility].patient forcefully pushed himself forward past the CNA and projected forward onto the floor. [Resident 1] was in doorway of room.[Resident 1's forehead hit the floor which resulted in a minor lac [laceration or cut], scant bleeding was noted.During a phone interview on 8/5/25, at 2:03 PM, with Resident 1's responsibly party (RP), the RP stated she received a call from the facility on 7/27/25 and was informed that Resident 1 fell out of his wheelchair. The RP explained Resident 1 could not walk, was not able to move himself and he would fall forward. The RP stated Resident 1 required max assistance.During a joint interview on 8/6/25, at 1:52 PM, with the MDS Coordinator (MDSC) 1 and MDSC 2, both MDSC 1 and MDSC 2 stated Resident 1 needed a Hoyer lift to be transferred from bed to wheelchair and was dependent. MDSC 1 and MDSC 2 explained dependent meant that staff had to perform 100% of the activity. MDSC 1 and MDSC 2 stated Resident 1's sitting balance in therapy was poor and he required 555049 Page 2 of 6 555049 09/08/2025 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few maximum assistance to maintain balance.During an interview on 8/7/25, at 3:03 PM, with the Medical Doctor (MD), the MD stated it was difficult to judge a resident's physical mobility because physical therapy recommended the ambulation status of the resident. The MD further stated he agreed with physical therapy if they recommended max assistance was needed for Resident 1's ability to be seated in a wheelchair.During a joint concurrent interview and record review on 9/8/25, at 9:28 AM, with the DOR and the Physical Therapist (PT), Resident 1's medical record was reviewed and indicated he was totally dependent with a 2 person assist for transfers. The PT stated she communicated with the nursing staff that Resident 1 could be transferred to a wheelchair and could tolerate sitting in a reclined position with a Dycem (a flexible, reusable, non-adhesive polymer material that can be cut to size and used on surfaces to secure people in chairs or wheelchairs, providing grip and stability by preventing sliding an slipping) on top of the wheelchair. The PT further stated Resident 1 had poor trunk control and it was not safe for him to be positioned in a 90-degree (a unit of measurement of angles) upright position. The PT stated after Resident 1's therapy sessions, he occasionally would stay in a wheelchair accompanied by a nurse or the activity staff to ensure that there was always someone supervising Resident 1. The PT further stated Resident 1 did not have a behavior of trying to move forward and he usually communicated when he was uncomfortable and would ask her to move him backward on the chair. Resident 1's care plan was reviewed with the DOR and PT, the DOR confirmed that interventions in the care plan did not include what was verbally communicated with the nursing staff which included the use of a recliner wheelchair and the placement of a Dycem for Resident 1. The DOR stated the purpose of the care plan was for staff to know the interventions and the goals for the residents. The PT stated Resident 1 was provided his own reclining wheelchair with a Dycem.During an interview on 9/8/25, at 10:04 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated on the day of the incident, the nurse told her and CNA 1 to get Resident 1 up because Resident 1 requested to be in a wheelchair and they just followed the instructions. CNA 2 further stated Resident 1 was sitting in a wheelchair in a 90-degree position in the hallway, yelling for approximately 2-5 minutes and Resident 1 requested to be back in bed. CNA 2 stated she was helping CNA 1 to put Resident 1 back in bed and CNA 1 was making the bed at the time. CNA 2 further stated Resident 1 was in a 90-degree position in the wheelchair, and she was standing in front of Resident 1 when she saw Resident 1 fall and hit his head on the floor and she tried to catch him, but it was too late. CNA 2 stated Resident 1 never had the behavior of leaning but he had a behavior of randomly screaming all the time. CNA 2 further stated that for all residents, the CNAs usually talked to the nurses to check if a resident could be up on a chair, how many people needed to assist the resident for transfer or if a Hoyer lift was needed. CNA 2 stated the CNAs relied on verbal communication with the nurses, nursing supervisors and therapists because they did not have access to the therapy notes and it was not in the plan of care. During an interview on 9/8/25, at 10:25 AM, with CNA 1, CNA 1 stated Resident 1 was asking to be in the wheelchair. CNA 1 further stated she used a Hoyer lift with the assistance of CNA 2 to transfer Resident 1 in a wheelchair. CNA 1 stated Resident 1 was in an upright position in a wheelchair for an hour in front of the nurses' station. CNA 1 further stated Resident 1 used his own regular wheelchair and not a recliner wheelchair. CNA 1 stated Resident 1 was not in a reclining wheelchair at that moment (7/27/25) and had never seen him in a reclining wheelchair. CNA 1 further stated the wheelchair was in Resident 1's room and he had 2 roommates and none of them had a reclining wheelchair. CNA 1 stated that after almost an hour up in the wheelchair, she took Resident 1 back to his room because it was almost an hour and she was preparing Resident 1's bed. CNA 1 further stated nobody asked her to put Resident 1 back to bed but Resident 1 looked uncomfortable, so she decided to 555049 Page 3 of 6 555049 09/08/2025 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheel him back to the room. CNA 1 stated she was fixing the bed and Resident 1 was by the door sitting in the same position. CNA 1 further stated when she turned her back around, Resident 1 was already on the floor. CNA 1 stated CNA 2 was not in the room, and she was by herself. CNA 1 further stated she did not put any resident on a chair until the PT evaluated the resident. CNA 1 stated by talking to the PT she would know how she would care for the resident. CNA 1 further stated this was the first time she got Resident 1 on a wheelchair, but she saw Resident 1 up in a wheelchair with the PT and other CNAs and that is why she knew Resident 1 could be in a wheelchair. CNA 1 stated Resident 1 did not have a behavior of pushing himself on the floor except the day of the incident. CNA 1 further stated Resident 1 could not stand up because he had contractures (a permanent stiffening and shortening of muscles, tendons, or skin that prevents a joint or body part from moving normally) on both legs.During an interview on 9/8/25, at 10:51 AM, with License Nurse (LN) 1, LN 1 stated Resident 1 was demanding to get up in a wheelchair and 2 CNAs helped him. LN 1 further stated Resident 1 usually would lay in bed, but the family requested to get him up. LN 1 stated Resident 1 was on therapy, and she saw the rehab staff use a Hoyer lift before. LN 1 further stated she looked at the therapy notes and called the DOR and DON to ask if Resident 1 could be in a wheelchair. LN 1 stated that the details on resident transfer and assist instructions were usually in the plan of care and it would include how the resident could be transferred. LN 1 further stated the nursing staff could also check the H&P (History and Physical, a formal assessment by a physician that documents the resident's medical history, current condition, and a physical exam to guide their individualized plan of care), the therapy orders and the care plan. LN 1 stated the rehab instructions for the residents should be in the rehab care plan. LN 1 further stated she usually checked the care plan or asked the PT in person. LN 1 stated Resident 1 did not want to participate in activities and only saw him up on a wheelchair when the family was visiting or during therapy sessions. LN 1 further stated there was a special request from Resident 1's family to get him up and for him to attend the activities but he never wanted to except for that day he requested to be in a wheelchair (7/27/25). LN 1 stated Resident 1 was sitting upright in a standard regular wheelchair on the day of the incident. LN 1 stated Resident 1 was in front of the nurses' station when he became agitated and started pushing himself forward. LN 1 further stated that Resident 1 did not usually do things like pushing himself forward and he did not have a behavior for it. LN 1 stated the purpose of the care plan was to meet the residents' goals and interventions and that. This included staff from all departments could get instructions on what to do and had the ability to check if there were changes with the interventions. LN 1 further stated the instructions for transfers, number of persons needed for assist, and the ADLs should all be in the care plan. LN 1 stated she only communicated with the rehab department verbally for instructions. LN 1 stated Resident 1 was a high risk for falls because he could not stand. During a joint interview on 9/8/25, at 12:46 PM, with the DOR and the PT, the DOR stated the Dycem was used as resistance to prevent Resident 1 from sliding on the wheelchair and having Resident 1 in a reclining position would also prevent him from falling forward. The DOR further stated if Resident 1 was left unsupervised in a wheelchair it could be a risk for fall. Both the DOR and the PT stated Resident 1 could not lean forward all the way. The PT stated she did not document that the Dycem needed to be used for Resident 1 and she just put it in her treatment notes that Resident 1 was able to tolerate 2 hours sitting in a wheelchair during therapy sessions. The PT further stated Resident 1 needed constant supervision and visual monitoring with staff by the nurse's station whenever he sat in a wheelchair. The DOR stated the specific rehab instructions for Resident 1's care were not documented because the Dycem and reclining wheelchair were already in place, and they had open communication with the 555049 Page 4 of 6 555049 09/08/2025 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing staff. The PT stated she verbalized to the nursing staff that Resident 1 was able to tolerate 2 hours of sitting and needed 2-persons to get him out of bed. The PT confirmed this was not documented. The PT stated Resident 1's back always needed to be supported. The PT further stated Resident 1 was provided with a wheelchair in a 75-degree angle and it could be readjusted. The PT stated she expected the nursing staff to keep Resident 1 in a reclining position with a Dycem underneath him and he needed someone to be with him. The PT further stated she never encountered Resident 1 trying to get out from the wheelchair. The PT stated Resident 1 was comfortable in a 60-75-degree position when sitting in a wheelchair. The DOR confirmed that no one called her on the day of the incident to ask for instructions regarding Resident 1's rehab plan of care.During an interview on 9/8/25, at 1:40 PM, with the Director of Nursing (DON), the DON stated he expected open communication between the rehab department and the nursing department regarding the plan of care for the residents. The DON further stated if the nursing staff had questions regarding a resident's level of care when the rehab staff were not at the facility then nursing staff could always call the DOR. The DON explained that the DOR was available 24/7 (24 hours a day, 7 days a week) and the staff could also use their critical judgment or check the doctor's order. The DON stated the standard practice was for the nursing staff to check the resident's plan of care. The DON further stated the care plan should detail the level of care, goals, and facility interventions for the resident's progress. The DON stated it served as a guide in managing resident care by outlining necessary actions to achieve the set goals. The DON further stated the type of wheelchair, certain devices and specific instructions for residents should be reflected in the care plan and in the therapy notes. The DON stated the rehab department communicated with the nursing staff and he expected what was communicated between rehab and nursing should be also be documented in the care plan. The DON confirmed that the rehab care plan did not reflect the specific interventions for Resident 1. The DON stated the importance of updating the care plan was for residents to get proper enhanced care and it was also used as a communication tool between all the departments. The DON further stated the care plan was ever changing and updated frequently. The DON stated he did not remember what was communicated from the rehab department regarding the plan of care for Resident 1.A review of Resident 1's Care Plan Report, under the section titled, Focus, indicated, .Mobility Deficit as evidenced by: Requiring assistance or is dependent in: Mobility.Chair/Bed-to-Chair Transfer (total D [dependent]).Lying to Sitting on the Side of Bed (total D).Sit to Lying (total D). Further review of the document under the section titled, Interventions, date initiated on 6/21/25, indicated, .Keep most frequently use personal items and things needed during care.within resident's reach.A review of Resident 1's Care Plan Report, date initiated on 6/21/25, under the section titled, Focus, indicated, .High risk for falls and injury related to Attempting to get out of bed unassisted, Limitation of mobility, Presence of Contracture [is a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement], Bladder incontinence [loss of bladder control], Bowel incontinence [loss of bowel control], CVA [cerebrovascular accident or stroke] w/ [with] right hemiparesis. Further review of the document under the section titled, Interventions, indicated, .Have things needed by the resident within reach.A review of Resident 1's Care Plan Report, date initiated on 6/17/25, under the section titled, Focus, indicated, .Skilled PT [physical therapy] intervention needed to improve B LE [bilateral lower extremity] strength, ROM [range of motion], activity tolerance, balance and safety awareness. Further review of the document under the section titled, Interventions, indicated, .PT.qd [once daily] 5x/wk [5 times per week] for 8 wks [weeks].tx [treatment] may include therapeutic exercise, therapeutic activity, neuro re-education, manual tx, w/c mgt [ wheelchair management], 555049 Page 5 of 6 555049 09/08/2025 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient education and caregiver training.A review of an undated facility policy and procedure (P&P) titled, Falls and Fall Risk, Managing, indicated, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .A review of an undated facility P&P titled, Safety and Supervision of Residents, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Systems Approach to Safety.2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.A review of an undated facility P&P titled, Care Plans, Comprehensive Person-Centered, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The comprehensive person-centered care plan will.m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.A review of the facility P&P titled, Documentation Requirements, revision date 1/1/17, indicated, .Each Rehabilitation Services resident/patient had medical record of care and treatment which includes subsequent referrals, initial evaluations and plan of care, copies of daily notes, copies of progress notes, and treatment care plans.A review of an undated facility policy and procedure (P&P) titled, Progress Notes, indicated, .Progress notes shall be maintained for each resident who is receiving specialized rehabilitative services. Progress notes reflect the resident's progress and response to his or her care plan, medication, etc. Progress notes must be recorded monthly and whenever changes occur in the resident's condition. Such information must be recorded by the Therapy Service responsible for entering such date on the appropriate progress record. 555049 Page 6 of 6