Health inspection·October 30, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents, (Resident 1) when Resident 1 was not repositioned or assisted with care needs in a timely manner. Residents Affected - Few This failure put Resident 1 at risk of discomfort and skin breakdown. Findings: A review of Resident 1 ' s admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included dementia (condition characterized by memory disorders, personality changes, and impaired reasoning) and muscle weakness. A review of Resident 1 ' s clinical care plan indicated, Resident is at risk for pressure injury development and skin breakdown r/t [related to] immobility, incontinence. Turn and reposition q2h [every 2 hours] and PRN [as needed] During an observation and interview on 10/29/24, at 12:45 PM, with family member (FM) 1, Resident 1 was observed sitting in her wheelchair, FM 1 was sitting in a chair beside Resident 1. FM 1 stated he visited from 9:30 AM until 2:30 PM everyday and Resident 1 was never repositioned or taken to the bathroom during those times. FM 1 further stated the reason Resident 1 had a urinary tract infection (UTI, when germs enter the urinary tract and cause an infection) was because staff never provided incontinence care (support services for people who are unable to control their bladder or bowel movements.) During an observation and interview on 10/29/24, at 1 PM, the Speech Therapist (ST) was observed feeding Resident 1 her meal. Resident 1 stated she wanted to go to the bathroom. FM 1 stated she needed to go to the bathroom, but no one would help her. The ST stated staff would assist Resident 1, the ST stated she would inform staff of Resident 1 ' s need. During an observation and interview on 10/29/24, at 1:33 PM, in Resident 1 ' s room, Resident 1 was observed sitting in her wheelchair. FM 1 stated Resident 1 had not yet been assisted to the bathroom. During an observation and interview on 10/29/24, at 2:48 PM, in Resident 1 ' s room, Resident 1 was observed sitting in her wheelchair. FM 1 stated staff had not repositioned her or provided bathroom assistance since before he arrived in the morning. During an interview on 10/29/24, at 2:59 PM, CNA 2 stated she had provided care to Resident 1 Page 1 of 2 055289 055289 10/30/2024 Lodi Creek Post Acute 321 West Turner Road Lodi, CA 95240

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few between 9 AM and 9:30 AM and transferred her to the wheelchair. CNA 2 stated she could not remember when she next provided care, but she thought she and CNA 1 had provided care at approximately 1 PM. During an observation and interview on 10/29/24, at 4:03 PM, Resident 1 was observed sitting in her wheelchair. CNA 3 stated Resident 1 was last provided care at 1 PM per verbal shift change report. CNA 3 stated she would provide care to Resident 1 after the evening meal (served around 5 PM). During an interview on 10/30/24, at 11:44 AM, CNA 1 stated she had not assisted in any care provided to Resident 1 on 10/29/24. During an interview and record review on 10/29/24, at 3:53 PM, the Health Information Manager (HIM) confirmed Resident 1 ' s documentation for 10/29/24 titled, TURNING & REPSOITIONING EVERY 2 HOURS & PRN [AS NEEDED], was blank after 6 AM. The HIM further confirmed the documentation for 10/29/24 titled, BLADDER CONTINENCE, indicated, Resident 1 had two episodes of incontinence documented at 1:18 AM, and there was no documentation after 1:18 AM. The HIM confirmed there was no documentation to indicate incontinence care/turning and repositioning was provided during the am shift. During an interview on 10/30/24, at 1:58 PM, the DON stated it was her expectation that all residents would be repositioned every 2 hours and their toileting needs would be met at the same time. The DON stated if the care was not provided there was a risk to Resident 1 of skin breakdown and discomfort. The DON further stated if the documentation was incomplete, she could not confirm the care was provided. A review of a facility policy titled Activities of Daily Living (ADLs) [activities related to personal care], Supporting, revised March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently including appropriate support and assistance with mobility (transfer and ambulation, including walking) elimination (toileting). 055289 Page 2 of 2