Health inspection·November 23, 2023

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 3), who required assistance with activities of daily living (ADL), was provided the scheduled twice weekly showers/baths. Residents Affected - Few This failure had the potential for Resident 3 to experience a feeling of neglect and negatively impact his psychosocial well-being. Findings: A review of Resident 3's History and Physical (H&P) indicated Resident 3 was admitted in 10/2023 with diagnoses including peripheral vascular disease (PVD, a progressive systemic circulation disorder of peripheral, near the surface, blood vessels) and an unspecified injury to shoulder and upper arm. Non-ambulatory was wheelchair bound. A review of Resident 3's Order Summary Report for November 2023, indicated the resident had the capacity to understand choices and make own healthcare decisions. During a review of Resident 3's Minimum Data Set (MDS, a comprehensive assessment and screening tool), dated October 26, 2023, the MDS indicated the resident was cognitively intact, had functional limitations to bilateral lower extremities and required help from another person to complete bathing, dressing, using the toilet. A review of Resident 3's care plan, dated 10/20/23, indicated the resident requires assistance with ADL functions: bed mobility, transfer, toilet use, bladder &bowel care, locomotion, and bathing. The interventions specified set-up and assist with personal hygiene, and to receive showers at least two times a week. A review of the facility's resident shower schedule showed Resident 3 was listed to receive showers/baths on Wednesdays and Saturdays, AM shift (morning shift). During a phone interview on 11/13/23 at 10:37 a.m. with Resident 3, Resident 3 stated he did not get a shower while at the facility. During an interview on 11/13/2023 at 3:30 p.m. with Director of Staff Development 1 (DSD 1), DSD 1 stated all Certified Nurse Assistants (CNAs) were in-serviced/trained on how to give proper showers to residents including the correct documentation. The DSD 1 also indicated it is a must for the CNAs to completely fill out a shower sheet [shower day skin inspection] and log it in the CNA task in Page 1 of 2 055491 055491 11/23/2023 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0676 the computer. DSD 1 stated, If the shower sheet was not done, then the shower was not given. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 11/13/23 at 4:50 p.m. with DSD 2, DSD 2 stated she was not able to find the shower sheets for Resident 3 on Wednesday, 10/25/23, and Saturday, 10/28/23. The CNA shower task log in the computer was marked not applicable only. DSD 2 verified she was not sure if a shower was given to Resident 3 on those dates. Residents Affected - Few During an interview on 11/13/23 at 5:10 p.m. with the Director of Nursing (DON), DON stated she expects all the CNAs to provide showers to residents as scheduled and for them to document the care given by completing a shower sheet and logging it in the computer for the supervisors to know if the care was provided. DON confirmed if the CNAs do not document the showers properly then the task was not completed. During a review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living (ADL), Supporting revised March 2018, the P&P indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . 055491 Page 2 of 2