Health inspection·July 2, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure necessary services were provided for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 went one week (6/19/24-6/26/24) without receiving a shower and Resident 2 did not have a shower for six days. Residents Affected - Few These failures placed Resident 1 and Resident 2 at risk for poor hygiene, poor skin integrity, increased risk of infection, and self-isolation. Findings: a. Review of Resident 1's admission record indicated Resident 1 was admitted with diagnosis of generalized weakness and difficulty walking. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/12/24, in section GG (functional abilities and goals) and section E (ability to shower/bathe self) indicated Resident 1 needed partial to moderate assistance with bathing and other Activities of Daily Living (ADL's). During an interview with Resident 1 on 7/2/24, at 2:26 PM, Resident 1 stated, Sometimes they only do showers once a week. They keep saying they have too many people to shower. Resident 1 also stated, Sometimes I'll get a shower once a week and sometimes not at all. Resident 1 stated bed baths were offered in place of a shower. Resident 1 stated the facility did not offer a choice of a shower when she received a bed bath. Resident 1 stated, I would prefer to have a shower and have never refused a shower. Resident 1 stated, I feel awful all over when I don't get a shower. During an interview on 7/2/24 at 2:26 PM, with Family Member (FM) 1, in response to Resident 1's missed showers, FM 1 stated, Usually I'll get involved and they'll put her on the schedule. FM 1 also stated, I've had to talk to them [facility] three times about her showers. She's been here since the beginning of June. b. Review of Resident 2's admission record indicated Resident 2 was admitted for generalized weakness and rehabilitation. During a concurrent Interview and record review with Certified Nurse Assistant (CNA) 1 on 7/2/24, at 2:44 PM, Resident 2's document titled, Task: Shower, dated 6/5/24 through 7/2/24, was reviewed. CNA 1 stated showers were given twice a week. CNA 1 stated when residents were new admissions, sometimes they were put on the schedule right away. CNA 1 explained, sometimes a resident was placed on the morning shift but not given a group (CNA the resident was assigned to). CNA 1 stated staff needed to double check both schedules or the showers could be missed. CNA 1 stated Resident 2 complained about her shower not being given to her family member. CNA 1 stated Resident 2's family member Page 1 of 2 055833 055833 07/02/2024 Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complained to staff over a period of three or four days about Resident 2 not getting a shower. CNA 1 stated Resident 2's family member ended up giving a shower to Resident 2. CNA 1 confirmed the documentation in the clinical record of missed showers for both Resident 1 and Resident 2. During a concurrent interview and record review with Licensed Nurse (LN) 1, on 7/2/24 at 3:11 PM, LN 1 stated showers were given twice a week. LN 1 confirmed no showers were documented as given for Resident 1 from 6/19/24 to 6/26/24. LN 1 stated Resident 2 should have had a shower on 6/15/24, but it was missed. LN 1 stated there was no reason documented for Resident 1 and Resident 2's missed showers, and no documentation of a refusal from either Resident 1 or Resident 2. LN 1 stated Resident 1's preference for a shower over a bed bath should have been honored. LN 1 indicated residents missing their showers could cause residents to become dirty, smell bad, and placed residents at risk for skin breakdown and complications. During a concurrent interview and record review with the Director of Staff Development (DSD) on 7/2/24 at 4:41 PM, the DSD stated the CNAs were supposed to double check the master shower sheet (A document of all of the showers scheduled for the facility). The DSD stated Resident 2 made a complaint about not receiving her showers. The DSD stated Resident 2 should have received a shower on Sunday 6/15/24, however the shower was missed. The DSD stated the risk of Resident 1 and Resident 2 missing their showers could result in issues such as feeling dirty and not wanting to leave their room due to having a foul body odor. The DSD stated showers should have been given as scheduled. The DSD confirmed that this practice of the residents missing their scheduled showers did not meet her expectations of the staff. During an interview with the Administrator on 7/2/24 at 5:00 PM, the Administrator stated her expectation was for all residents to have a shower twice weekly. The Administrator mentioned that showers may be missed under extenuating circumstances however confirmed that was not the case for Resident 1 and Resident 2 missing their showers. Review of the facility policy, Dignity and Respect, revised March 2023 indicated, .Residents shall be treated with dignity and respect at all times .means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Residents shall be groomed as they wish to be groomed . 055833 Page 2 of 2