Health inspection·November 18, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review failed to implement a comprehensive care plan (a guide that healthcare workers used to ensure residents receive tailored care to meet individual needs and goals) for one of four sampled residents (Resident 1) when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions).Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when the kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to generate a plan of care) . Section GG - functional status, dated 11/5/25, indicated there was impairment on one side of the upper extremity (shoulder, elbow, wrist, hand).A review of Resident 1's clinical record titled, Order Summary Report, dated 11/18/25, the order summary indicated, .Triamterene & Hydrochlorothiazide [a combination of two diuretic medications to assist the body of eliminating excess salt and potassium from the body, and increase urine flow, which reduces blood pressure] .1 tablet by mouth one time a day.A review of Resident 1's dehydration care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to meet individual needs and goals), the care plan indicated, .offer and encourage snack/fluids between meals.During a concurrent observation and interview on 11/18/25 at 9:15 a.m., with Resident 1, Resident 1 was observed in bed, and his water pitcher was on the dresser to the left of Resident 1's side of the bed and the straw was still wrapped in the paper wrapping. Resident 1 stated he could not reach his water pitcher.During a concurrent observation and interview on 11/18/25 at 1:55 p.m., with Licensed Nurse (LN) 1, LN 1 verified Resident 1's water pitcher was on the dresser out of Resident 1's reach. LN 1 stated that he was on diuretic medications (drugs that help kidneys remove extra salt and water from the body via urine output) and he was at risk for dehydration.During an interview on 11/18/25 at 2:45 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation for Resident 1 to have the water within reach. ADON further stated all of the residents should have water within reach as long as they do not have any fluid restrictions (when too much water would cause harm to the resident due to their diagnosis) or any contraindications (a physician's order for no fluid because of upcoming medical procedure).During a review of the facility's policy and procedure (P&P) titled, Hydration the P&P indicated, . the facility offers each resident sufficient fluid, including water and other liquids.to maintain proper hydration and health.ensure beverages are available and within reach. Page 1 of 2 555164 555164 11/18/2025 Arbor Rehabilitation & Nursing Center 900 North Church Street Lodi, CA 95240

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 1) hydration requirements were met when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions) and could have led to illness or kidney injury. Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when your kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to plan care) . Section GG - functional status, dated 11/5/25, indicated Resident 1 had impairment on one side of upper extremity (shoulder, elbow, wrist, hand).A review of Resident 1's clinical record titled, Order Summary Report, dated 11/18/25, the order summary indicated, .Triamterene & Hydrochlorothiazide [a combination of two diuretic medications to assist the body of eliminating excess salt and potassium from the body, and increase urine flow, which reduces blood pressure] .1 tablet by mouth one time a day.A review of Resident 1's dehydration care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to meet individual needs and goals), the care plan indicated, .offer and encourage snack/fluids between meals.During a concurrent observation and interview on 11/18/25 at 9:15 a.m., with Resident 1, Resident 1 was observed in bed, his water pitcher was on the dresser to the left of Resident 1's side of the bed and the straw was still wrapped in the paper wrapping. Resident 1 stated he could not reach his water pitcher.During a concurrent observation and interview on 11/18/25 at 1:55 p.m., with Licensed Nurse (LN) 1, LN 1 verified Resident 1's water pitcher was observed on the dresser and out of Resident 1. LN 1 stated that he was on diuretic medications (drugs that help the kidneys remove extra salt and water from the body via urine output) and that Resident 1 was at risk for dehydration.During an interview on 11/18/25 at 2:45 p.m. with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation for Resident 1 to have water within reach. ADON further stated all residents should have had water within reach as long as they do not have any fluid restrictions (when too much water would cause harm to the resident due to their diagnosis) or contraindications (a physician's order for no fluid because of upcoming medical procedure).During a review of the facility's policy and procedure (P&P) titled, Hydration the P&P indicated, . the facility offers each resident sufficient fluid, including water and other liquids.to maintain proper hydration and health.ensure beverages are available and within reach. Residents Affected - Few 555164 Page 2 of 2