Health inspection·December 26, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to consistently schedule and document quarterly Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care), care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents plan of care) for three of three sampled residents (Resident 1, Resident 2, and Resident 3). These failures had the potential for unmet care needs for Resident 1, Resident 2, and Resident 3. Findings: 1. A review of Resident 1's admission RECORD, indicated she was admitted to the facility in September of 2021, with diagnoses which included unspecified dementia (condition characterized by memory disorders, personality changes and impaired reasoning), and psychotic disorder with delusions (a mental disorder characterized by disconnection from reality). A review of Resident 1's clinical document titled, Multidisciplinary Care Conference v.3, dated 9/29/22, indicated there was no entry in the following sections: .Meeting Date and Time .Attendees .RESIDENT/RESIDENT REPRESENTATIVE .conference notification .Nursing .Care Plan Review .Social Services . The final page was unsigned. A review of Resident 1's clinical document titled, Multidisciplinary Care Conference v.3, dated 12/20/22, at 10:45 a.m., indicated, RESIDENT/RESIDENTS REPRESENTATIVE .conference notification, was blank. The section titled, Activity, was blank. the section titled, Nursing .Care Plan Review . was blank. The final page was unsigned. A review of Resident 1's clinical document titled, Multidisciplinary Care Conference v.3, dated 3/22/23, at 11:00 a.m., indicated no entry in the section, Nursing .Care Plan Review . Resident 1's electronic health record had no documentation of care conferences for the months of June or September of 2023. During a concurrent interview and record review on 12/26/23, at 12:11 PM, licensed nurse (LN) 1 stated care conferences were held quarterly for all long-term care residents. LN 1 confirmed Resident 1 did not have a care conference documented after 3/22/23. LN 1 stated she was not sure why the conferences were not completed in June and September of 2023. 2. A review of Resident 2's admission RECORD, indicated she was admitted in March of 2021 with Page 1 of 3 555245 555245 12/26/2023 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebrovascular accident (stroke) affecting right dominant side and dysphagia (difficulty swallowing). A review of Resident 2's clinical document titled, Multidisciplinary Care Conference v.3, dated 5/24/23, had no entries in the following sections: .Meeting Date and Time .Attendees .RESIDENT/RESDEINTS REPRESENTATIVE .conference notification .Nursing .Care Plan Review .Social Services . The final page was unsigned. A review of Resident 2's clinical document titled, Multidisciplinary Care Conference v.3, dated 11/16/23, had no entries in the following sections: .Meeting Date and Time .Attendees .RESIDENT/RESIDENTS REPRESENTATIVE .conference notification .Nursing .Care Plan Review . The final page was unsigned. Resident 2's electronic health record had no documentation of a care conference for the month of August 2023. 3. A review of Resident 3's admission RECORD, indicated she was admitted to the facility in June of 2022, with diagnoses which included, senile degeneration of the brain (condition characterized by memory disorders, personality changes and impaired reasoning). A review of Resident 3's clinical document titled, Multidisciplinary Care Conference v.3, dated 12/11/23, indicated, .Meeting Date and Time 12/11/23 11:00 . The section titled, Nursing .Care Plan Review . was blank. The section titled, Social Services, was blank. The section titled, Activity, was blank. Resident 3's electronic health record had no documentation of a care conference for the month of June 2023. During an interview on 12/26/23, at 12:47 PM, the Social Services Director (SSD), stated there had been only one social worker for a period of several months. The SSD stated during that time they prioritized short term resident care conferences. The SSD further stated long term care residents did not change that much. The SSD stated the purpose of the care conference was to make sure nothing had changed, to keep contact with families and to provide updates on the plan of care. The SSD further stated the care plan and any changes in resident preferences were updated during the care conference. During an interview on 12/26/23, at 1:10 PM, the Director of Nurses (DON), the DON stated the purpose of the care conference was to review the plan of care and update the family on the resident's condition, identify issues and new goals for all departments. The DON further stated it was her expectation that care conferences would occur every quarter. During a concurrent interview and record review on 12/26/23, at 4:12 PM, the DON confirmed Resident 1 should have had care conferences in June and September of 2023 and did not. The DON confirmed Resident 2 should have had a care conference in August of 2023 and did not. The DON confirmed Resident 3 should have had a care conference in June of 2023 and did not. During an interview on 12/26/23, at 2:10 PM, the Administrator (ADM) stated the purpose of the care conference was to keep families up to date on the residents stay. The ADM further stated care conferences were attended by the IDT which consisted of nursing, social services, dietary, activities, therapy, and the family. 555245 Page 2 of 3 555245 12/26/2023 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/27/23, at 12:55 PM, the Social Services Assistant (SSA) stated care conferences were scheduled every quarter and annually. The SSA confirmed there were several months when care conferences had not occurred for long term care residents . The SSA further stated the process during the care plan conference was for each department to review the care plans for their specific areas to ensure residents met their goals and to make the appropriate updates. The SSA stated after each department had completed their portion the final page of the form was signed and the document was locked in the electronic health record. The SSA confirmed missed care conferences and incomplete documentation of care conferences for Resident 1, Resident 2, and Resident 3. A review of a facility policy and procedure (P&P) titled, Care Planning – Interdisciplinary Team, revised September 2013, indicated, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .The care plan is .developed by a Care Planning/Interdisciplinary Team which includes, but is not limited to .The residents Attending Physician, The Registered Nurse responsible for the resident, The Dietary Manager/Dietician, The social services worker .The Activity Director/Coordinator, Therapists .Consultants .The Director Of Nursing .The Charge Nurse .Nursing Assistants .Others as appropriate .the resident and residents family .are encouraged to participate .Every effort will be made to schedule care plan meetings at the best time of day for the resident and the family . A review of a facility P&P titled, Resident Participation-Assessment/Care Plans, revised December 2016, indicated, .The care planning process will: Facilitate the inclusion of the resident and /or representative; Include the assessment of the resident's strengths and his or her needs: Incorporate the resident's personal and cultural preferences in establishing goals of care .a seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative . 555245 Page 3 of 3