Health inspection·August 12, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of five residents reviewed (Resident 50), the facility failed to ensure a change of condition was identified when Resident 5 had a decline in Activities of Daily Living (ADL) requiring total assistance in eating on July 18 and 19, 2025, and the meal intake was 50% or below on July 19, 2025.This failure had the potential to contribute to a delay in the care and treatment to address Resident 5's change of condition and affect the resident's overall health condition. Findings:On August 11, 2025, at 10:21 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care issue.On August 12, 2025, Resident 5's record was reviewed. Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease), diabetes mellitus (abnormal blood sugar) and heart failure.A review of Resident 5's Progress Notes, documented by the physician, on July 17, 2025, indicated Resident 5 had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS a resident assessment tool, dated July 19, 2025, indicated the following:-BIMS (Brief Interview of Mental Status) score of 12 (cognitively intact); and-Required supervision or touching assistance in eating.A review of Resident 5's care plan, dated July 16, 2025, indicated,- .Self care deficit related to inability to independently perform ADL's.Legend.S=Supervision.Eating.S.;- .Altered Nutrition.Goal: will eat greater than 75% .Interventions.Assist/feed resident.A review of Resident 5's Nutrition Amount Eaten Documentation Survey Report, indicated the following amount eaten:- .July 17, 2025.7 am.100% .;- .July 17, 2025.12 pm.100% .;- .July 17, 2025.5 pm.100% .;- .July 18, 2025.7 am.75% .;- .July 18, 2025.12 pm.75% .;- .July 18, 2025.5 pm.100% .;- .July 19, 2025,.7 am.50% .; and .July 19, 2025.12 pm.25% .A review of Resident 5's SBAR (Situation Background Assessment Record) Communication Form and Progress Note, dated July 19, 2025, at 10:52 p.m., indicated, .the change in condition.Resident unable to answer simple questions.unable to get words out.lethargic (a state of feeling tired, sluggish, and lacking energy).started on July 19, 2025 at 5:00 pm.Resident noted to have reduced movement, reduced alertness, cannot speak or get words out.resident unable to answer stroke (a medical emergency that occurs when blood flow to the brain is interrupted).MD (physician) notified, ordered to send out for eval (evaluation).A review of Resident 5's Order Summary Report, dated July 19, 2025, at 11:29 p.m., indicated, .Resident sent out (name of general acute hospital).rule out Stroke.A review of Resident 5's MDS section GG, indicated the following self-performance level in eating for the following dates:- July 17, 2025.8:21 am.independent.;- July 18, 2025.5:07 pm.set up assistance.;- July 19, 2025.12:20 pm.dependent.; andJuly 19, 2025.2:41 pm.dependent.On August 12, 2025, at 4:15 p.m., during an interview conducted with Certified Nursing Assistant (CNA) 1, she stated she was assigned to Resident 5 on July 19, 2025, 3 p.m. to 11 p.m. CNA 1 stated resident 5 was quiet, and not talkative, and had family visiting that evening. CNA 1 stated she went on her lunch break and returned around 7:30 p.m., and the paramedics were there to Residents Affected - Few Page 1 of 2 055474 055474 08/12/2025 Woodcrest Post Acute & Rehabilitation 8133 Magnolia Avenue Riverside, CA 92504

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfer her to the hospital.On August 12, 2025, at 5:30 p.m., a concurrent interview and record review of Resident 5's record was conducted with the Director of Nursing (DON). The DON stated when they notice a change of condition, the CNA should report it to the charge nurse. The DON stated if there is a change of condition from day shift it should be endorsed to the following shift. The DON stated Resident 5 had a decrease in meal intake or meal percentage on July 19, 2025, starting at breakfast meal at 50% and 25%, respectively for breakfast and lunch.the DON stated Resident 5 was dependent in eating, started on July 18, 2025, which was a decline when she was initially admitted on [DATE]. The DON stated the decrease in Resident 5's food intake and decline in ADL need in eating would be considered a change of condition and the doctor should have been notified.On August 18, 2025, at 12:32 p.m., during a phone interview conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the Licensed Nurse (LN) assigned to Resident 5 on July 19, 2025, from 3 p.m. to 11 p.m. LVN 1 stated there was no endorsement from the morning shift LN of any changes with Resident 5. LVN 1 stated when she was passing the medications and reached Resident 5's room, the resident was observed to be lethargic. LVN 1 stated the vital signs were stable, but Resident 5 was not able to answer questions. LVN 1 stated she verified with the family member present at bedside if that was normal for the resident, and the family member stated that was not normal for the resident. LVN 1 stated she was not sure of the time she was able to send out Resident 5 to the acute hospital. LVN 1 stated the physician should have been notified when Resident 5 had a decrease in meal intake as this was a change of condition. On August 18, 2025, at 4:55 p.m., during a phone interview with LVN 2, LVN 2 stated she was the LN assigned to the resident the morning shift of July 19, 2025. LVN 2 stated she did not recall the CAN notifying her of Resident 5's decrease in food intake. LVN 2 stated she did not recall Resident 5's family member reporting to her that Resident 5 was not her usual self. LVN 2 stated the physician should have been notified if the resident had a poor food intake or a decrease from previous meals. A review of the facility's policy and procedure titled, Acute Condition Changes- Clinical Protocol, revised date March 2023, indicated, .Direct care staff .including nursing assistants .recognizing subtle .significant changes .decrease in food intake .how to communicate .to the nurse . and, before contacting a physician .with an acute change of condition .nursing staff .collect pertinent details .to report to the physician . 055474 Page 2 of 2