Health inspection·February 9, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report hypotension (blood pressure less than 100/60 mm/Hg) to physician for one of two sampled residents (Resident 1).This failure resulted in Resident 1 being found hypotensive with a blood pressure of 76/44 and altered mental status (a sudden or gradual change in a person's baseline mental state, including confusion, decreased alertness, or disorientation).During record review of admission record, printed on 2/5/26, Resident 1 was admitted on [DATE].During record review of Resident 1's Minimum Data Set (MDS, an assessment used to guide care) dated 12/4/25, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 15 out of 15, indicated Resident 1's cognition intact.During a review of Resident 1's Care Plan Report, initiated 12/5/25, the report indicated, [resident 1] has altered cardiovascular status r/t persistent.hypotension . The ‘Goals' within the care plan indicated, Resident 1 will be free from complication of cardiac problems through the review date.During a review of Resident 1's Order Listing Report, initiated 12/1/25, the report indicated, Metoprolol Tartrate Oral Tablet 100 MG (Metoprolol Pharmacy Tartrate) Give 2 tablets by mouth at bedtime for HTN. Hold if SBP <100 or HR <60. During a review of Resident 1's Weights and Vitals Summary, dated 12/1/25 to 12/9/25, the summary indicated ten separate instances where Resident 1's SBP was less than 100 mm/Hg and not reported to physician. During a review of Resident 1's Change of Condition documentation, dated 12/9/25 at 10:41 p.m., the documentation indicated Resident 1 noted with hypotension but asymptomatic and altered mental status.noted to have hypotension after routine night medications around 2030. Current blood pressure measured at 75/44, Pulse: 76 at 11:30 p.m.Rechecked blood pressure several times mostly in range of 73-85 systolic and 37-46 diastolic.During an interview on 2/2/26, at 1:20 p.m., Licensed Vocational Nurse (LVN) 2 stated a low and reportable blood pressure is systolic blood pressure (SBP; top number in a blood pressure reading indicating the pressure in arteries when the heart contracts) less than 90 millimeters of mercury (mmHg; the standard medical unit used to measure blood pressure). LVN 2 stated a SBP less than 90 mmHg warranted a blood pressure recheck and communication to the physician, once blood pressure is confirmed. LVN 2 stated blood pressure should be assessed before and after any blood pressure medications were given to ensure resident safety and to assess for hypotension and hypertension. During a concurrent interview and record review on 2/2/26, at 1:36 p.m., Assistant Director of Nursing (ADON) stated blood pressure should be assessed before blood pressure medication administration, despite physician order for vital sign frequency. ADON stated Resident 1's blood pressure readings of 90/56 mm/Hg on 12/2/25 at 9:56 p.m., 86/56 mm/Hg on 12/8/25 at 6:58 p.m., and 86/56 mm/Hg at 10:20 p.m. should have been reported to physician. ADON stated there was no documentation that indicated the physician was notified of two instances of hypotension on 12/8/25. ADON stated it was very critical to report hypotension to physician, so physician is aware. During a concurrent interview and record review Page 1 of 3 055562 055562 02/09/2026 Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 2/9/26, at 10:32 a.m., Director of Nursing (DON) stated a reportable blood pressure was defined in physician orders. DON stated nurses should follow physician ordered parameters despite Blood Pressure Measuring policy and procedure (P&P) indicating to report hypotension to physician, and Guidelines for Notifying Physicians of Clinical Problems indicating BP<90 systolic. DON stated importance of reporting hypotension to physician was to ensure physicians were aware of resident blood pressure assessment. During a review of Resident 1's Facesheet, printed 2/18/26, the face sheet indicated Resident 1 was admitted to [General Acute Care Hospital-GACH] on 12/9/25 at 11:10 p.m. due to low blood pressure and confusion. During a review of Resident 1's Physical Exam note, done at GACH and printed 2/18/26, the physical exam note indicated on 12/9/25 at 11:45 p.m. Resident 1's blood pressure was 87/39 mmHg. During a review of the facility's policy and procedure (P&P) titled, Blood Pressure, Measuring, the P&P indicated, Hypotension is defined as blood pressure less than 100/60 mm/Hg, . Hypotension should be reported to the physician.During a review of the facility's guidelines titled, Guidelines for Notifying Physicians of Clinical Problems, the guidelines indicated, these guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely manner, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record,. Change in vital signs. Follow these general guidelines.Blood pressure <90 systolic. 055562 Page 2 of 3 055562 02/09/2026 Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 held Basic Life Support (BLS; a professional credential verifying training in life-saving techniques for healthcare providers and public safety personnel) certification.This failure had the potential to result in residents' increased risk of adverse events during life-threatening, cardiac or respiratory emergencies. During a review of LVN 1's competency and skills folder, the BLS certification indicated, Renew by 07/2024.During a concurrent interview and record review on [DATE], at 2:16 p.m., the Director of Staff Development (DSD) stated LVN's need BLS and cardiopulmonary resuscitation (CPR; emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) training. DSD stated importance of BLS is to ensure staff competency in life saving measures in the event of a critical situation.During a review of the facility's policy and procedure (P&P) titled, Emergency Procedures-Cardiopulmonary Resuscitation, the P&P indicated, Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Preparation for Cardiopulmonary Resuscitation.Obtain and/or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) that adheres to the American Heart Association Guidelines for all clinical staff members, including non--licensed personnel. 055562 Page 3 of 3