Health inspection·October 22, 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, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 1's physician was notified when Resident 1's urine color changed from yellow to dark amber. This failure had the potential for not providing the necessary care and services when the resident had a change in condition. Findings: Review of the facility's P&P title Notification of Changes revised dated [DATE], showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted to the facility on [DATE], and expired on [DATE]. Review of Resident 1's progress note dated [DATE], showed a nursing entry regarding Resident 1's dark colored urine output. However, further review of Resident 1's medical record failed to show if Resident 1's physician was notified when Resident 1 had dark colored urine output. On [DATE] at 1445 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated at the beginning of her shift on [DATE], she assessed Resident 1's urine color, which was yellow and clear. However, at the end of the shift LVN 1 observed Resident 1 had dark amber colored urine. LVN 1 stated she documented her observation on the resident's progress notes but did not report the resident's change in condition to the physician. LVN 1 stated she should have reported the change in the color of the urine of the resident to Resident 1's physician. LVN 1 verified there was no documentation to show Resident 1's physician was notified of Resident 1's dark amber colored urine. On [DATE] at 0937 hours, an interview was conducted with the PA . The PA was asked if he was notified of Resident 1's dark colored urine on [DATE]. The PA stated he could not recall if he was notified or not. The PA stated if he was notified then it would be documented in the Resident 1's medical record. On [DATE] at 1530 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified there was no documented evidence to show Resident 1's physician was notified about the resident's dark colored urine on [DATE]. The DON was informed and verified the above findings. Residents Affected - Few Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055622 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055622 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)