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 Page 1 of 2 055622 055622 10/22/2025 Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631

F 0755 Level of Harm - Potential for minimal harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **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 pharmaceutical services for one of three sampled residents (Resident 1). * The facility failed to ensure the medications were administered as ordered by the physician for Resident 1. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications. Findings: Review of the facility's P&P title Medication Administration revised [DATE], showed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 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 MAR for [DATE] showed two tablets of Tylenol (medication to treat pain and/or fever) was administered to Resident 1 on [DATE], for a temperature of 99 degrees Fahrenheit. Review of Resident 1's Order Summary Report dated [DATE], showed a physician's order dated [DATE], to administer acetaminophen (Tylenol-medication to treat pain and/or fever) 325 mg two tablets via GT every six hours as needed for fever, if the temperature was greater than 100.5 Fahrenheit. On [DATE] at 1445 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified Resident 1 was administered two tablets of Tylenol 325 mg medication on [DATE], for a temperature of 99 degrees Fahrenheit. On [DATE] at 1257 hours, an interview and concurrent closed medical record for Resident 1 was conducted with the QA Nurse. The QA Nurse was informed and verified LVN 1 failed to follow the physician's order when LVN 1 administered two tablets of the Tylenol medication to Resident 1 for a temperature of 99 degrees Fahrenheit. On [DATE] at 1530 hours, an interview was conducted the DON. The DON was informed and acknowledged the above findings. 055622 Page 2 of 2