Health inspection·March 3, 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 observation, interview, and record review, the facility failed to implement appropriate treatment and assessment of bowel elimination for one of four sample residents (Resident 1) when record indicated resident 1 has not had bowel movement (BM) from February 7, 2025, through February 11, 2025. Residents Affected - Few This failure potentially resulted in Resident 1 readmission to the hospital with abnormal vital sign. Findings: A review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included neurogenic bowel (a condition where the nerves that control bowel function are damaged or impaired, leading to abnormal bowel movements). A review of Clinical admission record dated February 7, 2025, indicated Last BM January 27, 2025. A review of the bowel elimination records for February 7, 8, 9, 10, and 11 of 2025 revealed that the chart indicated a mark of number 2, signifying the absence of bowel movements. A review Resident 1's Medical Administration Record (MAR) for February 2025 revealed the following: a. Senna Oral Tablet 8.6 mg was prescribed to be taken as 1 tablet by mouth at bedtime for bowel regularity. It was administered on February 8, 9, and 10, 2025, at 9:00 PM. b. Docusate Sodium Oral Capsule 250 mg was indicated to be taken as 1 capsule by mouth twice daily for stool softening. This medication was administered on February 8, 9, and 10, 2025, at 9:00 AM and 5:00 PM. c.Bisacodyl Suppository 10 mg, intended for rectal insertion of 1 suppository (a solid medical preparation in a roughly conical or cylindrical shape, designed to be inserted into the rectum) every 24 hours as needed for constipation, was not administered. d. Lactulose Oral Solution 20 gm/30mL (gm/mL- gram per milliliter is a measurement of a solution's concentration) was prescribed to be taken as 30 ml by mouth every 6 hours as needed for constipation. It was administered only once on February 10, 2025, at 12:08 PM. During concurrent interview and record review on March 3, 2025, at 12:40 PM, with the Director of Page 1 of 2 055693 055693 03/03/2025 Ontario Grove Healthcare & Wellness Centre, LP 933 E Deodar St Ontario, CA 91764

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing (DON 1), Resident 1' MAR was reviewed. The DON 1 indicated that the suppository had not been administered and expressed her belief that the Licensed Vocational Nurse (LVN) failed to document the resident's lack of bowel movements over several days, possibly due to not receiving a report from the Certified Nursing Assistant (CNA). Additionally, the DON 1 noted that the LVN may not have reviewed the resident's bowel movement records. The MAR revealed that on February 10, 2025, a PRN (as needed) dose of lactulose was administered; however, no nursing notes or reports were made to the physician concerning the resident's absence of bowel movements for multiple days. A review of the facility Policy & Procedure (P&P) titled, Bowel and Bladder Training/Toileting Program , dated August 21, 2020, indicated, .v. Pharmacological Interventions. a. The Resident's physician will give orders (interventions) for a medication regimen. The licensed nurse will carry out the orders. 055693 Page 2 of 2