Health inspection·November 20, 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 observations, interviews and record reviews the facility failed to ensure the Speech Therapist's ST - a speech language pathologist who assess and treat people who have speech, language, voice and swallowing disorders) recommendation was followed for 1 (one) of 9 (nine) residents (Resident 22), since June 27, 2025.This failure had the potential to place Resident 22's health at risk and to miss identifying any undetected disease.During a review of Resident 22's admission Record (contains demographic and medical information), it indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), moderate protein calorie malnutrition (poor intake leading to weight loss or weakness) and dementia (a group of diseases and illnesses that affect thinking, memory, reasoning, personality, mood and behavior). During a concurrent observation and interview on November 17, 2025, at 9:42 AM, with Resident 22, inside her room, Resident 22 was awake. Resident 22 reported she had difficulty swallowing her food and required hot drinks to soften foods. Resident 22 further stated she had to constantly remind the staff to provide hot drinks. Resident 22 stated her mouth feels extremely dry and she struggles to produce moisture. Resident 22 reported she kept telling the staff, when they pick up her meal tray, that she cannot swallow her food, but stated, they (staff) don't do anything about it.During an interview on November 19, 2025, at 9:18 AM, with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 22 usually request hot water and sugar for tea with meals. During an interview on November 19, 2025, at 10:05 AM, with the Director of Nursing (DON), the DON reported that Resident 22 eat poorly, sometimes due to not liking the food and preferring only tea. The DON stated on June 27, 2025, Resident 22 was evaluated by the speech therapist and was placed on an IDDSI (International Dysphagia Diet Standardization Initiative - a global standard to describe texture modified foods and thickened liquids used for individuals with dysphagia) diet level; however, the resident had not reported swallowing issues until yesterday [November 18, 2025]. The DON stated her expectation is for the CNAs to notify the nurses if they observed anything concerning, such as poor intake when they pick up meal trays. The DON acknowledged Resident 22's meal percentages are sometimes as low as 10% but could not identify any specific interventions implemented in response to poor intake. The DON further stated snacks are provided by dietary department. During an interview on November 19, 2025, with the License Clinical Psychologist (LCP), the LCP stated Resident 22 had longstanding complaints of difficulty swallowing and dry mouth for as long as I have known her. The LCP reported Resident 22 continues to voice swallowing concerns to nursing staff and that the nurses are aware of these ongoing complaints. During a review of Resident 22's Physician Orders, it indicated Fortified Diet IDDSI 7: Easy to chew texture (soft, tender food texture), IDDSI 0: Thin (liquid) consistency, **extra gravy on all meat, Extra 8 oz (ounce- unit of measurement) fluids on all trays. dated August 25, 2025. During a review of Resident 22's SLP Evaluation and Plan of Treatment, dated June 27, 2025, it indicated, Patient Referral and History.Current Referral: Reason for Referral/ Residents Affected - Few Page 1 of 5 555025 555025 11/20/2025 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Current Illness. Pt [patient] referred to skilled ST (Speech Therapy) due to difficulty with swallowing and aspiration precautions.Previous tests: Prior MBS (Modified Barium Swallow- a test used to check a person's ability to swallow)/FEES (Fiberoptic Endoscopic Evaluation of Swallowing - a procedure used to assess swallowing)/GI (Gastrointestinal)/ENT (Ears, Nose and Throat)= No. Assessment Summary. Clinical Impressions.Pt reports concern about xerostomia (dryness of her mouth) and food getting stuck. Pt independently uses liquids mixed with textures to help soften food prior to swallowing. Pt has hx [history] of GERD which seems to impact her efficiency in swallowing . Recommendations. Further testing: MBS/FEES/ENT/GI indicated=Yes. During a review of Resident 22's ENT consult, dated June 27, 2025, it indicated, PHYSICAL EXAM. THROAT/MOUTH: very dry mouth, difficulty swallowing and eating and decrease appetite possible due to dryness. During a telephone interview on November 19, 2025, at 6:00 PM, with the Speech Therapist (ST), the ST stated she evaluated Resident 22 on June 27, 2025, and again on November 18, 2025, due to the resident's ongoing complaints of difficulty swallowing. The ST reported she documented recommendations in the electronic record and will usually communicates referral needs to the Rehab Manager for physician follow up. When asked about Resident 22's MBS (Modified Barium Swallow) test listed in her June 27, 2025, evaluation, the ST stated she could not recall whether the facility followed up or if a physician was notified. During an interview on November 20, 2025, at 4:58 PM, with the Director of Nurses (DON), the DON stated referrals such as Modified Barium Swallow (MBS) requires a physician order and are scheduled by social services department, who tracks appointments and follows up on any missed or rescheduled evaluations. The DON further stated her and the social services department maintained a monthly tracking list of all pending and completed referrals to ensure they are not missed. During an interview on November 20, 2025, at 5:06 PM, with the ADON, the ADON confirmed the ST completed an evaluation on June 27, 2025, and recommended a Modified Barium Swallow (MBS) study for Resident 22. When surveyor asked about the follow up, the ADON stated she did not see any documentation indicating whether the physician was notified, whether the recommendation was accepted or declined, or why the MBS study was not completed. ADON acknowledged that there was no documentation in Resident 22's clinical records explaining why the MBS recommendation was not followed through. During a review of the facility's policy and procedure (P&P) titled, Physicians, Consulting, dated January 25, 2025, was reviewed. The P&P indicated, To promote continuity of care. Procedures. 4. If treatment or medication are ordered by the consulting physician, it will communicate to a licensed staff to carry out the new treatment order. 555025 Page 2 of 5 555025 11/20/2025 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a physician's order for RNA (Restorative Nursing Assistant, staff trained to help residents maintain or improve function) to perform AAROM ( active - assisted range of motion) was implemented for one (1) of nine (9) sampled residents (Resident 4) when there was no documented evidence that the AAROM was provided to Resident 4, since October 17, 2025.This failure placed Resident 4 at risk for functional decline due to the inability to verify that restorative nursing services were implemented as ordered.During a review of Resident 4's admission Record (contains demographic and medical information), it indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses of dementia (a group of diseases and illnesses that affect thinking, memory, reasoning, personality, mood and behavior), fracture of the lower end right radius (broken wrist bone that is healing but still requires exercises to restore movement and prevent stiffness), muscle weakness (a condition in which muscles are weak, making harder for the resident to perform movements or regain strength after an injury).During a record review of the Resident 4's SBAR-Change of Condition Report (Situation-Background-Assessment-Recommendation- a structured communication tool that helps to share information about the condition of a patient or issue that needs to be address), dated June 11, 2025, the SBAR indicated, A. Situation. 2. Witnessed fall in hallway., C. Assessment. 1. Assess Resident's signs/symptoms. she (Resident 4) was seen catch her foot on from of wc (wheelchair), causing her to fall on R (right) side landing on R wrist and then bumping forehead on w/c (wheelchair)., c/o (complain of) pain 7/10 to R wrist.During a review of Resident 4's Care Plan (a plan that serves as a guide, outlining the patient's health needs, the desired outcomes, and the necessary actions to achieve those outcomes), dated October 16, 2025, the care plan indicated, Resident is on restorative nursing program to maintain current functional status. Goal. will maintain current level of functioning through next review date. Interventions/Tasks. RNA for AAROM (active - assisted range of motion) exercises to bilateral UE/LE (upper and lower extremities) QD (daily) 3 x (three- times) week as tolerated.During a review of Resident 4's physicians order, dated October 16, 2025, it indicated, RNA(Restorative Nursing Assistant, staff trained to help residents maintain or improve function) for AAROM (Active - Assisted Range of Motion, exercises where staff help the resident move their joints) exercises to bilateral UE(upper extremities)/LE (lower extremities) QD (daily) 3 x(three times)/week as tolerated. every Mon, (Monday), Wed (Wednesday) and Fri (Friday).During an observation on November 18, 2025, at 1:55 PM, Resident 4 was seated in a wheelchair near the nurse's station. Resident 4 was awake and made brief verbal responses; however, she was unable to sustain conversation or describe whether she was receiving any restorative exercises.During a concurrent interview and record review on November 19, 2025, at 2:52 PM, with the Assistant Director of Nurses (ADON), the ADON reviewed Resident 4's RV - Restorative Nursing Summary, in the Electronic Medical Record System (EMR). The ADON could not find documented evidence that RNA provided AAROM treatment to Resident 4. The ADON further stated that the physician's order was not transcribed on the RNA MAR (MAR - Medication Administration Record, a document used to keep an accurate record of the type of medication or treatment and the time it is administered).During a review of the facility's policy and procedure titled, Restorative Nursing Services, dated January 25, 2025, it indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation. 2. Resident may be started on restorative nursing program upon admission, during the course of stay or when discharge from rehabilitative care. 3. Restorative goals and objectives are individualized and 555025 Page 3 of 5 555025 11/20/2025 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0688 Level of Harm - Minimal harm or potential for actual harm resident-centered and are outlined in the residents' plan of care. The ADON was unable to demonstrate that the facility followed the policy, as no documentation existed in the EMR showing that restorative services were provided in accordance with the resident's care plan or physician orders. Residents Affected - Few 555025 Page 4 of 5 555025 11/20/2025 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure resident bedrooms meet the required minimum 80 square feet (sq. Ft) per resident for 19 of 21 rooms measured in the facility (room [ROOM NUMBER]-8 and 11-21). This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms.During an environmental tour with the Maintenance Supervisor (MS), on November 18, 2025, at 4:16 PM, nineteen of the 21 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:1. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.2. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.3. room [ROOM NUMBER], the total floor area measured 292.8 sq ft and four beds occupied the room, which yielded 73.2 sq ft for each resident.4. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.5. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.6. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.7. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.8. room [ROOM NUMBER], the total floor area measured 146.4 sq ft and two beds occupied the room, which yielded 73.2 sq ft for each resident.9. room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident.10. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.11. room [ROOM NUMBER], the total floor area measured 150 sq ft and two beds occupied the room, which yielded 75 sq ft for each resident.12. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.13. room [ROOM NUMBER], the total floor area measured 151.28 sq ft and two beds occupied the room, which yielded 75.64 sq ft for each resident.14. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.15. room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.16. room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident.17 room [ROOM NUMBER], the total floor area measured 155 sq ft and two beds occupied the room, which yielded 77.5 sq ft for each resident.18. room [ROOM NUMBER], the total floor area measured 152.4 sq ft and two beds occupied the room, which yielded 76.2 sq ft for each resident.19. room [ROOM NUMBER], the total floor area measured 139.7 sq ft and two beds occupied the room, which yielded 69.85 sq ft for each resident.During an interview on November 19, 2025, at 4:50 PM with the Administrator, the administrator confirmed that 19 rooms out of 21 did not meet the required minimum 80 square feet (sq. ft) per resident. The administrator reported there had not been no resident complaints regarding the room size and that the facility did not have a policy addressing room - size requirements. During an interview on November 19, 0225, at 4:54 PM with the Maintenance Supervisor, the maintenance supervisor confirmed the measurements taken were accurate. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. 555025 Page 5 of 5