Health inspection·February 18, 2026

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 and record review, the facility failed to ensure care and treatment was provided, for one of four residents reviewed (Resident A), when Resident A had high blood pressure.This failure had potential for a delay in the care and treatment to address Resident A's high blood pressure and could affect the resident's overall health condition.Findings:On January 27, 2026, at 9:15 a.m., an unannounced visit was conducted to investigate a quality-of-care issue.On January 27, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure).A review of Resident A's Order Summary Report, included a physician's order, dated November 18, 2024, which indicated, .Terazosin HCL (medicate to treat high blood pressure) Oral Capsule 1 (one) MG (milligram - unit of measurement).Give 1 (one) capsule by mouth at bedtime for systolic (the first (top/upper) number) of > (more than) 140.A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated November 25, 2025, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 9 (impaired cognitive status).A review of Resident A's eINTERACT Change in Condition Evaluation, dated January 14, 2026, at 2:38 p.m., indicated, .Tachycardia (elevated heart rate), increased BP (blood pressure), decreased BP, c/o dizziness and shakiness.Resident had c/o (complaint of) feeling dizzy and shaky. VS (vital signs) were obtained to be as follows: at 0943am (9:43 a.m.) BP 157/122 mmHg (millimeter mercury - unit of measurement).Around afternoon 13:21 (1:31 p.m.) resident still c/o dizziness and shakiness with BP of 78/59 mmHg, Notified (name of physician) immediately with order to send out resident to ER for further evaluation.On January 27, 2026, at 2:39 p.m., during an interview conducted with the Registered Nurse (RN), she stated she was the licensed nurse in charge of Resident A when the resident was sent out to the hospital on January 14, 2026. The RN stated the following:-She was passing the morning medications for the residents in Station 2, and Resident A was complaining of dizziness and shakiness, and the resident's BP was obtained and indicated it was high at about 150/120 (could not recall the exact BP reading);-She notified the physician around 9:40 a.m., and received orders to monitor the resident and give supplemental oxygen, and obtain medical history from the resident. However, Resident A refused the oxygen.-She notified the physician around 1 p.m., that Resident A refused the oxygen, had history of stroke, and the BP taken was 78/59 with heart rate of 120 (normal range is 60 to 100 beats per minute). The physician ordered to send out Resident A to the acute hospital;-She stated she did not monitor or check Resident A's BP from 9 a.m. when the elevated BP was initially identified, not until 1 p.m., when the BP was low and had a high heart rate. She stated she should have closely monitored the resident's BP, frequently checked on the resident's status, and notified the physician timely.On January 27, 2026, at 4:15 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the following:-The RN notified her of Resident A's high blood pressure after 10 a.m., and advised the RN to call the physician; and-She Residents Affected - Few Page 1 of 2 555747 555747 02/18/2026 Murrieta Health and Rehabilitation Center 24100 Monroe Avenue Murrieta, CA 92562

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few expected the licensed nurse (LN) to call the physician if the resident's BP was high and with accompanying symptoms such as shaking and dizziness, to obtain a PRN (as needed) medication to address the high BP. The LN should monitor the resident's BP at least every hour, follow up with the physician and send the resident to the acute hospital for further evaluation if appropriate.A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .The blood pressure is generally defined as Normal when the systolic pressure is in the range of 101 to 129 mm/Hg and the diastolic pressure (the lower/bottom number) is in the range of 61 to 84 mm/Hg.Hypertension is usually defined as blood pressure over 140/90 mm/Hg.Hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day. Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician.Hypotension is defined as blood pressure less than 100/60 mm/Hg.Hypotension should be reported to the physician.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated February 2021, indicated, .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.the nurse will notify the resident's attending physician or physician on call when there has been a(an).need to alter the resident's medical treatment significantly.A review of the facility's undated policy and procedure titled, Emergency Physician Care, indicated, .Should the resident's attending physician be unavailable, the nurse supervisor/charge nurse must first attempt to contact the physician's designated referral physician or practitioner.should the designated referral physician be unavailable to assist in the emergency, the on-call physician or medical director shall be contacted. 555747 Page 2 of 2