The Pavilion At Sunny Hills

The facility failed to monitor Resident 1 after the resident was identified to have retained urine on 1/18/26.

These failures had the potential to negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Physician Orders revised 5/2019 showed whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order.

Review of the facility's P&P titled Bowel and Bladder Retraining dated 2/2023 showed the interdisciplinary team provide appropriate and sufficient services and assistance to:a. maintain bladder continence and/or bowel function in continent residents;b. restore bladder continents and/or bowel function as possible based on a comprehensive assessment and clinical condition;c. prevent urinary tractions to the extent possible;d. ensure that a resident is not catheterized unless required by his/her clinical condition; ande. ensure that a urinary catheter is removed as soon as possible unless the catheter is necessary because of the residence clinical condition. 1.

Each resident's continence status is assessed at admission and as needed such as when there is a change in urinary tract function. 2.

The continence assessment may include but is not limited to:a. prior history of bladder functioning and previous treatment and/or management, including the response to interventions and the occurrence of persistent or recurrent UTI (urinary tract infection);b. voiding patterns (such as frequency, volume, nighttime or daytime, quality of stream) and for those already experiencing urinary incontinence, voiding patterns over several days.

Closed medical record review for Resident 1 was initiated on 3/17/26. Resident 1 was admitted to the facility on [DATE], and discharged on 2/25/26.

Review of Resident 1's Plan of Care for January 2026 did not show a care plan problem for urinary retention.

Review of Resident 1's Order Summary Report dated 1/15/26, showed a physician's order to check PVR Q six hours x (times) three days. I/O (catheter if PVR greater than 250 cc.

Notify MD if two or more consecutive catheterizations, every six hours for three days.

Review of Resident 1's Medication Administration Record dated 1/18/26 at 1200 hours, showed the PVR was 337 cc.

Further review of the Medication Administration Record showed this was the last documented PVR sequence.

Review of Resident 1's Progress Note dated 1/18/26, showed no documentation an I/O catheterization was performed, as ordered by the physician, for a PVR of 337 cc.

Review of Resident 1's closed medical record for 1/18/26 at 1200 hours, did not show Resident 1 was reassessed after retaining 337 cc of urine.

Further review of the record did not show an I/O catheterization was performed per physician's order, the physician was not notified of the retention, and no further monitoring was conducted. On 3/25/26 at 0900 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with RN 1. RN 1 stated if the resident was still retaining urine after three days, the physician should be notified, there should be reassessment, monitoring, and a care plan problem should be created. RN 1 stated the monitoring would include an assessment for the abdomen tenderness, the amount or urine the resident was voiding, and if briefs were saturated or scant. RN 1 verified the above findings. On 3/26/26 at 1325 hours, the Administrator, Administrator Assistant, ADON, and DON were notified and acknowledged the above findings.

555733 03/26/2026

The Pavilion at Sunny Hills 2222 N.

Harbor Blvd.

Fullerton, CA 92835

Review of Resident 1's Weight and Vitals Summary showed the following weights:- dated, 1/15/26, a weight of 187 lbs.;- dated 1/24/26, a weight of 180 lbs.;- dated 2/1/26, a weight of 175 lbs ; (-5% change, comparison weight 1/15/26, 187 lbs., -6.4%, -12 lbs.)- dated 2/8/26, a weight of 175 lbs.

Review of Resident 1's Nutritional Assessment/Evaluation dated 1/21/26, showed the resident's goal weight was 185-190 lbs.

Further review showed the rate of unplanned weight gain/loss showed no weight change was checked off.

Review of Resident 1's IDT Progress Note for Weight Variance and Nutritional Condition dated 2/9/26, showed the resident's Wt.175 lbs. (2/8/26), no change x 1 week, -5# x 2 weeks, -12# 6% x 3 weeks since admission. On 3/25/26 at 1407 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the RD.

The RD stated she received copies of the weekly weights.

When asked if a seven pound weight loss in nine days would be concerning and require a follow-up, the RD stated, Yes.

When asked when she followed up on Resident 1, RD stated on 2/9/26. RD further stated ideally she should have followed up Resident 1.

When asked if Resident 1 had significant weight loss, RD stated Yes, it was six percent from admission. On 3/26/26 at 1325 hours, the Administrator, Administrator Assistant, ADON, and DON were informed and acknowledged the above findings.