Inland Valley Care And Rehabilitation Center

F-F641

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 10/24/2022 and readmitted the resident on 1/25/2023 with diagnoses that included psychosis (refers to symptoms that happen when a person is disconnected from reality), muscle wasting, and atrophy (wasting away).

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene.

During a review of Resident 1's Medication Administration Record (MAR, a log initialed and/or signed by the licensed nurse with the date and time a medication was administered to a resident) dated 5/5/2025 to 5/7/2025, the MAR did not indicate Resident 1 had pain.

During a review of Resident 1's Progress Notes (PN), dated 5/6/2025, timed at 7:51 am, the PN indicated at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am). The PN indicated Resident 1 was on two LPM of O2 via NC.

During a review of Resident 1's eINTERACT SBAR form dated 5/6/2025, timed at 8 am, the SBAR indicated RN 3 documented Resident 1 had a COC due to constipation. The SBAR form did not indicate Resident 1 had abdominal distention, firmness, bloating, or pain.

During a review of Resident 1's PN dated 5/6/2025 between 3 pm and 11 pm, the PN did not indicate an abdominal/GI evaluation (assessment) was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of Resident 1's SBAR Communication Form, dated 5/7/2025, timed at 1:06 am, the SBAR indicated Resident 1 had a COC. The SBAR indicated on 5/6/2025 at 10:55 pm, Resident 1 was in bed with Level of Harm - Minimal harm or eyes closed. The SBAR indicated at 11:10 pm, Resident 1 was heard, by LVN 4, calling out for O2. The potential for actual harm SBAR indicated Resident 1's O2 sats was 97 percent (%, unit of measurement) while receiving 3 LPM of O2 via NC. The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on 5/7/2025 Residents Affected - Some between 12:15 am and 12:30 am, Resident 1 complained of 8 out of 10 pain (severe pain) to the abdomen.

The SBAR indicated a GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion [breakdown of food]) evaluation was not done for Resident 1 (section left blank). The SBAR did not indicate Resident 1 was found with coffee-ground emesis (vomiting).

During a telephone interview on 5/7/2025 at 3:37 pm, with LVN 4, LVN 4 stated on 5/6/2025 at 11:10 pm, Resident 1 asked for an increase in oxygen [O2, colorless, odorless gas] because Resident 1, felt like it was hard to breathe. LVN 4 stated LVN 4 increased Resident 1's O2 from 2 liters per minute (LPM, unit of expressed flow rate) to 3 and a half LPM via nasal canula ([NC] a device-lightweight flexible plastic tubing used to deliver supplemental oxygen, tubing ending is placed in the nostrils and is fitted over the patient's ears). LVN 4 stated LVN 4 documented 3 LPM instead of 3 and a half LPM. LVN 4 stated LVN 4 was supposed to document Resident 1's oxygen saturation (measurement that indicates what percentage of blood saturated with oxygen) accurately, so it reflected Resident 1's condition correctly.

During a telephone interview on 5/8/2025 at 9:29 am, with LVN 4 stated LVN 4 forgot to document Resident 1's 8 out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) in Resident 1's MAR and document Resident 1 had coffee-ground emesis. LVN 4 stated it was important to ensure all LVNs documented accurately to reflect Resident 1's condition.

During a telephone interview on 5/8/2025 at 12:36 pm, with RN 3, RN 3 stated on 5/6/2025 at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and feeling pain (unrated) in the abdomen. RN 3 stated Resident 1 had a distended abdomen.

RN 3 stated RN 3 did not document Resident 1 feeling bloated and feeling pain (unrated) in Resident 1's SBAR form dated 5/6/2025, timed at 8 am. RN 3 stated documenting in the medical record helped physicians determine the treatment needed for Resident 1, and the physician orders needed.

During a telephone interview on 5/8/2025 at 2:40 pm, with RN 2, RN 2 stated, on 5/6/2025 before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 complained of abdominal pain. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had severe pain. RN 2 stated, RN 2 did not document the assessment, including Resident 1's pain, performed on Resident 1 in Resident 1's medical record.

During an interview on 5/8/2025 at 4:44 pm, with the DON, the DON stated when Resident 1 complained of constipation, licensed nurses were supposed to assess Resident 1's abdomen. The DON stated the importance of documenting the full assessment when Resident 1 had a COC (5/6/2025) was so that all staff were aware of what [treatment] was done for Resident 1. The DON stated if documentation was missing it affected the residents' care. The DON stated that clinical documentation can greatly impact care because of

the feedback in assessment and how that information is relayed to the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of the facility's P&P titled, Charting and Documentation, revised 7/2017, the P&P indicated that all services provided to the resident, progress towards the CP goals, or changes in the resident's Level of Harm - Minimal harm or medical, physical, functional pr psychosocial condition, shall be documented in the resident's medical record. potential for actual harm The P&P the medical record should facilitate communication between the Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) regarding the Residents Affected - Some resident's condition and response to care. The P&P indicated objective (not opinionated or speculative)

observations, medications administered, treatments or serviced performed, changes in the resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the CP goals and objectives were to be documented in the medical record. The P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments would include care-specific details including the assessment data and/or any unusual findings obtained during the procedure/treatment and how the resident tolerated the procedure/treatment.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 056431

F-F842

Findings:

During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage), chronic respiratory failure (a long lasting condition when the lungs cannot get enough oxygen)and muscle wasting and atrophy (thinning of muscle mass).

During a review of Resident 1's care plan (CP) titled, COPD, initiated on [DATE REDACTED] and reevaluated on , d+[DATE REDACTED], the CP indicated Resident 1 was at risk for discomfort, shortness of breath, and exacerbation (worsening) secondary (due to) COPD. The CP interventions indicated Resident 1 to receive O2 at two liters (unit of volume) per minute (LPM) via nasal canula (NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE REDACTED], the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Level of Harm - Minimal harm or Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting potential for actual harm hygiene. The MDS indicated Resident 1 was always incontinent (inability to control urination and bowel movement [BM]). Residents Affected - Some

During a review of Resident 1's Progress Notes (PN) dated [DATE REDACTED], timed at 7:51 am, the PN indicated at 6:05 am, Resident 1 complained of not having a BM for two days. The PN indicated Resident 1 complained of abdominal pain (unrated), bloating, and feeling uncomfortable during the night shift (11 pm to 7 am). The PN indicated Resident 1 was on two LPM of O2 via NC.

During a review of Resident 1's eINTERACT SBAR form dated [DATE REDACTED], timed at 8 am, the SBAR indicated Resident 1 had a COC due to constipation or impaction (hardened stool). The SBAR indicated Resident 1 had constipation and Resident 1 had not had a BM in two to three days. The SBAR indicated RN 3 notified MD 1 and MD 1 ordered magnesium citrate first, before a Kidney Ureter Bladder (KUB-imaging test) and X-ray (imaging study that uses radiation and takes pictures of the inside of the body) were taken. The SBAR form did not indicate Resident 1 had abdominal distention, firmness, or pain.

During a review of Resident 1's SBAR Communication Form dated [DATE REDACTED], timed at 1:06 am, the SBAR indicated Resident 1 had a COC. The SBAR form did not indicate an abdominal/GI evaluation (assessment).

The SBAR indicated on [DATE REDACTED] at 10:55 pm, Resident 1 was in bed with eyes closed. The SBAR form indicated at 11:10 pm, Resident 1 was heard, by LVN 4, needing O2. The SBAR indicated Resident 1's O2 sat was 97 percent (%) while receiving three LPM of O2 via NC. The SBAR indicated Resident 1's abdomen was distended. The SBAR indicated on [DATE REDACTED] between 12:15 am and 12:30 am, Resident 1 complained of eight out of 10 pain (pain scale 0 to 10, 0 means no pain and 10 means the worst possible pain felt) to the abdomen. The SBAR indicated Resident 1 received Norco (brand name for hydrocodone-acetaminophen- used to treat moderate to moderate to severe pain).

During a review of Resident 1's PN dated [DATE REDACTED], time at 8:25 am, LVN 4 documented (on [DATE REDACTED]) between 1:06 am and 1:09 am, LVN 4 made rounds (visually checking residents) to assess the effectiveness of Resident 1's pain medication (Norco), and LVN 4 found Resident 1 unresponsive. The PN indicated the RN [RN 4] was notified and [DATE REDACTED] was called. The PN indicated resuscitative efforts were immediately initiated while waiting for EMS. The PN indicated (on [DATE REDACTED]), between 1:16 am and 1:42 am, the EMTs arrived, presumed care, and [continued] resuscitative efforts for Resident 1. The PN indicated the EMTs pronounced Resident 1's time of death on [DATE REDACTED], at 1:42 am.

During a telephone call on [DATE REDACTED] at 1:02 pm, [DATE REDACTED] at 11:47 am, and [DATE REDACTED] at 12:59 pm, an attempt was made to reach LVN 3, but LVN 3 could not be reached.

During a telephone call on [DATE REDACTED] at 1:03 pm and on [DATE REDACTED] at 11:43 am, an attempt was made to reach RN 5, but RN 5 could not be reached.

During a telephone interview on [DATE REDACTED] at 1:11 pm, with RN 4, RN 4 stated RN 5 did not endorse to RN 4 that Resident 1 had abdominal distension or pain when RN 4 started RN 4's shift on [DATE REDACTED] at 11 pm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a telephone interview on [DATE REDACTED] at 3:37 pm, with LVN 4, LVN 4 stated on [DATE REDACTED] at 11:10 pm, Resident 1 asked for an increase in O2 because Resident 1, felt like it was hard to breathe. LVN 4 stated Level of Harm - Minimal harm or LVN 4 increased Resident 1's O2 from 2 LPM to 3 and a half LPM via NC. LVN 4 stated LVN 4 documented potential for actual harm the O2 administration as three LPM. LVN 4 stated LVN 4 did not know what Resident 1's O2 sats were

before increasing the O2, and did not assess Resident 1's O2 sats until after increasing Resident 1's O2. Residents Affected - Some LVN 4 stated LVN 3 did not endorse to LVN 4 that Resident 1 had abdominal distension and pain when LVN 4 started the shift on [DATE REDACTED] at 11 pm. LVN 4 stated LVN 4 informed RN 4 that Resident 1's O2was increased. LVN 4 stated, on [DATE REDACTED] at 12:15 am, Resident 1 complained of 8 out of 10 abdominal pain and Resident 1 had abdominal distension. LVN 4 stated Resident 1 received Norco for the abdominal pain, and 30 minutes after administering Norco, LVN 4 went to reassess Resident 1's pain, but Resident 1 was found unresponsive. LVN 4 stated LVN 4 informed RN 4 when LVN 4 increased Resident 1's O2 (on [DATE REDACTED] at 11:10 am) and when Resident 1 complained of ,d+[DATE REDACTED] abdominal pain, on [DATE REDACTED] at 12:15 am, because

these situations were COCs for Resident 1. LVN 4 stated when Resident 1 experienced a COC, LVN 4 was supposed to assess Resident 1 and notify MD 1. LVN 4 stated LVN 4 only informed RN 4 but did not notify MD 1 of Resident 1's COC.

During an interview on [DATE REDACTED] at 7:30 am, with CNA 5, CNA 5 stated on [DATE REDACTED] at 11 pm, Resident 1 complained Resident 1's whole stomach was hurting. CNA 5 stated CNA 5 touched Resident 1's stomach and it was, rock hard. CNA 5 stated LVN 3 and LVN 4 increased Resident 1's supplemental O2. CNA 5 stated LVN 3 and LVN 4 did not assess Resident 1's O2 sat level before increasing the O2. CNA 5 stated CNA 5 asked LVN 3 and LVN 4 if Resident 1 was going to be sent to the hospital because Resident 1 was asking to be sent. CNA 5 stated LVN 4 told CNA 5 they needed to wait for RN 4's instruction. CNA 5 stated Resident 1 continued to complain of stomach pain.

During a telephone interview on [DATE REDACTED] at 11:48 am, with RN 4, RN 4 stated, on [DATE REDACTED] around 11:10 pm, LVN 4 informed RN 4 that Resident 1 needed an increase in O2. RN 4 stated at around 11:30 pm (on [DATE REDACTED]), RN 4 assessed Resident 1 and Resident 1's abdomen was distended and hard to touch. RN 4 stated RN 4 did not auscultate (examination of the resident by listening to bowel sounds to assess for intestinal function) Resident 1's abdomen. RN 4 stated Resident 1 had distension, and a Hard to touch, abdomen even after receiving magnesium citrate. RN 4 stated when RN 4 arrived at Resident 1's code (blue), RN 4 observed a moderate amount of coffee-ground emesis on Resident 1's gown and body. RN 4 stated coffee-ground emesis indicated GI bleeding.

During a telephone interview on [DATE REDACTED] at 12:36 pm, with RN 3, RN 3 stated on [DATE REDACTED] at, around 4 am, Resident 1 complained of not having a BM, feeling bloated, and pain in the abdomen. RN 3 stated Resident 1 had a distended abdomen. RN 3 stated RN 3 did not assess Resident 1's abdomen, listen to bowel sounds, nor ask Resident 1 the pain level Resident 1 felt in Resident 1's abdomen. RN 3 stated RN 3 informed MD 1 Resident 1 was constipated. RN 3 stated RN 3 did not inform MD 1 of Resident 1's abdominal distension, feeling bloated, or the unrated abdominal pain. RN 3 stated providing all [pertinent] information helped MD 1 determine the treatment needed for Resident 1.

During a telephone interview on [DATE REDACTED] at 12:57 pm, with MD 1, MD 1 stated MD 1 was informed by facility nursing staff (unable to identify) on [DATE REDACTED] at 7:44 am, Resident 1 was constipated.

MD 1 stated MD 1 was notified Resident 1 continued to be constipated even after Resident 1 had received lactulose (synthetic, non-absorbable sugar used primarily as a laxative to treat constipation) and a water enema (procedure where water is introduced into the rectum to cleanse the bowel and treat constipation).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a telephone interview on [DATE REDACTED] at 2:40 pm, with RN 2, RN 2 stated, on [DATE REDACTED] before 10 am, Resident 1 informed RN 2 Resident 1 did not have a BM for two days. RN 2 stated RN 2 assessed Resident Level of Harm - Minimal harm or 1 and Resident 1 had hypoactive bowel sounds, abdominal distension, and firmness. RN 2 stated Resident 1 potential for actual harm complained of abdominal pain, but RN 2 did not ask/assess Resident 1's pain level. RN 2 stated based on RN 2's assessment of Resident 1, Resident 1 had severe pain. RN 2 stated RN 2 did not relay RN 2's Residents Affected - Some assessment to MD 1 because Resident 1's main complaint was constipation. RN 2 stated RN 2 was supposed to inform MD 1 of Resident 1's full assessment because Resident 1's situation could worsen.

During an interview on [DATE REDACTED] at 4:44 pm, with the DON, the DON stated when Resident 1 complained of constipation, licensed nurses were supposed to assess Resident 1's abdomen by listening to bowel sounds, checking for dehydration, distension, bloating, and pain. The DON stated the assessment could determine

the next steps to be taken, interventions needed, and escalating the assessment findings to MD 1 for new orders. The DON stated if LNs did not relay Resident 1's full assessment and symptoms to MD 1, It could affect Resident 1's treatment and outcome. The DON stated Resident 1's condition may not improve and could worsen.

During a review of the facility's P&P titled, Resident Examination and Assessment, revised ,d+[DATE REDACTED], the P&P indicated the purpose of the P&P was to examine and assess the resident for any abnormalities in health status, which provided a basis for the CP. The P&P indicated the GI assessment included to assess for: abdominal distension and hardness, constipation, and bowel sounds in all four quadrants (four sides of

the abdomen); hypoactive, normal, or hyperactive sounds. The P&P indicated to notify the physician of any abnormalities such as, but not limited to abnormal vital signs, labored breathing, distended, hard abdomen, or absence of bowel sounds, and worsening of pain, as reported by the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 056431 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056431 B. Wing 05/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Inland Valley Care and Rehabilitation Center 250 W. Artesia Street Pomona, CA 91768

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 46687

Residents Affected - Some Based on interview and record review, the facility failed to ensure accurate and complete documentation for one of one sampled resident (Resident 1), in accordance with the facility's policies and procedures (P&P) titled, Charting and Documentation and Change in a Resident's Condition or Status.

This deficient practice resulted in no documentation of Resident 1's full assessments during a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions) on 5/6/2025

and had the potential to result in complications leading to a physical decline to Resident 1.

Cross Reference: