The assessment painted a picture of serious respiratory distress.
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The Director of Nursing at Mid Valley Nursing & Rehabilitation acknowledged the change.
The fall happened on December 22, 2025.
When an inspector arrived at his room on December 30, 2025, just before noon, Resident 2 was visibly upset.
Federal inspectors found that Citrus Grove Post Acute failed to ensure a safe discharge for the resident on December 17, 2025.
That is what inspectors found at Imperial Healthcare Center following a complaint investigation completed December 31, 2025.
"[Resident 2] is not calm," Certified Nurse's Aide 1 told inspectors.
LVN B, interviewed by inspectors that afternoon, laid out how the system was supposed to work.
The incident happened at Temecula Healthcare Center on December 5, 2025.
Resident 1 at Sunnyview Care Center developed moisture-associated skin damage on his sacrococcyx and groin area.
Federal inspectors discovered the unreported incident during a complaint investigation completed on December 31.
It happened again on December 6.