Claremont Manor Care Center

Inspectors wroteBased on observation, interview, and record review, the facility's licensed staff failed to obtain informed consents (IC, the process, a form indicating a resident or responsible party voluntarily agrees to a medical treatment or procedure after understanding the risks, benefits, and alternatives) from two of two sampled resident's (Resident 35 and Resident 46) responsible parties by failing to:A. Obtain an IC from Resident 35 and/or the resident's responsible party prior to the administration of Mirtazapine 15 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount). Additionally, the facility failed to obtain an IC in a timely manner for the administration of Mirtazapine 30 mg when the dose was increased from 15 mg to 30 mg on 10/2/2025. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective medication reconciliation (systematic collection and verification of a resident's complete and accurate medications during transitions of care, aims to identify and resolve discrepancies and can result in preventable adverse drug events [SE, undesired harmful effect resulting from a medication] and helps to identify the loss or potential diversion [illegal distribution of prescription drugs or their use for unintended purposes] of controlled medications [medications with high potential for abuse]) system in place for controlled medications for 3 of 8 sampled residents (Resident 8, Resident 48, and Resident 49). This deficient practice resulted in unaccounted controlled medications for Resident 8, Resident 48, and Resident 49 and the potential for controlled medication diversion and misuse.

Inspectors wroteBased on interview and record review, the facility failed to complete an advanced directive acknowledgement form (ADAF) for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Advance Directives. This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 1. Additionally, there was a potential to result in confusion among the healthcare providers in the event Residents 1 required immediate medical care and/treatment and the potential for Resident 1 to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.

Inspectors wroteBased on interview and record review, the facility staff failed to notify Physician 1 and the responsible party of a change of condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for one of one sampled resident (Resident 17) when Resident 17 experienced a significant weight loss of 12 pounds (lbs., a unit of weight) within one week. This deficient practice had the potential to result in delated implementation of timely interventions and the potential to result in a physical decline to Resident 17.

Inspectors wroteBased on interview and record review the facility failed to provide transfer and bed-hold notification documentation for one of one sampled resident (Resident 42) as indicated in the facility's Policy and Procedure (P&P) titled, Admission, Transfer, & Discharge Rules, when:Resident 42 did not receive a written notice of transfer-discharge (a document a nursing facility must give a resident and/or their representative before the resident is moved out of the facility, explaining why the resident is being transferred, where they are going, the effective date, their right to appeal, and how to contact the State Long Term Care Ombudsman [an advocate who helps protect the rights, safety, and well-being of residents in nursing homes and other long-term care facilities]) when Resident 42 was discharged on 2/15/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pressure ulcer-injuries (PIs, lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) preventive interventions for one of one sampled resident (Resident 15) by failing to:Encourage and offer to turn and reposition Resident 15 who preferred lying in bed on Resident 15's back. Float (healthcare practice aimed at preventing PIs by suspending the heels off the bed surface, thereby reducing pressure and friction on the skin) Resident 15's heels when Resident 15 was lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow fall prevention interventions for one of two sampled residents (Resident 23) when on 3/12/2026, Resident 23 did not have bilateral fall mats (a specialized, thick cushion designed to be placed alongside a bed or chair to absorb the impact of falls and reduce the risk of serious injuries like fractures or head trauma) on the ground alongside Resident 23's bed and while Resident 23 was in bed. This deficient practice had the potential to result in falls and injury to Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two pill crushers were cleaned and the medication rooms were maintained free of food items. These failure had the potential to contribute to cross contamination of the residents' medications During a review of the facility's map, the map indicated the facility has two medication rooms located in nurses' stations 1 and 2. During a concurrent observation and interview on 3/12/2026 at 8:35 AM with Licensed Vocational Nurse (LVN) 3, in the nurses' station 1, the pill crusher had a reddish-brown color on the hinges and unidentified orange , white and yellow colored powder residue. LVN 3 stated the pill crushers are required to be cleaned daily at the end of each shift to prevent cross contamination of medications and avoid potential unintended chemical interactions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify food preferences and offer food substitutes for one of three sampled residents (Resident 4). This failure had the potential to adversely affect Resident 4's nutritional intake, dining experience, and overall quality of life. During a review of Resident 4's face sheet, the face sheet indicated Resident 4 had an initial admission on [DATE] with the diagnoses but not limited to: [...]

Inspectors wroteDuring a concurrent observation and interview on 3/10/2026 at 9:20 AM with the Kitchen Cook, five half gallon containers of milk with a best used by date of 2/26/2026 were found in the kitchen refrigerator. The Kitchen [NAME] stated expired milk should not be kept in the refrigerator, as it could be mistakenly served to the residents and potentially cause illness. During an interview on 3/11/2026 at 9:15 AM with the Director of Dining Services (DDS), DDS stated expired food items, including milk, must be discarded because retaining them in the refrigerators poses a potential health hazard to the residents. During a review of the facility's policy and procedure (P&P) titled, Production, purchasing, storage, the P&P indicated all food and supplies used in food preparation shall be stored in such a manner as to prevent contamination and maintain safety of the food for human consumption. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices and ensure a safe, sanitary environment for two of two sampled residents (Resident 5 and Resident 15). This deficient practice had the potential to cause healthcare associated infections that can cause pain and discomfort for residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent one of three sampled residents (Resident 1) from being verbally abused when Resident 2 threatened, cursed, and yelled at Resident 1. This failure resulted in Resident 1 being scared and angry and had the potential to result in Resident 1 experiencing feelings of decreased self-worth.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department) within two hours, in accordance with the facility's policy and procedure (P&P), titled Adult Abuse, revised April 2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to abuse while at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation involving abuse, for one of four sampled residents (Resident 1), was reported immediately but no later than 2 hours after the allegation was made, to the facility's administrator (ADM) and other proper authorities as indicated in the facility's policy and procedure (P&P), titled, Adult Abuse. This deficient practice resulted in the delay of notification to the State Agency (CDPH, California Department of Public Health) and the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation) and had the potential to result in compromised safety to Resident 1 due to the facility's failure to take corrective actions to prevent further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program, to prevent cockroaches in one of one kitchen for a facility licensed for a 59-bed count. This deficient practice had the potential to expose 38 residents currently residing in the facility to foodborne illness. Findings During a concurrent observation and interview on 2/11/25 at 1:15 p.m. while in the kitchen with the head chef (HC), HC stated he has only been employed at the facility for a few weeks. HC stated he doesn't know the last time the kitchen had a deep cleaning for the floors and all areas of the kitchen. HC stated the kitchen crew does daily sweeping and mopping two times (once during the day and once in the evening after dinner). During the tour of the kitchen, in the back of the cooking areas, there was grease and dirt build up observed on the pipes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 92), who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall ( move downward, typically rapidly and freely without control, from a higher to a lower level) by failing to: a. Ensure Registered Nurse 1 (RN 1) notified Resident 92's physician/medical doctor (MD 1) regarding Resident 92's increased agitation (unable to relax and be still) and confusion (unable to think clearly) when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P) titled, Change in Resident Condition. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered care plan (CP), for four of four sampled residents (Resident 37, Resident 27, Resident 6, and Resident 5), as indicated in the the facility's policy and procedure (P&P), tilted, Care Plan, by failing to, a. Develop a care plan (CP) for Resident 37 when there was a change in skin condition on 1/11/2025. b. Develop a CP for Resident 27 for anticoagulant (class of medication that help prevent blood clots from forming in the heart and blood vessels) use when Resident 27 received Eliquis (medication used to prevent blood clots) tablet 2.5 milligrams (mg, unit of measurement) by mouth twice a day. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (PIs, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for two of three sampled residents (Resident 32 and Resident 37) who had PIs by failing to ensure, A. Resident 32's LAL mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to Resident 32's weight of 138 pounds (lbs.). Resident 32's LAL mattress was set at 550 pounds (lbs.). B. For Resident 37, 1. The facility did not Provide documented evidence to show Resident 37 was repositioned every two hours during the night shift (10:30 PM to 6:30 AM) from 12/26/2024 to 1/24/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy titled Ordering and Receiving Non-Controlled Medications for two of two sampled residents (Resident 27 and 28) by failing to: a. Document the correct drug allergies into Resident 28's electronic medical record (EMR) when Resident 28 had 12 drug allergies and received Ambien (medication used to treat insomnia [difficulty in falling asleep]) nine times in 12/2024 which was indicated as one of the 12 drug allergies. b. Document the correct drug allergies in Resident 27's EMR when Resident 27's EMR did not indicate Resident 27 was allergic to clindamycin (type of antibiotic) and Norco (prescription medication used to treat moderate to severe pain) and incorrectly indicated an allergy to prednisone and prednisolone (medications used to treat swelling, redness, itching, and allergic reactions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's infection prevention guidelines by failing to: A. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics] in nursing homes) were followed during peri-care (washing the genitals [sexual organs located outside of the body] and anal [end of large intestine, allows feces to come out] area) in one of one sampled resident's room (Resident 4's room). B. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on Advance Directives (AD, legal document that indicates wishes for medical care if unable to speak for self) by failing to ensure one of one sampled resident's (Resident 27) code status was correct when Resident 27 had a Medical Doctor (MD) order for full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or the resident's representative wish to perform all lifesaving procedures to keep the resident alive) and an emergency Medical Services Prehospital Do Not Resuscitate (DNR, medical order by MD to not provide cardiopulmonary resuscitation [CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) Form (EMSPDNR). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Registered Nurse 1 (RN 1) notified one of one sampled resident's (Resident 92) physician/medical doctor (MD 1) regarding Resident 92's increased agitation (unable to relax and be still) and confusion (unable to think clearly) when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P) titled, Change in Resident Condition. This deficient practice had the potential to result in a physical decline to Resident 92.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Advance Beneficiary Notice of Non-coverage (SNFABN, a form that informs residents/responsible parties [RPs] Medicare may not cover certain items or services) form was signed for one of one sampled resident (Resident 26). This failure had the potential to result in the resident or the resident's RP to not make informed decisions regarding possible denied medical coverage.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan (CP) for two of two sampled residents (Resident 92 and Resident 5) when, A. Resident 92's CP for alteration in cognitive function related to Alzheimer's Disease (AD, a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks)/Dementia was not updated to include Resident 92's increased confusion on 1/20/2025. B. Resident 5's CP for depression was not updated to include use and current physician order for trazadone (medication used to treat depression [causes feelings of sadness and/or a loss of interest in activities]). These deficient practices had the potential to result in Residents 92 and 5 to not receive the necessary care and services in accordance with their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy titled Oxygen Therapy by failing to: a. Connect Resident 12's Nasal Cannula (NC, medical device that provides oxygen through a tube and into the nose) tubing to the oxygen concentrator machine when Resident 12's NC was observed to be disconnected and on the floor. b. Label and date Resident 12's humidifier bottle when opened. These failures had the potential to result in complications associated with oxygen therapy for Resident 12.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure a routine pain medication was available for one of one sampled resident (Resident 7). This deficient practice had the potential to result in pain and psychosocial decline to Resident 7.

Inspectors wroteBased on interviews and record review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for one of five sampled residents (Resident 32) by: 1. Ensuring that the use of Quetiapine (medication used alone or together with other medicines to treat bipolar disorder [depressive and manic episodes] and schizophrenia [a serious mental health condition that affects how people think, feel, and behave]) was clinically indicated and necessary for Resident 32. This deficient practice had the potential to result in use of unnecessary psychotropic drugs and could have led to side effects (injuries resulting from medication use including physical and mental harm, or loss of function) and adverse consequences to Resident 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff stored and prepared food under sanitary conditions in one of one kitchen (Kitchen 1). This deficient practice placed the residents at risk for foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 4). This deficient practice had the potential to result in a delay or the inability for Residents 4 to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse to the state agency (California Department of Public Health, CDPH) and law enforcement no later than two hours for one of seven sampled residents (Resident 2) and indicated in the facility's abuse prevention policy and procedure (P&P), titled, Adult Abuse,. This deficient practice resulted in the delay of notification to the state agency and had the potential for the residents residing at the facility to be subjected to further abuse.

Inspectors wroteBased on interview and record review, the facility failed to immediately remove a potential threat for one of seven sampled residents (Resident 2). On 9/13/24, the facility received a report that indicated Certified Nursing Assistant 1 (CNA 1) squeezed Resident 2's brief around his genitalia (male or female reproductive organs) area to check if Resident 2's brief was wet. The facility failed to remove (CNA 1) from resident care duties and failed to make every attempt to prevent further potential abuse while the facility's investigation was in progress as indicated in the facility's abuse prevention policy and procedure (P&P), titled, Adult Abuse,. This deficient practice had the potential to result in further abuse for Resident 1 and for the residents residing at the facility.

Inspectors wroteBased on interviews and record review, the facility failed to report an alleged verbal abuse of one of three sampled residents (Resident 2) by Resident 3 within the required time frame to the State Survey Agency (SSA), Long-Term Ombudsman (LTO), and the local law enforcement (LLE). This failure had the potential to result in further abuse of Resident 2 and/or other residents related to the delayed investigation of alleged abuse and the necessary interventions to prevent abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to: 1. Conduct annual N95 mask (respirator, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for one (1) of four (4) sampled staff members 2. Notify all residents and family representatives about the facility's COVID-19 outbreak in a timely manner. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the dignity of two of two sampled residents (Residents 14 and 17): a. For Resident 14, facility staff failed to promptly respond to Residents 14's call light (a device used by a resident to signal his or her need for assistance from staff). Resident 14 felt rushed when staff provided care for Resident 14. b. For Resident 17, facility staff failed to promptly respond to Resident 17's call light during the night shift. These failures resulted with feeling frustration to Residents 14 and Resident 17 to felt like Resident 17 wanted to die. The failures had the potential to result in both residents to feel like their concerns were unheard and disrespected.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for two of two sampled residents (Resident 35 and Resident 37) by failing to ensure: a. A physician's order, that indicated continuous oxygen (O2, gas that the body needs to live) administration through a nasal cannula (NC, a device that gives you additional oxygen through your nose) two liters (L, measurement of volume) per minute (2L/min), was followed for Resident 35. On 1/8/24, Resident 35's NC was attached to an empty O2 tank. b. For Resident 37, the facility failed to conduct a comprehensive weekly assessment and take vital signs monthly as indicated in the facility's policy and procedure titled, Assessment, Licensed Weekly Summary, and Vital Signs, Monitoring of. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistive hearing devices were available to maintain hearing for two of two sampled residents (Residents 34 and Resident 35). a. Resident 34 was hard of hearing (HOH) and was not provided with hearing aids during activities as indicated in the care plan, titled, Communication, Alteration in related to Hard of Hearing. b. Resident 35 was HOH and was not provided with audiology services to address Resident 35's hearing impairment nor provided with hearing aids. These failures resulted in Resident 34 looking frustrated, not being able to hear, and unable to participate in activities. The failures had the potential to result in further hearing loss and impact Residents 34 and Resident 35's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices in accordance with the facility's policy and procedures (P&P), by: a. Failing to label, and date opened food items stored in a refrigerator located in one of two kitchens (Main Kitchen). b. Failing to maintain one of one refrigerator's, in the Service Kitchen located by the Dining Room, temperature at or below 41 degrees F (Fahrenheit, a unit of measurement). These deficient practices had the potential to result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) due to expired or potentially expired foods for all residents residing at the facility and who consumed meals by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices for two of two sampled residents (Resident 96 and Resident 146) in accordance with the facility 's policy and procedures (P&P) by failing to: a. Ensure Resident 96's nasal cannula (NC, is a device to deliver oxygen or increased airflow to a person in need of respiratory help) was not touching the floor. b. Ensure Resident 146's dentures were labeled and stored properly when not in use. These failures had the potential to result in infections and physical declines to Residents 96 and 146.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Resident 22 appropriate accommodations when Resident 22's call light cord was not with-in reach. This failure had the potential to result in delayed care and treatment to Resident 22 and Resident 22's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to transmit a Minimum Data Set (MDS) within 14 days after a resident's Discharge Assessment was completed for one of one sampled resident (Resident 7). This failure had the potential to result in an inaccurate assessment of the facility's quality indicators and/or care area concerns for review.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for falls for one of one sampled resident (Resident 14), as indicated in the facility's policy and procedure (P&P), titled, Fall Prevention and Management. Resident 14's care plan for falls was not updated to include additional or different interventions following Resident 14's fall at the facility on 10/10/2023. This failure had the potential for Resident 14 to not receive appropriate care and interventions to prevent further incidents of falls. (Cross reference F689)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments were completed every shift/daily to prevent pressure injuries (PI, pressure ulcer, injury to skin and underlying tissue resulting from prolonged pressure on the skin and/or underlying soft tissue usually present over a bony prominence) for one of one sampled resident (Resident 147) as indicated by Resident 147's care plan titled, Risk for Skin Breakdown, and the facility's policy and procedure (P&P) titled, Assessment, Body. This deficient practice resulted in a facility acquired Stage 3 (the ulcer/injury has gone through all layers of skin into the fat tissue, exposing the patient to infection) PI on Resident 147's coccyx (tailbone) area on 1/3/24.

Inspectors wroteBased on interview and record review, the facility's interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) failed to assess a resident's fall risk and reassess fall prevention interventions for one of one sampled resident (Resident 14), as indicated in the facility's policies and procedures (P&P), titled, Fall Prevention and Management Program. This failure had the potential to result in Resident 14 to sustain an injury and/or harm due to additional falls. (Cross reference F657)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral feeding ([also referred to as tube feeding] the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) syringe was replaced after 24 hours for one of two sampled residents (Residents 5). This failure had the potential to result in Resident 5 to develop an infection and complications including but not limited to diarrhea and vomiting.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had a Registered Nurse (RN) at least 8 consecutive hours a day for 7 days a week for three out of 42 days reviewed for staffing assignments. This failure had the potential to result in a decline in residents' physical and/or psychosocial wellbeing due to insufficient monitoring, and coordination of care and services by an RN.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of one Daily Nurse Staffing Form, and post actual worked nursing hours at the start of each shift. This failure resulted in inaccurate nursing staff hours worked, the failure had the potential to result in residents and family members obtaining misleading information from the posted form that indicated projected hours and not actual hours worked.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices during a Coronavirus (COVID-19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's Policy and Procedure (P&P) by failing to annually conduct N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) fit testing (the use of a protocol to evaluate the fit of a respirator on an individual) for sixty three (63) of sixty eight (68) staff members. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all treatments and services were provided to one of three sampled residents (Resident 1) by failing to follow Resident 1's physician's order to obtain a neurology consult (a medical doctor who specializes, diagnoses, treats and manages disorders of the brain and nervous system [brain, spinal cord and nerves]). This deficient practice resulted in Resident 1 not being seen and evaluated by an neurologist and had the potential to cause a negative impact on Resident 1's well-being.