Inspection·June 4, 2024

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 report a possible overdose of narcotics for one of three sampled residents (Resident 1) per the facility policy of within 24 hours to the state agency. Residents Affected - Few This failure had the potential for the possible overdose of narcotics to go uninvestigated and unreported thereby increasing the chances of potential harm to (Resident 1). Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic respiratory failure (lungs cannot get enough oxygen), end stage renal disease (loss of kidney function), type 2 diabetes (condition affecting how body processes sugar), renal dialysis (treatment to filter blood), post-traumatic stress disorder (disorder in which a person has difficulty recovering for experiencing or witnessing a terrifying event). During a review concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Nurse Note dated [DATE], at 8:25AM LATE ENTRY: Patient was sent to acute hospital for unresponsiveness with shallow breathing, Vital Signs: Blood Pressure 105/53, Pulse 93, Respirations 18, Temperature 96.9, 0xygen 67%, unprescribed and unlabeled opened bottle of pills was found on bedside table. Called paramedics at 08:00, paramedics arrived at 08:03, left at 08:15 to emergency department on gurney. Doctor and POA were notified. Power of Attorney (POA) asked if her brother had visited and stated that her brother has a history of providing patient with narcotics. When l called brother, he stated Where did he get the pills from. Bottle of pills were not noted in patient's room in undersigned's previous shift nor during change of shift when getting bedside report from NOC shift nurse on [DATE], at 07:15, then at 07:45 checked on patient again and did not notice any distress. Notice of transfer sent to Ombudsman. 2. Situation Background Assessment Recommendation (SBAR) Communication Form /Change of Condition dated [DATE]. 2024 at 10:45: Unresponsiveness; Called 911, resident had unprescribed and unlabeled pills at bedside. 3. Acute hospital emergency department admitted [DATE], Diagnosis: cardiac arrest, opioid overdose intentional self-harm, initial encounter, hyperkalemia (high potassium levels), and End Stage Renal Disease. Suspected Norco overdose with cardiac arrest. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055299 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055299 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Loma Linda Post Acute 25383 Cole Street Loma Linda, CA 92354 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)