Health inspection·February 13, 2025

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 observation, interview, and record review, the facility failed to maintain an accurate record of Lactulose (medication used to reduce the amount of ammonia in the blood of patients with liver disease) for one of four sample residents (Resident 1) when on January 25, 2025, at 9:00 PM, License Vocational Nurse (LVN1) did not sign on Resident 1 MAR that Lactulose was given. Residents Affected - Few This failure potentially resulted in Resident 1 readmission to the hospital with ammonia level of 124 µmol/L (Micromoles per liter a unit used to measure the concentration of a substance in a solution). Normal blood ammonia level for ESRD patient is generally considered to be below 35 micromol/L. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Liver Failure (a conditions that stop the liver from working or prevent it from functioning well), End Stage Renal Failure (ESRD - a condition in which the kidneys have permanently lost heir ability to function properly). A review of Resident 1's Orders, dated January 17, 2025, indicated Lactulose Oral Solution 10 g/15mL (g/mL - means the density of a substance, essentially how much mass (in grams) is contained within a given volume (in milliliters) of that substance) was ordered to be given 30 mL by mouth three times a day for ESRD. A review of Resident 1's MAR indicated that Lactulose oral solution 10 g/15 mL to be given at 9:00 AM, 1:00 PM, 9:00 PM. On January 25, 2025, record showed that Lactulose were administered at 9:00 AM and 1:00 PM. During concurrent telephone interview and record review on February 13, 2025, at 12:59 PM, with the Director of Nursing (DON 1), the DON 1 stated on January 25, 2025, at 9:00 PM, Lactulose was not administered by the nurse because the nurse did not sign on the MAR. He further stated if it was not sign it was not given. During concurrent telephone interview and record review on February 13, 2025, at 2:19 PM with LVN 1, LVN 1 stated on January 25, 2025, at 9:00 PM, she believes that she gave the medication to Resident 1, but it was her mistake that she didn't sign on the MAR. Stated she understand that if it was not sign it was not given. Page 1 of 2 055619 055619 02/13/2025 Las Colinas Post Acute 800 East 5th Street Ontario, CA 91764

F 0684 Level of Harm - Minimal harm or potential for actual harm A review of the facility Policy & Procedure (P&P) titled, Medication Administration dated April 2019, indicated, .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Residents Affected - Few 055619 Page 2 of 2