F 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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 ensure one of four clinically compromised residents
(Resident 1) was provided transportation for his dialysis treatment appointment.
Residents Affected - Few
This failure had the potential to result in a delay of treatment that could adversely affect and further
compromise Resident 1 ' s health.
Findings:
During a review of Resident 1 ' s admission RECORD (general demographics) on May 23, 2024, the
document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that include
diabetes mellitus (a condition that affects the way the body process blood sugar), end stage renal dialysis
(a condition that cause the kidney to cease working), hypertension (a condition with blood pressure that is
higher than normal), congestive heart failure (a condition that occurs when the heart muscle does not pump
blood as well as it should) and hyperparathyroidism (a condition where the thyroid does not create and
release enough thyroid hormone into the bloodstream).
A review on May 23, 2024, at 2:40 PM, of Resident 1 ' s document, titled, PHYSICIAN HISTORY &
PHYSICAL dated, 05/10/2024, indicated, . PAST MEDICAL HISTORY . History This is an [AGE] year-old
male past medical history significant for end-stage renal disease on HD [(Hemodialysis) a way to clean the
blood if the kidneys are no longer working properly] .
During a review of the Physician Orders on May 23, 2023, the order dated May 10, 2024, indicated,
DIALYSIS CENTER: DAVITA [NAME] RANCH ADDESS & CONTACT INFOR: 7223 CHURCH ST. UNIT
A14 [NAME], CA 92346 (909) [PHONE NUMBER] DIALYSIS DAYS: T, TH, S (Tuesdays, Thursdays,
Saturday) NEPHROLOGIST: DR. [NAME] TRANSPORTATION AND CONTACT INFO: [SPECIFY] SPECIAL
INSTRUCTIONS: TIME 12:15 PM.
A review on May 23, 2024, at 2:40 pm, of Resident 1 ' s COC (Change of Condition)/INTERACT
ASSESSMENT FORM (SBAR) (Situation Background Assessment Recommendation) v1.4 dated, May 9,
2024, indicated, 7:00 AM . Res (Resident) noted in bed ready for dialysis, with paperwork and sacks lunch.
12.00 PM CNA (Certified Nursing Assistant) notified charge nurse of transportation not arriving. Chains of
command followed. Transportation was called. Transportation claims to not have known about routine
scheduled pick up for resident. MD (Medical Director) notified, family aware. 1300 PM we were able to get
in touch with dialysis center to reschedule extra chair time for resident for following day (5/10/24 @ (at) 7:15
AM. Transportation notified. MD notified, family made aware. Orders to monitor res for fluid overload r/t
(related to) missed dialysis .
(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:
056429
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
056429
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Laurel Convalescent Hospital
7509 N. Laurel Ave
Fontana, CA 92336
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 0745
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During an interview May 23, 2024, at 4:25 PM, with the Director of Nursing (DON), the DON was asked
about the missed dialysis treatment on May 9, 2024, for Resident 1. The DON stated, The resident should
not have missed his dialysis treatment. She further stated, The staff should have called and notified the
transportation services for pick up for dialysis, upon his return from the hospital.
During a concurrent interview and review on May 23, 2024, at 4:25 PM, with the Administrator (Admin) the
facility ' s policy and procedure (P&P), titled, Transportation, Social Services, dated, December 2008, was
reviewed. The P&P indicated, Our facility shall help arrange transportation for residents as needed . 2).
Social services will help the resident as needed to obtain transportation . The Admin stated, The staff did
not follow the facility policy. The resident should not have missed his dialysis treatment on May 9, 2024. The
Admin further stated, The staff should have called for transportation for dialysis treatment for the resident
when he returned from the hospital.
Event ID:
Facility ID:
056429
If continuation sheet
Page 2 of 2
