F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to follow their policy when staff did not notify the physician and
alternative physician promptly for a change of condition for one of four sampled residents (Resident 1).
This failure had the potential to result in a delay of treatment for redness, swelling and tender to touch of
the left foot of Resident 1.
Findings:
During a review of Resident 1 ' s admission Record (general demographics) on May 22, 2024, the
document indicated Resident 1 was last admitted to the facility on [DATE], with diagnosis that included type
2 diabetes mellitus (a condition of that occurs when the sugar in the blood is too high), osteoporosis ( a
condition that causes bones to become weak and more likely to break), hypertension, rheumatoid arthritis
(a condition of joint swelling and pain), contracture of muscle left lower leg (a condition that occurs when
the muscles, tendons, joints and tissues tighten or shorten).
During a review on May 22, 2024, at 10:00 am, of Resident 1 ' s document, COC (Change of
Condition)/INTERACT ASSESSMENT FORM (SBAR) (Situation Background Assessment
Recommendation) v1.4 dated, May 14, 2024, at 11:47 am, the document indicated, .0900 alerted by cna
(Certified Nursing Assistant) that pt is complaining of L. (left foot) pain. 0915 resident assessed. All vitals
WNL (within normal limit) redness and swelling noted to L. foot tender to touch .0920 dr (Doctor) [Name of
physician] notified, picture attached. No response . 1435 dr [Name of physician] updated, no response this
shift. endorsing to next shift. daughter contacted and no response, message left .
A review on May 22, 2024, at 10:00 am, of Resident 1 ' s Progress Notes, dated, May 14, 2024, at 9:47 pm,
indicated, MD made aware of resident noted with edema and discoloration to left ankle and foot. MD order
for CBC (complete blood count) AND XRAY TO LEFT FOOT AND ankle. Resident made aware .
A review on May 22, 2024, at 10:00 am of Resident 1 ' s Progress Notes, dated, May 15, 2024, at 2:28 am,
indicated, RECEIVED NEW ORDER FROM DR. [Name of physician]. MAY TRANSFER RESIDENT TO
ACUTE HOSPITAL TO RULE OUT DVT (deep vein thrombosis) due to left leg swelling discoloration .
During an interview on May 22, 2024, at 1:48 PM, with the Registered Nurse Supervisor (RNS), the RNS
was asked about a change of condition of Resident 1. The RNS stated, Usually, we call to report to the
physician immediately any change of condition and follow new orders if any. The RNS further stated,
Usually, another call is made shortly to follow up with the physician if there is not an
(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
05/24/2024
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 0580
immediate response.
Level of Harm - Minimal harm
or potential for actual harm
A review of the facility ' s policy and procedure (P&P), titled, Change of Condition dated, March14, 2024,
indicated, Purpose: TO ENSURE PROPER ASSESSMENT AND FOLLOW-THROUGH FOR ANY
RESIDENT WITH A CHANGE OF CONDITION . CONTENT: A. ALL CHANGES OF CONDITION IN A
RESIDENT SHALL BE HANDLED PROMPTLY . C. Upon a Change in Condition for any reason, nursing
staff members are to take the following actions . b. PHYSICIAN SHALL BE CALLED PROMPTLY. If for
some reason physician cannot be reached, alternative physician shall be contacted. If alternate cannot be
reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and
include the correct time of the activity .
Residents Affected - Few
During a concurrent interview and record review on May 22, 2024, at 1:55 PM, with the Administrator
(Admin), the P & P titled, Change of Condition dated, March14, 2024, was reviewed. The Admin.
acknowledged that nursing staff did not follow facility policy for promptly notifying the physician of a change
in condition of Resident 1. The Admin. further stated, The staff should have called and notified an
alternative physician or the Medical Director.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056429
If continuation sheet
Page 2 of 2
