Health inspection·May 25, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. ased on interview and record review, the facility failed to protect against physical and verbal abuse for one of three sampled residents (Resident 1) when Resident 1 fell out of bed and a Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed and Resident 1 ' s hip rubbed against the footrest. The CNA 1 stated to Resident 1 Stop that! you ' re being annoying! This failure caused Resident 1 to suffer physical and verbal abuse. Findings: An unannounced visit was made to the facility on May 21, 2024, at 9:48 AM, to investigate a facility reported incident regarding an allegation of physical and verbal abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an initial admission date of April 9, 2019. Resident 1 had diagnoses that included partial paralysis of the left side of the body following a stroke and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of a Registered Nurse Supervisor ' s (RNS) witness statement, undated, indicated, RN [RNS]: I walked into the room and noticed that resident [Resident 1] had rolled off her bed unto the other mattress, so I said to CNA [CNA 1], ' hold on, let me put on my gloves. ' Unfortunately, she didn't wait, and CNA [CNA 1] pulled resident by one arm onto the bed and the resident rubbed hip against the footrest. The RNS was unavailable for interview. During an interview with Resident 1 on May 21, 2024, at 11:14 AM, Resident 1 stated, I'm sorry I don't feel like talking. During an interview with a Minimum Data Set/Licensed Vocational Nurse (MDS/LVN 1) on May 21, 2024, at 2:14 PM, The MDS/LVN 1 stated she was walking out of her office and overheard CNA 1 say, Stop that! you're being annoying! from Resident 1 ' s room. The MDS/LVN 1 stated she knew CNA 1 well enough to know it had been her voice. During an interview with a Licensed Vocational Nurse/Infection Preventionist (LVN/IP) on May 21, 2024, at 2:21 PM, The LVN/IP stated she saw CNA 1 walk into Resident 1's room and heard her state Stop that! you're being annoying! (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 05/25/2024 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)