Health inspection·September 30, 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 prevent for one of three sampled residents Resident 1, two pressure injuries from reopening and an physician order placed a Computed tomography (CT) to right foot, instead of left foot. Residents Affected - Few This failure placed a clinically compromised Residents (Resident 1) health and safety at risk and could have delayed treatment. 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: contracture right knee (stiffness), vascular dementia (brain damage by multiple strokes, causing memory loss), flaccid neuropathic bladder (bladder doesn ' t contract, lead to urine retention). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. SKIN PROGRESS REPORT: July 12, 2024, Coccyx Stage 4, measuring 3.5cmx4.6cmx0.1cm . Reopened sacrococcyx wound. 2. Skilled Nursing Facility (SNF) Wound Care Note dated July 12, 2024, Left hip reopened stage 3 measuring, 0.7x0.7x0.1, post debridement measurements 0.7x0.7x0.2. 3. Interdisciplinary Team (IDT) Note dated August 02, 2024, ' Meeting with daughter to discuss plan of care. Notified doctor family has concerns of foul smell and we are referring to osteomyelitis . 4. Order dated August 02, 2024, at 1457: May have Computed tomography (CT) (computerized X-ray imaging to Right heel to rule out osteomyelitis. (ORDER FOR THE WRONG FOOT, Right heel resolved June 03, 2024, per notes). During an interview on September 05, 2024, with the Treatment Nurse (TXT), the TXT nurse states, Resident 1 had right and left heel wounds, the right one was resolved. We were just treating his Left heel, I ' m not sure who put in the order for the Right Foot CT scan, that nurse is no longer here anymore. The wound specialist did not see signs of infection, we did notice a slight smell .she wound debride every time she came, there was slough to it. The daughter told me around the time he was sent out, it does not look well. (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 09/30/2024 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)