Health inspection·October 2, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review the facility failed to follow their Policy when the nursing staff failed to provide care for 2 of 3 sampled Residents (Resident 1 and 2). Residents Affected - Few This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) psychosocial health and safety at risk. When facility staff failed to provide Resident ' s 1 and 2 with requested care and services. Findings: During an interview on October 2, 2024, at 4:37 PM, with Resident 1, Resident 1 in bed, is alert and oriented. Resident 1 stated it will take hours for the nursing staff to change her diaper no matter what time of day she activates the call light. During review of Resident 1 ' s admission Record (General demographics) on October 2, 2024, indicates admitted to facility on September 18, 2024, with diagnosis (DX) include Enterocolitis (inflammation of both the small intestine and the colon) muscle weakness, abnormalities of gait (the way a person walks) and mobility, hypertension (high blood pressure), Gastro-esophageal reflux (heartburn). During an interview on October 2, 2024, at 4:45 PM, with Resident 2. Resident 2 in bed, is alert and oriented Resident 2 stated three hours was the longest he had to wait before his call light was answered. He further added, sometimes they answer the light, leave without giving him the assistance he needs, and never return. During review of Resident 1 ' s admission Record (General demographics) on October 2, 2024, indicates admitted to facility on March 1, 2024, with diagnosis (DX) include Myocardial infraction (heart attack), abnormal posture, muscle weakness, pleural effusion (a condition where too much fluid builds up in the space between the lungs and the chest wall), type 2 Diabetes Mellitus (a chronic disease that occurs when the body can ' t properly use glucose, or blood sugar), Hypertension (High blood pressure). During concurrent observation and interview on October 2, 2024, at 5:20 PM with the Certified Nursing Assistant (CNA 1). From 4:43 PM to 5:20 PM, the call light was heard, but nobody answered. CNA 1 claimed that since she had not heard the call light, the sound must have come from the DSD office; however, when examining the call light panel, it was discovered that the sound was coming from a resident ' s room. During an interview on October 2, 2024, at 5:43 PM, with the Director of Staff Development (DSD 1), (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 10/02/2024 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)