Inspection·December 13, 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 one of three sampled residents (Resident 1), who was diabetic, obese, and immobile and at risk for skin breakdown develop pressure injuries (pressure on body prominence causes breakdown to tissue) as follows: Residents Affected - Few a. Left heel, left great toe and 1st metatarsal developed a deep tissue injury (DTI). And right medial foot fluid blister. b. Acquired an open wound to left elbow and sacral (tailbone) c. No family notification of left elbow and sacral open wound and wound treatment. This failure had the potential to result in a clinically compromised resident, (Resident 1) to be placed at risk for unnecessary pain, infection and death due to wounds not being identified and treated to prevent progressing. 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 which included: myocardial infarction type 2 (heart attack), diabetes type 2 (body does not produce enough insulin, or resist insulin), hemiplegia and hemiparesis (partial paralysis on one side of body), hypertension (high blood pressure). During a record review of Resident 1's medical records, reviewed and verified the following with Assistant Director of Nursing (ADON): a. admission Reassessment dated [DATE], wound sites: Abdomen (gastrostomy (gastrostomy tube-a tube surgically inserted through abdominal wall to administer medications and liquid nourishment), right inner arm discoloration, sacrococcyx (tailbone)(scar tissue). No other skin breakdown. b. Change of Condition (COC) dated May 25, 2024, 10:54, Multiple skin Conditions: Treatment nurse noted that resident had multiple skin conditions. As follows: 1 Right medial foot fluid filled bister 2. Left heel Deep Tissue Injury (DTI) 3x3 Unstageable full thickness or tissue loss depth unknown (UTD). 3. Left Great Toe (DTI 0.5x0.5xUTD. 4. Left 1stMetatarsal DTI 1.5x1.5 UTD. c. COC dated July 03, 2024, at 1359, Noted with Left elbow trauma wound reopened and pressure injury to sacrum .treatment initiated as order .attempted to call daughter {name}, no answer and could (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 12/13/2024 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)