Other·April 21, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED SURVEY for COMPLAINT No: CA00519873. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 36870, HFEN and Surveyor 38217, HFEN. FOR COMPLAINT No: CA00519873: THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FINDINGS WERE CITED AT F273, F281, F309, AND F514. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ACLS - advanced cardiac life support Agonal respiration - shallow breathing pattern that is often related to cardiac arrest and death Anemia - a condition that develops when blood lacks enough red blood cells or hemoglobin, resulting in inadequate oxygen to the body's cells BP - blood pressure bpm - beat per minute BMP - basic metabolic panel (a blood test to measure blood sugar, electrolyte balance, and kidney function) Cardiopulmonary - pertaining to the heart and lungs CBC - complete blood count (a blood test to determine health status, including anemia and infection) LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 1 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Chief complaint - the primary reason for a person seeking medical attention CMP - Comprehensive Metabolic Panel (a blood test to evaluate organ function and check for conditions such as diabetes, kidney function and liver function) CNA - Certified Nursing Assistant Code Blue - A medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest COPD - chronic obstructive pulmonary disease (lung disorder, such as asthma, that increases airway resistance) CPR - cardiopulmonary resuscitation (manual use of chest compressions and ventilation to persons in cardiac arrest) Diabetes - a disease that affects the body's ability to use insulin resulting in abnormal carbohydrate metabolism DON - Director of Nursing ED - Emergency Department EMS - emergency medical service g/dL - grams per deciliter (some medical tests report results this way) GI - gastro-intestinal (refers to stomach and large and small intestines) Hematoma - a localized collection of clotted blood in the tissues outside of the blood vessels. Hemoglobin - a protein in red blood cells that carries oxygen. A low hemoglobin count may indicate anemia Hypoglycemia - low blood sugar KUB = kidneys, ureters, bladder (an x-ray of the abdomen, providing information about abdominal organs) LVN - Licensed Vocational Nurse MAR - Medication Administration Record MDS - Minimum Data Set (a portion of the RAI consisting of a set of screening, clinical, and functional status elements used to assess the residents) MI - myocardial infarction (heart attack, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 2 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE changes in the heart muscle that occur due to the sudden deprivation of circulating blood) ml - milliliter(s) mmHg - millimeter(s) of mercury NG tube - nasogastric tube (a tube used to suction stomach contents; inserted through the nose and down the esophagus to the stomach) OTA - Occupational Therapy Assistant Pneumonia - infection that inflames the air sacs of one or both lungs PT - Physical Therapist PTA - Physical Therapy Assistant RAI - Resident Assessment Instrument (a standardized assessment tool) RN - Registered Nurse SSD - Social Service Director STAT - used as a directive to medical personnel to respond immediately Status post - refers to a condition after a procedure or diagnosis Urinary retention - an inability to completely empty the bladder WBC - white blood cell count

F273 SS=D COMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT CFR(s): 483.20(b)(2)(i)

F273 (b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 3 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure a comprehensive assessment was conducted for one of two sampled residents (Resident 1). Resident 1 did not have an RAI completed at any time during the six weeks she was a resident at the facility. The failure to conduct a comprehensive assessment had the potential for the facility not having adequate and/or accurate information to plan and provide appropriate care and services to Resident 1. Findings: The RAI helps nursing home staff gather definitive information on a resident's strengths and needs to be addressed in an individualized care plan. It also assists staff with identify and tracking changes in the resident's status. The utilization of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified. The RAI includes the MDS. Review of the facility P&P titled Comprehensive Assessments dated 5/2014, showed it is the facility's policy to complete a comprehensive assessment of the resident's needs which are based on the State's specific RAI and the facility's interdepartmental assessment forms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 4 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Medical record review for Resident 1 was initiated on 2/6/17. Resident 1 was admitted to the facility on 12/8/17, for rehabilitation following a traumatic injury. Review of the RAI for Resident 1 dated 12/15/16, showed the OT and PT portions of section O (Special Treatment, Procedures, and Programs) were completed by the DOR on 12/16/16. The RAI also showed section B (Hearing, Speech, and Vision), section C (Cognitive Patterns), section D (Mood), section E (Behavior), and section Q (Participation in Assessment and Goal Setting) were completed by the Case Manager on 2/3/17, 14 days after Resident 1 was transferred out of the facility. In addition, no other sections of the MDS was completed including: *Section F - Preferences for Customary Routine and Activities *Section G - Functional Status *Section H - Bladder and Bowel *Section I - Active Diagnoses *Section J - Health Conditions *Section K - Swallowing/Nutritional Status *Section L - Oral/Dental Status *Section M - Skin Conditions *Section N - Medications *Section P - Restraints *Section V - Care Area Assessment Summary On 2/6/17 at 1535 hours, an interview with the MDS Coordinator was conducted. When asked if an RAI had been completed on Resident 1, the MDS Coordinator stated no, it had not been done. When asked if it should have been completed, the MDS Coordinator stated it should have been done within 14 days of the resident's admission date of 12/8/16. The MDS Coordinator stated it was not done due to the staff turnover and lack of an assistant available FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 5 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to complete the RAIs.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to provide services in accordance with the accepted standards of clinical practice for one of two sampled residents (Resident 1). Resident 1 had an initial nursing assessment completed upon admission to the facility by two LVNs, not by an RN. This failure had the potential for Resident 1 not receiving necessary nursing care that met the professional standards and developing medical complications. Findings: According to California Code of Regulations, Title 16-25-18.5, the LVN performs services requiring technical and manual skills which include the following: basic assessment, which the LVN Scope of Practice defines as data collection. The LVN may not perform an assessment that requires an analysis or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 6 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE synthesis (evaluation) of data. Data collected by the LVN can be used by the RN to assist in the assessment process. LVNs are not independent practitioners, but may implement components of patient care assigned to them by the RN responsible for the patient. Medical record review for Resident 1 was initiated on 2/6/17. Resident 1 was admitted to the facility from an acute care hospital intensive care unit on 12/8/16, for rehabilitation following a traumatic injury. Review of the Licensed Nurse Initial Admission Record dated 12/8/17 at 2348 hours, showed a comprehensive nursing assessment was completed by LVNs 3 and 4. There was no documented evidence Resident 1 was assessed by an RN on admission to the facility. On 2/15/17 at 1535 hours, a telephone interview was conducted with DON 3. When asked who was responsible for conducting an initial nursing assessment when a resident was admitted to the facility, DON 3 stated it was usually completed by RN 1. When asked if it should always be an RN, DON 3 stated yes. On 2/22/17 at 1450 hours, a telephone interview was conducted with DON 1 who was the Acting DON at the time Resident 1 resided at the facility. When DON 1 was asked who was responsible for conducting an initial nursing assessment for a resident, DON 1 stated whoever the charge nurse was at the time. When asked if it was always completed by an RN, DON 1 stated it was done by the licensed nurses, and could be an RN or LVN. DON 1 further stated at the time, she was DON at the facility, it was their policy to have specially trained LVNs perform the initial nursing assessments on residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 7 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 8 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to identify a significant change of condition in a timely manner for one of two sampled residents (Resident 1). Over the course of two and a half days, Resident 1 became weak, could no longer participate in PT, developed abdominal pain, became incontinent, and vomited blood. Failure to identify the significant decline in Resident 1's condition resulted in Resident 1 not receiving care and treatment timely necessary to maintain her physical well-being, causing her to be transported urgently to an acute care hospital ED in an unstable condition. Three minutes after arrival at the ED, Resident 1 suffered a cardiopulmonary arrest and subsequently died. Findings: On 1/30/17 at 1030 hours, a telephone interview was conducted with Resident 1's family member (Family Member 1). Family Member 1 stated he and his family were concerned the facility did not address all of Resident 1's health issues, especially her low hemoglobin and need for a GI workup to rule out internal bleeding. Family Member 1 stated he had requested a care plan conference with the Case Manager and Administrator on Resident 1's admission to the facility, but the care conference was not scheduled until 12/30/17, 22 days later. Family Member 1 stated "nothing was done" after the care conference to address the "blood problem" until 1/20/17, when Resident 1 was transferred via 911 ambulance to the acute care hospital after her health had declined. The family member stated according to the ED physician, Resident 1's hemoglobin level was 4.5 gm/dL (normal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 9 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE range: 11.0-15.0 g/dL). Family Member 1 stated Resident 1 received a blood transfusion in the ED but died shortly after being transferred to the acute care hospital. Medical record review for Resident 1 was initiated on 2/6/17. Resident 1 was admitted to the facility from an acute care hospital on 12/8/16, for rehabilitation following a traumatic injury. Review of the Physician Discharge Summary from the acute care hospital dated 12/8/16, included the following discharge diagnoses: multiple injuries due to trauma, acute blood loss anemia, status post blood transfusion, pelvic hematoma, poorly controlled diabetes with hypoglycemia, hypertension, COPD, and urinary retention and frequency. Documentation also showed Resident 1 had chronic anemia and her hemoglobin upon discharge was 8.1 g/dL. There was a pending GI workup as an outpatient, and she was to be discharged to the skilled nursing facility for rehabilitation. Review of the History and Physical examination dated 12/12/16, showed Resident 1 had the capacity to understand and make decisions. Review of the Licensed Nurse Initial Admission Record dated 12/8/17 at 2348 hours, showed a comprehensive nursing assessment was completed by LVNs 3 and 4. There was no documented evidence to show an RN assessment was completed upon the resident's admission to the facility. Cross reference to

F281. Review of the RAI dated 12/15/16, showed majority of the assessments, except for the PT and OT sections, had not been completed during Resident 1's six week stay at the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 10 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE For example, the sections of the RAI used to measure residents' functional abilities, strengths, weaknesses, and risk factors were all blank. The Care Area Assessment Summary was also left blank. According to the RAI Manual dated 10/2014, the Care Area Assessment Summary should be used to guide decision-making, direct facility staff to specific areas of concern, and develop a comprehensive plan of care. Review of the laboratory results for Resident 1 showed the following: * On 12/13/16, the CBC test results showed the hemoglobin level was 7.1 g/dL (normal hemoglobin range: 11.5-15.0 g/dL) and the physician was notified with no new orders. * On 12/30/16, the CBC test results showed the hemoglobin level was 8.8 g/dL and the physician was notified with no new orders. * On 1/10/17, the CBC test results showed the hemoglobin level was 8.6 g/dL and the physician was notified with no new orders. * On 1/20/17, the CBC test results showed the hemoglobin level was 4.5 g/dL and the WBC count was 25.8 thousand (normal WBC range: 4.0-10.5 thousand) and the physician was notified and ordered Resident 1 to be transferred to the acute care hospital ED. On 2/6/17 at 1545, an interview was conducted with the Case Manager who stated she had been covering for the vacationing SSD. The Case Manager stated she and the rest of the IDT held a care conference with Resident 1 and her family sometime after 12/28/16. The Case Manager stated Resident 1's progress, nursing care, and laboratory test results were all discussed. The Case Manager stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 11 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE family had been concerned about the resident's hemoglobin level (7.1 g/dL) obtained on 12/13/16. The Case Manager stated she reassured the family that a hemoglobin level of 7.1 g/dl result did not fall within the parameters for a blood transfusion, but she would request another blood count from the physician. Review of Resident 1's Progress Notes showed a nurse's Change of Condition note dated 1/19/17 at 1800 hours, was documented by LVN 1. The note showed Resident 1 reported vomiting blood. LVN 1 notified the resident's physician (Physician 1) and received an order for anti-nausea medication and a CBC test to be done the following morning. A second nurse's progress note dated 1/19/17 at 2207 hours, showed Resident 1 was forgetful and complaining of abdominal pain. LVN 1 documented he notified his supervisor to assess Resident 1 and notified the physician. LVN 1 documented Physician 1 ordered a CMP test and abdominal x-ray; both orders were to be carried out in the morning. There were no vital signs documented in the nurse's note at or around this time. On 2/15/17 at 1605 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to review his documentation for Resident 1 from 1/19/17. When asked if he observed the vomit Resident 1 reported to him, LVN 1 stated no, he did not see it. He stated he did not know how much there was or what it looked like because Resident 1 could not remember, just that it was red with blood. LVN 1 was asked if he checked Resident 1's abdomen. He stated no, he requested his supervisor (RN 1) to assess Resident 1. He stated RN 1 did assess Resident 1 and notified the resident's physician. LVN 1 stated Resident 1 appeared to be "fine" and remained alert and oriented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 12 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/16/17 at 1600 hours, a telephone interview and concurrent medical record review was conducted with RN 1. RN 1 stated he remembered working the evening shift on 1/19/17 with LVN 1. RN 1 stated the DON (DON 1) informed LVN 1 via text to have him (RN 1) assess Resident 1, but RN 1 did not remember what time. RN 1 stated he remembered assessing Resident 1 but did not recall the time. He stated there was a family member at her bedside. RN 1 stated her vital signs were taken and were "normal." He said Resident 1 was complaining of abdominal pain. He stated the family told him Resident 1 had been complaining of abdominal pain for the last three months and all of her tests were "negative." RN 1 stated he informed LVN 1 to call the physician who ordered the KUB and CMP tests to be done the following morning. RN 1 stated he recalled LVN 1 informing him a CNA (CNA 1) had helped Resident 1 clean up the "coffee ground" vomit earlier in the shift on 1/19/17. When RN 1 was asked where he documented his assessment of Resident 1, RN 1 stated he normally did not document anything in the medical record when he was asked to help another nurse. When asked what his assessment findings were for Resident 1 on 1/19/16, he stated her abdomen was soft but tender, her vital signs were stable, and the resident was not " tachycardic" (rapid heart rate) and not vomiting, pale or weak. RN 1 did not think there was a "significant change" in her condition. Review of the Physical Therapy Notes showed Resident 1 was experiencing a change of condition from 1/18/17 to 1/20/17 as evidence by the following notes: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 13 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a. Review of Physical Therapy Treatment Encounter note dated 1/18/17, signed by PTA 1, showed Resident 1 was feeling fatigued, had increased pain, and required frequent rest periods due to fatigue and pain. Review of PT 1's note dated 1/19/17, showed Resident 1 refused to ambulate due to feeling nauseous and having stomach pain, and the nursing staff were notified. b. Review of Physical Therapy Treatment Encounter Note dated 1/18/17, signed by PTA 2 showed Resident 1 reported feeling fatigued and had increased pain. On 1/19/17, PTA 2 documented Resident 1 refused to attempt ambulate due to feeling nauseous and having stomach pain, and the nursing staff were notified. c. Review of Physical Therapy - Therapy Addendum notes dated 1/20/17 from 08300840 hours, showed a summary note documented by PT 1. PT 1 and OTA (OTA 1) asked to help assess Resident 1 for a decline in her functional mobility. The note showed PT 1 performed an assessment and asked Resident 1 how she was feeling. Resident 1 responded, "yucky." On 2/16/17 at 0955 hours, a telephone interview and concurrent medical record review was conducted with PT 1. PT 1 confirmed she assessed Resident 1 for a change in her functional status on 1/20/17. PT 1 stated she assessed Resident 1 to rule out a possible stroke such weakness on one side. PT 1 stated OTA 1 stated she had informed the nursing staff Resident 1 was not feeling well. On 2/16/17 at 1000 hours, a telephone interview and concurrent medical record review was conducted with PTA 1. PTA 1 stated she had worked with Resident 1 on 1/16 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 14 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/17/17. PTA 1 stated Resident 1 was motivated and functioning well on these two days. The resident did not complaint of any decreased energy or fatigue; the only thing the resident mentioned was that she had a long history of chronic hip and back pain. On 2/16/17 at 1008 hours, a telephone interview and concurrent medical record review was conducted with PTA 2. PTA 2 stated he took care of Resident 1 on 1/18 and 1/19/17. PTA 2 stated on 1/18/17, Resident 1 felt weak and had abdominal pain, and he let the nurse know. PTA 2 stated Resident 1 was able to get out of bed, sit in the chair, and walk to the bathroom. PTA 2 stated they stayed in Resident 1's room to do her treatment on that day; however, normally, Resident 1 would walk (using her walker) to the gym to do her exercises. PTA 2 stated Resident 1 had not been feeling well and refused therapy twice on 1/19/17. He stated he let the nurse know how Resident 1 was feeling and that she had refused treatment. PTA 2 added Resident 1 looked "off." However, review of the medical record showed no documented evidence the licensed nursing staff had assessed the resident and reported the resident's change in health condition to the physician for proper and prompt medical interventions after the PT staff had informed the licensed nursing staff of the resident's change in condition. Review of the Occupational Therapy Treatment notes showed Resident 1 was experiencing a change of condition from 1/18/17 to 1/20/17 as evidence by the following notes: a. Review of Occupational Therapy Treatment Encounter Note dated 1/18/17, signed by OTA 1, showed Resident 1 was able to work in her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 15 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE room only, declined a shower three times because she was too cold, complained of nausea, and was not feeling well enough. The nursing staff were notified Resident 1 refused to shower. b. The Occupational Therapy Treatment Encounter Note dated 1/19/17, signed by OTA 1, showed Resident 1 appeared confused, notified the nursing staff of the change of condition. The OTA documented Resident 1 required a lot of encouragement to participate with her therapy treatment. c. Review of Occupational Therapy Treatment Encounter Notes dated 1/20/17, signed by OTA 1, showed Resident 1 had increased fatigue and was lethargic, the nursing staff were notified STAT, and both CNA and OTA assisted Resident 1 with positioning and incontinent brief management. PT 1 was called into room to assess Resident 1. Resident 1 was encouraged to eat but had no appetite; the nursing staff member was present in room; the OTA went back to check Resident 1 later, but she had been transferred to the ED. On 2/17/17 at 0945 hours, a telephone interview and concurrent medical record review was conducted with OTA 1. OTA 1 stated she was very familiar with Resident 1, knew her well, and had worked with her throughout her stay. OTA 1 was asked to review her documentation in Resident 1's medical record for the dates 1/18/17-1/20/17. After reviewing her documentation, OTA 1 spoke of the following timelines for Resident 1: * On 1/18/17 (Wednesday), Resident 1 was functioning at a high level. * On 1/19/17 (Thursday), Resident 1 had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 16 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decline in her function status; prior to Thursday, Resident 1 had been ambulating to the bathroom with standby assistance and the use of her walker and was able to toilet herself. Resident 1 had been cognitively intact and was doing "great." She stated on Thursday (1/19/17), Resident 1 was not "herself." OTA 1 observed Resident 1 lying in bed wearing only her robe. OTA 1 stated Resident 1 was a modest woman who would normally not be in that state of undress. She said Resident 1 seemed a little "loopy and out of it." * On 1/20/17 (Friday), OTA 1 stated she was a little "alarmed" to find Resident 1 lying in bed wearing a hospital gown and an incontinence brief as she had was always continent and always wore underwear. She stated she immediately went to the charge nurse and the charge nurse went into the resident's room. OTA 1 stated she also notified PT 1 to help evaluate Resident 1 as they were both concerned Resident 1 might have had a "stroke." She stated Resident 1 had no appetite and refused to eat. PT 1 recommended to let Resident 1 rest and try to work with her later in the morning. OTA 1 stated she went back to Resident 1's room later in the morning and learned the resident had been transferred by ambulance to the hospital. Review of the licensed nurses' progress notes showed on 1/18/17, there were no vital signs documented. In addition, there was no documentation to show Resident 1 had any changes of condition such as nausea, vomiting, or abdominal discomfort as identified by PT, OTA, and CNA staff. Review of the meal percentage intake for Resident 1 for January 2017 showed Resident 1 had a decline in her oral meal intake between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 17 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/16/17 to 1/20/17. For example, on 1/16/17, she ate 100% of all meals. On 1/17 and 1/18/17, she ate an average of 50% of her meals. On 1/19/17, she only ate 25% of each meal and on 1/20/17, she refused to eat her breakfast and was later transferred to the ED. On 2/21/17 at 1550 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she was not assigned to Resident 1 on Thursday (1/19/17), but remembered helping her at around 1800 hours on that day. CNA 1 stated she was in the hallway and went into Resident 1's room because she had vomited on herself and on the floor. CNA 1 stated the vomit was bloody but also had "black" in it like "coffee grounds." CNA 1 stated she went out of the room to tell LVN 1 Resident 1 vomited; however, LVN 1 was busy so she went back to clean up the resident's vomit. On 2/22/17 at 1050 hours, a telephone interview was conducted with CNA 2. CNA 2 she had cared for her many times. CNA 2 stated during the last two days, the resident was in the facility complaining of "belly pain." CNA 2 stated she did not recall Resident 1 complaining of belly pain before 1/18/17. She stated when Resident 1 got up to the bathroom, she was "holding her belly" and said her "belly hurt." CNA 2 stated she "knew something was wrong" with Resident 1 and reported her change of condition to the nurse in charge. CNA 2 further stated on 1/20/17, Resident 1 was wearing an incontinence brief. CNA 2 Resident 1 was not herself because she had never been incontinent before. She stated she reported her observations to LVN 2. She stated LVN 2 told her that Resident 1 was "fine" and that they were monitoring her. CNA 2 stated she changed Resident 1's incontinence brief and observed dark urine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 18 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that Resident 1 was very weak and sweaty. She said she reported Resident 1's condition to LVN 2 again. LVN 2 told CNA 2 they were monitoring Resident 1 and they were trying to get an order for an IV. CNA 2 stated there was a family member (Family Member 2) at Resident 1's bedside the entire morning of 1/20/17. He was very concerned about her change of condition and wanted her transported to the acute care hospital. The CNA stated the Medical Director came into Resident 1's room and took her pulse, and stated her heart rate was up and asked everyone to leave the room. The resident was transferred to the ED. Review of the resident's plan of care showed no documented evidence the staff developed a care plan problem to address Resident 1's anemia. A short-term care plan problem showed Resident 1 vomited on 1/19/17, however, it did not address Resident 1 had vomited blood. In addition, there was no other care plan problem to address Resident 1's change of condition related to her incontinence, inability to perform PT/OT exercises, loss of appetite, abdominal pain, fatigue, or her altered mental status from 1/18/17 to 1/20/17, found in the medical record. On 2/22/17 at 1110 hours, a telephone interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was familiar with Resident 1 and worked as a desk nurse on the day shift from 1/17/171/20/17. LVN 2 was asked to review a nurses' progress note she designated as a Late Entry on 1/19/17 at 1146 hours. LVN 2 stated she wrote the note but did not remember exactly what time the assessment of Resident 1 took place; it just occurred sometime before lunch. LVN 2 verified she did not write down the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 19 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE actual time of the assessment. When asked what prompted her to perform an assessment for Resident 1 at the time, LVN 2 stated because Resident 1 vomited on the afternoon shift the day before and she had received a text from DON 1 at approximately 1030 hours on 1/19/17, asking her to assess Resident 1. LVN 2 stated Resident 1 was alert during the assessment, and had no discomfort, nausea, or vomiting. LVN 2 described the course of events that occurred with Resident 1 on the morning of 1/20/17. LVN 2 stated LVN 6 asked LVN 2 to assist her with Resident 1 because Family Member 2 was in the room and asking Resident 1 being transferred to the acute care hospital. She stated she "checked" on Resident 1 was awake but not talking like she normally did and did not respond verbally when her name was called. LVN 2 stated another LVN (LVN 6) took Resident 1's vital signs and was going to take them again because they were abnormal. LVN 2 called the Medical Director and DON 1 to inform them of Resident 1's condition. LVN 2 remembered Resident 1 had laboratory tests drawn earlier that morning and went to check the results in the computer. LVN 2 stated she retrieved the CBC results from the computer and identified a critical value notification from the laboratory company. She stated she then texted Physician 1 and told him about the laboratory notification and asked for an order for an IV. She said the Medical Director came into the room to assess Resident 1 and took her pulse. The Medical Director stated Resident 1's pulse was weak and rapid and ordered staff to call 911. LVN 2 called 911 at 1005 hours. When LVN 2 was asked if she had been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 20 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notified of Resident 1 inability to do PT or OT the two days prior to her being transferred to the ED, LVN 2 stated no, the report would have been given the nurse assigned to Resident 1. On 2/22/17 at 1450 hours, a telephone interview was conducted with DON 1. DON 1 was asked to explain how the nursing staff responded to Resident 1's change of condition. The DON stated on the morning of 1/19/17 (Thursday), she received a "forwarded" text from the Administrator regarding Resident 1's "stomach." The DON asked LVN 2 to assess Resident 1 sometime before lunch. She stated LVN 2 told her Resident 1 "was fine" and even better by the end of LVN 2's shift on 1/19/17. Later, DON 1 heard from LVN 1 that on the evening on 1/19/17, Resident 1 had vomited. The DON stated she told LVN 1 to text Physician 1 and obtain an order for laboratory work and asked RN 1 to assess Resident 1. The DON stated the staff's assessments should have been documented in the resident's medical record. On 2/23/17 at 1600 hours, a telephone interview was conducted with Family Member 2. The family member stated he had visited Resident 1 on multiple occasions at the facility. Family Member 2 stated he was with Resident 1 on Tuesday (1/17/17) and she was "okay." He stated he was with Resident 1 on Thursday (1/19/17) for most of the day, and she was "not well," so he asked Family Member 3 to come stay with her so he could leave. Family member 2 stated on 1/19/17, the facility called him told him Resident 1 had been incontinent. He stated he went to the facility at 1000 hours on 1/19/17, and noticed Resident 1 was not feeling well and told him her stomach was "upset." He stated he tried to assist the resident to the bathroom, but she was unable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 21 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to make it and became "sweaty." Family Member 2 called for help and the staff put Resident 1 on a bedpan. He stated Resident 1 could not eat because her stomach hurt. He stated he informed the nurses something was not right with Resident 1, especially as the day progressed. He stated he had to leave the facility but returned later that evening. One of the staff had informed him the resident had vomited and there was blood in it. Family Member 2 stated he noticed a definite decline in Resident 1's mental status and was uncomfortable leaving her. He stated he asked Family Member 3 to come and stay with her. Family Member 2 stated he went to the facility early on 1/20/17, because Family Member 3, who had been with her the night before, was very worried about Resident 1's condition. He stated both he and the other family members wanted Resident 1 to be transferred to the acute care hospital early Friday morning (1/20/17), but the facility staff had refused. He stated two days prior, Resident 1 was able to walk, eat, and could get out of bed to the bathroom with minimal assistance; however, on Friday (1/20/17), Resident 1"could not do anything." Family Member 2 stated a nurse came into Resident 1's room on 1/20/17 around 0945 hours, and checked the resident's oxygen saturation rate. The nurse then called for help and four staff members came into the room including the Medical Director. The Medical Director asked Resident 1 questions, but the resident did not respond. The Medical Director instructed someone to call an ambulance. Family Member 2 stated he heard a staff member was overheard inform the Medical Director the resident s blood test results. The Medical Director responded by saying "she is septic, we need to call 911." The Medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 22 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director told Family Members 2 and 3 Resident 1 had a WBC count of 27 thousand and her hemoglobin was 4.5. The family member stated the paramedics arrived and administered oxygen to Resident 1; she became verbally responsive and complained she had "pain all over." Resident 1 was transferred to the acute care hospital ED. The family member stated when they arrived to the ED, Resident 1 was "gasping for air" and her eyes were "rolled back" and a Code Blue was called. Review of the acute care hospital ED records dated 1/20/17, showed the following: a. The History of Present Illness dated 1/20/17 at 1116 hours, Resident 1 was admitted to the ED with increasing generalized weakness, altered level of consciousness, and a WBC count of 27 thousand (normal range: 3.7-10.5 thousand), and she had abdominal distention. While in the ED Resident 1 went into cardiac arrest and a code blue was called. On 1/20/17 at 1140 hours, Resident 1 was placed on a ventilator. b. Review of the laboratory test results for Resident 1 dated 1/20/17 at 1116 hours, showed the WBC level was 26.7 thousand and the hemoglobin level was 4.4 g/dL (normal range: 11.0-16.0 g/dL). c. Review of Medical Decision-Making Progress notes for Resident 1 dated 1/20/17, showed at 1119 hours, a Code Blue was called and Resident 1 was intubated (breathing tube placed). At 1202 hours, Resident 1 was pronounced dead. d. Review of a Physician's note dated 1/20/17 at 1509 hours, showed the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 23 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Course - Resident 1 was brought to the ED by EMS after she became weak and obtunded (having diminished arousal and awareness) for the past couple of days. On arrival to the ED, Resident 1 was severely obtunded, pale, and had agonal respirations. Resident 1 lost pulse and a Code Blue was called. Resident 1 was intubated and received blood transfusion. The resident had evidence of coffee ground substance present on the NG tube as well as during the intubation. Resident 1 coded a second time requiring ACLS. The Code was called at 1202 hours due to prolonged resuscitation and a grave prognosis. The patient most likely had a "severe upper GI bleed," leading to severe anemia, hypertension, MI, and ultimate cardiac arrest.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 24 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the accurate and complete medical record was maintained for one of two sampled Residents (Resident 1). Resident 1's medical record did not reflect accurate vital signs. This failure posed a risk of facility staff and/or physicians having inaccurate information of Resident 1's clinical condition. Findings: Medical Record review for Resident 1 was initiated on 2/6/17. Resident 1 was admitted to the facility on 12/8/16, for rehabilitation following a traumatic injury. Review of Daily Skilled Notes showed the staff were documenting the exact same vital signs for several consecutive days. For example: * On 12/10 and 12/11/16, the resident's BP was 122/60 mmHg and her pulse was 90 bpm. * From 12/19 - 12/23/16, Resident 1's BP was documented as 126/70 mmHg and pulse was 83 bpm. * On 12/27 and 12/28/16, the resident's BP was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 25 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 138/71 mmHg and pulse was 83 bpm. * On 12/29 and 12/30/16, Resident 1's BP was 135/78 mmHg and pulse was 86 bpm. * From 1/1 - 1/4/17, Resident 1's BP was 158/79 mmHg and pulse was 86 bpm. * For 1/2, 1/3, and 1/5/17, there were no vital signs or Daily Skilled Note documented. * From 1/6 - 1/12/17, Resident 1's pulse rate was documented as "18" without intervention, reporting, or correction. A low pulse rate of 18 without any documented intervention or documented evidence the physician was notified. * From 1/14 - 1/18/17, the staff documented Resident 1's BP was 126/72 mmHg and her pulse was 76 bpm. On 2/15/17 at 1535 hours, a telephone interview and concurrent medical record review was conducted with LVN 1. When asked how often LVN 1 took the vital signs for residents. LVN 1 stated he took them once every shift, but sometimes the CNA took them. When asked where he documented the vital signs, LVN 1 stated sometimes in the nurses' progress notes and sometimes in the Daily Skilled Notes. When asked if they could be documented anywhere else in the medical record, LVN 1 stated maybe in the "vital signs paper work." When asked if the "vital signs paper work" was part of the medical record, LVN 1 stated no, it was for the nurses' use only. LVN 1 was asked to review the Daily Skilled Notes he wrote regarding the resident's vital signs on 1/7/17, as B/P 130/68 mmHg and "P" 18 bpm and 1/12/17, B/P of 131/68 mmHg and "P" 18 bpm. When asked if he wrote these two notes and vital signs, LVN 1 stated yes. LVN 1 stated the "P" meant the "pulse rate." When asked to read back what he documented for the resident's pulse rate, LVN 1 stated what he wrote it in error as the resident's pulse rate could not have been 18 bpm as documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 26 of 27 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555257 (X3) DATE SURVEY COMPLETED 03/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALM TERRACE HEALTHCARE & REHABILITATION CENTER 24962 Calle Aragon Laguna Woods, CA 92637 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE When asked what he would do if the vital signs were abnormal, LVN 1 stated he would re-take them but did not do so on those two days. On 2/22/14 at 1110 hours, a telephone interview and concurrent medical record review was conducted with LVN 2. When asked how often she took routine vital signs, LVN 2 stated she took them every morning before administering the medications to the residents. When asked where she documented the vital signs, LVN 2 stated she wrote them down on a "paper endorsement," which was not part of the resident's medical record. LVN 2 stated she then transcribed the vital signs onto MAR or the Daily Skilled Notes. LVN 2 was asked to review her notes from 1/14 to 1/16/17. LVN 2 verified the same set of vital signs were documented for five days in a row. LVN 2 stated she did not take the vital signs as documented on 1/14 to 1/16/17; however, she stated she had signed the note dated 1/16/17. LVN 2 stated she recalled taking Resident 1's vital signs on 1/16/17, but failed to document them on the resident's medical record. On 2/22/17 at 1450 hours, a telephone interview was conducted with DON 1. When asked how often routine vital signs should be taken for the residents, the DON stated at least once per day. DON 1 was informed Resident 1's medical record failed to show documented evidence her vital signs were taken every day. DON 1 verified they should be taken and documented every day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBX011 Facility ID: CA060000255 If continuation sheet 27 of 27