Other·December 7, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate a complaint from October 13, 2017 to November 3, 2017. Complaint Number: CA00556559 Representing the California Department of Public Health: 38215 Census: 45 Sampled Residents: 3 An Immediate Jeopardy [(IJ), a crisis which has threatened or is likely to threaten the health and safety of a resident.] was called under 483.20, Resident Assessment (refer to F 279) on October 24, 2017 at 3:47 PM, and verbally notified in the presence of the Director of Nursing. The facility failed to monitor one of three sampled residents (Resident A) and prevent him from wandering to another resident's room where he obtained a sandwich that had been left on the resident's table. Resident A choked on the sandwich, on October 8, 2017 at 1:30 PM, requiring cardiopulmonary resuscitation (CPR-an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into lungs.) The corrective action plan was reviewed and following observations, interviews, and record reviews, the IJ was lifted in the presence of the 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: 64U711 Facility ID: CA240000029 If continuation sheet 1 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 of Nursing and Regional Nurse Consultant on October 25, 2017 at 12:37 PM.

F279 SS=J DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 2 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their care plan for one of three sampled residents (Resident A) for wandering into other residents' rooms and for grabbing snacks and putting them in his mouth. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 3 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 failure resulted in Resident A wandering into another resident's room, where he grabbed a sandwich, choked and collapsed. Resident A required cardiopulmonary resuscitation (CPRan emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs) and is now on a ventilator (a machine that helps someone breathe) in the acute care hospital. Findings: The clinical record for Resident A was reviewed. A document titled, "Admission Record" dated October 13, 2017, indicated Resident A was admitted on June 8, 2015, with diagnoses of dementia (a condition of progressive memory loss), schizophrenia (a mental condition with distorted thought disorder), and depression. During an interview with Certified Nursing Assistant 1 (CNA 1) on October 13, 2017 at 9:45 AM, she stated,"He [Resident A] goes to everybody's room, gets other resident's food and had been doing that for a long time. He was not on one on one supervision." During an interview with CNA 2 on October 13, 2017 at 3:30 PM, he stated, "He goes from room to room. He gets trays from other residents during mealtime. Only the nurse on the floor supervises a section of the facility. He needs a one on one supervision." A review of Resident A's care plans reflected Resident A had been identified as being at risk for choking and had three episodes of choking as follows: a. Care plan dated March 17, 2016, reflected Resident A "...grabbing snacks from cart, will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 4 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 put all snacks in his mouth at one time." b. Care plan dated August 25, 2017, (after the first choking incident) "Resident (Resident A) at risk for choking, impulsive, eats fast." c. Care plan dated September 30, 2017, indicated, "... physical aggression, taking trays out of other resident's hands..." d. A care plan titled "Alteration in nutrition-risk for choking" initiated November 18, 2016, listed two incidents. 1. October 6, 2017, "choked on fish," interventions included diet changed to regular, chopped, no bread. 2. October 8, 2017, "choked on P and J (peanut butter and jelly) sandwich." Further review of Resident A's care plans indicated a behavior care plan initiated August 14, 2016, for "wandering." Interventions included: "Will go in and out of other residents' room. Intervene as appropriate." The clinical record of Resident A was reviewed. A document titled "Speech therapy" dated August 31, 2017, indicated, "... Recommendations, Supervision for oral intake=close supervision ..." During a review of the clinical record of Resident A from the acute care hospital on August 25, 2017, a document titled "Patient Notes" indicated,"...Pt was seen choking by an RT (respiratory therapist), and Heimlich (emergency procedure to remove foreign object from the mouth) was attempted which was unsuccessful ...CPR was initiated ...foreign object was removed ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 5 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 the clinical record for Resident A from the acute care hospital where he was transferred on October 8, 2017, was conducted. A document titled " Hospital course " indicated, " ... [Resident A] has been known to take food from other residents in the facility ...He has issues with choking and apparently choked while eating. The staff found the patient, unresponsive and called 911. When paramedics arrived, the patient was in full arrest (not breathing, no pulse)...Patient was intubated and CPR was performed. After 25-30 minutes there was return of spontaneous circulation ...He underwent a bronchoscopy (a procedure to check the airways) with removal of the food particles from the tracheo-bronchial tree (airways going to lungs) ...He remains intubated on mechanical ventilation (machine that helps patient breathe) ...patient has remained comatose (deep unconsciousness for prolonged or indefinite period, especially as a result of severe injury or illness). During an interview with the Director of Nursing (DON) on October 13, 2017 at 3:00 PM, she stated, Resident A preferred to eat in his room during mealtimes and was not on one to one supervision. Only the nurse assigned on the floor supervised the rest of the residents who ate in their rooms. She stated the speech therapist did not have an in-service with the staff about his recommendations, after Resident A's first choking incident. The facility policy and procedure titled, "Assistance with Meals," dated November 2010, indicated, "Residents shall receive assistance with meals in a manner that meets the individual needs of each residents." An Immediate Jeopardy [(IJ), a crisis which has threatened or is likely to threaten the health and safety of a resident.] was called under FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 6 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 483.20, Resident Assessment (refer to F 279) on October 24, 2017 at 3:47 PM, and verbally notified in the presence of the Director of Nursing when the facility failed to monitor one of three sampled residents (Resident A) and prevent him from wandering to another resident's room where he obtained a sandwich that had been left on the resident's table. Resident A choked on the sandwich, on October 8, 2017 at 1:30 PM, requiring cardiopulmonary resuscitation (CPR-an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into lungs.). The corrective action plan included: a. Residents' snacks will be passed, they will be allowed ample time to consume them, and if they are not consumed within that time, snacks will be collected and discarded due to infection control and to protect wandering residents from potential choking hazards. Snacks will be available at residents' request. Snacks are kept on snack cart in locked break room after kitchen has closed. b. For residents that have impulsive eating behaviors, wandering, and with previous history of choking, the following protocol will be implemented: -Physician notification. -Request for speech therapy evaluation, specific interventions, identified by speech therapy or any other special services, will be added to residents care plan. -Dietician evaluation. -RNA (restorative nursing assistant-a nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 7 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 assistant with special rehabilitation training) feeding program. -Resident will be monitored as indicated to prevent future incidents. - Care plan will be initiated or updated accordingly, to include specific instructions identified by speech therapist such as 1:1 observations to prevent any future potential choking incident. -1:1 sitter during meal periods and snack times, to reduce risk of any unsupervised consumption of foods, and prevent any future choking episode. Resident care plan will reflect interventions so that plan of care will be evaluated per care plan schedule and as needed. c. All nursing staff were immediately given an in-service on October 24, 2017. The corrective action plan was reviewed and following observations, interviews, and record reviews, the IJ was lifted in the presence of the Director of Nursing and Regional Nurse Consultant on October 25, 2017 at 12:37 PM.

F492 COMPLY WITH FEDERAL/STATE/LOCAL FORM CMS-2567(02-99) Previous Versions Obsolete

F492 Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 8 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=G LAWS/PROF STD CFR(s): 483.70(b)(c) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. (c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report to California Department of Public Health (CDPH) when one of the three sampled residents (Resident A) experienced three choking incidents within two months. Two of the choking incidents required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 9 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 cardiopulmonary resuscitation (CPR -an emergency procedure in which the heart and lungs are made to work by compressing the chest underlying the heart and forcing air into the lungs), the most recent resulting in Resident A being placed on a ventilator (a machine that helps some breathe). Findings: A review of Resident A's clinical record indicated he was admitted on June 8, 2015, with diagnoses of dementia (a condition of progressive memory loss), schizophrenia (a mental condition with distorted thought disorder), and depression. A review of the nursing progress notes indicated Resident A had three incidents of choking as follows: a. On August 25, 2017, "...Staff noted patient was non responsive. Patient did not respond to verbal command, staff initiated the Heimlich maneuver (emergency procedure to remove foreign object from the mouth) was attempted which was unsuccessful ... CPR was initiated , with no result. Code Blue (when pulse or respirations are not detected) called at 1:08 PM ...chest compression initiated..." b. On October 6 , 2017, "... he (Resident A) was choking...the Heimlich maneuver was initiated. Resident began to cough and food was ejected from resident's mouth..." c. On October 8, 2017,"...Charge nurse assessed resident (Resident A) and noted he was choking on a sandwich...Heimlich maneuver was performed and was not successful...CPR initiated..." An interview and concurrent review of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 10 of 11 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: _______________ 555025 (X3) DATE SURVEY COMPLETED 11/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST ACUTE 2278 Nice Ave Mentone, CA 92359 (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 facility's policy and procedure titled, "Unusual Occurrences," undated, was conducted with the Director of Nursing (DON) on October 13, 2017, at 10:15 AM. The policy indicated, "It is the policy of the facility to comply with California Code of Regulations, Title 22, Division 5, Chapter 3, Article 5,7254: Occurrences such as epidemic outbreaks, poisoning, fires, major accidents, death from unnatural causes or other catastrophes and and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours..." The DON stated, that when Resident A had the repeated incidents of choking, and required cardiopulmonary resuscitation, "I did not report the three incidents to CDPH (California Department of Public Health), I was not sure if it was reportable or not." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 64U711 Facility ID: CA240000029 If continuation sheet 11 of 11