Other·August 16, 2018

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 regarding a complaint. Complaint Number: CA00579710 Representing the California Department of Public Health: 36159 The inspection was limited to the specific complaint investigated and does not represent a full inspection of the facility, One deficiency was reported for complaint number: CA00579710

F684 SS=G Quality of Care CFR(s): 483.25

F684 07/27/2018 § 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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to monitor the resident for a loss of appetite that resulted in a significant weight loss, failed to notify the physician of a decrease in meal intake, weight loss, and increased weakness, failed to implement the care plan to 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: YR8P11 Facility ID: CA240000029 If continuation sheet 1 of 14 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 07/16/2018 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 address the change of condition (COC), and failed to notify the responsible party of a COC for one of three sampled residents, (Resident A). These failures resulted in an emergency transfer to the acute care hospital, where she later died. Findings: An abbreviated survey was conducted on April 3, 2018 to investigate a complaint related to quality of care (QOC). A review of Resident A's facesheet (contains demographic information) indicated that she was admitted to the facility on July 5, 2017, with diagnoses which included dementia (brain disease that causes memory disorder, personality changes, and impaired reasoning), schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), peripheral vascular disease (PVD-diseases of the blood vessels located outside of the heart and brain), and an ileostomy (an artificial opening on the abdomen for bowel elimination). A review of Resident A's nursing progress notes dated December 14, 2017, indicated Resident A was transferred from the skilled nursing facility (SNF) to the acute care hospital on December 14, 2017, for a complaint of chest pain. A review of the emergency room's (ER) laboratory results dated December 14, 2017 (tests of material from the human body to provide information to treat a disease), chest xray (CXR-picture of the upper chest) results, and electrocardiogram (EKG-test that measures heart beat rate & rhythm), indicated the findings were all within normal range and Resident A was returned to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 2 of 14 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 07/16/2018 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 nursing admission record, dated July 5, 2017, indicated Resident A's weight at admission was 96.6 lbs (pounds), height 57 inches. A review of the "Weight Summary Report" dated December 20, 2017, indicated Resident A's weight for the week of December 6, 2017 was 96 lbs. A review of the facility's tracking of the percentage of meals eaten by Resident A (from "Missed Meals," meal percentages, "Documentation Survey Reports") indicated: December 7, 2017: breakfast 0, lunch 80%, dinner 0. December 8, 2017: breakfast 0. lunch 0, dinner 0. December 9, 2017: breakfast 0, lunch 80%, dinner 0. December 10, 2017: breakfast 0, lunch 80%, dinner 0. December 11, 2017: breakfast 0, lunch 0, dinner 40%. December 12, 2017: breakfast 35%, lunch 100%, dinner 0. December 13, 2017: breakfast 0%, lunch 80%, dinner 50%. December 14, 2017: breakfast 100%, lunch 0, dinner 0. December 15, 2017: breakfast 0, lunch 75%, dinner 0. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 3 of 14 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 07/16/2018 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 December 16, 2017: breakfast 0, lunch 80%, dinner 0. December 17, 2017: breakfast 0, lunch 100%, dinner 0. December 18, 2017: breakfast, lunch & dinner 0%, 50% of snack at 9:30 PM. December 19, 2017: breakfast, lunch & dinner 0%. December 20, 2017: breakfast, lunch & dinner 0%. December 21, 2017: breakfast 0%, lunch-left the facility to the acute hospital. A review of the Registered Dietician (RD) weight note on December 15, 2017, indicated, "Resident's current weight 89 lbs (pounds) . . . She lost 6 lbs/- (negative) 6.3% in the last week. Unsure of reason for wt. [weight] loss. Recommendation 1) Continue diet with supplement 2) Continue to monitor." A review of the "Weight Summary Report" dated December 20, 2017, indicated Resident A's weight for the week of December 20, 2017 was 80 lbs, a change of -15 lbs. The RD noted the findings on December 22, 2017, and documented, "Will chart when the resident returns from the hospital." This was a 15 lb weight loss in two weeks from December 6, 2017 to December 20, 2017. During a telephone interview with the RD on May 11, 2018 at 3:30 PM, she stated that she did not remember Resident A, and does not remember a resident whose weight decreased to 80 lbs. When asked if a resident had lost 15 lbs in 14 days what interventions would you incorporate, she stated, "We would have an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 4 of 14 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 07/16/2018 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 IDT (Interdisciplinary Team-a group of healthcare professionals) meeting, see what the dietary supervisor would say, and asked to be kept informed." During an interview with the Director of Nursing (DON) on April 3, 2018, at 5:05 PM, she stated, I remember her well. When asked was the family notified regarding the COCregarding not eating, she stated that, IDT's meetings were not being done previously the right way , . . .I know we had done family phone calls, they were aware of her behaviors. The DON further stated, "She was less responsive on December 21, 2017, they [the family] were notified that she was going to the hospital. I was in my office, the daughter came and said something is wrong with my mom, "I and the nurse went and looked at her . . .the nurse called 911. . . I had seen her up earlier in the day myself, no unusual complaints that I can remember." When asked were Resident A's extremities discolored, the DON stated that her hands and feet were discolored that day and stated, "I would not say blue." During an interview with LVN 1 on April 26, 2018 at 1:00 PM, she stated she did not remember Resident A's physical status prior to the 911 emergency transfer. LVN 1 stated, "I don't remember that week if there were any changes, but for sure she did have blue tinged fingers, and legs, we were getting her up because her family was coming." During an interview with a Certified Nursing Assistant (CNA 1) on April 26, 2018 at 2:30 PM, she stated, ". . . she [Resident A] was in bed a lot towards the end, she used to be in the WC (wheelchair), go everywhere." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 5 of 14 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 07/16/2018 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 During a telephone interview with Resident A's physician on May 18, 2018 at 3:28 PM, when asked if he was notified regarding Resident A's, refusing to eat, weight loss, or hospital visit on December 14, 2017, he stated, "I don't want to say yes or no, I don't recall." During an interview with CNA 2 on May 23, 2018 at 11:50 AM, she stated, "She [Resident A] wouldn't open her mouth, she wouldn't drink anything, the three days that I was here before she passed." CNA 2 further stated that as a float (not assigned to a group of residents) one of her duties was to make sure Resident A ate, and stated "The nurses were already aware that she was not eating at that point, she had not been eating good for a week, she ate well, but two weeks prior to her passing she went to eating half, that last week she went to not eating at all." When asked if the doctor had been made aware CNA 2 stated, "You would think so, but I do not know." During an interview with CNA 3 on May 23, 2018 at 12:52 PM, she stated, "I know she [Resident A] didn't get out of bed that week . . . she wasn't coming to the DR (dining room)." CNA 3 further stated, that Resident A used to come to the DR, in and out all day long. During an interview with CNA 4 on May 23, 2018 at 1:12 PM, she stated that what she remembered about Resident A was that towards the end, she didn't want to eat, that she was in bed and weak. During an interview with LVN 3 on May 23, 2018 at 1:24 PM, when asked what is the protocol when a resident has a COC, she stated, " . . .the LVN is suppose to do an assessment, depending on the COC, contact the doctor, follow orders, put them on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 6 of 14 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 07/16/2018 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 monitoring for the COC x 72 hours. . ." During a telephone interview with a Licensed Vocational Nurse (LVN 2) on May 24, 2018 at 11:25 AM, she stated, "I can't remember her being a critical change of condition (COC), but I do remember her having a COC." During a telephone interview with CNA 5 on May 30, 2018 at 9:43 AM- she stated, "I know she (Resident A) wasn't acting the same, I knew something was wrong with her, she was declining . . ." CNA 5 further stated, that she opened the gate for Resident A's daughter on December 21, 2017, and informed her that Resident A was not doing good and her daughter stated that no one told her. During a concurrent interview and record review with the DON on June 21, 2018 at 3:05 PM, she stated when a resident has an unwitnessed fall, neuro checks (a check for level of consciousness) are done for 72 hours. When asked to provide the neuro check charting for Resident A after her unwitnessed fall on December 20, 2017, when found on the floor at 01:00 AM by the CNA, she stated, " . . . I don't have it." A review of Resident A's Nutritional Care Plan with the DON, stated to minimize any unplanned weight changes daily, and the physician and the family were to be notified of any significant weight loss. When asked was the physician notified regarding Resident A's 6.3% weight loss from 96 lbs to 89 lbs noted for the week ending December 14, 2017, the DON stated, "I can't find that we notified him." When asked was the physician notified on December 20, 2017, of Resident's weight of 80 lbs, she stated, at that time they were waiting for the IDT meeting scheduled for December 22, 2017, and, "I don't have any record of him being FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 7 of 14 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 07/16/2018 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 notified." A review and concurrent interview with the DON of Resident A's ileostomy bowel elimination record, indicated constipation for December 20, 2017. When asked for documentation of notification to the charge nurse, the DON stated there was no record of notice. During an interview with the Dietary Manager on June 25, 2018 at 10:40 AM, when asked after Resident A's was weighed on December 20, 2017 and had lost 15 pounds in two weeks,what was done, she stated, "At that time nothing, until we would have our meeting with the dietician on the 22nd [December 22, 2017]." A review of the nurse's "Progress Notes" for Resident A, dated December 15, 2017 through December 20, 2017, reflects there was no documentation of any COC, or that the doctor had been notified of her weight loss, or change of behavior. A review of the physician's note dated December 18, 2017, there is no mention of Resident A's weight loss, not eating, or that she was sent to the emergency room on December 14, 2017 with a complaint of chest pain. A review of the "Nurse's Weekly Summary" dated December 19, 2017 at 10:24 PM, indicated, "Blood Pressure 132/86, Pulse 100, Respirations 17, Temperature 97.9 (clinical measurement of a patient's essential body functions) date: December 14, 2017." The record did not provide any documentation of weight loss, loss of appetite, or change in behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 8 of 14 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 07/16/2018 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 Resident A's clinical record, did not indicate the daughter/responsible party (RP) was notified of Resident A's COC of not eating for consecutive days from December 16, 2017 through December 21, 2017, or about her weight loss, prior to her arrival on December 21, 2017. A review of the nurse's "Progress Notes" for Resident A dated December, 21, 2017, indicated: a. 1:33 AM- "@ (at) 0100 [1:00 AM] CNA came to report finding res [resident] on the floor in her room. Upon assessment, res was laying on her back, res had c/o (complained of) pain to buttocks. . . .res appears weak and drowsy. MD (medical doctor) notified. will contact POA (power of attorney) in the morning." b. "08:41 AM (8:45 AM)- Reported to MD that Resident is showing signs of increase weakness, resident unable to sit up when asked . . .Also got report that resident is not eating and had one episode of vomiting from noc shift. . .it is unable to be determined if she is in pain r/t (related to) resident not responding when asked. Also got report that resident previously reported pain in back on noc (night) shift. Stat (now) CBC (complete blood counttest that measures the cells that make up your blood) w/diff (with differential) and BMP (a group of eight laboratory blood tests used as a screening tool) ordered. Also stat lumbar (spine) back and bilateral (both) hip x-ray ordered." c. "11:16 AM- Spoke with MD informing him lab technician is unable to get an adequate blood draw for labs as ordered due to COC. New orders: OK to send out to acute care-COC." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 9 of 14 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 07/16/2018 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 d. "11:50 AM- Approximately 11:50 Resident left on gurney with EMT (emergency medical transport). Resident noted weak and unable to stand on her own or transfer self. Resident noted with peripheral (outer) cyanosis (bluish discoloration of the skin) to bilateral feet and hands. . . .Unable to obtain O2 sat (oxygen saturation). . . ." Resident A's stat laboratory findings at the acute care hospital ER (emergency room) on December 21, 2017 indicated: Sodium 116 LL (low low-lethargy, confusion, severe death) (normal range 136-144) Chloride 81 LL (low low-excessive fatigue, weakness, difficulty breathing) (normal range 101-111) Carbon Dioxide 11 L (low- measures respiratory exchange (normal range 22-32) BUN 132 HH (high high- water depletion due to decreased intake & excessive loss) (normal range 8-26) Creatinine 5.7 H (high- kidneys aren't working well) (normal range 0.6-1.1) Glucose 180 H (high- excessive sugar in the blood) (normal range 70-110) WBC 22.7 H (high- increased levels to fight an infection) (normal range 4.5-10.7) A review of the ER's physician notes, dated December 21, 2017, for Resident A indicated, (arrival time 12:11 PM), "Vital signs at 1:18 PM Temperature 33C (Celsius = 91 degrees Fahrenheit), P (Pulse) 99, R (Respirations) 20, BP (blood pressure) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 10 of 14 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 07/16/2018 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 87/45, pulse ox (oxygen saturation) 97% on 15L NRB (liters non-rebreather mask -oxygen concentration). History of Present Illness: 66 y/o (year old) female BIBA (brought in by ambulance) from SNF presents to the ER with ALOC (altered level of consciousness), lethargy, and cyanosis today. . .reported patient has been having symptoms of loss of appetite and N/V (nausea & vomiting) few days. Staff had noted cyanotic appearance to pt's lips, hands and feet." "Physical Exam: General: patient was not awake, not alert, not responsive to any stimuli. Skin was very pale, Patient is cachectic (weakened condition). Respiratory: Very labored breathing, bilateral air entry. Abdomen: Tense . . . no bowel sound. Ileostomy (an artificial opening on the abdomen for bowel elimination) pouch with blood in it. Assessment and Plan: 1. Septic shock (severe infection of the body causing organs to shut down). 2. Small-bowel obstruction, questionable hernia (a protruding of the abdominal wall). 3. Acute hypoxic (deprived adequate oxygen) respiratory failure. 4. Lactic acidosis (excessive acids in the blood). 5. Severe hyponatremia (low sodium). 6. Acute kidney injury. 7. Altered level of consciousness. 8. Gastrointestinal (stomach & intestines) bleeding, bacteremia (infection). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 11 of 14 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 07/16/2018 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 Plan: As per patient's family wishes, will keep patient on palliative approach (relief from distressing symptoms) to keep her comfortable. Start patient on morphine drip (intravenous pain medicine) and Ativan prn (anti-anxiety medicine as necessary)." A review of the Nurse's note dated December 21, 2017, for Resident A in the ER: "On arrival patient was undressed. Ileostomy bag was leaking." A review of the Nurse's note dated December 22, 2017, for Resident A indicated "Pt (patient) passed away at 2045 [8:45] with her family at bedside." A review of Resident A's death certificate dated January 11, 2018, indicated causes of death were: A. Septic shock, B. Hyponatremia, C. Acute kidney injury, D. Small bowel obstruction. A review of the facility's care plans (individualized plans for the medical care of a resident) (not dated) for Resident A indicated: 1. "Resident has an altercation in nutritional status . . .Interventions . . .Report significant weight loss and gain to MD and family" 2. "The resident has risk for dehydration . . .Interventions . . Monitor and document intake and output as per facility policy. Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities, Monitor/document bowel sounds and frequency of BM." 3. "The resident has a communication problem related to confusion, dementia . . .Interventions . . .Anticipate and meet needs . . FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 12 of 14 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 07/16/2018 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 .Monitor/document/report PRN (as necessary) any changes in: Ability to communicate . . ." A review of the facility's policy and procedure titled "Nutritional Care Management" dated 2012, indicated, "12. If there is a five percent weight change in 30 days . . ., the Physician, dietary, and the resident plus interested representative will be notified and date placed in Weight Record. a. When the Physician is notified, the Licensed Nurse will document calling the physician and Physician's response in Nursing Progress Note." A review of the facility's policy and procedure titled, "Change in a Resident's Condition or Status" (Revised December 2011) indicated, "Our facility shall promptly, notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition . . .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . . .d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly;. Refusal of treatment . . ." A review of the facility's policy titled "Charting and Documentation" (Revised August 2008) indicated, "1. All observations, . . . must be documented in the resident's clinical records. . .3. All incidents, accidents, or changes in the resident's condition must be recorded." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YR8P11 Facility ID: CA240000029 If continuation sheet 13 of 14 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 07/16/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: YR8P11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000029 (X5) COMPLETE DATE If continuation sheet 14 of 14