Other·October 10, 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 a standard abbreviated survey to investigate a complaint. CA00541152 Representing the California Department of Public Health: 35184 The inspection was limited to the specific complaint and does not reflect the findings of a full inspection of the facility. Two deficiencies was issued for complaint: CA00541152

F157 SS=G NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or 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: O6BW11 Facility ID: CA240000094 If continuation sheet 1 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative (s). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to notify the physician of abnormal laboratory results for one of three sampled residents (Resident 1) which delayed treatment and resulted in Resident 1 being hospitalized due to a diagnosis of pneumonia (lung infection), acute renal failure (kidney failure), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 2 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 hyperkalemia (high potassium), and respiratory failure (very low blood oxygen levels). Findings: During a record review, the face sheet (a form that includes birth date, diagnoses, date of admission, etc.) indicated Resident 1 was admitted to the facility on February 24, 2017, with diagnoses that included hyperosmolality (increase in body fluids), hypernatremia (high sodium level in the blood), type 2 diabetes (high sugar in the blood). During a review of the physician's orders, dated June 20, 2017, a telephone order dated June 20, 2017 at 1:51 PM, was obtained by the licensed vocational nurse (LVN) for Resident 1 to have stat (immediately) labs to be drawn to include a complete blood count (CBC- used to rule out infections, anemia, and leukemia), and a basic metabolic panel (BMP- used to monitor blood glucose levels and electrolytes which keep body fluids in balance). A second telephone order was obtained dated June 20, 2017 at 2:03 PM, for Resident 1 to be started on intravenous (IV- into the blood stream via a vein) hydration of normal saline at 80 cc (cubic centimeters a unit of measure)/ hour for 2 liters every shift until June 22,2017. During a review of the nurses' notes dated June 20, 2017 at 8:35 PM, the licensed nurse documented Resident 1 had a change of condition (lethargy). During a review of the laboratory results report dated June 20, 2017, the report revealed the blood sample was collected on June 20, 2017 at 6:35 PM. The laboratory results were reported to the facility on June 20, 2017 at 11:43 PM. The laboratory results showed the BMP was abnormal as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 3 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 Glucose 132 mg (milligrams)/dl (deciliter- units of measurement) (high) 65-99 normal range (can indicate diabetes where the body cannot produce or utilize insulin) BUN (Blood Urea Nitrogen-waste product of the liver)148 mg/dl (high) 7-25 normal range (indicates kidney function, dehydration or heart failure) Creatinine (measures kidney functions in the blood) 6.39 mg/dl (high) .70-1.25 normal range (indicates impaired kidney function) Sodium serum (salt in the blood) > (greater than)165 (high) 135-146 normal range ( indicates dehydration, and can increase blood pressure) The CBC (complete blood count) was also abnormal as follows: White blood cells (WBC) 21.5 thousand/unit (high) 3.8-10.8 normal range (indicates infectious process) During a review of the nursing notes for June 20, 2017 and June 21, 2017, there was no documented evidence to show the physician was notified about the abnormal labs for Resident 1. During a review of the nursing care plans for Resident 1, a care plan for being at risk for dehydration dated February 24, 2017, under the interventions, included that staff were to report abnormal labs to the MD (medical doctor). During a review of the nursing notes dated June 21, 2017 at 3:37 PM, the note revealed Resident 1 continued to be lethargic and had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 4 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 an altered level of consciousness, and a desaturation of oxygen levels (the oxygen levels in the blood are low and cannot nourish the body cells causing respiratory distress), at which time Resident 1 was transferred to the acute care hospital via the paramedics ambulance. During a review of the general acute care hospital history and physical form dated June 21, 2017, the history and physical revealed Resident 1 was admitted with a diagnosis of pneumonia (lung infection), acute renal failure (kidney failure), hyperkalemia (high potassium), and respiratory failure (very low blood oxygen levels). Resident 1 had to be intubated (breathing tube inserted to maintain his airway) and placed on a respirator (a machine used to breathe for a person) while in the emergency room. During an interview with the Assistant Director of Nursing (ADON), conducted on August 15, 2017 at 10:40 AM, the ADON verified the MD had not been notified of Resident 1's abnormal labs drawn on June 20, 2017. The ADON stated, "The documentation wasn't specific to state the MD was notified of abnormal labs." During a telephone interview with the Director of Nursing (DON), conducted on August 23, 2017 at 9:30 AM, the DON stated, "The nurses should be documenting in the progress notes or it should be written on the lab results that the MD was notified of abnormal labs. We are not doing a good job on that." During a review of the facility policy and procedure, undated, and titled, "Resident Rights: Notification, Physician," the policy indicated: "It is the policy of this facility to notify the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 5 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 resident's Physician of changes in the resident's condition and/or status : 1. Licensed Nurses may notify the attending Physician for the following: B. There is a significant change in the resident's physical, mental, or psychosocial status."

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 6 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 7 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, this facility failed to maintain the infection control policies and procedures for two of two unsampled residents (Resident A and Resident B) when a certified nursing assistant (CNA 1) went between two isolation rooms without washing his hands or using personal protective equipment (PPE). This had the potential for cross contamination of harmful bacteria by exposing an already compromised population to harmful bacteria in a universe of 182. Findings: During an observation on August 15, 2017 at 9:00 AM, a certified nursing assistant (CNA 1) was observed walking into an isolation room to care for a resident (Resident A) without wearing any personal protective equipment (PPE -gown, gloves, or mask). Resident A had a diagnosis to include extended spectrum beta lactamase resistance (ESBL - an infection in the urine requiring strict contact isolation isolation requiring the use of gloves,and gowns when you have direct contact with someone). CNA 1 was observed to have contact with the resident. CNA 1 left Resident A's room without washing his hands and went immediately into a second isolation room without applying PPE to care for Resident B. CNA 1 was then observed applying gloves to empty Resident B's urinal. The CNA 1 was then observed to remove the gloves and place them in the trash can and leave the room without washing his hands. Resident B had a diagnosis to include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 8 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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 methicillin resistant staphylococcus aureus (MRSA- an infection in a wound requiring contact isolation). During an interview conducted on August 15, 2017 at 9:15 AM, with the registered nurse (RN- charge nurse), the RN confirmed by visual observation that CNA 1 was in the isolation room of Resident B without any PPE. RN 1 stated, "They are supposed to wear proper equipment." During a concurrent interview with CNA 1 on August 15, 2017, CNA 1 stated, "I wasn't wearing PPE like I was supposed to be for both rooms." During an interview with the director of staff development (DSD), conducted on August 15, 2017 at 10:28 AM, the DSD stated, "CNA 1 should have been wearing at least a gown and gloves for contact isolation." During a review of the facility policy and procedure undated, and titled, "Infection Control Policy/Procedure" the policy revealed under the section procedures: "1. Use standard precautions 2. Private room if possible or cohort, (room) resident infected or colonized with the same organism. 3. Gloves a. Don gloves upon entry into the room b. Remove glove before exiting the room c. Observe hand hygiene 4. Gowns FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 9 of 10 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: _______________ 055619 (X3) DATE SURVEY COMPLETED 09/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAS COLINAS POST ACUTE 800 E 5th St Ontario, CA 91764 (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. Don gown upon entry into the room b.Remove gown before exiting the room c. Observe hand hygiene " FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O6BW11 Facility ID: CA240000094 If continuation sheet 10 of 10