Other·May 1, 2019

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 annual Recertification Survey conducted on March 18, 2019 through March 22, 2019. Representing the California Department of Public Health: 39907, HFEN 38480, HFEN 40519, HFEN 40273, HFEN 39429, HFEN 33786, HFEN 41337 Total Resident Census: 95 Total Resident Sample: 25 There were three Immediate Jeopardy (IJ) situations identified during this survey. 1) An IJ was called under 483.25 Quality of Care (Refer to 689 Free of Accident Hazards/supervision/devices on March 18, 2019 at 4:15 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The Admin and DON were informed of the findings related to the space heater being used in a Resident's (Resident 342) room. A corrective Action Plan (CAP) was requested. A record review conducted on March 21, 2019 at 2:30 PM, the in-services training, interviews with the staff and record review confirmed compliance with the Skilled Nursing Facility's (SNF) corrective action plan which included the space heater was immediately removed from Resident 342's room, blankets were offered 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: YZF911 Facility ID: CA240000285 If continuation sheet 1 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 the resident to keep him warm. The MS adjusted room temperature to 75 degrees Fahrenheit (F-a unit of measurement). All residents room were checked by the MS/assistant to ensure no other rooms have space heater. No other rooms were identified to have deficient practice. ADMIN provided one on one in service education to the MS and maintenance assistant that no space heater is to be in resident's room. All employees present were provided with in-service education by the DSD after the deficient practice was identified to ensure resident's safety. Will continue to provide on-going in-services for all employees. Certified Nursing Assistants (CNA) while doing the inventory upon admission and readmission, they are to remove any space heater, maintenance supervisor/assistant are to do the daily round son all new residents to the facility to ensure no space heater. During admission process the admission coordinator will notify resident and family that no space heaters are allowed in to the facility. The staff developer will continue to provide ongoing in service education on space heater. Department heads are to do visual checks on their assigned room rounds and ensure that no space heater are in the resident's rooms. All staffs were also informed via On-shift regarding space heater. An acceptable CAP was verified with the facility to be implemented through observation, interview and record review. The IJ was lifted on March 19, 2019 at 3:35 PM, the presence of the ADMIN, and DON. 2) A second IJ was called under 483.80 Infection Control (refer to 880 Infection Prevention and Control) on March 20, 2019 at 1:15 PM in the presence of the administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON were informed of the findings related to the glucometer. A corrective FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 2 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Action Plan (CAP) was requested. A record review conducted on March 21, 2019 at 2:30 PM, the in-services training, interviews with the staff and record review confirmed compliance with the Skilled Nursing Facility's (SNF) corrective action plan which included employee asked to come in for a 1:1 inserviced/ re- education about, Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of glucose monitoring system record. Employee received performance corrective notice. Deficient practice immediately rectified, and employee will be monitored for performance during the next 30 days. Initiated in service/ reeducation amongst Licensed Nurses(LN) about Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of glucometer quality control (QC) monitoring system record. Ordered new glucometers: once available old glucometers to be replaced and initial QC check performed prior to use. Update policy and procedures for glucometer to include steps how to clean the equipment. All residents who uses the glucometer for blood sugar monitoring are being assessed by a Registered Nurse(RN) for any signs and symptoms of infection. Glucometers will continuously be monitored fro QC by checking daily. All staff were informed electronically via On- shift regarding proper handwashing. All LNs were reminded electronically via On- shift regarding proper disinfection of glucometers. The Staff Developer (DSD) or Designee will continue to provide ongoing in services or re- education about handwashing and proper disinfection of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 3 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 glucometers. The DSD or designee will review glucometer QC monitoring weekly for completeness for four weeks. The corrective plan will be used as a part of our QAPI and will be reviewed at the monthly utilization review meeting for evaluation and recommendations. An acceptable CAP was verified with the facility to be implemented through observation, interview and record review. The IJ was lifted on March 21, 2019 at 2:30 PM, the presence of the ADMIN, and DON. 3) An Immediate Jeopardy (IJ) (A crisis situation in which the health and safety of individual(s) are at risk) was called under 483.45 (refer to 755 Pharmacy services/procedures/pharmacist/records) on March 20, 2019 at 4 PM, in the presence of the administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON were informed of the findings related to following doctor's order for the administration of insulin and blood sugar monitoring. A corrective Action Plan (CAP) was requested. A record review conducted on March 21, 2019 at 2:10 PM, the in-services training, interviews with the staff and record review confirmed compliance with the Skilled Nursing Facility's (SNF) corrective action plan which included Resident assessed with no signs or symptom of hyperglycemia or hypoglycemia, Resident chart and MAR in room 117 B (Resident 47) and 121 B (Resident 80) was reviewed to ensure appropriate orders. DON have inserviced the identified nurse assigned for that particular patient immediately. All licensed nurses were given an On-Shift memo and notification in regards to insulin parameters and blood sugar readings documentation. Director of Nursing Services or designee will identify other residents with insulin and parameter FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 4 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 order. Physician orders and MAR is being reviewed and updated to ensure that no other Resident experienced the same deficient practice. During admission process, admission nurse will review orders for insulin and make sure that Parameters are properly indicated and written in the telephone orders and MAR. RN (Registered Nurse) Supervisor will review all residents identified with insulin and parameter orders and will ensure that the MAR will indicate area to record blood sugar reading, Medical Record or designee will review recapped MAR monthly times two months before giving to licensed nurse for use. Will ensure there is a specific area to record blood sugar readings. An acceptable CAP was verified with the facility to be implemented through observation, interview and record review. The IJ was lifted on March 21, 2019 at 2:30 PM, the presence of the ADMIN, and DON. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 5 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F688 Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/22/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure restorative nursing assistant services [RNA-a certified nurse assistant trained to perform specific rehabilitation services] was initiated timely for one of 25 sampled residents (Resident 85) after being discharged from physical therapy (PT-rehabilitation focusing on regaining or improving physical abilities) services. This failed practice placed Resident 85 at risk for a decline in functional mobility and quality of life when RNA services was initiated 63 days after the resident was discharged from PT services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 6 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Findings: During an observation on March 18, 2019, at 10:30 AM, in Nursing Unit A, Resident 85 was seen walking the corridor with a front wheeled walker (an assistive device used for walking) with two staff members present. During a review of Resident 85's clinical record, the facesheet (contain demographic information) indicated Resident 85 was admitted on November 12, 2018, with diagnoses of weakness, abnormal posture, and difficulty in walking. Resident 85's "History and Physical" dated November 13, 2018, indicated Resident 85 did not have the capacity to understand and make decisions. A review of Resident 85's Resident Assessment Instrument (RAI-a facility comprehensive tool), dated February 18, 2019, indicated Resident 85 was not steady with walking and required staff assistance. Resident 85's "Physician and Telephone Order" dated March 6, 2019, indicated an order for "RNA for ambulation with FWW [front wheeled walker] QD [every day] 5xwk [five times a week] as tolerated." The "Physician and Telephone Order" dated January 1, 2019, indicated Resident 85 was discharged from PT services. During an interview with the Therapy Director (T.D.) on March 19, 2019, at 1:36 PM, he stated once a resident is discharged from therapy services and the recommendation is for RNA services, a physician order and referral is completed to initiate RNA services. The T.D. further stated, there should not be a delay when a resident is transitioning from therapy services to RNA services if RNA services is recommended. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 7 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 review of Resident 85's "PT [physical therapy] Discharge Summary" dated January 2, 2019, indicated a recommendation for RNA for ambulation five times a week. There was no documented evidence of a physician order or referral to RNA services at that time. The "Joint Mobility Screening" dated February 18, 2019, indicated Resident 85 "may benefit from RNA ambulation program to improve safety and reduce risk for fall." There was no documented evidence of a physician order or referral to RNA services at that time. During an interview and record review with the Director of Nursing (DON), on March 19, 2019, at 3:18 PM, she acknowledged the "PT [physical therapy] Discharge Summary" dated January 2, 2019, indicated a recommendation for RNA for ambulation five times a week and the "Joint Mobility Screening" dated February 18, 2019, indicated Resident 85 "may benefit from RNA ambulation program to improve safety and reduce risk for fall." The DON further acknowledged the physician order for RNA services was not obtained until March 6, 2019, 63 days after the original recommendation for RNA services. She stated she did not know the cause of delay. The facility's policy and procedure titled "Screening Referral To Rehabilitation Services" reviewed March 19, 2019, indicated " ...if a referral for RNA services is indicated, the therapist will follow-up with facility RNA referral process. RNA to provide services ..." The facility's policy and procedure titled "Discharge Summary/RNA Referral" reviewed March 19, 2019, indicated "the therapist needs to complete a hands-on training with the RNA ...this needs to be completed prior to the last day of therapy ...specific RNA orders need to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 8 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 be completed in the chart ..."

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 04/22/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free of hazards when one resident (Resident 342) was observed with an electrical space heater in his room with the doors closed for one of 95 sampled residents. This failure had the potential to develop electrical hazards to the residents through the improper use or maintenance of the space heater, which can potentially jeopardize the resident's safety with fire risks, burns and death. Findings: During an observation on March 18, 2019, at 11:10 AM, a space heater was found on the bedside table and it was used by the resident (Resident 342) in the room with the doors closed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 9 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 concurrent interview with Resident 342 he stated he always felt the room was cold and would like to keep the space heater nearby him turned on. Resident further stated he told the facility staff about the room temperature and they did not do anything. A review of Resident 342's "Admission Record" (basic information containing demographic and medical information) indicated, Resident 342 was admitted on March 5, 2019, with a diagnoses of Hypertension (high blood pressure), polyneuropathy (Polyneuropathy is a condition in which a person's peripheral nerves are damaged), and Diabetes mellitus (DM- high blood sugar). During a review of Resident 342's admission Minimum Data Set (MDS, an assessment tool) dated March 12, 2019, indicated a Brief Interview for Mental Status (BIMS, an assessment tool) with a score of 15 (a BIMS score of above 13 show little to no impairment on a person's cognition). During an interview with the Maintenance Supervisor (MS) on March 18, 2019, at 2:37 PM, the MS acknowledged that Resident 342 was using a space heater and the resident did not want to remove it. The MS further stated as long as the space heater cord was good and there were no frayed wires, it was safe to use. During an interview with the administrator (ADMIN) on March 18, 2019, at 2:40 PM, the ADMIN acknowledged Resident 342 was using a space heater in his room. During a concurrent interview and observation with the Director of Nursing (DON) in Resident 342's room, on March 18, 2019, at 2:43 PM, the DON stated it was not okay to have a space heater being used with doors closed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 10 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 The DON further acknowledged the room (Resident 342's) doors were closed and the space heater being used by Resident 342. The DON further stated the family brought in the space heater couple of days after his admission. During a review of Resident 342's "Interdisciplinary Team Conference" record (IDT- group of health care professionals from diverse fields), dated March 17, 2019, the IDT meeting conducted for the refusal to leave the door open and prefers to use portable heater. During a review of Resident 342's clinical record reflects, a "Care plan: Noncompliance" (an individualized plan for the medical care of a resident) dated March 17,2019, which indicated, "Patient prefers to use his personal heater, patient refused to leave door open with a goal of turn on heater for a few hours and recheck" During a concurrent interview and record review with the Licensed Vocational Nurse (LVN 6) on March 18, 2019, at 2:55 PM, LVN 6 stated the resident (Resident 342) preferred to close his room doors always and complains the room was cold. LVN 6 further reviewed Resident 342's inventory list dated March 5, 2019, and acknowledged there was no space heater listed. LVN 6 stated CNAs and any other staff would usually update the inventory list any time the family brings any other personal belongings with a plastic tab for additional belongings and acknowledged there were no additional belongings updated in the inventory list of Resident 342. During a follow up interview with the MS on March 18, 2019, at 3:15 PM, the MS stated when a resident or family brings in any portable electric equipment, the MS or his assistant will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 11 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 do a continuity test of the equipment initially and then monthly. The MS was unable to provide the initial continuity test document on March 18, 2019. During a follow up interview and record review with the DON on March 19, 2019, at 10:05 AM, the DON reviewed and acknowledged the facility's record titled "Maintenance Request Log" for the month of March, 2019. The Maintenance Request Log did not indicate Resident 342 had a complaint of the room temperature. This failure to follow the regulation resulted in an Immediate Jeopardy (IJ- immediate danger of harm). An IJ situation was identified and called on March 18, 2019, at 4:15 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON was informed of the observations, interviews, and record reviews with the facility staff concerning the space heater for Resident 342. The facility provided a corrective action plan, which included the space heater was immediately removed from Resident 342's room, blankets were offered to the resident to keep him warm. The MS adjusted room temperature to 75 degrees Fahrenheit (F-a unit of measurement). All residents room were checked by the MS/assistant to ensure no other rooms have space heater. No other rooms were identified to have deficient practice. ADMIN provided one on one in service education to the MS and maintenance assistant that no space heater is to be in resident's room. All employees present were provided with in-service education by the DSD after the deficient practice was identified to ensure resident's safety. Will continue to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 12 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 provide on-going in-services for all employees. Certified Nursing Assistants (CNA) while doing the inventory upon admission and readmission, they are to remove any space heater, maintenance supervisor/assistant are to do the daily rounds on all new residents to the facility to ensure no space heater. During the admission process the admission coordinator will notify residents and family that no space heaters are allowed in the facility. The staff developer will continue to provide ongoing in service education on space heater. Department heads are to do visual checks on their assigned room rounds and ensure that no space heater are in the resident's rooms. All staffs were also informed via On-shift regarding space heater. MS/Assistant will do a daily monitoring for 4 weeks, then monthly for three months, then quarterly for a year and onwards. MS/Assistant will report to the ADMIN of his findings. The ADMIN will report the findings and monitoring as part of our QAPI during the monthly Utilization review meeting for evaluation and recommendations. The IJ was lifted on March 19, 2019, at 3:35 PM, in the presence of the ADMIN and DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure corrective action plan was implemented.

F698 SS=E Dialysis CFR(s): 483.25(l)

F698 04/22/2019 §483.25(l) Dialysis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 13 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure nursing assessments were completed and documented before or after renal (kidney) dialysis (dialysis a process of cleaning and purifying the blood) for four of four (4) sampled residents (Resident 29,84,90 and 89) when: 1.Resident 29's clinical record did not show any evidence that the post dialysis assessment (an evaluation of the resident's health status which included the cognitive status, temperature, blood pressure, breathing pattern, dialysis dressing site) was completed by the nursing staff. 2. Resident 84's clinical record did not show any evidence of a completed post dialysis assessment by the nursing staff. 3. Resident 90's clinical record did not show any evidence of a completed pre and post dialysis assessment by the nursing staff. 4. Resident 89's clinical record did not show any evidence of a completed post dialysis assessment by the nursing staff. These failures had the potential to lead to a delay in the recognition of complications associated with dialysis such as prolonged bleeding or difficulties with vascular access (vascular access - a way to reach the blood for dialysis). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 14 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Findings: 1.During a review of Resident 29's clinical record, the Admission Record (a document containing demographic and medical information) indicated the resident was admitted to the facility on January 1, 2019, with a diagnoses that included end stage renal disease (ESRD- a disease that causes irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 29's annual Minimum Data Set (MDS- an assessment tool) dated on January 18, 2019, indicated, a Brief Interview Metal Status (BIMS- a screening tool used to determine metal status) with a score of 15 (a BIMS score of above 13 show little to no impairment on a person's cognition). Further review of the MDS indicated, Resident 29 was on a special treatment of dialysis. During a review of the clinical record for Resident 29's "Physician's Orders" dated on February 25, 2019, indicated "Monitor central line dialysis access to right chest every shift, Dialysis days: Tuesday, Thursday and Saturday, Dialysis center [NAME]." During a concurrent interview and record review with the Director of Staff Development/Infection Preventionist (DSD/IP) on March 20, 2019 at 6:50 AM, DSD/IP indicated that staff should have filled out the Post- Dialysis section of the form. The DSD/IP reviewed Resident 29's "Dialysis communication record" (an assessment form used for dialysis residents) for the following date verified they were incomplete: March 5, 2019, on the post dialysis assessment, cognitive status, vital signs, thrill, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 15 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 bleeding at site, breathing pattern/breath sounds and the signature of the nurse were left blank. During a concurrent interview and record review on March 20, 2019 at 7:02 AM with Licensed Vocational Nurse (LVN 5), indicated that the LN is responsible for filling out the "Dialysis Communication Record". LVN 5 stated "it (post dialysis assessment) should never be left blank". During a concurrent interview and record review with the Director of Nurses (DON) on March 20, 2019 at 10:09 AM indicated that it is very important that staff assess a resident after dialysis because there could be a change in condition. She stated that they might leave the dialysis center stable but could have a change of condition during transport. She stated that the LVN is responsible for completing the Pre and Post Dialysis Assessment and if anything is unusual they must call the Licensed Nurse. She indicated that they should document the assessment on the "Dialysis Communication Record". The DON verified that it is their policy that a LN should complete the pre and post dialysis assessment. Based on the policy, the DON verified that staff did not follow policy and procedure. 2. During a review of Resident 84's clinical record, the Admission Record (a document containing demographic and medical information) indicated the resident was admitted to the facility on March 22, 2018, with a diagnoses that included end stage renal disease (ESRD- a disease that causes irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 84's annual Minimum Data Set (MDS- an assessment tool) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 16 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 dated on February 18, 2019, indicated, a Brief Interview Metal Status (BIMS- a screening tool used to determine metal status) with a score of 12 (a BIMS score of above 13 show little to no impairment on a person's cognition). Further review of the MDS indicated, Resident 84 was on a special treatment of dialysis. During a review of the clinical record for Resident 84's "Physician's Orders" dated on February 25, 2019, indicated "Monitor fluid restriction, fore arm for pain, itching, bleeding and swelling. Monitor shunt/graft site and document Bruit and thrill. Dialysis days: Monday, Wednesday, Friday, Dialysis center [NAME]." During a review of the clinical record for Resident 84's, "Dialysis communication record", the following dates were incomplete: March 1, 2019, March 6, 2019 and March 15, 2019 on post dialysis assessment, cognitive status, vital signs, thrill, bleeding at site, breathing pattern/breath sounds and signature of the nurse were left blank. 3. During a review of Resident 90's clinical record, the Admission Record (a document containing demographic and medical information) indicated the resident was admitted to the facility on February 22, 2019, with a diagnoses that included end stage renal disease ((ESRD- a disease which causes irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 90's annual Minimum Data Set (MDS- an assessment tool) dated March 11, 2019, indicated, a Brief Interview Mental Status (BIMS- a screening tool used to determine mental status) with a score of 11(a BIMS score of above 13 show FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 17 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 little to no impairment on a person's cognition). Further review of the MDS indicated, Resident 90 was on special treatment of dialysis. During a review of the clinical record for Resident 90's "Physician's Orders' dated February 22, 2019, indicated "Monitor shunt/graft site right upper arm for bruit and thrill, monitor shunt/ graft site for the following site at right upper arm for swelling, pain, bleeding, itching. Dialysis days: MondayWednesday- Friday, dialysis center [NAME]." During an interview with resident (Resident 90) on March 19, 2019, at 9:00 AM, Resident 90 stated he is a dialysis dependent resident and his access site was his right upper arm. During a concurrent interview and record review of the dialysis communication record with the Licensed Vocational Nurse (LVN 3) on March 20, 2019, at 7:23 AM, LVN 3 stated Licensed Nurses (LN) are expected to do pre and post dialysis assessment prior to sending out and after receiving from the dialysis center. LVN 3 further stated pre and post dialysis assessment included resident's cognitive status, vital signs, access site for bruit and thrill, graft site for any bleeding, breath sounds and it will be documented in a record called dialysis communication record. LVN 3 further reviewed Resident 90's clinical record titled "Dialysis communication Record" (an assessment form used for dialysis residents) for the following date were incomplete: March 13, 2019, on post dialysis assessment, cognitive status, vital signs bruit, thrill, bleeding at site, breathing pattern/breath sounds and the signature of the nurse were left blank. During a concurrent interview and record review with the Director of Nursing (DON) on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 18 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 March 21, 2019, at 2:57 PM, the DON stated assigned LNs are expected to do pre and post dialysis assessment for the dialysis resident, specifically their cognition, vital signs, dialysis access site for bruit and thrill, bleeding and breath sounds. The DON reviewed the care plan reviewed on March 14, 2019 for Resident 90, indicated, "Post dialysis: document date, time and condition of when I come back ... ." The DON further reviewed and verified Resident 90's clinical record titled "Dialysis communication Record" for the following date were incomplete: a) March 13, 2019, on post dialysis assessment-facility, cognitive status, vital signs bruit, thrill, bleeding at site, breathing pattern/breath sounds and the signature of the nurse were left blank. b) March 15, 2019, on pre and post dialysis assessment-facility cognitive status were left blank. c) March 15, 2019, post dialysis assessmentfacility breath sounds and the signature of the LN were left blank. d) March 18, 2019, on post dialysis assessment-facility, cognitive status and the signature of the LNs were left blank. The DON further reviewed the facility's undated policy and procedure titled "Care of resident receiving renal dialysis" indicated, "Complete dialysis communication record and complete post dialysis assessment." The DON further stated facility did not follow the policy and procedure for pre and post dialysis assessment. The facility's undated policy and procedure titled "Care of resident receiving renal dialysis" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 19 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 indicated, " ...9. Complete dialysis communication record ...a. Complete pre dialysis assessment ...complete post dialysis assessment on return from treatment ... ." 4. During a review of the clinical record for Resident 89's "Admission record" (a document containing demographic and medical information) indicated the resident was admitted on February 21, 2019, with a diagnoses of end stage renal disease ((ESRDa disease which causes irreversible kidney failure) with dependence on renal dialysis. During a review of the clinical record for resident 89's "History and physical" (H&P) dated February 23, 2019, the H&P indicated, resident has the capacity to understand and make decisions. During a further review of Resident 89's "Physician Telephone Orders" dated February 26, 2019, indicated, "Starting March 5, 2019, Dialysis days will be Tuesday at 1:15PM, Thursday at 1:15 PM, Saturday at 1:15PM. During a concurrent observation and interview with Resident 89 on March 20, 2019, at 7:12 AM, Resident 89 was sitting on his wheelchair self-propelling to the hall way. Resident 89 stated, he was a dialysis patient and his dialysis access site was his left arm. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 3) on March 20, 2019, at 7:25 AM, LVN 3 stated Licensed Nurses (LN) are expected to do pre and post dialysis assessment prior to sending out and after receiving from the dialysis center. LVN 3 further reviewed Resident 89's clinical record titled "Dialysis communication Record" (an assessment form used for dialysis residents) for the following date were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 20 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 incomplete: March 16, 2019, on post dialysis assessmentfacility, cognitive status, vital signs bruit, thrill, bleeding at site, breathing pattern/breath sounds and the signature of the nurse were left blank During a concurrent interview and record review with the Director of Nursing (DON) on March 21,2019, at 2:39 PM, the DON stated post dialysis assessment should include not only checking the site for bruit , thrill and signs and symptoms for bleeding ,itching but also included with the cognitive status, breath sounds and vital signs. The DON further reviewed Resident 89's "Dialysis Communication Record" dated March 16, 2019, and acknowledged the post dialysis assessment - facility was left blank. The DON further reviewed Resident 89's "Care Plan" (an individualized plan for the medical care of a resident) for hemodialysis revised on March 11,2019, and verified the post dialysis assessment should include with date time and condition when he comes back. The DON further stated the facility did not follow the policy and procedure for pre and post dialysis assessment. The facility's undated policy and procedure titled "Care of resident receiving renal dialysis" indicated, " ...9. Complete dialysis communication record ...a. Complete pre dialysis assessment ...complete post dialysis assessment on return from treatment ... ." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 21 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F726 Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/22/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 22 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 by: Based on observation, interview, and record review, the facility failed to ensure licensed staff had appropriate competencies and skills necessary to perform their daily essential duties and responsibilities when: 1. For Resident 24, the staff did not carry out a physician order for discharge planning for 4 days. 2. For Resident 69, the Licensed Vocational Nurse (LVN 1) administered Pantoproprazole (a medication used to treat stomach problems) Delayed Release (DR-a medication that does not easily break down and release into the bloodstream when ingested) 40 milligrams (mg, unit of measurement) 1 tablet one hour and 45 minutes before the resident received and began to eat his breakfast. 3. The glucometer quality control (QC) log (a had missing entries with no documented evidence of an intervention performed by licensed staff on the following dates: A. Nurse Unit B: March 5, 2019; March 15, 2019; and March 16, 2019; B. Nurse Unit C: March 5, 2019; March 15, 2019; and March 16, 2019; C. Nurse Unit A: March 18, 2019; 4. The glucometer QC log had a level one and/or level two QC solution result out of range with no documented evidence of an intervention performed by licensed staff on the following dates: A. Nurse Unit C: January 27 and 28, 2019 level two QC solution result documented at 278 with a recommended range of 207 to 258 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 23 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 February 4, 2019 level two QC solution result documented at 261 with a recommended range at 205 to 256. B. Nurse Unit A: February 10, 2019 level two QC solution result documented at 285 with a recommended range at 211 to 265. C. Nurse Unit B: March 1, 2019 level one QC solution result documented at 90 with a recommended range at 95 to 106. 5. For Resident 25, LVN 1 dissolved two packets of Potassium Chloride (a medication used to prevent or treat low blood levels of potassium) powder 20 milliequivalent (mEq) in 25 cubic centimeters (cc, unit of measurement) of water when the pharmacy instructions indicated to dissolve in four to eight ounces (oz, unit of measurement) of cold water. 6. Expired Quality Control(QC) solution (a solution used as a QC check to verify the accuracy of blood glucose (blood sugar) test results was used to perform the QC check of the glucometer (device used to check blood sugar) on one of the three (3) medication cart (Medication cart C). 7. For Resident 242, the staff did not obtain a sputum culture as ordered by the physician for 10 days. These failed practices had the potential to affect an already compromised universe of 95 resident's safety and ability to attain and maintain their highest practicable physical, mental and psychosocial well-being when standard infection control practices were not followed, medication administration instructions were not followed potentially decreasing the therapeutic effect, not following manufacturer's guidelines for the glucometer QC solution FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 24 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 potentially effecting the accuracy of resident's blood sugar results, and a delay in care and services. Findings: 1. During an observation and interview with Resident 24, on March 18, 2019, at 3:31 PM, Resident 24 stated he would like to be at a facility closer to his children. During a review of Resident 24's clinical record, the facesheet (contains demographic information) indicated Resident 24 was admitted on September 27, 2018, with diagnosis that included mixed receptiveexpressive language disorder and epilepsy. Resident 24's "Physician and Telephone Orders" dated March 18, 2019, indicated an order for "D/C [discharge] planning to a lower level of care near children's home." During an interview with Licensed Vocational Nurse (LVN 6), on March 19, 2019, at 10:05 AM, she stated all physician orders need to be noted and carried out by a licensed nurse as soon as an order is received or written, During an interview and record review with the Director of Nursing (DON), on March 19, 2019, at 10:16 AM, she stated as soon as the physician or practitioner writes an order, it should be carried out by licensed staff right away. The DON acknowledged the March 18, 2019 physician order for discharge planning was not noted and carried out by the licensed staff. The DON reviewed the facility's policy and procedure titled "Physician Orders and Telephone Orders" revised January 2004. The DON acknowledge the licensed staff did not follow the policy and procedure for Resident 24. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 25 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 follow-up interview and record review with the Director of Nursing (DON), on March 22, 2019, at 10:45 AM; 4 days after the physician order was received, she acknowledged there was still no documented evidence the physician order for discharge planning was noted and carried out by licensed staff. The facility's policy and procedure titled "Physician Orders and Telephone Orders" revised January 2004, indicated " ...5. All orders must include the date and time received and must be "noted" by the professional staff taking the order." 2. During an observation of medication administration on March 20, 2019, at 5:55 AM, on medication cart A with LVN 1, he administered Pantoproprazole DR 40 mg 1 tablet to Resident 69. A review of Resident 69's Pantoproprazole DR 40 mg bubble pack (definition), indicated "take 1 Tab [tablet] by mouth every morning 30 mins [minutes] before breakfast for GERD [definition]". Resident 69's "Medication Administration Record" dated March 2019, indicated the Pantoproprazole DR 40 mg 1 tablet was scheduled to be given daily at 6:45 AM. During an interview with LVN 1, on March 20, 2019 at 7:20 AM, he stated the facility starts serving breakfast at 7:15 AM. LVN 1 acknowledged by giving Resident 69 his Pantoproprazole DR medication at 5:55 AM and breakfast starts being served at 7:15 AM, the medication was given too early based on the order and pharmacy instructions. During an observation on March 20, 2019, at 7:40 AM, Resident 69 received his breakfast FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 26 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 tray and began eating indicating the Pantoproprazole DR was given one hour and 45 minutes before the resident received and began to eat his breakfast. The facility's policy and procedure titled "Med Pass" undated, indicated " ...B. Special-time meds [medication] are to be given as close to the scheduled time as possible. These meds are not subject to a two-hour window. Specialtime meds may include: a. AC [before] meals; b. PC [after] meals; c. Meds to be given with meals; d. Meds to be given at a specific time according to order." 3. During an interview with LVN 1 on March 20, 2019, at 6:10 AM, he stated the night shift licensed staff is responsible for completing the QC check for the glucometers and document the results on the QC log daily. LVN 1 further stated the importance of completing this task is to ensure the resident's blood sugar results are accurate. A.A review of nursing unit B's "Daily Quality Control Record" dated March 2019, indicated a missing entry on March 5, 15, and 16, 2019 with no documented evidence of an intervention performed by licensed staff. B. A review of nursing unit C's "Daily Quality Control Record" dated March 2019, indicated a missing entry on March 5, 15, and 16, 2019 with no documented evidence of an intervention performed by licensed staff. C. A review of nursing unit A's "Daily Quality Control Record" dated March 2019, indicated a missing entry on March 18, 2019 with no documented evidence of an intervention performed by licensed staff. During an interview and record review with the Director of Nursing (DON), on March 20, 2019, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 27 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 at 9:16 AM, she acknowledged the missing entries on the "Daily Quality Control Record" for March 18, 2019 for nursing unit A and for March 5, 15, and 16, 2019 for nursing unit B and C. The DON further stated the expectation is for the QC check to be performed nightly and the importance of making sure the QC was done is to ensure the resident's blood sugar results are accurate. A review of [Product Name] blood glucose monitoring system use instruction manual revised January 2017, indicated "Healthcare Professional: Perform control solution tests in accordance with your state regulatory guidelines ...record result in the quality log book." The facility was unable to provide a policy and procedure on the frequency and documentation of quality control for the glucometer. 4. During an interview with LVN 1 on March 20, 2019, at 6:10 AM, he stated the night shift licensed staff is responsible for completing the QC check for the glucometers and document the results on the QC log daily. LVN 1 further stated if the results are out of range, he would retest the QC solution and attempt to troubleshoot. A. A review of nursing unit C's "Daily Quality Control Record" dated January 2019, indicated the level two control result was out of range at 278 on February 27 and 28, 2019 with an expected level 2 control range at 207 to 258. The "Daily Quality Control Record" dated February 2019, indicated the level two control result was out of range at 261 on January 4, 2019 with an expected level 2 control range at 205 to 256. There was no documented evidence of an intervention performed by licensed staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 28 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 B. A review of nursing unit A's "Daily Quality Control Record" dated February 2019, indicated the level two control result was out of range at 285 on February 10, 2019 with an expected level two control range at 211 to 265. There was no documented evidence of an intervention performed by licensed staff. C. A review of nursing unit B's "Daily Quality Control Record" dated March 2019, indicated the level one control result was out of range at 90 on March 1, 2019 with an expected level one control range at 95 to 106. There was no documented evidence of an intervention performed by licensed staff. During an interview and record review with the Director of Nursing (DON), on March 20, 2019, at 9:16 AM, she acknowledged the out of range QC solution results and stated the licensed nurse should have performed a retest. She further stated, if the ranges continued to be out of range, licensed staff would get a new glucometer and inform maintenance. A review of [Product Name] blood glucose monitoring system use instruction manual revised January 2017, indicated after troubleshooting and retesting the system, "do not use the system to test you blood glucose until the control solution result is within range" The facility was unable to provide a policy and procedure on out of range quality control solutions. 5. During an observation of medication administration on March 20, 2019, at 6:50 AM, on medication cart A with LVN 1, LVN 1 opened two packets of Potassium Chloride 20 mEq to equal 40 mEq and placed the powdered content into a plastic cup. The LVN 1 poured water into the plastic cup and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 29 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 administered the medication to Resident 25 via percutaneous endoscopic gastrostomy tube (PEG tube- a surgical opening from the abdominal wall into the stomach for the introduction of food). A review of Resident 25's Potassium Chloride 20 mEq packets medication pouch indicated "dissolve 2 packets (=40mEq) in water. Then give via peg-tube daily" and to "completely dissolve in 4-8 oz [ounce, unit of measurement] of cold water." Resident 25's "Admission Orders" dated March 8, 2019, indicated to "mix (dissolve) 2 packets with 8oz of water prior to administration." During an interview with LVN 1, on March 20, 2019 at 7:20 AM, he stated he dissolved the Potassium Chloride powder in "25 cc of water". When asked how much water should the medication be dissolved in, he stated from his knowledge it should be at least eight ounces. LVN 1 acknowledged the instructions on the medication pouch to dissolve the medication in four to eight ounces of water. During an interview with the Registered Nurse (RN 1) on March 20, 2019, at 11:48 AM, she acknowledged the instructions on Resident 25's Potassium Chloride medication pouch to dissolve the medication in four to eight ounces of water and stated 25 cc of water was not sufficient to dissolve and administer the medication. A review of the facility's job description "Licensed Vocational Nurse" revised June 26, 2018, indicated " ...Administer medications according to policy and procedure ..." The facility's policy and procedure titled "Medication Administration-General Guideline" dated April 2008, indicated " ...2. Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 30 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 are administered in accordance with written orders of the attending physician." 6. During a medication administration observation on March 20,2019, at 6:22 AM, observed the QC solution from the medication cart C, bottle did not have any date on the bottle and instead the QC solution's box's inside was dated as December 1,2018. During a concurrent interview with the Licensed Vocational Nurse (LVN 5) on March 20, 2019, LVN 5 stated 11:00PM to 7:00 AM shift staffs are expected to perform the QC check daily. LVN 5, further acknowledged that he did not know the expiration date of the QC solution and how many days the solution can be used once after the bottle opened. LVN 5, reviewed the QC solution bottle and verified there were no dates on the QC solution bottle and he further stated there was a date inside the QC solution box and it was December 1, 2018. During a concurrent interview and record review with the Director of Nursing (DON) on March 20, 2019, at 9:11 AM, the DON stated the 11:00 PM -7:00 AM (night shift) Licensed Nurses (LN) are responsible for QC check of the glucometer. The DON further stated, once the QC solution bottle opened LNs would be placing the date of opening on the bottle and the solution should be discarded after 90 days of opening. The DON further reviewed the QC solution of medication cart C and verified the solution box was dated as December 1, 2018. The DON further stated based on the date the QC solution passed 90 days and should have been discarded. During a review of the [NAME] control solution manufacturer's insert revised on March 2014, indicated, " ...Use the control solution within 90 days (3 months) of first opening. It is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 31 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 recommended that you write the date of opening on the control solution bottle label ("Date opened") as a reminder to dispose of the opened solution after 90 days ..." A review of [Product Name] blood glucose monitoring system user instruction manual revised January 2017, indicated, " ...Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label ("Date opened") as a reminder to dispose of the opened solution after 90 days ..." 7. During an interview and observation with Resident 242, on March 18, 2019, at 9:42 AM, Resident 242 states he was recently in the hospital during Christmas time for Pneumonia (a lung infection) and has had an intermittent cough. During a review of Resident 242's clinical record, the facesheet (contain demographic information) indicated Resident 242 was admitted on March 8, 2019, with diagnosis that included heart failure (heart disease that affects the pumping action of the heart muscles). Resident's "History and Physical" dated March 11, 2019, indicated Resident 242 has the capacity to understand and make decisions. A review of Resident 242's "Physician and Telephone Orders" dated March 12, 2019, at 7:35 AM, indicated an order for "X-ray [chest xray, an imaging test that uses small amounts of radiation to take a picture of the chest] today, sputum c&s [culture and sensitivity, a sample of chest secretions tested for bacteria or other infectious agents] ..." due to a productive cough. A review of the "Resident Care PlanShort Term Problems" dated March 12, 2019 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 32 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 indicated a goal to resolve the productive cough with complications by March 19, 2019. During an interview and record review with the Director of Staff Development/Infection Preventionist (DSD/IP), on March 22, 2019, at 9:42 AM, she stated when a sputum culture and sensitivity is ordered, the resident is expected to expectorate in a specimen cup and the specimen is sent to the laboratory for testing. When asked what is the expectation of the licensed staff if they cannot obtain a sample, the DSD/IP stated the licensed staff is responsible for notifying the physician for further instructions and document in their nurse's notes. The DSD/IP found the laboratory requisition in the lab book indicating the specimen had not been obtained. She further acknowledged there was no documented evidence the physician was notified the sputum specimen was not collected, 10 days after the original telephone order was received. During an interview with the Director of Nursing (DON), on March 22, 2019, at 9:53 AM, she stated licensed staff need to attempt to obtain a specimen at least 3 times and if unable to collect the specimen, the physician needs to be notified for further instructions. The facility's policy and procedure titled "Laboratory Tests" undated, indicated " ...2. Specimens will be drawn and/or obtained as ordered." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 33 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F755 Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 SS=J PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/22/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for two of 23 residents (Resident 47 and 80) who receive insulin (an injectable medication which helps keep blood sugar level from getting too high or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 34 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 too low) that the insulin is administered according to the physician's orders when: 1. For Resident 47, review of the Medication Administration Record (MAR), revealed Licensed Vocational Nurse (LVN 5) failed to administer insulin in accordance with the physician's orders, which resulted in LVN 5 not giving insulin when the blood sugar orders indicated it should be given, and giving the insulin without verifying the blood sugar result as ordered. This placed Resident 47 at risk for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). 2. For Resident 80, Licensed Vocational Nurse (LVN 7) did not perform the blood sugar testing and administer the insulin as per the physician's order on March 17, 2019. These failures had the potential to cause harm and even death to Resident 47 and Resident 80 due to the effects of hyperglycemia and hypoglycemia. Findings: 1. A review of Resident 47's clinical record, indicated Resident 47 was admitted to the facility on October 4, 2017 with diagnoses which included diabetes Mellitus (a disease that affects the blood sugar levels). A review of Resident 47's physician's orders, dated January 6, 2019, indicated, "Glargine (a medication use to treat diabetes, Lantus a long acting insulin) insulin 7 units (a unit of measurement) subcutaneously (an injection under skin) Q AM (every morning) hold if BS (blood sugar) is below 100." A review of the Resident 47's medication administration record (MAR) for the month of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 35 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 March 2019 indicated the following: On March 2, 2019, March 3, 2019, March 5, 2019, March 9, 2019, March 10, 2019, March 14, 2019 and March 19, 2019, there was no documented evidence in Resident 47's clinical record the blood sugar testing had been performed and documented. A further review of the MAR for the month of March 2019, indicated the following: On March 1, 2019, the long acting insulin was held with a documented blood sugar of 100. On March 17, 2019, the long acting insulin was held with a blood sugar documented as 100. On March 18, 2019, the long acting insulin was held with a blood sugar documented as 108. A further review of the MAR for the month of March 2019, indicated the following: On March 3, 2019, insulin was administered with no blood sugar results documented. On March 5, 2019, there was no long acting insulin given and no blood sugar results documented. On March 2, 2019, The long acting insulin was held and there was no blood sugar reading. On March 3, 2019, the long acting insulin was administered with no blood sugar results. On March 5, 2019, there was no blood sugar reading. There was no long acting insulin given. On March 7, 2019, the long acting insulin was held with no blood sugar reading. On March 9, 2019, the long acting insulin was held with no documented blood sugar reading. On March 10, 2019, the long acting insulin was held with no documented blood sugar reading. On March 14, 2019, the long acting insulin was held with no documented blood sugar reading. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 36 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 an interview with LVN 3, on March 19, 2019 at 2:00 PM, she stated, "I would check the blood sugar and record it on the MAR and hold for the parameter." LVN 3 stated "It was not being consistently documented on the MAR." During an interview with medical records (MR), on March 19, 2019 at 3:32 PM she confirmed and stated the insulin is being held at times when the orders show it should have been given. During an interview and concurrent record review with the Director of Nurses (DON) on March 19, 2019 at 3:36 PM, the DON confirmed there was no documented evidence the blood sugars were checked on March 2, 2019, March 3, 2019, March 5, 2019, March 9, 2019, March 10, 2019, March 14, 2019, and March 19, 2019. The DON stated, "Doctor's orders were not followed." The DON further stated, "Insulin should have been given March 1, 2019, March 17, 2019, and March 18, 2019. The DON confirmed there was no documented evidence in the nurses notes to show a change of condition for holding the long acting insulin. There was no documented evidence of notification to the physician for the held insulin. This had the potential to cause harm or death to Resident 47. During an interview on March 20, 2019 at 7:30 AM, with LVN 5, regarding the blood sugar check on March 1, 2019, when Lantus (long acting) insulin was held for blood sugar of 100, he stated that it was what he did, held it in error. On Mach 2, 2019, LVN 5, held Lantus insulin but did not document it anywhere. On March 3, 2019 Lantus insulin was given per LVN 5, with no documented blood sugar check. LVN 5 stated, I cannot prove that I did check the blood sugar. LVN 5 stated he held the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 37 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Lantus insulin on March 18, 2019, for a blood sugar result of 108. LVN 5 stated he did not document the blood sugar result and gave the Lantus insulin on March 19, 2019. LVN 5 verified the MAR documentation. During a record review of the Licensed Nurse Competency Check List for LVN 5 it revealed LVN 5 as being signed off as competent for "Demonstrates ability to perform blood sugar checks using glucometer . . ." on October 12, 2018 and for "Demonstrates ability to administer medications efficiently and correctly" on October 12, 2018. During a telephone interview on March 20, 2019 at 2:25 PM, with the facility pharmacist (PHARM), she stated she reviews the Medication Administration Record (MAR) of which she audits once a month and if she found a discrepancy she would talk to the charge nurse and give her a report and also report it to the Director of Nurses. The PHARM states her last two reviews were done on February 17, 2019 and chart review only on March 17, 2019. The PHARM was informed for the date of February 28, 2019 there was no blood sugar documented and the Lantus Insulin was held, and on March 1, 2019 blood sugar documented as 100 and Lantus Insulin was held, and on March 2, 2019 no blood sugar documented and Lantus Insulin was held for Resident 47. The PHARM stated, "I don't have anything on that, I haven't reviewed all the MAR's for the month of March". The PHARM stated, "I did not inform anyone of the discrepancy on the MAR for Resident 47". The PHARM stated, "Insulin is considered a high alert medication". A review of the facility's policy and procedure titled, "Blood Sugar Monitoring with Insulin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 38 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Administration," undated, indicated, "This facility will administer insulin according to the physician's orders. 2. The blood sugar value will be documented and, if ordered, insulin coverage given will be administered and documented." A review of the facility's policy and procedure titled, "Medication Administration-General Guidelines," dated April 2018, indicated, "Medications are administered in accordance with written orders of the attending physician. 2. During a review of the clinical record for Resident 80, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 80 was admitted on May 13, 2018, with a diagnoses of dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning). During a review of Resident 80's "History and Physical" (H&P) dated August 17, 2018, the H&P indicated resident has a diagnosis of Diabetes Mellitus (DM- elevated blood sugar) and resident does not have the capacity to understand and make decisions. During a review of the clinical record for Resident 80, the "Order Summary Report" dated February 26, 2019, indicated, "Finger stick blood sugar(BS) Monitoring :BID (twice a day) AC meals (before meals)with regular insulin sliding scale coverage sub Q (Subcutaneous-route to administer insulin under the skin with a needle) as follows: 150-200 = 2U (Unit is a measurement), 201250 = 4U, 251-300 = 6U, 301-350 = 8U, 351400 = 10U. Notify MD if blood sugar is above 400 and below 60 MG/DL(Milligrams -MG/Desi liter-DL- unit of measurement) two times a day for DM. Insulin NPH (Human) (Isophane) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 39 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 suspension (type of medicine to control the blood sugar level) 100U/ML inject 4 unit sub Q two times a day for DM hold if BS below 100 MG/DL. During a review of the clinical record for Resident 80, the "Medication Administration Record" (MAR- record of drugs administered to the resident) for the month of March 2019, indicated, on March 17, 2019, at 4:30 PM, neither the BS was performed nor the sliding scale insulin was administered. During further review of the MAR indicated on March 17,2019, at 6:00 PM, for insulin NPH BS level and the site of insulin administration were left blank. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 6) on March 20, 2019, at 12:20 PM, LVN 6 reviewed Resident 80's MAR for the Month of March 2019 and verified March 17, 2019, at 4:30 PM, neither the BS was performed nor the sliding scale insulin administered. During further review of the MAR indicated on March 17, 2019, at 6:00 PM, for insulin NPH BS level and the site were left blank. LVN 6 further stated if they withhold or did not perform the BS the LVN will document behind the MAR for the rationale to withhold the medication. LVN 6 further reviewed the back side of the MAR and acknowledged there was no documentation on March 17, 2019, indicated with the reason for withholding the medication. During a concurrent interview and record review with the Director of Nursing (DON) on March 20, 2019, at 12:25 PM, the DON reviewed Resident 80's MAR for the Month of March 2019 and verified March 17, 2019, at 4:30 PM and 6:00 PM, the BS and the insulin administration were left blank. The DON further reviewed resident 80's care plan (an individualized plan for the medical care of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 40 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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) for "Accucheck (finger stick BS monitoring) revised on February 27, 2019, indicated administer my medications as ordered." The DON further stated, "If it was not documented, it was not happened." The DON further reviewed Resident 80's "Multidisciplinary Progress Record" and acknowledged there no documentation by the Licensed Nurses (LNs) for the rationale for not having performed the BS and the medication was not administered. During a telephone interview with Licensed Vocational Nurse (LVN 7), on March 20, 2019, at 4:25 PM, LVN 7 acknowledged she was assigned to Resident 80 on March 17, 2019. LVN 7 further stated she was expected to document on the resident's MAR immediately after the BS check and the medication administration with the site and amount of insulin given. The facility's undated policy and procedure titled, "Blood Sugar Monitoring with Insulin Administration", indicated, " ...1. If ordered, blood sugar will be monitored using a glucometer. 2. The blood sugar value will be documented and if ordered, insulin coverage will be administered and documented ... ." During a follow up interview and record review with the DON on March 21, 2019, at 9:45 AM, the DON reviewed the facility's undated policy and procedure titled, "Blood Sugar Monitoring with Insulin Administration", and acknowledged the facility did not follow the policy and procedure for blood sugar monitoring and insulin administration. The facility's undated policies and procedure [NAME] titled Appendix ... indicated, "insulin ...use of antidiabetic medications should include monitoring for example, periodic blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 41 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 sugar) for effectiveness based on desired goals ... ." An IJ situation was identified and called on March 20, 2019, at 4:00 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The DON and the ADMIN were informed of the observations, interviews, and record reviews concerning insulin administration and blood sugar monitoring being performed. A Corrective Action Plan (CAP) was requested. Observation, staff interviews, and record review were conducted on March 21, 2019 at 10 AM to ensure the corrective action plan provided by the facility was implemented. The facility's corrective action plan included Resident assessed with no signs or symptom of hyperglycemia or hypoglycemia, Resident chart and MAR in room 117B (Resident 47) and 121B (Resident 80) was reviewed to ensure appropriate orders. DON have in-serviced the identified nurse assigned for that particular patient immediately. All licensed nurses were given an On-Shift memo and notification in regards to insulin parameters and blood sugar readings documentation. Director of Nursing Services or designee will identify other residents with insulin and parameter order. Physician orders and MAR is being reviewed and updated to ensure that no other Resident experienced the same deficient practice. During admission process, admission nurse will review orders for insulin and make sure that Parameters are properly indicated and written in the telephone orders and MAR. RN (Registered Nurse) Supervisor will review all residents identified with insulin and parameter orders and will ensure that the MAR will indicate area to record blood sugar reading, Medical Record or designee will review recapped MAR monthly times two months FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 42 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 before giving to licensed nurse for use. Will ensure there is a specific area to record blood sugar readings. An acceptable Corrective Action Plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on March 21, 2019 at 2:30 PM, in the presence of the ADMIN., and DON.

F770 SS=D Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 04/22/2019 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of 25 sampled residents (Resident 71) a throat culture swab (a lab test that is done to identified a bacteria) was done as ordered by the doctor. This failure had to potential to adversely affect FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 43 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 the health of Resident 71. Findings: A review of Resident 71's clinical record, indicated Resident 71 was admitted to the facility on August 17, 2017 with diagnoses which included hypertension (high blood pressure), dysphagia (difficulty swallowing), and hemiplegia (unable to move one side of the body). A review of Resident 71's physician's orders, dated February 7, 2019, indicated Resident 71 had a lab order for a throat culture swab related to cough/sore throat to be done on February 8, 2019. A review of Resident 71's lab results for the month of February 2019, indicated there was no documented evidence the throat culture swab was done on February 8, 2019. During an interview with MDS Licensed Vocational Nurse (MDS LVN) on March 19, 2019 at 10:30 AM. MDS LVN confirmed there was no documented evidence in Resident 71's clinical record a throat culture swab was done on February 9, 2019 as ordered by the physician . MDS LVN stated, "It was not." During an interview with the Director of Nurses (DON) on March 20, 2019 at 10:15 AM, the DON confirmed there was no documented evidence the throat culture swab was not done. The DON stated. "It should have not been missed." A review of the facility's policy and procedure titled, "Laboratory Test," undated, indicated, "2. Specimens will be drawn and/or obtained as ordered." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 44 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F773 Lab Srvcs Physician Order/Notify of Results CFR(s): 483.50(a)(2)(i)(ii)

F773 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 04/22/2019 §483.50(a)(2) The facility must(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure for one of 25 sampled Residents (Resident 22) an abnormal LFTS (liver functional tests- a group of lab tests to determine the level of liver enzymes) and lipid panel (a group of lab tests to determine cholesterol level) physician was notified about abnormal LFTS and lipid panel results. This failure had to potential to adversely affect the health of Resident 22. Findings: A review of Resident 22's clinical record, indicated Resident 22 was admitted to the facility on July 4, 2015 with diagnoses which included hypertension (high blood pressure), diabetes mellitus (high blood sugar) and osteoporosis (brittle bones). A review of Resident 22's physician's orders, dated December 20, 2018, indicated Resident 22 had an order for LFTS and lipid panel to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 45 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 done. A review of Resident 22's lab results, dated, December 20, 2018 at 6:41 PM, indicated the following: Bilirubin (a liver enzyme) was elevated, cholesterol was low, and HDL (a type of cholesterol) was low. A review of Resident 22's Clinical record indicated there was no documented evidence the physician was notified about the abnormal labs results. During an interview with the Director of Nurses (DON) on March 20, 2019 at 10:30 AM. The DON confirmed there was no documented evidence in Resident 22's clinical record the physician was notified about the abnormal lab results. The DON stated, "The doctor should have been notified and documented." During an interview with MDS Licensed Vocational Nurse (MDS LVN) on March 20, 2019 at 10:15 AM, The MDS LVN confirmed there was no documented evidence the physician was notified. The MDS LVN stated. "The doctor should have been notified." A review of the facility's policy and procedure titled, "Laboratory tests," undated, indicated, "Abnormal labs results will be communicated to attending physician in a timely manner."

F805 SS=D Food in Form to Meet Individual Needs CFR(s): 483.60(d)(3)

F805 04/22/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(3) Food prepared in a form designed to meet individual needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 46 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 observation, interview, and record review, the facility failed to follow their policy and procedure for one of 25 sampled residents (Resident 6), when the Licensed Vocational Nurse (LVN 1) was observed mixing four teaspoons (tsp, a unit of measurement) of thickening powder (a powder used to thicken fluids or food for individuals on a mechanically altered diet) into a 32-ounce (oz, a unit of measurement) pitcher of water and placed it at the bedside for resident use. This failed practice had the potential to result in harm which increased Resident 6's risk of aspiration (when a person inhales food, stomach acid, or saliva into the lungs) due to the recommended amount of thickening powder not being properly mixed by designated dietary staff in the specified amount of water. Findings: During an observation on March 20, 2019, at 6:42 AM, at Medication Cart A, Certified Nursing Assistant (CNA 1) approached LVN 1 with a pitcher of ice water and asked LVN 1 to add thickening powder to the container for Resident 6. LVN 1 was observed using a plastic spoon equivalent to one teaspoon to add the thickening powder to the pitcher of ice water. During an interview with LVN 1 on March 20, 2019, at 7:20 AM, LVN 1 stated the nursing staff is allowed to mix thickened liquid consistencies for resident use. LVN 1 confirmed he mixed 4 teaspoons of the thickening powder to a 32-ounce pitcher of water. During a review of Resident 6's clinical record, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 47 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 the face sheet (contains demographic information) indicated Resident 6 was initially admitted to the facility on November 28, 2011 and was re-admitted to the facility on March 13, 2019 under hospice care, with diagnoses of protein-calorie malnutrition (when protein and calorie intake does not meet the individual's needs), cerebrovascular disease (a group of diseases that affect blood supply to the brain), and aphasia (impaired ability to speak or express oneself). A review of Resident 6's "History and Physical" dated March 17, 2019, indicated Resident 6 had a recent diagnosis of aspiration pneumonia (a lung infection that occurs when a person inhales food, stomach acid, or saliva into the lungs instead of the stomach) and "does not have the capacity to understand and make decisions." Resident 6's "Admission Orders" dated March 13, 2019, at 7:30 PM, indicated a diet order of "nectar thickened liquid (a mildly thickened fluid) for oral gratification x [times] 2 days then reassess." During an interview with LVN 2 on March 20, 2019, at 12:40 PM, he stated thickened liquids should be obtained from the kitchen, "we don't mix it ourselves." The LVN 2 further stated, the dietary staff will mix the thickened liquid to the correct consistency. During an interview and record review with the Registered Dietician Consultant (RD-C), on March 20, 2019, at 1:15 PM, she stated the dietary staff is responsible for providing thickened consistency fluids to ensure the fluid is mixed at the correct physician ordered consistency. During an observation and interview with LVN 2 on March 20, 2019, at 2:39 PM, the LVN 2 confirmed the "Lyons ReadyCare Instant Food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 48 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 Thickener" date opened January 12, 2019, indicated for every 4 oz of fluid, 1 tablespoon of thickener powder was needed to mix to a nectar-like consistency. If the nursing staff was allowed to mix thickened consistency water, LVN 1 needed to mix a total of eight tablespoons of "Lyons ReadyCare Instant Food Thickener" in the 32 oz pitcher of water provided to Resident 6 to get a nectar thick consistency instead of 4 teaspoons. During an interview and record review with the Director of Nursing (DON), on March 21, 2019, at 9:04AM, she stated the nursing staff is not allowed to mix thickened consistency fluids. The DON further stated, the nursing staff should get thickened fluids from the kitchen. The DON reviewed the policy and procedure titled "Thickened Liquids" revised 2019. The DON acknowledged staff did not follow the policy and procedure for Resident 6. A review of the facility's "Beverages" document undated, indicated to add a half cup of "Lyons ReadyCare Instant Food Thickener" to 32-oz of water and to " ...use level measuring spoon and/or cup for accurate results." The facility's policy and procedure titled "Thickened Liquids" revised 2019, indicated " ...4. Water pitchers will be thickened in the dietary department. Nursing staff will distribute the water pitchers to the resident."

F808 SS=D Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 04/22/2019 §483.60(e) Therapeutic Diets §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 49 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to have a physician order for a mechanically altered diet (the texture of food items are changed from the original consistency) for one of 25 sampled residents (Resident 6). This failed practice had the potential to cause harm and inadequate nutrition to Resident 6; who was at risk for aspiration, when staff provided a meal tray for 15 out of 17 meals to Resident 6 without a physician order specifying the type of diet needed. Findings: During a review of Resident 6's clinical record, the face sheet (contains demographic information) indicated Resident 6 was initially admitted to the facility on November 28, 2011 and was re-admitted to the facility on March 13, 2019 under hospice care, with diagnoses of protein-calorie malnutrition (when protein and calorie intake does not meet the individual's needs), cerebrovascular disease (a group of diseases that affect blood supply to the brain), and aphasia (impaired ability to speak or express oneself). A review of Resident 6's "History and Physical" dated March 17, 2019, indicated Resident 6 had a recent diagnosis of aspiration pneumonia (a lung infection that occurs when a person inhales food, stomach acid, or saliva into the lungs instead of the stomach) and "does not have the capacity to understand and make decisions." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 50 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 an observation on March 20, 2019, at 8:30 AM, in Resident 6's room, she was in bed lying in an upright position with a covered meal tray on the bedside table. The meal card listed Resident 6's diet as an "oral gratification puree diet with Nectar Thicken Liquid (NTL)." During a review of Resident 6's "Admission Orders" dated March 13, 2019, at 7:30 PM, indicated a diet order of "nectar thickened liquid for oral gratification x [times] 2 days then reassess." A review of Resident 6's "Certified Nursing Assistant ADL [activities of daily living] Sheet" dated March 2019, indicated Resident received her first meal on March 14, 2019 after being re-admitted to the facility and a diet reassessment was due no later than March 15, 2019. The "Certified Nursing Assistant ADL [activities of daily living] Sheet" further indicated Resident 6 received a total of 17 meals A review of Resident 6's hospice plan of care assessment, dated March 13, 2019, at 4:30 PM, indicated "...Explained to sons, (son's name), the risks of aspiration of feeding PO [by mouth] at this time is very high but (son's name) insisted that patient should be eating something by mouth ..." During an interview and record review with the Registered Dietician Consultant (RD-C), on March 20, 2019, at 1:15 PM, she acknowledged Resident 6's admission diet order and stated speech therapy was responsible for reassessing the resident's diet. The RD-C further acknowledged Resident 6's "Nutritional Assessment" dated March 15, 2019, indicated "Rec [recommend] NAS [no added salt] Puree with NTL with all meals ...SLP [speech language pathologist, definition] assessed resident and rec [recommended] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 51 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 puree with NTL as per SLP 3/15/19." The RD-C stated there was no order in place for a diet as per recommendation. During an observation and interview with the resident representative (RR), on March 20, 2019, at 1:25 PM, in Resident 6's room, the RR was feeding Resident 6 an "oral gratification puree diet with NTL" per meal card and stated Resident 6 ate all of her pudding and "she's eating good ...she's almost done, I'm feeding her the meat now." During an interview and record review with the Registered Nurse (RN 1), on March 20, 2019, at 2:30 PM, she acknowledged the admission order for Resident 6 dated March 13, 2019 and stated reassess means the speech therapist will have to evaluate and recommend a diet. She further stated there was not an updated order in the chart reflecting the current diet order and Resident 6 should not receive a meal tray without a physician order. During an interview and record review with the Director of Nursing (DON), on March 20, 2019, at 12:00 PM, she acknowledged there was no diet order for Resident 6. The DON further stated, all residents should have a physician order for their diet and the nursing staff was responsible for informing the physician of any RD recommendations. The DON reviewed the policy and procedure titled "Consultant Dietician Recommendation Completion" revised 2019. The DON acknowledged staff did not follow the policy and procedure for Resident 6. The facility's policy and procedure titled "Consultant Dietician Recommendation Completion" revised 2019, indicated " ...2. MD [medical doctor] will be notified of any recommendations within 72 hours. Evident as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 52 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 noted in the following: a. Nurse's notes reflect that recommendations have been relayed to the MD. b. Physician's Orders reflect new MD orders based on noted recommendations."

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 04/22/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. Diet Aide 1 (DA 1) failed to practice appropriate hand hygiene and came into the kitchen from outside and did not stop to wash their hands. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 53 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 2. Metal bowls, sheet pans and baking pans were found stacked and stored wet. These failures had the potential for the growth of harmful bacteria and cross contamination that could lead to food borne illness for a medically compromised population of 95 residents who received food from the kitchen out of a facility census of 95. Findings: 1. During an initial tour of the kitchen on March 18, 2019 at 8:05 AM, DA 1, left the kitchen to remove her jacket and grab her apron and came back into the kitchen and proceeded to handle clean dishware without first washing her hands. According to the FDA Food Code 2017, staff should hand wash "Employees must wash their hands after any activity which may result in contamination of the hands. Handwashing is a critical factor in reducing fecal-oral pathogens that can be transmitted from hands to RTE food as well as other pathogens that can be transmitted from environmental sources." During an interview on March 18, 2019 at 8:05 AM, DA 1 stated she forgot to wash her hands because she had to grab her apron and put her jacket away. During an interview with the Registered Dietitian- consultant (RD-C) on March 18, 2019 at 11:05 AM, she stated she instructs the dietary staff to wash their hands upon entering the kitchen, upon removal or change of gloves, between touching dirty vs. clean dishes, before preparing foods, between touching raw and cooked foods, after handling carts, etc. and she gives in-service instruction to the staff on proper hand washing. During a review of the facilities policies and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 54 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 procedures titled "Infection Control for the Foodservice Department" (review date 5/2006), it states "Careful hand washing by personnel will be done as follows: a) prior to entering the work area and reporting to the work station". 2. During an observation on March 20, 2019 at 8:50 AM, in the main kitchen area, with the Cook and DA 2, metal bowls, sheet pans and baking pans of various sizes were observed on shelves in the food production area, stacked and stored wet without air circulation. Items were separated and placed on the counter to verify with staff that they did in fact have water drops. Diet Aide 2 and the Cook verified that the items had water. According to the FDA Food Code 2017, "Items must be allowed to drain and air-dry before being stacked and stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow." During an interview on March 20, 2019 at 8:52 AM with DA 2, indicated that all dishware should be dry before storing. During an interview on March 20, 2019 at 9:05 AM, indicated that dishes should be air dried. RD indicated that the expectation is that staff should not store dishes wet. During a review of the facilities policies and procedures titled "Dish washing proceduresDish machine" (review date 2019), it states that "dishes and utensils will be air dried before storage".

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 04/22/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 55 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(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 §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 56 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (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 observation, interview, and record review, the facility failed to ensure for one of 25 sampled Resident (Resident 22) an abnormal LFTS (liver functional tests- a group of lab tests to determine the level of liver enzymes) and lipid panel (a group of lab tests to determine cholesterol level) results were available in Resident 22 clinical record. This failure had to potential to adversely affect the health of Resident 22 by not having the abnormal lab available in Resident 22 clinical record for health care providers to review. Finding: A review of Resident 22's clinical record, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 57 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 indicated Resident 22's was admitted to the facility on July 4, 2015 with diagnoses which included hypertension (high blood pressure), diabetes mellitus (high blood sugar) and osteoporosis (brittle bones). A review of Resident 22's physician's orders, dated December 20, 2018, indicated Resident 22 had an order for LFTS and lipid panel to be done. A review of Resident 22 clinical record on March 20, 2019 at 10:15 AM, revealed there was no lab results available in the Resident 22 clinical record. During an interview with MDS Licensed Vocational Nurse (MDS LVN) on March 20, 2019 at 10:15 AM, The MDS LVN confirmed there was no lab results available in Resident 22's clinical record. The MDS LVN stated, "The lab should be available in the resident's chart for the doctor to review." During an interview with the Director of Nurses (DON) on March 20, 2019 at 10:30 AM. The DON confirmed there was no lab results available in Resident 22's clinical record. The DON stated, "The labs should be available in the resident's chart."

F868 SS=D QAA Committee CFR(s): 483.75(g)(1)(i)-(iii)(2)(i)

F868 04/22/2019 §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 58 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; §483.75(g)(2) The quality assessment and assurance committee must: (i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to identify systemic issues that included the following: 1. The staff not disinfecting multi use glucometer before and after use for residents. 2. The staff not following doctor's orders for insulin administration and blood sugar monitoring. 3. The staff allowing personal use of a space heater in resident's room. These failures may increase the risk for the following: 1. Residents to be exposed to blood borne infection for non-disinfected glucometers. 2. Residents not receiving the correct dose of insulin administration based on blood sugar monitoring according to the physician's orders. 3. Residents safety due to the personal use of a space heater in resident's room. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 59 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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. .During an observation on March 20, 2019, at 5:35 AM, the licensed vocational nurse (LVN 5) did not disinfect the glucometer before and after it was used for the Residents 56, 30 and 9. LVN 5 continued to check the blood sugar without disinfecting the glucometer and placed the glucometer on Resident 56's bed and checked the blood sugar and placed the glucometer on the medication cart B without disinfection of the glucometer. 2. During an observation, record review, and interview, the licensed vocational nurse failed to administer insulin in accordance with the physician's order which resulted in licensed vocational nurses not giving insulin when blood sugar orders indicated it should be given, and giving insulin without verifying the blood sugar results. 3. During an observation on march 18, 2019, at 11:10 AM, a space heater was found on the bedside table and it was used by the resident (Resident 342)'s room with the doors closed. During a meeting for the QAPI (Quality Assurance and Performance Improvement) review on March 22, 2019 at 1:45 PM, attended by the administrator (ADMIN) and Director of Nurses (DON), the ADMIN and DON discussed the current Quality Assessment and Assurance (QAA) issues which they identified prior to the recertification. During an interview with the ADMIN on March 22, 2019 at 2 PM, the ADMIN stated that the Quality Assurance consists of the following members: ADMIN.,DON, dietary supervisor, director of staff developement, activity director, medical records director, social service director, three doctors, pharmacy consultant, and laboratory consultant. The ADMIN. stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 60 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 "The QAPI meets at least quarterly to discuss issues." A review of the facility's QAPI's Performance Improvement Project (PIP) for the months of: January 2018, February 2018, March 2018, April 2018, May 2018, June 2018, July 2018, August 2018, September 2018, October 2018, November 2018, and December 2018, revealed there was no documented evidence QAPI committee had PIPs identified for nurses not disinfecting glucometers before and after use; for nurses not following doctor's orders for insulin administration and blood sugar monitoring; and space heaters being allowed for personal use in the resident's room. A review of the facility's QAPI's PIP for the month of January 2019, February 2019, and March 2019, revealed there was no documented evidence QAPI committee had PIPs identified for nurses not disinfecting glucometers before and after use; for nurses not following doctor's orders for insulin administration and blood sugar monitoring; and space heaters being allowed for personal use in the resident's room. During an interview with the ADMIN on March 22, 2019 at 2:30 PM, the ADMIN., confirmed there was no PIP addressing the identified systemic issues for the year 2018 and current year 2019. The ADMIN. stated, "I was not aware of nurses not disinfecting glucometers before and after use; the nurse not following doctor's orders for insulin administration and blood sugar monitoring. I was not aware that the space heater in the resident's room was not allowed." During an interview with the DON on March 22, 2019 at 2:45 PM, the DON confirmed there was no PIP addressing the identified systemic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 61 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 issues. DON stated, "I did not know about the nurses not disinfecting glucometers before and afer use; the nurse not following doctor's orders for insulin administration and blood sugar monitoring, and the space heater in the resident's room was not allowed." DON further stated, "We have QAPI those issues." A review of the facility's document titled, "Quality Assurance Improvement Plan," undated, indicated under "I. QAPI Goals/purpose Statement," indicated, "Our purpose is to take a proactive approach to continually provide the best services to all residents in accordance with the state and federal regulations."

F880 SS=J Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 04/22/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 62 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures 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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(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: YZF911 Facility ID: CA240000285 If continuation sheet 63 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 §483.80(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, the facility failed to ensure the glucometer (a device used to perform the finger stick blood test (pricking with a tiny needle and then using a little strip and a glucometer to test blood sugar levels) was disinfected according to the manufacturer's guidelines and adhere to use specified Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that destroy bacteria, virus, and fungi) and to the facility's policy and procedure to use the appropriate disinfectant before and after residents' use for four of 35 sampled residents (Residents 63, 56, 30, and 9) in the universe of 95 residents. 1. For Resident 63, the Licensed Vocational Nurse (LVN 2) did not disinfect the glucometer before resident use. 2. For resident 56, 30 and 9 the LVN 5 did not disinfect the glucometer before, after and between the finger stick blood test. These failures created an overall danger of transmission of a blood borne infection (disease that can be spread through contaminated blood and other body fluids) to 35 residents who shared a potentially contaminated glucometer. Findings: 1. During a review of the clinical record for Resident 63, the "Admission Record" (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 64 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 document containing demographic and medical information) indicated, Resident 63 was admitted on February 4, 2019, with a diagnoses of Hypertension (high blood pressure), Type 2 Diabetes Mellitus (DMelevated blood sugar). During a review of Resident 63's "Order summary report" dated February 26, 2019, indicated, Finger stick blood sugar monitoring: AC meals (before meals) .... During a review of the clinical record for Resident 63, the "Medication Administration Record" (MAR- record of drugs administered to the resident) for the month of March 2019, indicated the finger stick blood sugar monitoring was performed three times (6:30AM, 11:30AM, 4:30PM) before meals. During an observation on March 18, 2019, at 12:19 PM, LVN 2 took the glucometer out of the medication cart then put on gloves. LVN 2 then placed the glucometer on Resident 63's bed and performed a finger stick blood test. LVN 2 removed the gloves along with the blood test strip and placed the glucometer on the medication cart. LVN 2 disinfected the glucometer with the disinfectant wipes. LVN 2 did not disinfect the glucometer prior to use and he failed to perform hand hygiene after the finger stick blood sugar was checked on Resident 63. During an interview with LVN 2 on March 18, 2019, at 12:28 PM, LVN 2 acknowledged he did not wash his hands after Resident 63's finger stick blood test and instead he wore the gloves in order to prevent infection. LVN 2 further stated he would not disinfect the glucometer prior to use and only disinfect after the use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 65 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 2. A review of the clinical record for Resident 56, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 56 was admitted on January 4, 2018 with diagnoses that included, Hypertension (high blood pressure), Type 2 Diabetes Mellitus (DMelevated blood sugar). During a review of Resident 56's "History and Physical" (H&P) dated May 10, 2018 indicated, Resident 56 had a medical diagnosis of DM and Resident 56 did not have the capacity to understand and make decisions. During a review of Resident 56's "Order summary report" dated February 26, 2019, indicated, blood sugar monitoring: BID (twice a day) AC meals (before meals) .... During an observation on March 20, 2019, at 5:35 AM, LVN 5 placed the glucometer on the Medication Cart B and inserted the strip, put on gloves and placed the glucometer on Resident 56's bed and performed the finger stick blood test on Resident 56. LVN 5 removed gloves and the discarded the lancet (tiny needle) in to the sharp container and placed the glucometer on the medication cart B. LVN 5 did not disinfect the glucometer before and after the finger stick blood test on Resident 56. A review of the clinical record for Resident 30, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 30 was admitted on December 24, 2018, with diagnoses that included Anemia (decreased hemoglobin in the blood, resulting in pallor), Hypertension (high blood pressure), Type 2 diabetes Mellitus (DM-elevated blood sugar). During a review of Resident 30's "Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 66 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 summary report" dated February 26, 2019, indicated, Finger stick blood sugar monitoring BID (twice a day) AC meals (before meals) @6:30 AM and 4:30 PM .... During an observation on March 20, 2019, at 5:51 AM, LVN 5 took the strip out of the container and attached to the glucometer, put on gloves and placed the glucometer on Resident 30's bed. LVN 5 pricked the right index finger of the resident (Resident 30) and obtained the blood sample and placed the glucometer with the blood sampled strip on the medication cart B and removed the blood strip after the meter read the blood sugar. LVN 5 did not disinfect the glucometer before and after the finger stick blood test on Resident 30. A review of the clinical record for Resident 9, the "Admission Record" (a document containing demographic and medical information) indicated, Resident 9 was admitted on June 17, 2016, with diagnoses that included, heart failure (Inability of the heart to pump adequate blood supply to other organs), Hypertension (high blood pressure), Type 2 Diabetes Mellitus (DM-elevated blood sugar). During a review of Resident 9's "Order summary report" dated February 26, 2019, indicated, Finger stick blood sugar monitoring daily ... . During an observation on March 20, 2019, at 5:58 AM, LVN 5 attached the blood sugar strip on the glucometer then put on gloves and placed the glucometer on Resident 9's bedside table and obtained the blood sample to the strip after pricking the finger of the resident with a lancet. LVN placed the glucometer on the Medication Cart B after removing the blood sampled strip. LVN 5 did not disinfect the glucometer before and after the finger stick FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 67 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 blood test on Resident 30. During an interview with LVN 5 on March 20, 2019, at 6:05 AM, LVN 5 stated he did not clean the glucometer with disinfectant wipes before and after these three residents (Residents 56, 30 and 9). LVN 5 further stated he usually cleans the glucometer with alcohol swabs or if the disinfectant wipes available. LVN 5 was unable to find a disinfectant wipe on his medication cart. During an interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on March 20, 2019, at 8:48 AM, the DSD/IP, stated staff are expected to clean the glucometer with the facility approved disinfectant wipes [BRAND NAME] before, after and between the resident's use. The DSD/IP further stated the facility used red lid [BRAND NAME] disinfectant wipes to disinfect the glucometer, in order to prevent the cross contamination and blood borne infection. During a review of the facility's undated policy and procedure titled "Cleaning Glucometers indicated ...3. Wipe glucometer thoroughly with appropriate disinfectant, such as Sani-cloth HB, Cavi Wipe, or Sani- cloth plus, and leave for recommended time ...6. Wipe the outside of the meter ...after each resident use ...." During a concurrent interview and record review with the Director of Nursing (DON) on March 20, 2019, at 9:02 AM, the DON, stated staffs are expected to disinfect the glucometer with the facility's approved disinfectant wipes [red lid BRAND NAME], before after and between resident's finger stick blood test and wait for air dry. The DON further reviewed the facility's approved disinfectant wipes canister and stated the kill time was 2 minutes and staff are expected to wait for two minutes after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 68 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 disinfection of the glucometer. The DON further reviewed the facility's undated policy and procedure titled "Cleaning Glucometers" and acknowledged the facility did not follow the policy and procedure. During a review of the [BRAND NAME] undated glucometer's reference manual, indicated, the EPA registered wipes with the name [BRAND NAME]. The failure to follow and implement infection control prevention policy and procedure and manufacturer's guideline resulted in an Immediate Jeopardy (IJ- immediate danger of harm). An IJ was identified and called on March 20, 2019, at 1:15 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON was informed of the observations, interviews, and record reviews with the facility staff. The facility provided a corrective action plan, which included employee asked to come in for a 1:1 in serviced/ re- education about, Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of glucose monitoring system record. Employee received performance corrective notice. Deficient practice immediately rectified, and employee will be monitored for performance during the next 30 days. Initiated in service/ reeducation amongst Licensed Nurses(LN) about Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 69 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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 glucometer quality control (QC) monitoring system record. Ordered new glucometers: once available old glucometers to be replaced and initial QC check performed prior to use. Update policy and procedures for glucometer to include steps how to clean the equipment. All residents who uses the glucometer for blood sugar monitoring are being assessed by a Registered Nurse(RN) for any signs and symptoms of infection. Glucometers will continuously be monitored fro QC by checking daily. All staff were informed electronically via On- shift regarding proper handwashing. All LNs were reminded electronically via On- shift regarding proper disinfection of glucometers. The Staff Developer (DSD) or Designee will continue to provide ongoing in services or re- education about handwashing and proper disinfection of glucometers. The DSD or designee will review glucometer QC monitoring weekly for completeness for four weeks. The corrective plan will be used as a part of our QAPI and will be reviewed at the monthly utilization review meeting for evaluation and recommendations. Facility's policy and procedure titled "Disinfecting Glucometers" dated March 20, 2019 updated with ...3. Wipe glucometer thoroughly with disinfectant wipes (Red BRAND NAME). Keep glucometer wet for two minutes and allow to dry ... ." The IJ was lifted on March 21, 2019, at 2:30 PM, in the presence of the ADMIN and DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure corrective action plan was implemented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YZF911 Facility ID: CA240000285 If continuation sheet 70 of 71 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: _______________ 056429 (X3) DATE SURVEY COMPLETED 03/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAUREL CONVALESCENT HOSPITAL 7509 N. Laurel Ave Fontana, CA 92336 (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: YZF911 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000285 (X5) COMPLETE DATE If continuation sheet 71 of 71