Other·December 28, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey to investigate a complaint. Complaint Number: CA00583222 Representing the California Department of Public Health: 36159 The inspection was limited to the specific complaint investigated and does not represent a full inspection of the facility. One deficiency was written for: CA00583222

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident C), was free from a significant medication error when Resident C received a medication, Potassium Chloride (a medication used to prevent or treat low blood levels of potassium) in excess of what the physician ordered. This failure was the result of nursing staff not clarifying multiple orders for potassium with the physician, and resulted in Resident C not receiving the prescribed dosage of medication, developing hyperkalemia (high potassium level), suffering cardiac arrest and death. 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: G2YP11 Facility ID: CA240000289 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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: An abbreviated survey was made to the facility on April 18, 2018, to investigate a complaint regarding nursing services. A review of Resident C's clinical record face sheet (contains demographic information), set forth she was admitted to the facility on March 28, 2018, with diagnoses which included: post fall, urinary tract infection (UTI-a high amount of bacteria in the urine), and congestive heart failure (CHF-heart muscle doesn't pump blood as well as it should). A review of the laboratory results received for Resident C, dated March 28, 2018 documented Resident's low potassium level at 3.2 (normal 3.5 to 5.0). A review of the physician's order for Resident C, dated March 28, 2018, set forth: "KCL (potassium) 20 meq (millequivalents-a unit of measurement) tablet daily x 3 days." A review of the Medication Administration Record (MAR) noted that beginning March 29, 2018 through March 31, 2018 at 9:00 AM, Resident C received KCL ER (extended release) tablet 20 meq for three days. Review of laboratory results dated March 29, 2018 set forth that Resident C's potassium level was lower than the previous day at 2.4 (low-hypokalemia). A review of the physician's order for Resident C dated March 29, 2018, set forth that the physician increased the potassium dose for Resident C as follows: "KCL liquid 60 meq PO [by mouth] x 1 now, then Q4H (every four hours) x 3 (three doses) total-[indication] K: 2.4 (hypokalemia)." This would be a total of 240 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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 meq of potassium in 24 hours. A review of the medical record for Resident C did not demonstrate any documentation that nursing staff clarified with the physician whether the previous 20 meq potassium tablets were to be continued in addition to the new order for KCL liquid. A review of the MAR reflected that on March 29, 2018 at 2:17 PM, Resident C received KCL ER tablet 20 meq, and was administered three tablets [60 meq] PO STAT (now) as a supplement for KCL liquid. (Resident C's physician had ordered KCL liquid). A review of the MAR noted that on March 29, 2018 at 6:00 PM, Resident C received KCL liquid 20 meq/15ml (a unit of measurement) 60 meq PO. A review of the laboratory results dated March 30, 2018, reflected Resident C's potassium level was within the normal range at 3.6. A review of the physician's order dated March 29, 2018 set forth: "For AM [March 30, 2018], start KCL liquid 40 meq PO daily--[indication] hypokalemia." A review of the medical record for Resident C did not demonstrate any documentation that nursing staff clarified if this order was to be added to the initial order of 20 meq and the secondary order of 60 meq, for a total of 120 meq daily, commencing the morning of March 30, 2018. A review of the MAR noted that beginning March 30, 2018, Resident C received KCL 60 meq three times a day (TID) through April 2, 2018 at 7:00 AM. The physician's order was for one initial dose STAT and then three additional doses for March 29, 2018 only. Resident C was to have a maintenance dose of 40 meq daily starting on March 30, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the MAR noted that on March 30, 2018 through April 1, 2018, Resident C received KCL liquid 20 meq/15ml, 40 meq PO daily at 9:00 AM. A review of the MAR and the physician's orders reflected that Resident C received potassium doses as follows: a. March 29, 2018- Resident C received 20 meq. tablet, plus 60 meq (three 20 meq tablets) and 60 meq of KCL liquid= a total of 140 meq of KCL b. March 30, 2018 and March 31, 2018Resident C received a 20 meq tablet, 40 meq KCL liquid, and three doses of 60 meq KCL liquid= 240 meq of KCL c. April 1, 2018- Resident C received 40 meq KCL liquid, and three doses of 60 meq KCL liquid=220 meq KCL A review of the facility's pharmacy delivery record for KCL for Resident C noted a delivery date of March 28, 2018 of Potassium CL ER 20 meq tablet. A total of three tablets were delivered. During a telephone interview with a representative from the facility's pharmacy on July 17, 2018 at 11:55 AM, when asked the quantity delivered for Resident C, the representative stated, "We delivered three tablets, because the order was for three days only." When asked whether the pharmacy received another potassium order for Resident C, the representative stated they received a KCL liquid order on April 1, 2018 at 4:33 PM, (four days after the order was issued by the physician). A review of the pharmacy's delivery record for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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 C did not demonstrate that the facility had notified the pharmacy of the physician's order for KCL liquid, nor did the record document that the facility received KCL liquid on March 29, 2018. Rather, the pharmacy delivery record documented that the pharmacy did not deliver any KCL liquid for Resident C until April 1, 2018. A review of the facility's "Progress Notes" for Resident C, written April 2, 2018, 03:13 AM, set forth:, "At approx [approximately] 0000 (12 midnight), Charge nurse and RN [Registered Nurse (RN 1)] notified of pt (patient) c/o (complaint of) SOB (shortness of breath). Checked O2 SAT (saturation-the level of oxygen carried by the blood), reading at 75%. Pt was then put on O2 (oxygen). . . RN 1 began to review pt chart at this time and noted pt receiving very high doses of KCL . . . RN 1 noted . . . order on 3/29 (March 29) for KCL 60 meq x 1 now, then Q4H (every 4 hours) x 3 more doses. Then start KCL 40 meq in AM Q (every) daily. Order in PCC (MAR) showed start KCL meq TID (3x a day) on 3/29 with no end date. Then started KCL 40 meq QD (every day) on 3/30 with no end date. Also noted order pt starting KCL 20 meq QD x 3 days on 3/29 until 04/01/18. Called [medical practitioner oncall] . . .approx 0212 received call from MD [name]. Explained the medication error and possible hyperkalemia . . .new order. . . pt was transferred to acute hospital [name] ER (emergency room) at 0235 (AM)." During an interview with the Director of Nursing (DON) on April 18, 2018 at 5:15 PM, she stated, "The RN Supervisor (RN 1) explained that he responded to (Resident C's) change of condition [possible hyperkalemia] (COC-a change in a patient's physical and safety wellbeing) and sent her the hospital. We also interviewed the nurse [Licensed Vocational FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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 Nurse (LVN 1)] who was writing the order, what she wrote on the MAR was TID (three times a day). During a telephone interview with LVN 1 on June 27, 2018 at 2:20 PM, she stated, "I did receive the [name of MD] orders for [Resident C on March 29, 2018], I carried it out, I did not put a stop date, I went ahead and faxed it to the pharmacy . . . they never received the order." When asked how did she know the pharmacy never received the order, she stated that she was told on Monday, April 2, 2018. LVN 1 further stated that the KCL order was written for every four hours x 3 doses, and when asked to explain what happened, LVN 1 stated she transcribed the order as TID (three times a day). LVN 1 in explaining her role as a desk LVN, stated, ". . . but me as a nurse [Charge Nurse], I would have double checked just because it was KCL, and the protocol should have been to look at the labs to see the results." LVN 1 stated that the pharmacy confirmation [of the new order] was not in the folder, "but nobody brought it up the next day." LVN 1 was asked where the nurses obtained the KCL liquid that had been administered to Resident C if the pharmacy had not delivered any KCL. LVN 1 stated, "We don't have it in the e-kit (emergency kit- a supply of back up medications), the first dose was a tablet, I don't know what happened after that." A telephone interview was conducted with the DON on June 27, 2018 at 3:00 PM. She stated the order was faxed to the pharmacy and, "We had the KCL liquid delivered on April 2, 2018." When asked to clarify if no KCL liquid had been delivered for Resident C, where was the medication obtained, the DON stated, ". . . a different resident who is on the liquid [KCL]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE When asked if this was the facility's protocol if the nurse does not have the medication the physician ordered, she stated, "No, that is not our normal protocol." In addition, the DON stated, "The protocol is that the nurse who is obtaining the order from the doctor, they have to enter the order on the PCC [MAR] program." The DON stated that the order was not confirmed by the nurse administering the medication. When asked about the KCL 60 meq liquid continuing to be given TID, along with KCL 40 meq liquid daily, the DON stated that the nurses should look at the high alert [medication most likely to cause significant harm] of the medication, not just the schedule [administration times]. During an telephone interview with RN 1 on June 28, 2018 at 2:40 PM, he was asked to describe what happened before Resident C was sent out to the acute care hospital. RN 1 stated, "From what I can remember, the pt [patient-Resident C] complained of SOB (shortness of breath, [the] Charge Nurse administered O2 [oxygen], she [Resident C] was still talking, stated she was having trouble breathing and said she was having palpitations (a noticeably strong rapid heart rate). I went through her chart and noticed the orders, saw she was on multiple orders of KCL . . . noticed a discrepancy of the daily order for potassium and contacted the MD on call. RN 1 stated that after speaking with the MD on call, he called 911 emergency and when the paramedics arrived, "[I] told the paramedics that Resident C may be possible KCL overload, they saw that her heart rate was a little off, and said it may be due to the extra K+, and took her immediately." RN 1 continued, "The SOB (shortness of breath) and the decompensation was something new for her." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE When asked did the nurses recap (recapitulatechecking the new orders for correctness) physician's orders at night, he stated, "Because of this, we have gone back to checking the orders at night." A review of the facility's procedure titled, "Charge Nurse" (not dated) [received June 28, 2018 from the DON] The policy set forth: "Drug Administrative Functions . . . Ensure that prescribed medication for one resident is not administered to another. Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. A review of the facility's job description titled, "Registered Nurse" (not dated) [received June 28, 2018 from the DON]. The policy set forth: "Drug Administrative Functions . . . Ensure that prescribed medication for one resident is not administered to another. Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies." A review of the facility's policy/procedure titled, "Physician Orders," (Revised May 2015). The policy set froth: "3. When transcribing orders nurse must verify the order given to avoid errors." A review of the facility's policy/procedure titled, "Medication Administration," (Revised November 2017) set forth: "17. If there is a question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of a document entitled, "Nursing Home to Hospital Transfer Form," for Resident C, dated April 2, 2018 at 03:04 AM, occurred. The document noted reason for transfer of Resident C as follows: "Shortness of Breath (bronchitis, pneumonia). Also, vital signs (clinical measurement of a patient's essential functions) at transfer were documented as follows: blood pressure 98/64 (normal 120/80), heart rate 99 (normal 60-100 beats per minute), respiratory rate 20 (normal 12-20), temperature 96.7, O2 SAT 94% on oxygen at 3L (liters). The acute care hospital's Emergency Room (ER) physician's notes for Resident C dated April 2, 2018 at 02:59 AM, set forth: "Chief Compliant: Patient presents for evaluation of shortness of breath." Resident C's vital signs were recorded at 03:07 AM as follows: BP (blood pressure) 168/83, pulse 118 (rapid), respiration rate 43 (fast), temperature 97.4. Resident C's 12 lead EKG (electrocardiogramrecords the electrical activity of the heart) physician interpretation, dated April 2, 2018 at 03:09 AM, "shows atrial fibrillation with rapid ventricular response (rapid & irregular), Rate (beats per minute): 108, . . . Clinical impression: abnormal EKG." Resident C's laboratory data on April 2, 2018 at 03:31 AM, set forth the following: White blood count [WBC] 20.8 H (highleukocytosis indicates an infection or a reaction to a drug) (normal 4.0-8.6). Potassium [K+] 8.5 H (high-hyperkalemia can cause suppression of electrical activity of the heart and cause the heart to stop beating, as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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 normal K+ levels maintain the heart's electrical rhythm) (normal 3.3-5.2). GFR [glomerular filtration rate] 35 L (low-a test to check how well the kidneys are working) (normal >=60). The ER physician's progress note dated April 2, 2018 set forth: "Discusses plan for calcium (IV-intravenous for hyperkalemia) and sodium bicarb (IV-for kidneys) intervention with family ... Dr. re-checks on pt, and discusses results indicating hyperkalemia and plan for breathing treatment and Lasix (diuretic medicine) intervention ... pt has become bradycardic (slow heart rate) at 10 bpm (beats per minute), explains to family will proceed with sodium bicarb and calcium chloride intervention. Despite intervention, time of death at 0525 (AM)." The physician notes dated April 2, 2018 set forth the following: "Attending [Physician] Note: . . .88-year-old female, DO NOT RESUSCITATE, comfort measure, presents with shortness of breath. Was noted to be profoundly bradycardic. Cardiac monitor showed a wide-complex bradycardia. My initial suspicion was related to hyperkalemia. Was given calcium, sodium bicarbonate empirically (based on observation and experience). This immediately improved her heart rate to above 100 and an irregular wide-complex rhythm. . . . Laboratory results confirmed hyperkalemia greater than 8. Renal function was mildly abnormal but her GFR was 35 with a creatinine of 1.4 (normal -blood levels measure kidney function). Her son arrived to the ER and supplied additional history. She was recently discharged and transferred to the rehabilitation from [name] hospital. Apparently, she had a laboratory study showing hypokalemia (low potassium) and they were supplementing her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055374 (X3) DATE SURVEY COMPLETED 11/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UPLAND REHABILITATION AND CARE CENTER 1221 E Arrow Hwy Upland, CA 91786 (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 with oral potassium. This would explain the severe hyperkalemia in the setting of her mild to moderate renal dysfunction." "Diagnosis Final: Primary: Hyperkalemia, Additional: Acute Respiratory Fail (failure) W/Hypoxia (with-oxygen deficiency), Cardiac Arrest (sudden cessation of heart function)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G2YP11 Facility ID: CA240000289 If continuation sheet 11 of 11