Artesia Christian Home Inc.

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) belongings were safe.This deficient practice resulted in Resident 1 jewelry being lost.Findings:During a

review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a concurrent interview and record review on 11/26/2025 at 1:17 p.m., with the Associate Director of Social Services (ADSS), Resident 1's Resident Inventory List, signed and dated 6/20/2023, was reviewed. The ADSS stated, the list indicated Resident 1 had a necklace with a heart [NAME]. The ADSS stated Resident 1's necklace listed in the inventory list was lost. The ADSS stated it was of sentimental value because Resident 1 has had it since she graduated from high school.During an interview on 11/26/2025 at 2:27 p.m., with the ADSS, the ADSS stated residents should not lose their personal belongings in the facility.

During a review of the facility's policy titled, Theft and Loss, revised 01/2025, the policy indicated the following: a) It was the policy of the facility to protect and safeguard the belongings of its residents. b) Upon admission all valuables of the resident will be labeled and will be listed on the resident personal property and inventory list. c) Items of value brought to or removed from the facility shall be added or deleted from

the inventory list by facility representatives at the time item is brought in or taken. Facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory.During a review of the facility's policy titled, Resident Rights, revised 12/2016,

the policy indicated residents have the right to retain and use personal possessions to the maximum extent that space and safety permit.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Artesia Christian Home Inc.

11614 E. 183rd St Artesia, CA 90701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to serve requested menu items to one of three sampled residents (Resident 1).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 1's admission Record, the admission

Record indicated Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia (a progressive state of decline in mental abilities), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS indicated Resident 1 had moderately impaired cognition (how we think, learn and remember). The MDS indicated Resident 1 needed set-up assistance when eating.During a review of Resident 1's General Order, dated 9/18/2023, the order indicated a diet order for Regular Diet, ground meat only with thin liquids.During a concurrent observation and interview on 11/26/2025 at 12:16 p.m., in the Dining Room, with the Director of Staff Development (DSD), there were no coleslaw and roasted vegetables observed on Resident 1's plate. The DSD stated there was no coleslaw and roasted vegetables on Residents 1's plate. During an interview and record

review on 11/26/2025 at 12:16 p.m., with the DSD, Resident 1's Diet Ticket, dated 11/26/2025 printed at 11:51 a.m., was reviewed and the ticket indicated Resident 1 ordered Jicama Coleslaw and Balsamic Oregano roasted Vegetables. The DSD stated the staff ask the residents what they want to eat, and the resident preferences were indicated in the diet tickets, so they need to be served as requested. The DSD stated Resident 1 should have been served coleslaw and roasted vegetables.During a telephone interview

on 11/26/2025 at 1:01 p.m., with the Registered Dietician (RD), the RD stated food items on the Diet Ticket reflect resident preferences and need to be served to the residents.During a review of the facility's policy titled, Resident Meal Service, revised 01/2025, the policy indicated residents will be offered menu choices for all meals, beverages, and snacks and are based on their prescribed diet and food preferences. The policy indicated menu served will be honoring residents' rights.

Event ID:

Facility ID:

If continuation sheet