Camino Healthcare

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had a comprehensive care plan in place to include in and out self-catheterization (a procedure where a thin tube (catheter) is temporarily inserted into the bladder to drain urine, then immediately removed). This deficient practice placed Resident 1 at risk for insufficient care and services related to self-catheterization.Findings:

During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE REDACTED] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025,

the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order to allow for in and out selfcatheterization. During a concurrent interview and record review on 9/9/2025 at 11:50 a.m. with the Minimum Data Set Nurse (MDSN), Resident 1's Care Plan and Order Summary Report was reviewed. The MDSN reviewed Resident 1's Order Summary Report and stated Resident 1 had an order to self-catheterize himself and Resident 1 should have a care plan to reflect that. The MDSN reviewed Resident 1's care plan and stated Resident 1 did not have a care plan for in and out self-catheterization and was important to have one to identify the needs of Resident 1 and to guide their care. During a review of the facility's policy and procedure (P&P) titled Care Planning, dated 1/2021, the P&P indicated the interdisciplinary team (IDT- ) shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Camino Healthcare

13922 Cerise Avenue Hawthorne, CA 90250

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) received their medication while being out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice resulted in Resident 1 not taking his prescribed antibiotics when it was due and could potentially lead to complications.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE REDACTED] with diagnoses that included fracture of the vertebra (one of

the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a

review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order for cephalexin (an antibiotic, a medicine that kills bacteria) 500 milligrams (mg- unit of measurement) to be taken four times a day by mouth for a urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1's Medication Administration Record (MAR) dated 8/2025, the MAR indicated Resident 1 did not receive cephalexin on 8/20/2025 at 5 p.m., 8/21/2025 at 1 p.m. and 5 p.m., and on 8/22/2025 at 5 p.m. and 9 p.m. because he was out of the facility. During a concurrent interview and record review on 9/10/2025 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's MAR was reviewed. LVN 2 stated if a resident was to go out on pass and there were important medications due, the nurse would have to notify the doctor to obtain an order to allow the resident to take

the medication while they are away from the facility. LVN 2 stated education would be given to the resident or their representative on how to take the medication. When the resident takes the medication while away from the facility, the MAR has an option for the nurse to select that the resident took the medication while

they were away on pass. LVN 2 reviewed Resident 1's MAR for the month of August and stated the cephalexin was not given at the scheduled times because Resident 1 was out of the facility. LVN 2 further stated it was important to take antibiotics when they are scheduled because you want the bacteria to be killed and the infection to be gone. During a review of the facility's policy and procedure (P&P) titled Out on Pass or Leave of Absence, dated 12/2023, the P&P indicated if applicable, resident medications will be dispensed and explained to the resident representative to include instructions on when and how the medications are to be taken.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Camino Healthcare

13922 Cerise Avenue Hawthorne, CA 90250

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) temperature was reassessed after acetaminophen (a fever reducing medicine) was given. This deficient practice had the potential for nursing staff to delay care for Resident 1 if a given intervention was not effective.Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE REDACTED] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate). During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility. During a review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order for acetaminophen 650 milligrams (mg- unit of measurement) every 6 hours as needed for pain or fever. During a review of Resident 1's Medication Administration Record (MAR), dated 8/2025, the MAR indicated Resident 1 received acetaminophen on 8/16/2025 at 8:05 a.m. for a fever of 102.7 Fahrenheit (F- unit for temperature) and at 4:48 p.m. for a fever of 103.2 F. During a review of Resident 1's Progress Notes dated 8/16/2025, the Progress Notes did not show any documentation for Resident 1's temperature after acetaminophen was given. During a review of Resident 1's Temperature Vital Signs dated 8/16/2025, the Temperature Vitals Signs did now show any documentation for Resident 1's temperature after acetaminophen was given.

During a concurrent interview and record review on 9/9/2025 at 2:11p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's MAR, Temperature Vital Signs, and Progress Notes were reviewed. LVN 1 reviewed Resident 1's MAR and stated acetaminophen was given twice on 8/16/2025 for fever and pain. LVN 1 stated after administering the medication, nursing staff should reassess the temperature for effectiveness and doing so was important because it would tell you if the intervention worked or not, if it did not, other interventions could be used, or staff could also call to notify the doctor for further interventions. LVN 1 reviewed Resident 1's Temperature Vitals Signs dated 8/16/2025, and Progress notes dated 8/16/2025 and stated Resident 1's temperature was not reassessed after given acetaminophen. During a review of the facility's policy and procedure (P&P) titled Administration of Drugs dated 5/2020, the P&P indicated when as needed medications are administered, the nurse must record any results achieved from administering

the drug and the time such results were observed

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Camino Healthcare

13922 Cerise Avenue Hawthorne, CA 90250

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure accurate and complete documentation was done for one of one sampled resident (Resident 1) when going out of the facility on pass (permission to be able to leave the facility temporarily). This deficient practice had the potential for facility staff to not be aware of where a resident was when they were out of the facility.Findings:During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE REDACTED] with diagnoses that included fracture of the vertebra (one of the bones that make up the spinal column), paraplegia, and retention of urine (unable to urinate).During a review of Resident 1's History and Physical (H&P), dated 4/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/15/2025, the MDS indicated Resident 1 was able to make himself understood and had the ability to understand others. The MDS further indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn), had no impairment to the upper and lower extremities (pertaining to the arms and legs), and used a wheelchair for mobility.During a

review of Resident 1's Order Summary Report, dated 9/10/2025, the Order Summary Report indicated Resident 1 had an order to go out on pass on 8/22/2025.During a review of Resident 1's Progress Notes, dated 8/22/2025 at 11:31 p.m., the Progress Notes indicated Resident 1 went out on pass earlier in the day, and no further documentation was seen earlier in the day when Resident 1 went out on pass.During a concurrent interview and record review on 9/9/2025 at 2:11 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes were reviewed. LVN 1 stated when a resident goes out of the facility on pass,

they would require the resident to sign out on the out on pass binder which should include the date and time of when they left the facility and when they came back. The staff would also need to ask and document where the resident would be going and about how long they would be away so the next staff member would have that information if the resident did not return in the specified time and be able to notify the doctor and

the resident's emergency contact. LVN 1 reviewed Resident 1's Progress Notes and out on pass binder and stated there was no documentation to show when Resident 1 left the facility, what time he was expected to be back and where he went to.During a review of the facility's policy and procedure (P&P) titled Out on Pass or Leave of Absence, dated 12/2023, the P&P indicated nursing, or designee will document when the resident leaves and returns, including any instructions given upon leaving, pertinent information regarding their return or events which took place while on leave. Information included may include date, time and with whom the resident left and returned to facility, medications provided, equipment loaned and quantities, location where resident will be over the course of the leave, general condition of the resident on return, changes or incidents experienced during leave, unused medications or supplies, and other significant information.

Event ID:

Facility ID:

If continuation sheet