Lawndale Healthcare & Wellness Centre Llc

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice

before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to: 1.Ensure a written room change with a reason was provided for one of 4 sampled residents (Resident 1). This deficient practice resulted in Resident 1 losing his bed while in the hospital.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 initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's history and physical (H&P), dated 8/28/2025, the H&P indicated Resident 1 did not have the capacity to make decisions and was unable to make his needs known. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/2/2025, the MDS indicated Resident 1 was cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Change of Condition (COC) form, dated 9/2/2025, the COC indicated Resident 1 was transferred to the general acute care hospital (GACH) due to persistent cough, increased secretions despite receiving intravenous (IV) antibiotic treatment for pneumonia. During a review of the facility's census, dated 9/3/2025, the census showed Resident 1's bed was occupied by another resident. During a concurrent interview and record review, on 9/10/2025 at 10:23 a.m., with the Director of Nursing (DON), the DON reviewed the census for 9/2/2025 and 9/3/2025. The DON stated Resident 1 was transferred to the hospital on 9/2/2025 and on 9/3/2025, Resident 1's bed was occupied by another resident due to a room change. The DON stated she did not know why a room change occurred. The DON stated, This should not have happened. The DON stated the risk of conducting a room change when a resident is transferred to the hospital could result in a resident losing their bed. During a review of the facility's policy and procedures (P&P), titled Room or Roommate Change, revised 3/2019, the P&P indicated, Prior to changing a room or roommate assignment,

the resident, the resident's representative (if available), and the resident's new roommate will be provided timely advance notice of such a change. and The notice of a change in room or roommate assignment must be in writing and will be given the reason(s) for such change.

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

Lawndale Healthcare & Wellness Centre LLC

15100 S Prairie Lawndale, CA 90260

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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

would not be returning. The RM stated the risk f not readmitting a resident could result in, I don't know, I just know it's not something I've done before so I wouldn't know what the risk are. During a concurrent interview and record review, on 9/10/2025 at 10:23 a.m., with the Director of Nursing (DON), the DON stated the protocol for readmitting a resident required her (the DON) to be notified if a resident was to be readmitted to

the facility by the AC and RM. The DON stated she was not aware of Resident 1 being denied readmission to the facility. The DON reviewed the census for 9/2/2025-9/3/2025 and stated Resident 1 was transferred to

the hospital on 9/2/2025. The DON stated on 9/3/2025, Resident 1's bed was occupied by another resident.

The DON stated Resident 1's bed hold was not honored. The DON stated the risk of not readmitting a resident could result in a resident's rights issue. The DON stated, It is a resident's right to want to come back to their home. During an interview, on 9/10/2025 at 11:00 a.m., with the Administrator (Admin), the admin stated he was informed by the facility's RM and Resident 1's doctor that Resident 1 would not be returning to the facility per Resident 1's PG. The admin stated bed holds are honored for 7 days. The admin stated the risk of not readmitting a resident could result in a lack of patient care causing a resident to be stranded in a hospital. During an interview, on 9/10/2025 at 11:33 a.m., with Resident 1's PG, Resident 1's PG stated she was informed by the GACH SW that Resident 1 could not return to the facility due to her stating she did not want Resident 1 to return. Resident 1's PG stated she never said that. Resident 1's PG stated the facility had given Resident 1's bed away. Resident 1's PG stated she called the RM and told her

she never said Resident 1 could not return to the facility. Resident 1's PG stated Resident 1 should have been able to return to the facility. Resident 1's PG stated the facility did not honor Resident 1's bed hold.

During a review of the facility's policy and procedures (P&P), titled Readmission, revised 10/2013, the P&P indicated The Facility will allow residents who were previously residents of the Facility to be readmitted to

the Facility.

Event ID:

Facility ID:

If continuation sheet