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Complaint Investigation

California Post Acute

August 1, 2024 · Los Angeles, CA · 909 S Lake Street
Citations 5
CMS Rating 1/5
Beds 66
Provider ID 055461
Healthcare Facility
California Post Acute
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

CALIFORNIA POST ACUTE in LOS ANGELES, CA — inspection on August 1, 2024.

Found 5 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0558
Reasonably accommodate the needs and preferences of each resident.

During a review of Resident 1's admission Record, dated 8/1/2024, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease).

During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 had adequate vision and did not wear corrective lenses.

During an observation on 8/1/2024 at 10:28 a.m. in Resident 1's room, Resident 1 ' s bed control hanging off right side of the bed, call light tangled with phone charger, both are hanging off left side of the bed. Resident 1 was unable to reach either.

During an interview on 8/1/2024 at 11:30 a.m. with Certified Nurse Assistant (CNA 1), CNA 1 stated, the call light placed within reach either by a resident ' s hand or close to them. If a resident has a vision issue, CNA 1 will instruct that the call light is on their right or left side. CNA 1 stated the importance of placing the call light within reach is so residents can get assistance. CNA 1 stated Resident 1, can see and has glasses but not sure if the glasses were prescribed.

During concurrent interview and record review on 8/1/2024 at 11:37 a.m. with Assistant Director of Nursing (ADON), Resident 1's MDS, diagnosis, and care plan reviewed.

The ADON confirmed and stated Resident 1 had a diagnosis of glaucoma, and thta the resident's MDS and care plan did not address the resident's diagnosis. ADON stated Resident 1, is not blind, he can see. ADON stated if Resident 1 cannot see call light, cannot call for assistance. ADON stated the facility's policy on call light indicated the call light must be within reach of the resident.

During a record review of the facility's policy and procedures titled, Communication System - Call lights, dated 2024, the P&P indicated, call cords will be placed within the resident's reach in the resident's room.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

055461 08/01/2024

California Post Acute 909 S Lake Street Los Angeles, CA 90006

During a review of Resident 1's admission Record, dated 8/1/2024, indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease).

During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 had adequate vision and did not wear corrective lenses.

During concurrent interview and record review on 8/1/2024 at 11:22 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 1 ' s MDS, diagnoses, and care plan and confirmed Resident 1 had a diagnosis of glaucoma.

TheMDSN confirmed the resident's MDS and care plan did not address the diagnosis.

The MDSN stated the resident was at risk for injury and weight loss due to not seeing food, and would not reach the call light.

During a record review of the facility's policy and procedures (P&P) titled, Comprehensive Assessments, dated 2024, the P&P indicated, Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate). (1) Determine Care Area Assessments (CAAs - foundation upon which a resident ' s individual care plan is formulated) that have been triggered during completion of the MDS; and (2) Expanding on the triggered CAAs and the data gathered in Step 1, begin to define problems and symptoms within the context of the overall clinical picture.

During a record review of the facility's P&P titled, Comprehensive Assessments, dated 2024, the P&P indicated, Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals.

055461 08/01/2024

California Post Acute 909 S Lake Street Los Angeles, CA 90006

During a review of Resident 1's admission record, dated 8/1/2024, indicated Resident 1 was admitted on [DATE], with a diagnosis of glaucoma, bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and paraplegia (inability to deliberately control or move your muscles of the legs and lower body, typically caused by spinal injury or disease).

During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 has adequate vision and does not wear corrective lenses.

During concurrent interview and record review on 8/1/2024 at 11:22 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 1's MDS, diagnoses, and care plan and confirmed Resident 1 had a diagnosis of glaucoma.

The MDSN confirmed the MDS and care plan did not address the diagnosis.

The MDSN stated the risk to the resident is injury, resident cannot reach call light, weight loss due to not seeing food.

During a record review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, dated 2024, indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making.

During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 has adequate vision and does not wear corrective lenses.

During concurrent interview and record review on 8/1/2024 at 11:22 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 1's MDS, diagnoses, and care plan and confirmed Resident 1 had a diagnosis of glaucoma.

The MDSN confirmed the MDS and care plan did not address the diagnosis.

The MDSN stated the risk to the resident is injury, resident cannot reach call light, weight loss due to not seeing food.

During a record review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, dated 2024, indicated, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making.

055461

During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) indicated Resident 1 had adequate vision and did not wear corrective lenses.

During concurrent interview and record review on 8/1/2024 at 11:22 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 1 ' s MDS, diagnoses, and care plan and confirmed Resident 1 had a diagnosis of glaucoma.

TheMDSN confirmed the resident's MDS and care plan did not address the diagnosis.

The MDSN stated the resident was at risk for injury and weight loss due to not seeing food, and would not reach the call light.

During a record review of the facility's policy and procedures (P&P) titled, Comprehensive Assessments, dated 2024, the P&P indicated, Define issues, including problems, risk factors, and other concerns (to which all disciplines can relate). (1)

Determine Care Area Assessments (CAAs - foundation upon which a resident ' s individual care plan is formulated) that have been triggered during completion of the MDS; and (2) Expanding on the triggered CAAs and the data gathered in Step 1, begin to define problems and symptoms within the context of the overall clinical picture.

During a record review of the facility's P&P titled, Comprehensive Assessments, dated 2024, the P&P indicated, Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals.

055461

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055461 B.

Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

California Post Acute 909 S Lake Street Los Angeles, CA 90006

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CALIFORNIA POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.