California Post Acute

F-F641

Findings:

During a review of Resident 1's admission record, dated 8/1/2024, indicated Resident 1 was admitted on [DATE REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 055461

F-F656

Findings:

During a review of Resident 1's Admission Record, dated 8/1/2024, indicated Resident 1 was admitted to the facility on [DATE REDACTED], 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 055461 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50296

Residents Affected - Few Based on interview and record review, the facility failed to ensure care plan was developed for one of three sample residents (Resident 1) addressing the resident's 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).

This failure had the potential to cause Resident 1 to experience worsening vision.

Cross referenced with