California Post-acute Care

F-F609.

Findings:

During a review of Resident 103's Admission Record (Face Sheet), the Face Sheet indicated Resident 103 was admitted to the facility on [DATE REDACTED] with diagnoses that included epilepsy (a chronic brain disorder that causes seizures), muscle weakness (when muscles do not have the strength they normally do), and hypertension (high blood pressure).

During a review of Resident 103's Minimum Data Set ([MDS], a resident assessment tool), dated 1/31/2025,

the MDS indicated Resident 103's cognition (process of thinking) was intact. The MDS indicated Resident 103 required set up or clean-up assistance with eating, oral hygiene, and upper body dressing.

During a review of Resident 103's History and Physical (H&P), dated 1/26/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions.

During a review of Resident 103's Progress Note, dated 2/26/2025 and timed at 8:06 p.m., the Progress Note indicated on 2/26/2025, Resident 103 called the police because she feels unsafe here. The Progress Note indicated a certified nursing assistant (CAN) was in her face while lying in bed.

During an interview on 11:59 a.m., with Resident 103, Resident 103 stated CNA 1 was very prejudice (feeling unfavorable toward a person) against her and CNA 1 made her feel unsafe in the facility. Resident 103 stated she informed the registered nurse (RN) on duty of her feelings.

During an interview on 2/27/2025 at 12:47 p.m., with RN 1, RN 1 stated Resident 103 told her, That lady threatening, referring to CNA 1. RN 1 stated Resident 103 did not elaborate how CNA 1 threatened her, only that Resident 103 stated, I do not feel safe. RN 1 stated the Director of Nursing (DON) and Administrator (ADM) were made aware of Resident 103's allegation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 055052 Department of Health & Human Services Printed: 09/07/2025 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 055052 B. Wing 02/28/2025

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

California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

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 0610 During an interview on 2/27/2025 at 1:40 p.m., with the DON, the DON stated she was made aware of Resident 103's statement to RN 1 of feeling unsafe in the facility. The DON stated she interviewed Resident Level of Harm - Minimal harm or 103 who stated, The CNA was in my face and was being smart with me and that Resident 103 called the potential for actual harm police because she felt unsafe. The DON stated she interviewed Resident 103's roommate, who was a witness to the interaction between Resident 103 and CNA 1. The DON stated based on Resident 103's Residents Affected - Few roommate's statement, she determined it was a misunderstanding. The DON stated although she did an initial investigation to ensure Resident 103 was safe, a thorough investigation by the Administrator had to be conducted to ensure Resident 103's and other resident's safety. The DON stated when an abuse allegation was made against a staff member in the facility, that staff member had to leave the facility immediately and suspended for the duration of the investigation. The DON stated CNA 1 worked the rest of her shift on 2/26/2025 and was not suspended.

During an interview on 2/27/2025 at 2:12 p.m., with the ADM, the ADM stated he was aware there was an exchange of words between Resident 103 and CNA 1 but determined there were no threats made after Resident 103's roommate was interviewed. The ADM stated he was unaware that Resident 103 stated she felt unsafe. The ADM stated CNA 1 should not have been allowed to finish her shift on 2/26/2025 and should have been sent home after the facility gained knowledge of Resident 103's allegation. The ADM stated suspending CNA 1, while the facility conducted a thorough investigation, would ensure no other potential abuse could occur by CNA 1, if CNA 1 was found to be at fault. The ADM stated although Resident 103 was moved to a different room and did not have further contact with CNA 1, allowing CNA 1 to continue working put other residents in her care at risk for abuse.

During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated, The facility will protect the resident from further harm during the investigation period . The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 055052

F-F610.

Findings:

1a. During a review of Resident 18's Admission Record (Face Sheet), the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 18's Minimum Data Set ([MDS], a resident assessment tool), dated 1/9/2025,

the MDS indicated Resident 18's cognition (process of thinking) was severely impaired. The MDS indicated Resident 18 required moderate assistance (helper does less than half the effort) with toileting, bathing, dressing, and personal hygiene.

During a review of Resident 18's History and Physical (H&P), dated 1/8/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions.

During a review of Resident 18's Progress Note, dated 2/26/2025 and timed at 6:20 p.m., the Progress Note indicated Resident 18 was making bad comments to her roommate.

1b. During a review of Resident 103's Admission Record (Face Sheet), the Face Sheet indicated Resident 103 was admitted to the facility on [DATE REDACTED] with diagnoses that included epilepsy (a chronic brain disorder that causes seizures), muscle weakness (when muscles do not have the strength they normally do), and hypertension (high blood pressure).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 055052 Department of Health & Human Services Printed: 09/07/2025 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 055052 B. Wing 02/28/2025

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

California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

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 0609 During a review of Resident 103's MDS, dated [DATE REDACTED], the MDS indicated Resident 103's cognition was intact. The MDS indicated Resident 103 required set up or clean-up assistance with eating, oral hygiene, and Level of Harm - Minimal harm or upper body dressing. potential for actual harm

During a review of Resident 103's H&P, dated 1/26/2025, the H&P indicated Resident 103 had the capacity Residents Affected - Few to understand and make decisions.

During a review of Resident 103's Progress Note, dated 2/6/2025 and timed at 5:20 p.m., the Progress Note indicated on 2/6/20205, Resident 18 spoke bad words to Resident 103 and Resident 103 responded to Resident 18 that she will F [Resident 18] up if [Resident 18] will not stop talking.

During an interview on 2/27/2025 at 12:36 a.m., with Registered Nurse (RN) 1, RN 1 stated on 2/26/2025,

she was informed of the verbal altercation between Resident 18 and Resident 103. RN 1 stated she informed

the DON and the Administrator (ADM).

During an interview on 2/27/2025 at 2:07 p.m., with the ADM, the ADM stated when there was knowledge of

an abuse allegation or altercation had to be reported to the State Agency, the ombudsman, and law enforcement within two hours. The ADM stated he was aware of the verbal altercation between Resident 18 and Resident 103 but did not know Resident 103 stated, I will F you up to Resident 18. The ADM stated the altercation was not reported because he thought the altercation was a simple argument and was not aware any threats were made. The ADM stated due to Resident 103's verbal threat towards Resident 18, the altercation should have been reported.

2. During a review of Resident 103's Progress Note, dated 2/26/2025 and timed at 8:06 p.m., the Progress Note indicated on 2/26/2025, Resident 103 called the police because she feels unsafe here. The Progress Note indicated a CNA was in her face while lying in bed.

During an interview on 11:59 a.m., with Resident 103, Resident 103 stated CNA 1 was very prejudice (feeling unfavorable toward a person) against her and CNA 1 made her feel unsafe in the facility. Resident 103 stated she informed the RN on duty of her feelings.

During an interview on 2/27/2025 at 12:47 p.m., with RN 1, RN 1 stated Resident 103 told her, that lady threatening, as she referred to CNA 1. RN 1 stated Resident 103 did not elaborate how CNA 1 threatened her, only that Resident 103 stated, I do not feel safe. RN 1 stated the DON and ADM were made aware of Resident 103's allegation.

During an interview on 2/27/2025 at 1:40 p.m., with the DON, the DON stated she was made aware of Resident 103's statement to RN 1 of feeling unsafe in the facility. The DON stated she interviewed Resident 103 who stated, The CNA was in my face and was being smart with me and that Resident 103 called the police because she felt unsafe in the facility. The DON stated she interviewed Resident 103's roommate, who was a witness to the interaction between Resident 103 and CNA 1. The DON stated based on Resident 103's roommate's statement, she determined it was a misunderstanding and did not need to be reported.

The DON stated the facility was required to report all abuse allegations, whether the reporter believes the allegation was true or false. The DON stated Resident 103's allegation should have been reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 055052 Department of Health & Human Services Printed: 09/07/2025 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 055052 B. Wing 02/28/2025

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

California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

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 0609 During an interview on 2/27/2025 at 2:12 p.m., with the ADM, the ADM stated he was aware there was an exchange of words between Resident 103 and CNA 1 but determined there were no threats made after Level of Harm - Minimal harm or Resident 103's roommate was interviewed. The ADM stated he was unaware Resident 103 stated she felt potential for actual harm unsafe in the facility. The ADM stated Resident 103's allegation and statement of feeling unsafe in the facility should have been reported to the State Agency, the ombudsman, and law enforcement to ensure notification Residents Affected - Few and to ensure an onsite inspection was conducted.

During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated all alleged violations regarding suspected or alleged abuse were to be reported, no later than two hours to the State Agency, the ombudsman, and law enforcement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 055052 Department of Health & Human Services Printed: 09/07/2025 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 055052 B. Wing 02/28/2025

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

California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

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 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679 potential for actual harm Based on interview and record review, the facility failed to implement interventions to prevent further Residents Affected - Few potential abuse for one of three sampled residents (Resident 103) when Resident 103 informed the Director of Nursing (DON), on 2/26/2025, that Certified Nursing Assistant (CNA) 1, made her feel unsafe in the facility.

This deficient practice resulted in CNA 1 not being suspended for the rest of her shift, which put Resident 103 and the other residents in the facility at risk of further potential abuse.

Cross Reference