California Post-acute Care
CALIFORNIA POST-ACUTE CARE in LYNWOOD, CA — inspection on February 28, 2025.
Found 33 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
During an interview on 2/28/2025 at 8:32 a.m., with the Director of Nursing (DON), the DON stated after the breakfast trays were distributed and all the residents were assisted with feeding, the CNAs were responsible for removing breakfast trays if the resident was done eating.
The DON stated breakfast trays should not be left in the residents' rooms until the next mealtime.
The DON stated Resident 99 should have been asked if his breakfast tray could be removed from his room.
The DON stated leaving the breakfast tray could cause Resident 99 to feel unattended and frustrated the tray was taking up space on the bedside table which could be used for something else in his routine.
During a review of the facility's policy and procedure (P&P) titled, Assisting the Impaired Patients with In-Room Meals, dated 4/2018, the P&P indicated, Remove the tray when the patient has finished his or her meal.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an interview on 2/28/2025 at 8:38 a.m., with the Director of Nursing (DON), the DON stated once the order for Trazodone and Seroquel for Resident 81 were received, the licensed nurse was responsible for verifying that Resident 81 consented to receive those medications.
The DON stated verifying informed consent with Resident 81 would indicate Resident 81 understood the indication for the medications, the side effects, and the risks.
The DON stated Resident 81 should have been given the opportunity to exercise his right to make an informed decision regarding his care.
During a review of the facility's policy and procedure (P&P) titled, Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated, Informed consent will be obtained from the resident, who has decisional capacity, whenever psychoactive medications are prescribed, ordered, or when orders are increased by the physician.
Informed consent will either be noted in the physician order for the psychoactive medication, on the appropriate consent form, or documented elsewhere in the medical records.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
directives and a copy of this policy.
The P&P indicated the facility will inquire at the time of admission
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an interview on 2/28/2025 at 1:46 p.m. with RP 1, RP 1 stated the MDS Nurse (MDSN) left a voicemail on her phone around 1:00 p.m. on 2/28/2025 informing her an incident occurred on Sunday (2/23/2025). RP 1 stated she was never made aware any incidents that occurred on 2/23/2025.
During an interview on 2/28/2025 at 2:00 p.m. with the MDSN, the MDSN stated she attempted to call RP 1 to inform her of Resident 97's elopement attempt and left a voicemail on 2/28/2025.
The MDSN stated RP 1 should have been notified on 2/23/2025 of Resident 97's elopement attempt because it was RP 1's right to be informed of any incidents regarding RP 1's father.
- During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast
pace in the hallway with a razor in his right hand, unsupervised.
During an interview on 2/27/2025 at 3:37 p.m. with LVN 1, LVN 1 stated he was the assigned LVN for Resident 97 on the 3 p.m. to 11 p.m. shift on 2/24/2025 and witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025. LVN 1 stated the physician and RP 1 were to be made aware of any changes in the physical or mental condition for a resident. LVN 1 stated he should have made RP 1 and Resident 97's physician aware Resident 97 obtained a used razor without facility knowledge, but did not have time during the shift to do so. LVN 1 stated it was RP 1's right to be informed of any changes that occurred for Resident 97. LVN 1 stated he should have made Resident 97's physician aware so he could have obtained an order for one-to-one supervision for Resident 97 or received orders to further address Resident 97's behaviors. LVN 1 stated this resulted in Resident 97 obtaining a razor again on 2/25/2025.
During an interview on 2/28/2025 at 1:46 p.m. with RP 1, RP 1 stated she was not aware Resident 97 obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025.
During a review of the facility's Policy and Procedure (P&P) titled Change of Condition dated 8/2017, the P&P indicated the facility would promptly notify the resident, his or her attending physician, and representative of changes in residents medical/mental condition and/or status.
The P&P indicated the license nurse would document in the nurses' notes information relative to changes in the resident's medical/mental condition or status.
During a review of the facility's P&P titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated, All reports of suspected abuse will also be reported to the resident's family and attending physician.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
Policy, dated 6/2022, the P&P indicated all alleged violations regarding suspected or alleged abuse
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
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.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of Resident 115's admission Record, the admission record indicated Resident 115 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness (a decreased ability of muscles to contract and generate force), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and abnormalities of gait and mobility (changes in walking or movement that can occur due to a number of possible causes).
During a review of Resident 115's Minimum Data Set (MDS- a resident assessment tool), dated 11/19/2024, indicated Resident 115's cognitive skills was intact (ability to think and reason).
The MDS also indicated Resident 115 required setup assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of the facility's residents smoking list, the smoking list indicated Resident 115 smoked cigarettes.
During a review of Resident 115's medical chart, the medical chart indicated there was no smoking assessment.
During an observation, on 2/26/2025, at 10:01 a.m., Resident 115 was observed smoking with four other residents on the smoking patio. Resident 115 was observed not wearing a smoking apron.
During an interview, on 2/27/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated all residents who smoked required a smoking assessment.
The DON stated the smoking assessment was used to determine if a resident can smoke independently or required supervision and safety materials.
The DON stated Resident 115 was a smoker.
The DON stated Resident 115 did not have a smoking assessment.
The DON stated the risk of not completing a smoking assessment could result in inadequate supervision, safety issues, and injuries.
During a review of the facility's policy and procedures (P&P), titled Safety and Supervision of Residents, dated 1/2018, the P&P indicated Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. and The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a concurrent interview and record review on 2/26/2025 at 8:24 a.m., with the MDSN, Resident 51's MDS, dated [DATE], was reviewed.
The MDSN stated Resident 51's MDS was not completed by 1/17/2025 and submitted no later than 14 days after.
The MDSN stated the residents' MDS's were completed at least upon admission, quarterly, and annually.
The MDSN stated Resident 51's MDS was not on her calendar, and she overlooked completing Resident 51's MDS on time.
The MDS stated it was important to conduct the residents' MDS on time to ensure accurate assessments were available.
During an interview on 2/28/2025 at 8:45 a.m., with the DON), the DON stated a resident's MDS was a full assessment and provided a full picture of who the resident is.
The DON stated the MDS was utilized to create the plan of care for each resident.
The DON stated when a MDS was not completed on time, the facility would not have the current and most accurate picture of the resident, and the facility could potentially not give the most appropriate care the resident required.
During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment Schedule, dated 10/2023, the P&P indicated, The facility conducts a comprehensive assessment to identify patient's needs per the guidelines set by the Resident Assessment Instrument (RAI).
The following assessments will be completed based on the guidelines set by the RAI Manual: admission Assessment, Significant Change of Condition, Quarterly Assessments, Medicare Pay Per Performance (PPS) Assessments, Correction Assessments, Tracking Assessments, [and] Discharge Assessments.
A review of the facility's policy and procedures, titled Minimum Data Set Assessment (MDS) Schedule, dated 10/2023, indicated Non-comprehensive MOS assessments include a select number of items on the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status.
Non-comprehensive assessments include Quarterly and SCQA assessments.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of Resident 5's admission Record, the admission record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia.
During a review of Resident 5's History and Physical (H&P) dated 12/26/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was moderately impaired.
The MDS indicated Resident 5 was dependent on staff for all activities of daily living.
During a review of Resident 5's PASRR Level I Screening, dated 1/2/2025, the PASRR Level I screening indicated result was positive for a serious mental illness (SMI).
The PASRR Level I screening indicated a SMI level II mental health evaluation was required.
During a review of Resident 5's electronic medical record, unable to locate a SMI level II health evaluation. c.
During a review of Resident 19's admission Record, the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of bipolar disorder and dementia.
During a review of Resident 19's H&P dated 12/14/2024, the H&P indicated Resident 19 had the capacity to understand and make decisions.
During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decision making was intact.
The MDS indicated Resident 19 needed supervision for eating, shower/bathing, dressing and oral hygiene.
During a review of Resident 19's PASRR Level I Screening, dated 12/13/2024, the PASRR Level I screening indicated result was positive for SMI.
The PASRR Level I screening indicated a SMI level II mental health evaluation was required.
During a review of Resident 19's electronic medical record, unable to locate a SMI level II health evaluation.
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California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
developed and implemented for each resident.
The P&P indicated the care plan would include
indicated care plans must be revised as information about the residents and the residents condition
the resident's condition.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024 and Self-harm Care Plan, initiated 12/2/2024, were reviewed.
The DON stated the two care plans should have been revised to include different interventions in addition to the implementation of one-to-one supervision and placement of a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) on 2/23/2025.
The DON stated if the care plans were revised, then Resident 97 would not have unsafely obtained a razor on 2/24/2025 and 2/25/2025 without staff knowledge.
The DON stated the lack of care plan revisions on 2/23/2025 and 2/24/2025 resulted in missed opportunities to implement different safety interventions for Resident 97.
During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the facility was to ensure assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of Resident 327's Order Summary, dated 2/26/2025, the Order Summary indicated
blood glucose checks every six hours.
During a concurrent interview and record review on 2/26/2025 at 7:44 a.m. with LVN 1, Resident 327's Blood Sugar Summary, dated 2/2025, MAR, dated 2/2025, Nursing Progress Notes, dated 2/24/2025, were reviewed. LVN 1 stated Resident 327's blood sugar level was 450 mg/dL on 2/24/2025 at 6:08 a.m.
The MAR indicated 12 units of insulin lispro injection solution (a drug to lower blood sugar levels) was administered at 6:00 a.m.
The Nursing Progress Notes indicated Resident 327 left the facility for his dialysis session on 2/24/2025 at 7:30 a.m. and arrived back at the facility around 2 p.m. LVN 1 stated there was no documentation to indicate the blood sugar level was rechecked before Resident 327 left for his dialysis session at 7:30 a.m. LVN 1 stated the Blood Sugar Summary indicated Resident 327's blood sugar was checked at 3:43 p.m. (on 2/24/2025). LVN 1 stated Resident 327's blood sugar level should have also been checked once Resident 327 arrived at the facility from dialysis (2 p.m.). LVN 1 stated Resident 327's blood sugar level should have been rechecked 15 minutes after the administration of insulin to ensure Resident 327's blood sugar level normalized before he was transported to dialysis. LVN 1 stated there was potential that Resident 327's blood sugars could have been too low or too high before or after is dialysis session, which would have led to delayed physician notification.
During an interview on 2/28/2025 at 10:30a.m. with the Director of Nursing (DON), the DON stated she expected the licensed nurses to recheck the temperature and blood sugar level if either or were abnormal.
The DON stated the reassessment was important to ensure interventions were effective and if the physician needed to be called for orders.
The DON stated there was potential Resident 327 could have exhibited a prolonged fever, altered mental status, or an emergent situation during and after dialysis.
During a review of the facility's Policy and Procedure (P&P), titled, Physician Notification, dated 12/2016, the P&P indicated the licensed nurse to report immediately to the physician if the resident exhibited the following:
- Blood glucose greater than 300 mg/dl.
- Respiratory rate above 28 breaths/ minute.
- Temperature greater than 100.5 degrees F.
During a review of the facility's P&P, titled, Hemodialysis, Care of Residents, dated 6/2023, the P&P indicated the facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes for residents on hemodialysis.
During a review of the facility's LVN Job Description, revised 10/19/2015, the Job Description indicated the LVN delivered efficient and effective nursing care while achieving positive clinical outcomes.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's document titled, Serena Elite User's Manual, undated, the user manual
comfortable level without bottoming out.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's residents smoking list, the smoking list indicated Resident 115 smoked cigarettes.
During a concurrent observation and interview, on 02/26/2025 at 8:43 a.m., with the Activities Assistant (AA), the AA stated the Activities staff were responsible for supervising residents during smoke breaks.
The AA stated she was the only staff member who watched the residents during their smoking breaks on the patio.
The AA stated residents could choose their own smoking time.
The AA stated the smoking patio was only closed during lunch and dinner.
The AA stated she was not sure on which residents required a smoking apron.
During an interview, on 02/27/2025 at 2:30 p.m., with the DON, the DON stated Resident 115 was a smoker.
The DON stated Resident 115 did not have a smoking assessment indicating if Resident 115 was an independent smoker or needed interventions such as supervision and/or smoking aprons.
The DON stated the risk of Resident 115 not being properly supervised and wearing a smoking apron could result in staff being unaware of Resident 115 smoking status and a safety issue.
During a review of the facility's P&P titled, Smoking Policy-Residents, dated 6/2022, the P&P indicated the facility shall establish and maintain safe resident smoking practices.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an interview on 2/28/2025 at 2:11 p.m. with the Director of Nursing (DON), the DON stated all nursing staff that enter a resident's room must assess foley catheter bags and make sure they covered.
The DON stated foley catheter bags must be covered at all times.
The DON stated a resident with a foley catheter bag that is not covered with a privacy bag would feel embarrassed and create dignity issues.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, Nasal Cannula, dated August 2017, the P&P indicated an Oxygen sign must be visibly posted.
The P&P indicated to post the Oxygen sign and explain to the resident, his/her roommate and all other visitor the regulations regarding the use of smoking materials near oxygen.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's P&P titled, Emergency Pharmacy Service and Emergency Kits, undated, the P&P indicated, Medications are not borrowed from other residents.
The ordered medication is obtained either from the emergency box or from the provider pharmacy.
The P&P indicated, When an emergency or starter dose of a medication is needed, the nurse unlocks the container/cabinet [and] breaks the container seal and removes the required medication.
During a review of the facility's policy and procedure (P&P) titled, Pain Management Program, dated January 2019, the P&P indicated the pain management program was based on a facility-wide commitment to resident comfort.
The P&P indicated pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and based on his or her clinical condition.
The P&P indicated strategies for prevention and management of pain may include assessing resident's potential for pain, recognizing the onset, presence and duration of pain, treating the underlying causes of pain, and developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, monitor appropriately for effectiveness and/or adverse consequences.
Cross Reference F-F755
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an interview on 2/27/2025 at 3 p.m., with the Director of Nursing (DON), the DON stated assessing the AV shunt after a resident returned from hemodialysis was important because the AV shunt can continue to bleed.
The DON stated if Resident 36's AV shunt had any signs of bleeding, the AV shunt dressing should have been reinforced.
The DON stated, if Resident 36's AV shunt had continued bleeding, it would have been an emergency because Resident 36 could have bled out.
During a review of the facility's policy and procedure (P&P) titled, Hemodialysis, Care of Residents, dated June 2023, the P&P indicated, The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes for resident outcomes for residents on hemodialysis.
The P&P indicated care following dialysis treatment:
- Check graft site for bleeding every 4 hours or twice during the shift after the resident returns, or
- If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse
per physician's order.
trained in this procedure.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's Policy and Procedure (P&P), titled, Exercising Resident Rights, dated 11/2017, the P&P indicated the facility protected and promoted the rights of each resident and ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
administered.
The P&P indicated, Schedule Two controlled medications are reordered when a
P&P indicated If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification.
This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's policy and procedure (P&P) titled, Anticoagulation Therapy Management, dated 7/2017, the P&P indicated, Throughout anticoagulant therapy, monitor the resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, 'Hold' anticoagulant medication and notify physician immediately.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a review of the facility's policy and procedure (P&P) titled, Psychoactive Medication Assessment, dated 7/2017, the P&P indicated, The facility will use a psychoactive medication assessment to document information collected for the resident.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
Guidelines, dated 1/2022, the P&P indicated the nurse should call the provider pharmacy prior to the
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
Based on observation and interview, the facility failed to:
- Ensure a medication bottle had a legible label in Station B's medication cart.
- Ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body
or given artificially via medication) pens were labeled in Station A's medication storage room.
This deficient practice had the potential to result in medication errors.
Findings
During a concurrent observation and interview, on 2/26/2025, at 9:06 a.m., with Registered Nurse 2 (RN 2) in Station A's medication storage room, RN 2 observed one opened and one unopened Fiasp FlexTouch (a pre-filled, disposable insulin pen containing insulin aspart, a rapid-acting insulin) insulin pens in the medication refrigerator. RN 2 stated there was no label to indicate which resident the medication belonged to. RN 2 stated the risk of having unlabeled medication in the refrigerator could result in administering to the wrong resident and medication errors.
During a concurrent observation and interview, on 2/26/2025, at 11:13 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 observed a medication bottle with an illegible label in the medication cart.
LVN 4 stated the label was not intact. LVN 4 stated the medication would not be safe to give. LVN 4 stated the risk of storing a medication with an illegible label could result in medication errors.
During a review of the facility's policy and procedures (P&P), titled Medication Administration- General Guidelines, dated 1/2022, the P&P indicated FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. and Medication- label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an observation on 2/27/2025 at 7:46 a.m. in the kitchen, Dietary [NAME] (DC) 2 scooped scrambled eggs onto a plate and poured salsa on top of the eggs.
During an interview on 2/27/2025 at 7:50 a.m. with DC 2, DC 2 stated on 2/27/2025, she served residents scrambled eggs for breakfast. DC 2 stated she cooked her daily meals based on the facility's dietary menus. DC 2 stated scrambled eggs were on the breakfast menu for 2/27/2025.
During a concurrent interview and record review on 2/28/2025 at 2:33 p.m. with the Dietary Manager (DM), the menu dated 2/27/2025 was reviewed.
The menu indicated residents were supposed to receive an omelet for breakfast.
The DM stated cooks must follow the menus when cooking for residents.
The DM stated she was not aware that scrambled eggs were served instead of an omelet.
The DM stated an omelet was beaten eggs folded in half and it was different than scrambled eggs.
The DM stated she must be informed of all food changes and the dietary cook did not notify her of the omelet substitution.
The DM stated she must be notified of all food changes because she must notify the dietician (an expert on diet and nutrition) and find out if the food item changes had the same nutritional value, same number of calories, and protein.
The DM stated she must be informed of food substitutions because she had to inform the residents.
The DM stated it was important to follow the menus because they were developed to provide a nutritional value to residents.
During a review of the facility's Policy and Procedure (P&P) titled Menu Planning, dated 2023, the P&P indicated all menu changes, and the reason for the change are to be noted on the back of menu sheet.
The P&P indicated the DM and dieticians are the only ones that could make permanent food changes from the menu.
The P&P indicated the DM must get the dieticians approval for any food changes.
The P&P indicated menu changes should also be noted on the menus on the resident's board and on any other menus which may be posted.
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
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During an interview on 2/27/2025 at 8:39 a.m. with the DM, the DM stated the facility did not have shelled egg and only had liquid eggs.
The DM stated there were residents that requested fried eggs for breakfast but did not receive them.
The DM stated the facility could not provide fried eggs to residents when they requested them because there was only liquid eggs.
The DM stated it was important to have shelled eggs available for residents because food preferences make them happy.
- During an observation on 2/26/2025 at 12:19 p.m. in the kitchen, Dietary Aide (DA) 1 was observed
making a sandwich while wearing gloves. DA 1 did not remove the gloves when he walked to the dry storage room to get food items. DA 1 came back with ham and continued making the sandwich. DA 1 walked to the trash can and touched the trash lid and returned to finish making the sandwich. DA 1 did not remove his gloves.
During an interview on 2/27/2025 at 9:00 a.m. with the DM, the DM stated dietary staff must remove their gloves before they move to another task.
The DM stated dietary staff must change their gloves for infection control.
The DM stated this practice could potentially cause a cross contamination and could cause residents to get sick.
- During an observation on 2/27/2025 at 8:48 a.m. in the walk in refrigerator, there was one apple
observed in the apple bin.
The orange bin was empty.
During an interview on 2/27/2025 at 8:50 a.m. with the DM in the refrigerator, the DM stated the facility should have 10 pounds of oranges and 10 pounds of apples available for residents.
The DM stated it was important to have apples and oranges available for residents because this was their home and food was important to them.
The DM stated when a resident requested fresh fruit, the facility should be able to give them an apple or an orange.
During a review of the facility's Policy and Procedure (P&P) titled Labeling and Dating of Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
The P&P indicated food delivered to the facility needs to be marked with received date.
The P&P indicated newly opened food items will need to be labeled with an open date and a used by date.
The P&P indicated all prepared food must be covered, labeled and dated.
The P&P indicate produce must be dated with received date.
During a review of facility's P&P titled Storage of Food and Supplies, dated 2023, the P&P indicated the storeroom (dry storage room) would be clean at all times.
During a review of facility's P&P titled Glove Use Policy, dated 2023, the P&P indicated appropriate use of gloves is essential in preventing food borne illness.
The P&P indicated gloves needed to be changed before beginning a different task.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
During a concurrent interview and record review on 2/25/2025 at 3:30 p.m., with the Director of Nursing (DON), the facility's MRR dated, December 2024 and January 2025, were reviewed.
The DON stated she was unable to locate the MRR recommendations and responses from the residents' physicians starting from before December 2024.
The DON stated she could request the recommendations from the consulting pharmacists but would not be able to obtain the responses from the residents' physicians.
During an interview on 2/28/2025 at 9:32 a.m. with the DON, the DON stated residents' records should be retained in-house for at least five years.
The DON stated she was hired and started as the DON in January 2025 and could not locate the MRR prior to December 2024.
The DON stated the MRR was important documents to retain because the MRR contained recommendations from the consulting pharmacists and the documentation whether the residents' physicians agreed, and a new order was placed or disagreed with the recommendations with a rationale.
The DON stated without the complete MRR documentation, the facility was unable to ensure recommendations were carried out and if the appropriate adjustments to medications were made.
During a review of the facility's policy and procedure (P&P) titled, General Record Policies, dated 11/2021, the P&P indicated, Clinical records, electronic, and/or manual, will be kept for each resident admitted for care.
055052 02/28/2025
California Post-Acute Care 3615 E.
Imperial Hiwy Lynwood, CA 90262
resident's name, room number, and date changed.
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.
055052
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 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
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] and readmitted on [DATE] 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] 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).
055052
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 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
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired.
The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Order Recap Summary Report, dated 2/25/2025, the report indicated Resident 97 was ordered one-to-one continuous monitoring on 10/7/2024.
1.
During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and to provide one-on-one sitter to closely monitor the resident and prevent (Resident 97) from leaving the facility.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated Resident 97 became agitated and attempted to leave the facility.
There was no documentation to indicate one-to-one supervision was rendered after the incident.
During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast pace unsupervised in the hallway with a razor in his right hand.
During observations made on 2/24/2025 at 2:30 p.m., 2/24/2025 at 4:15 p.m., and 2/25/2025 at 9:30 a.m., Resident 97 was not observed with one-to-one supervision.
055052
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 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
During a review of Resident 97's Admission Record, the Admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and an immunocompromised disease (an impaired immune system).
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired.
The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and provide one-on-one sitter to closely monitor the resident and prevent from leaving the facility.
During a review of Resident 97's Elopement Risk Assessment, dated 10/5/2024, the risk assessment indicated Resident 97 was at high risk for elopement.
During a review of Resident 97's Risk for Self-harm Care Plan, initiated 12/2/2024, the care plan indicated the facility was to render close supervision by sustaining observation or awareness at all times by being on one- to-one monitoring.
The care plan also indicated the nurse would remove all potentially harmful objects such as sharp objects, cords, and medications from the resident's environment.
During a review of Resident 97's At Risk for Elopement Care Plan Intervention, dated 1/24/2025, the care plan intervention indicated to monitor wander guard on Resident 97's right wrist for placement every shift.
During a review of Resident 97's Order Recap Summary Report, dated 2/25/2025, the report indicated Resident 97 was ordered one-to-one continuous monitoring on 10/7/2024.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated Resident 97 was agitated and attempted to leave the facility.
There was no documentation to indicate one-to-one supervision was rendered.
During observations made on 2/24/2025 at 2:30 p.m., 2/24/2025 at 4:15 p.m., and 2/25/2025 at 9:30 a.m., Resident [NAME] was not on one-to-one supervision by facility staff.
055052
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 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
During an observation on 2/24/2025 at 11:27 a.m., in Resident 36's room, Resident 36's left arm was observed still wrapped in the thin gauze dressing with reddish drainage seeping through the dressing and the cotton ball sitting on top of the dressing.
During a review of Resident 36's Admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE].
The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 36's History and Physical (H&P), dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 36's cognition (ability to think, remember, and reason) was moderately impaired.
The MDS indicated Resident 36 received hemodialysis, could eat independently (resident completes the activity by himself with no assistance) and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated an active order for AV shunt site: Left arm - Monitor for signs and symptoms of bleeding every shift on 9/15/2024.
During a review of Resident 36's Order Summary report dated 2/27/2025, the order summary report indicated an active order for Dialysis - every day shift on Monday, Wednesday and Friday for renal failure on 9/11/2024.
055052
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 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
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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.