Health Inspection

California Post-acute Care

February 28, 2025 · Lynwood, CA · 3615 E. Imperial Hiwy

Citations 5

CMS Rating 1/5

Beds 130

Provider ID 055052

Healthcare Facility

California Post-acute Care

Lynwood, CA · View full profile →

Inspection Summary

CALIFORNIA POST-ACUTE CARE in LYNWOOD, CA — inspection on February 28, 2025.

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

FF609

Minimal harm or 103 who stated, The CNA was in my face and was being smart with me and that Resident 103 called the Few roommate's statement, she determined it was a misunderstanding. The DON stated although she did an affected

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

FF610

Minimal harm or upper body dressing. Few to understand and make decisions. affected

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

FF656

one monitoring. Few witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025. affected

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.

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

FF689

Minimal harm or have a wander guard and should have had one placed on his wrist or ankle. Few Findings: affected

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).

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

FF755

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48131 Few to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) affected

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

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 LYNWOOD, 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 CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

California Post-acute Care

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