California Post-acute Care

F-F740.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 055052 Department of Health & Human Services Printed: 08/28/2025 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 04/16/2025

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 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 47286 potential for actual harm Based on interview and record review, the facility failed to ensure the posted nurse staffing information: Residents Affected - Few 1. Included the facility's name and actual direct hours provided.

2. Was documented on the State-specific nursing hours per patient day (NHPPD) form.

This created the potential for possible inaccuracy in calculating the required number of nursing hours, and for facility residents/visitors to not receive clear information about the daily facility staffing.

Findings:

During an observation on 4/16/2025 at 10:14 a.m., an untitled document indicating the nurse staffing information for 4/16/2025 was posted next to nurse's station A. The nurse staffing information was not printed on a State-specific NHPPD form, did not indicate the facility's name, and did not indicate if the posted hours were projected direct care hours or actual direct hours provided.

During a concurrent interview and record review, on 4/16/2025 at 12:45 p.m. with Payroll Staff 1, the untitled nurse staffing posting, dated 4/16/2025 was reviewed. Payroll Staff 1 stated the untitled nurse staffing posting dated 4/16/2025, did not indicate the facility's name, and stated it was not printed on a State-specific NHPPD form. Payroll Staff 1 also stated the posting did not indicate if the hours were projected direct care hours or actual hours. Payroll Staff 1 stated she was responsible for updating the daily nurse staffing posting, and could not recall if the document ever included the facility's name or was ever printed on a State-specific NHPPD form.

During a concurrent interview and record review, on 4/16/2025 at 2:46 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Staffing Sufficiency Requirements, dated 2/2017, and

the untitled nurse staffing posting dated 4/16/2025, were reviewed. The DON stated the P&P indicated the nurse staffing posting was to include the facility name and the actual direct care hours provided, and was to be documented on State specific nursing hours per patient day (NHPPD) forms. The DON stated the nurse staffing posting dated 4/16/2025, was not in accordance with the facility's P&P.

During a concurrent observation and interview, on 4/16/2024 at 2:51 p.m., with the DON, the nurse staffing postings at all three facility nursing stations were observed. The DON stated none of the nurse staffing postings were in accordance with the facility's P&P and stated there were no other postings available to facility residents and visitors indicating the information missing from the current postings. The DON stated it was the facility residents' (and their families/responsible parties') right to know the staffing levels in the facility as staffing affected the quality of care provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 055052 Department of Health & Human Services Printed: 08/28/2025 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 04/16/2025

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286

Residents Affected - Few Based on interview and record review, the facility failed to ensure behavioral health services were provided to one of four sampled residents (Resident 3) by failing to:

Ensure Resident 3's Level I Preadmission Screening and Resident Review (PASRR, a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility) accurately reflected Resident 3's multiple diagnoses of serious mental illness and prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).

Develop and implement resident-specific care plans for Resident 3's diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder (a condition characterized by excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life).

Monitor and document behavioral manifestations of Resident 3's diagnoses of anxiety disorder, schizophrenia, and psychosis while administering psychotropic medications.

These deficient practices placed Resident 3 at risk for not receiving the care and services needed for his diagnosed mental illnesses, including placement at an appropriate facility, and prevention of adverse effects associated with administration of psychotropic medications such as falls and excessive sedation.

Findings:

During a review of Resident 3's Admission Record, the Admission Record indicated Resident 3 was admitted

on [DATE REDACTED]. Resident 3's admitting diagnoses included schizophrenia, psychosis, and anxiety disorder.

During a review of Resident 3's Nursing Admission Assessment, dated 4/7/25, the assessment indicated Resident 3 was disoriented, could sometimes understand others, and was sometimes understood by others.

The assessment indicated Resident 3 could ambulate without any problems with a device.

During a review of Resident 3's active physician orders, dated 4/7/2025, the orders indicated Resident 3 was receiving:

Ativan (lorazepam, a medication that acts on the brain and nerves to produce a calming effect that relieves symptoms of anxiety), one (1) milligram (mg, a unit of dose measurement) every six (6) hours as needed for anxiety

Ativan (lorazepam) two (2) mg every six (6) hours as needed for excessive anxiety

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 055052 Department of Health & Human Services Printed: 08/28/2025 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 04/16/2025

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 0740 Chlordiazepoxide HCl (a sedative and hypnotic medication used to treat anxiety) 25 mg every 12 hours for anxiety Level of Harm - Minimal harm or potential for actual harm During review of Resident 3's Level I PASRR, dated 4/8/2025, the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, such as schizophrenia, anxiety disorder, and psychosis. The Level I Residents Affected - Few PASRR did not indicated Resident 3 had prescriptions for psychotropic medications.

During a review of Resident 3's record titled Notice of PASRR Level I Screening Results, dated 4/8/2025, the

record indicated a Level II Mental Health Evaluation was not required because the Level I PASRR screening indicated Resident 3 did not have diagnoses of serious mental illness.

During a concurrent interview and record review, on 4/16/2025 at 12:26 p.m., with the Director of Nursing (DON), Resident 3's Admission Record, physician orders dated 4/7/2025, and Level I PASRR screening, dated 4/8/25, were reviewed. The DON stated the Admission Record, and physician orders dated 4/7/25, indicated Resident 3 had diagnoses of serious mental illness and was receiving psychotropic medications.

The DON stated the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, or his orders for psychotropic medications. The DON stated an inaccurate Level I PASRR screening placed Resident 3 at risk of being placed in a facility that could not meet his behavioral health needs, and could prevent him from receiving the mental health services he required.

During a concurrent interview and record review, on 4/16/2025 at 12:31 p.m., with the DON, Resident 3's current physician orders were reviewed. The DON stated Resident 3 did not have orders for monitoring the behaviors for which he was receiving psychotropic medications. The DON stated Resident 3 should have orders for behavioral monitoring to assess the effectiveness of the psychotropic medications being administered, and to determine if adjustments were needed to meet the resident's needs.

During an interview, on 4/16/2025 at 12:33 p.m., with the DON, the DON stated Resident 3 did not have care plans for his diagnoses of schizophrenia, anxiety disorder, or psychosis. The DON stated Resident 3 did not have care plans for the psychotropics being administered for his diagnoses of schizophrenia, anxiety disorder, or psychosis. The DON stated it was important to have care plans for psychotropic medications because the medications could cause side effects such as altered mental status and increased risk for falls.

The DON stated care plans for the diagnosed serious mental illnesses were important to identify and implement non-pharmacologic (non-medication) interventions that could be attempted to address the resident's behavioral manifestations, prior to or instead of administering additional psychotropic medications.

The DON stated non-pharmacologic interventions should always be attempted first before the addition of pharmacologic interventions.

During a review of the facility policy and procedure (P&P) titled Psychoactive Medication Management, dated 7/2017, the P&P indicated residents were to have an individualized care was to be developed for residents with behavioral and psychotropic medications. The P&P indicate the care plan was to include the mood or behavior problem and its manifestations, and non-drug interventions. The P&P indicated residents were to be monitored for behaviors every shift.

During a review of the facility P&P titled Behavioral Health Services, dated 1/2023, the P&P indicated it was

the facility's policy to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated these behavioral health services included a PASRR screening, ongoing monitoring of mood and behavior, and development and implementation of a care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 055052