California Post-acute Care

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

right to prevent any altercations. LVN 2 stated verbal abuse was talking aggressively, insulting, yelling, and calling the resident names. LVN 2 stated staff should not yell at the residents for any reason. LVN 2 stated all staff should protect the residents from abuse. During an interview on 9/5/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated it was not acceptable for any staff to yell at a resident because

the residents had the right to be treated with respect. The DON stated it was not acceptable for CNA 1 to exchange words aggressively with Resident 1 on 8/25/2025 around 4:30 a.m. The DON stated the incident was a violation of Resident 1's rights and considered verbal abuse. The DON stated verbal abuse was being verbally aggressive toward the residents such as shouting and yelling. The DON stated on 8/25/2025 around 4:30 a.m., CNA 1 should have stopped and left the scene. The DON stated the staff were expected to be professional. During a telephone interview on 9/10/2025 at 9:40 a.m. with the Administrator (ADM),

the ADM stated he expected the staff to be professional and provide customer service regardless of what

the residents were doing or saying. The ADM stated he did not remember when Resident 1 informed him of not wanting CNA 1 to be assigned to him (Resident 1). The ADM stated it was important to know Resident 1's care preference when making nursing assignments. The ADM stated the nursing assignment should be readjusted right away so residents were not assigned staff they did not prefer. The ADM stated it was part of residents' rights and should not be violated because it could cause potential arguments and accidents.

The ADM stated verbal abuse included saying demeaning, disrespectful, and insulting words to the residents. During a review of the facility's Policy and Procedure (P&P) titled Quality of Life-Dignity, dated 4/2018, the P&P indicated residents shall be treated with dignity and respect at all times. The P&P indicated staff shall speak respectfully to residents at all times. The P&P further indicated that demeaning practices and standards of care that compromise dignity are prohibited. During a review of the facility's P&P titled Quality of Life- Accommodation of Needs, dated 4/2018, the P&P indicated that the resident's individual needs and preferences shall be accommodated to the extent possible. The P&P indicated that in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. During a review of the facility's P&P titled Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The P&P indicated that the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict. The P&P further indicated that Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documenting wandering behavior. The DON stated based on the care plan, Resident 5's location had to be monitored once a shift and licensed nurses had to document their observations. The DON stated monitoring involved watching the residents and it was implemented for the residents' safety. The DON stated Resident 5 was able to leave the facility on 8/29/2025 because staff failed to monitor Resident 5's location. The DON stated Resident 5 had a standing order to leave on pass but was still required to notify staff if Resident 5 left the facility.During an interview on 9/9/2025 at 2:06 p.m. with the Director of Nursing (DON), the DON stated she expected her staff to develop interventions for care plans and implement them for resident safety and to prevent the incident from repeating. The DON stated interventions had to be revised or added after an incident because the previous interventions did not work.During a review of facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to revise a care plan for one of two sampled residents (Resident 4) after the resident was observed touching another resident. This deficient practice increased

the risk of Resident 4 inappropriately touching another resident. Findings:During a review of Resident 2's admission Record, dated 9/4/2025, the admission Record indicated Resident 2 was admitted to the facility

on [DATE REDACTED]. Resident 2's diagnoses included Tourette's syndrome (disorder characterized by repetitive, involuntary movements or vocalizations) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 4's History and Physical (H&P) dated 10/21/2024, the H&P indicated Resident 4 was alert, awake and oriented times 3 (mental status, indicating they are awake, alert, and aware of their person, place, and time). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent for dressing and toileting hygiene. The MDS indicated Resident 4 required set up assistance for eating and oral hygiene. The MDS indicated Resident 4 required supervision for shower/bathing and personal hygiene. During a review of Resident 4's care plan titled, Inappropriate Statements and Touching, dated 5/1/2025, the care plan indicated Resident 4's goal was to reduce the frequency of inappropriate verbal and physical behaviors. The interventions indicated to increase Resident 4's supervision in common areas and resident education on use of appropriate language and touching. The care plan was revised on 9/1/2025 due to Resident 4 touching the legs of another resident. The care plan indicated no new goals or interventions were developed on 9/1/2025. During a review of Resident 4's Situation, Background, Assessment, Recommendation form ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) , dated 9/1/2025, the SBAR indicated Resident 4 was observed touching the legs of another resident. The SBAR indicated there was a new order to educate Resident 4 on proper behavior and to separate the residents. During an interview on 9/3/2025 at 3:08 p.m. with Registered Nurse (RN) 1, RN 1 stated residents had to be separated to prevent alleged abuse from happening again. During an interview on 9/5/2025 at 2:42 p.m. with the Director of Nursing (DON), the DON indicated she expected licensed staff to revise care plans when residents have a new issue. The DON stated a revision to the care pan meant a new intervention was developed. The DON stated a new intervention must be developed because the existing interventions did not work and it outlined the plan of care. The DON stated if a care plan was not revised the resident would not have an up-to-date plan of care and staff would practice the previous interventions that did not work. 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 staff must review and update the care plan when there has been a significant change in the resident's condition. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

witnessed the resident leave the facility. The DON stated if there was not a signature on the form it indicated a nurse did not witness the resident leaving the facility and there was no way of verifying when

the resident left. The DON stated the purpose of the form was to communicate which resident left the facility and to indicate what time they would be back. The DON stated if the form was not filled out correctly

it could affect the residents safety During a review of the facility's policy and procedure (P&P) titled Resident on Pass dated 1/2018, the P&P indicated all residents leaving the premises must be signed out.

The P&P indicated a sign-out register (therapeutic leave form) was located at each nurse's station.

Registers must indicate the resident's expected time of return. The P&P indicated residents must be signed

in upon return to the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

might feel no one wanted to talk to them about the situation, and they might feel isolated. The DON stated

the SSD should have visited Resident 2 and Resident 4 and asked what happened and how they felt about

the situation and refer them to see a psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness), if needed. The DON stated the SSD should have documented their visit with

the residents and developed a care plan and implemented interventions. During an interview on 9/9/2025 at 10:00 a.m. with the SSD, the SSD stated part of his job duties was to assist residents with their psychosocial needs by developing care plans, performing psychosocial evaluations and referring residents to see a doctor to talk about their psychosocial concerns. The SSD stated to assist residents with their psychosocial needs he must visit residents and find out if they have any concerns. The SSD stated for alleged sexual abuse he must make sure residents were safe and away from the abuser. The SSD stated

he would make sure there was no additional contact between the two residents and he would order a psychiatrist visit. The SSD stated he immediately had to assist residents with their psychosocial needs after

an alleged sexual abuse incident to capture the situation, emotional state and to provide psychosocial support. The SSD stated he did not remember developing a care plan for Resident 2 or Resident 4 and there was not much to be done for them because they did not want to be helped. The SSD stated a care plan should have been developed to address any needs Resident 2 and Resident 4 had with interventions to keep the residents safe. The SSD stated he did not remember when he actually saw Resident 2 and Resident 4 after the alleged sexual abuse but it was days after the incident. The SSD stated he did not know why he did not see Resident 2 and Resident 4 right after the incident. During a review of the facility's job description for Social Services Designee, dated 10/19/2015, the job description indicated the social services designee would participate in development of a written plan of care for each resident that was identified with a psychosocial needs issue, develop goals to be accomplished for residents with psychosocial needs, and develop appropriate social services interventions. During a review of the facility's Policy and Procedure (P&P) titled Abuse and Neglect Prohibition, dated 6/2022, the P&P indicated to protect a resident during an investigation the facility would assign a representative from social services or a designee to monitor the resident's feelings concerning the incident, as well as the resident's involvement in

the investigation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/05/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

benefits to meet their needs. During an interview on 9/5/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated it was unacceptable not to complete the documentation on the MAR. The DON stated the licensed nurses should sign the MAR after the medication administration to verify completion.

The DON stated it was the standard of practice. b. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was

a change of condition among the residents) form, dated 8/25/2025 at 5:55 a.m., the SBAR indicated on 8/25/2025 at 4:30 a.m., Resident 1 was agitated (feeling or appearing nervous, upset, or disturbed) with Certified Nursing Assistant (CNA) 1 and accused CNA 1 of violating his (Resident 1)'s patient rights. The SBAR indicated Resident 1 requested CNA 1 to pull his curtain back, turn off the light, and close the door.

The SBAR indicated Resident 1 stated CNA 1 left the room without doing so, disrespected his space, and disturbed his peace. The SBAR indicated CNA 1 called Resident 1 names and escalated the verbal altercation. The SBAR indicated CNA 1 refused to leave. The SBAR indicated that CNA 1 was Mistakenly assigned to Resident 1. During a concurrent interview and record review on 9/4/2025 at 12:51 p.m. with the LVN 1, Resident 1's nursing progress notes from 8/25/2025-8/29/2025 were reviewed. The nursing progress notes indicated there was no documentation regarding Resident 1's changes of conditions (COC) for the evening shift on 8/25/2025. LVN 1 stated the licensed nurses should document Resident 1's COC every shift for 72 hours. LVN 1 stated that documenting residents' COC was important for maintaining the residents' health and was part of the nursing care plan. LVN 1 stated if there was no documentation, the staff would be clueless on Resident 1's emotion and psychosocial well-being and possibly delayed necessary care. LVN 1 stated it affected the quality of care negatively. During an interview on 9/5/2025 at 3:50 p.m. with the DON, the DON stated it was unacceptable not to document Resident 1's COC on the nursing progress notes, for the evening shift on 8/25/2025. The DON stated the licensed vocational nurse assigned to Resident 1 should document the COC every shift on the nursing progress notes for 72 hours.

The DON stated it was the standard of care to document the COC every shift. The DON stated the nurses documented to assess and follow up the problems. The DON stated she expected the licensed nurses to finish the documentation by the end of the shift. The DON stated the documentation should be accurate, clear, and timely. The DON stated staff would not know what happened to the residents in real time without

the documentation. During a review of the facility's Licensed Vocational Nurse Job Description, revised on 10/19/2015, the Job Description indicated, the licensed vocational nurse's responsibilities included implementing the plan of care, administering medications per physician orders, and documenting accurately and thoroughly. During a review of the facility's policy and procedure (P&P) titled Diabetic Management, dated 7/2017, the P&P indicated to document insulin administration on the medication sheet.

During a review of the facility's P&P titled Documentation guidelines, dated 11/2021, the P&P indicated, documentation was required for resident's condition and changes in the resident's condition. The P&P indicated the facility should promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident. The P&P indicated the facility should document the name, dosage, and time of administration of all medications and treatments.

The P&P further indicated, when administration of medications/treatments or other care was not recorded as required by law, it will be presumed that the medication, treatment or care were not provided.

Event ID:

Facility ID:

If continuation sheet