California Post-acute Care

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

with diagnoses including dysphagia, cerebral infarction and gastrostomy status. During a review of Resident 6's MDS dated [DATE REDACTED], the MDS indicated Resident 6 had no cognitive impairment.During an interview on 9/16/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated licensed nurses must ensure to clean residents' feeding pumps. LVN 1 stated it was important to keep feeding pumps clean to prevent any cross contamination (transfer of harmful bacteria from one place to another) with the feeding tube connected to the residents. LVN 1 also stated residents' privacy curtains must be cleaned to prevent any infection and to provide a clean, home-like environment for residents.During a concurrent observation and interview on 9/16/2025 at 11:44 a.m., with Housekeeping (HK), in Resident 1, 2, 5 and 6 rooms, HK stated, the walls and privacy curtains for Residents 1, 2, 5 and 6 were dirty with black and brown spots of dried formula. The HK stated the residents' curtains and walls must be cleaned and changed. HK stated it was the facility's responsibility to keep a clean and sanitized environment for residents.During an interview

on 9/16/2025 at 12:03 p.m., with the Housekeeping Supervisor (HS), the HS stated it was housekeeping's responsibility to clean the residents' rooms every day. The HS stated, housekeeping must be vigilant in checking the curtains and walls. The HS stated, housekeeping should change and clean the walls and curtains when dirty. The HS stated it was important to take care of the residents and keep a clean environment.During an interview on 9/16/2025 at 3:24 p.m., with the Director of Nursing (DON), the DON stated the facility needed to provide a home-like environment for all residents. The DON stated residents have the right to have their curtains and walls cleaned. The DON stated housekeeping should clean resident's walls, feeding pumps and curtains. The DON also stated it was the facility's responsibility to keep rooms clean, free of infections and prevent any infestations of roaches due to unclean environment.During

a review of the facility's Policy and Procedures titled, Drapery & Cubicle Curtain Maintenance dated 4/2015,

the P&P indicated curtains are cleaned when visibly soiled or stained.During a review of the facility's P&P titled, Housekeeping Cleaning Schedule dated 4/2015, the P&P indicated, related facility standards included wall washing.During a review of the facility's P&P titled, Resident's Homelike Environment, dated 12/2017, the P&P indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike settings. These characteristics included cleanliness and order.

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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

09/16/2025

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary practices were followed in the kitchen when:1. The grill food waste receptacle was not emptied or kept clean.2.

Empty, crushed soda cans and a cell phone were kept in the resident's food storage shelf.This deficient practice had the potential to attract pests and result in harmful bacterial growth or cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness.Findings:During

a concurrent observation and interview, on 9/16/2025 at 9:20 a.m., with the Dietary [NAME] (DC) in the kitchen, the grill trash receptacle was observed full of oil and food wastes. Three empty crushed soda cans and black cell phone were also observed in the white shelf next to two boxes of powdered sugar. The DC stated she did not use the grill in the morning (on 9/16/25). The DC stated the oil and food waste from the grill trash receptacle should be cleaned every day. The DC also stated she was out for two days and was not sure if anyone had cleaned the receptacle while she was gone. The DC stated it was the cook's responsibility to clean the grill after each use. The DC stated the white shelf was used to store residents' cereals or food items and it was not acceptable to have empty cans and personal items on the shelf. The DC stated leaving food waste from the grill receptacle, failure to clean the grill and leaving trash like empty soda cans in the resident food shelf could attract cockroaches or other insects and could place residents at risk for foodborne illnesses such as abdominal pain, diarrhea and vomiting.During an interview on 9/16/2025 at 3:43 p.m. with the Director of Nursing (DON), the DON stated staff needed to keep the kitchen clean and to ensure food or dirty items were not left to prevent any pest infestation.During a review of the facility's [NAME] Job Description dated 10/19/2015, the Job Description indicated the Cooks responsibilities and accountabilities included: handling and always preparing food in a safe and sanitary manner. The Job Description indicated the cook properly labels, dates and stores foods, maintains clean, organized and sanitary work areas. The Job Description also indicated the [NAME] performs after-use and scheduled cleaning of surfaces and equipment in accordance with established policies and cleaning procedures.During a review of the facility's P&P titled, Dietary Cleaning Task frequency, dated 4/2020, the P&P indicated the grill will be cleaned after each use.

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