Studebaker Healthcare Center
STUDEBAKER HEALTHCARE CENTER in NORWALK, CA — inspection on September 10, 2025.
Found 3 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
Nurse will immediately call the attending physician, if the LVN is unable to reach the attending physician or the physician on call during emergency situations, she will notify the facility's medical director.
The P/P indicated the licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Studebaker Healthcare Center
13226 Studebaker Rd Norwalk, CA 90650
SUMMARY STATEMENT OF DEFICIENCIES
During a review of the facility's policy, and procedure (P/P) titled, Grievances and complaints, dated October 1, 2023, the P&P the purpose of the policy is to ensure that residents, family members and representatives know about the procedure for filing grievances and complaint, any resident, representative, family member or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, theft of property without fear of threat or reprisal In any form.
The P/P indicated upon receiving a resident grievance/complaint form, the Grievance official or designee begins an investigation into the allegations.
The Grievance official will take immediate action to prevent further potential violations of resident right while the alleged violation is being investigated.
The P/P further indicated the facility will inform the resident or his or her representative of the finding of the investigation and any corrective actions recommended in a timely manner, if the resident is not satisfied with the result of the investigation or recommended actions, he may file a written complaint to local Long Term Ombudsman office or to the department of public health.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Studebaker Healthcare Center
13226 Studebaker Rd Norwalk, CA 90650
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on 9/9/2025 at 12:10 a.m., LVN 1 stated on 8/20/2025 at approximately 12 a.m., she observed Resident 1 with a cough and congestion, he was restless and agitated but did not appear to be SOB. LVN 1 stated Resident 1 did not want to lay in bed because he thought he might choke. LVN 1 stated this was the first time she observed Resident 1 in this condition, so she initiated a COC by texting Resident 1's physician's via the nurse supervisor's cell phone to notify him that Resident 1 had a cough and congestion but stated she did not notify Resident 1's physician that Resident 1 felt like he was choking. LVN 1 stated Resident 1's physician did not respond during her shift (11 p.m. - 7 a.m.) so she endorsed Resident 1's care to the oncoming nurse (7 a.m. - 3 p.m.). LVN 1 stated she should have followed up with Resident 1's physician when he did not respond to the text messages, notified the Medical Director and/or the Director of Nursing (DON).
During an interview on 9/10/2025 at 1 p.m., Resident 1's physician stated he received text messages from the facility nursing staff at approximately 12:30 a.m., and 3:30 a.m., on 8/20/2025 regarding Resident 1's cough and congestion but he was not informed that Resident 1 felt like he was choking. Resident 1's physician stated he did not know why he did not respond to the text messages until almost 9 a.m. Resident 1's physician stated if the nursing staff had reported that Resident 1 felt like he was going to choke he would have ordered different interventions, such as an Xray and/or transferred Resident 1 to the GACH.
During an interview on 9/10/2025 at 2:20 p.m., the DON stated physicians should be available to respond to calls or text messages from the nursing staff 24 hours a day to meet the needs of the residents.
The DON stated when LVN 1 did not receive a response from Resident 1's physician she should have called her (DON) or the Medical Director.
During a review of the facility's policy, and procedure (P/P) titled, Physician Services and Visits dated 10/1/2023, the P/P indicated the purpose of the policy is to ensure that the facility provides residents with care under an Attending Physician.
The P/P indicated physician services include .providing consultation or treatment when called by the facility and provision for alternate physician coverage in the event the Attending physician is not available.
During a review of the facility's P/P titled, Change of Condition Notification, dated 10/1/2023, the P/P indicated. the Licensed Nurse will immediately call the attending physician, if the LVN is unable to reach the attending physician or the physician on call during emergency situations, she will notify the facility's medical director.
The P/P indicated the licensed nurse will document the time the attending physician was contacted, the method by which he/she was contacted, response time and whether orders were received
Facility ID: