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
During an
feeling short of breath (SOB) and was afraid to lie down in bed because he was afraid that he might choke. Resident 1 stated he asked LVN 1 to call his physician to inform him that he (Resident 1) was having difficulty breathing and was SOB. Resident 1 stated for the majority of the 11 p.m. - 7 a.m. shift on 8/20/2025, he sat up on the edge of his bed or in a wheelchair because it helped him breathe. Resident 1 stated LVN 1 gave him pain medicine for his headache and cough drops for his throat which really didn't help. Resident 1 stated he felt increasingly anxious and nervous and thought the nursing staff did not believe he was having difficulty breathing. Resident 1 stated his family called 911 on 8/21/2025 and he was transferred to the GACH on 8/21/2025 at approximately 7 a.m.
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, Change of Condition Notification dated 10/1/2023, the P/P indicated the purpose of the policy is to ensure residents, family, legal representative and physicians are informed of changes in the resident's condition in a timely manner.
The P/P indicated the attending physician will be notified in a timely with a resident's change in condition, the notification to the attending physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and or signs and symptoms for which the notification is required, in emergency situations (resident is experiencing unexpected shortness of breath, intense pain, unexpected bleeding, serious abnormal labs or x-ray), 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.
056425 09/10/2025
Studebaker Healthcare Center 13226 Studebaker Rd Norwalk, CA 90650
investigation and any corrective actions recommended in a timely manner, if the resident is not
facility's policy, and procedure (P/P) titled, Grievances and complaints, dated October 1, 2023, the
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.
056425 09/10/2025
Studebaker Healthcare Center 13226 Studebaker Rd Norwalk, CA 90650
During a
appear to be SOB. LVN 1 stated Resident 1 did not want to lay in bed because he thought he might
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.