Health inspection·September 16, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean and home-like environment for 4 of 6 sample residents (Residents 1, 2, 5 and 6) by failing to ensure:1. The walls behind Resident 1 and 6's headboards were clean.2. The feeding pumps (device that delivers formula [liquid, nutrient-rich mixture designed to provide complete nutrition] directly into the stomach of a resident who is unable to take food or liquids by mouth) for Residents 1 and 2 were clean.3. Resident 2, 5 and 6's privacy curtains were clean.This deficient practice had the potential to violate resident's right to have a clean, home-like environment and cause residents to get ill due to unsanitary living conditions.Findings:During an observation on 9/16/2025 at 8:30 a.m. in Residents 1, 2, 5 and 6's rooms, the walls behind Resident 1 and 6's headboards were observed with black spots which appeared to be dried feeding tube formula. Resident 1 and 2's feeding pumps were observed with black and brown spots which appeared to be dried formula. Resident 2, 5 and 6's privacy curtains were also observed with black and brown dried spots which appeared to be dried formula. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia ( a progressive state of decline in mental abilities) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/10/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as bed mobility, transfers, dressing and personal hygiene. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dysphagia following cerebral infraction and dementia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and was totally dependent on staff for ADLs such as transfers, dressing and personal hygiene. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including dysphagia and brain disorder. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had no cognitive impairment and required supervision or touching assistance for ADLs such as upper body dressing and transfers. During an interview on 9/16/2025 at 10:20 a.m., with Resident 5, Resident 5 stated, his privacy curtain was dirty and had not been changed. Resident 5 stated his room was his space and home and wanted it to be clean. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055052 Printed: 05/15/2026 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 055052 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)