Health inspection·September 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview and record review, facility failed to ensure that the Licensed nurse (LVN) notified Resident 1 ' s family member (FM) about a change of condition (COC -a sudden or acute deviation from a patient ' s baseline that may lead to complications or death if left untreated) for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedures (P&P) titled Change of condition management guideline revised 9/11/2023, by failing to notify Resident 1 ' s FM after a COC occurred on 8/6/2024. This deficient practice violated Resident 1 ' s FM ' s right to be notified of Resident 1 ' s care services provided and had the potential to result in lack of proper care and services. Findings: A review of Residents 1 ' s admission Record indicated the facility initially Resident 1 on 9/1/2011 and readmitted Resident 1 on 8/30/2024 with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1 ' s Minimum Data Set (MDS - a standard assessment and care screening tool) dated 6/7/2024, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. MDS also indicated that Resident 1 is always incontinent of bowel and bladder. A review of Resident 1 ' s Skin assessment date 8/6/2024, at 3:05 P.M., indicated that Resident 1 had perianal (the area of skin surrounding the anus) moisture associated skin damage (MASD -skin inflammation [body ' s response system to injury or infection] or erosion [loss of the outer layer of the skin] cause by prolonged exposure to moisture). During an interview on 9/17/2024, at 2:32 P.M., with family member (FM), FM stated she was not aware that Resident 1 had MASD. During a concurrent interview and records review on 9/18/2024, at 12:07 P.M., with Medical Records Director (MRD), Resident 1 ' s COC and nursing progress notes for the month of 8/2024 were reviewed. MRD stated there is no documented evidence of MASD in the coc or the progress notes the only coc ' s I see are for when she (Resident 1) had covid, those are the only two in there for the month of 8/2024. (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 2 Event ID: 055350 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 055350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Culver West Health Center 4035 Grandview Blvd. Los Angeles, CA 90066 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)