Health inspection·November 12, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement residents' care plan interventions for one of three sampled residents (Residents 1), who had wandering (walking around slowly in a relaxed way or without any clear purpose or direction) behavior to monitor Resident 1's whereabouts. This failure resulted in Resident 1 entering her previous room after Resident 1 had alleged physical altercation (a dispute between individuals in which one or more persons sustain bodily injury arising out of the dispute) with her previous roommate. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last re-admission was 4/16/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and repeated falls. During a review of Resident 1's History and Physical (H&P), dated 10/28/2024, the H&P indicated, Resident 1 had no capacity to make decision due to dementia. During a review of Resident 1's Minimum Data Set (MDS - a mandated resident assessment tool), dated 10/25/2024, the MDS indicated Resident 1 moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed-to-chair transfer, and wheel her wheelchair 150 feet. During an observation on 11/12/2024, at 11:20 a.m., in activity room, Resident 1 was wheeling herself around the room and went out to hallway without assistance from staff. During an interview on 11/12/2024, at 11:27 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated, Resident 1 had alleged physical altercation with roommate and moved to different room to prevent future incident. CNA 1 stated, Resident 1 should not enter previous room for same reason. CNA 1 stated, she checked Resident 1's location from time to time, but she did not document. CNA 1 stated, she did not see Resident 1 enter her previous room today. CNA 1 stated, she noticed Resident 1 was wandering the hallway sometimes. During an interview on 11/12/2024, at 1:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1's whereabouts should be monitored regularly, since she was involved in recent alleged physical altercation with her previous roommate to prevent further altercations for safety as care (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: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Palos Post-Acute Care Center 1430 West 6th Street San Pedro, CA 90732 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)