Health inspection·October 25, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one resident ' s (Resident 1) Minimum data Set (MDS – a federally mandated resident assessment tool), dated 10/14/2024, indicated Resident 1 had broken teeth. Residents Affected - Few This deficient practice resulted an inaccurate depiction of Resident 1 ' s current health status. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] with diagnoses including seizures(a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) , dementia (a progressive state of decline in mental abilities), age related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) and muscle weakness. During a review of Resident 1's Minimum Data Set, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment and was dependent (helper does all the effort) with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1did not have any obvious or likely cavity or broken natural teeth. During a review of Resident 1 ' s Nursing admission and Assessment, dated 10/8/2024 at 8:29 p.m., the assessment indicated Resident 1 was missing 2 front lower natural teeth. During an interview and record review on10/25/2024 at 1:00 p.m. with Registered Nurse (RN)1, Resident 1 ' s Nursing admission Assessment, dated 10/8/2024. and MDS dated [DATE], were reviewed. Resident 1 ' s admission assessment indicated Resident 1 had 2 missing front teeth and the MDS indicated Resident 1 did not have any dental problems. RN 1 stated Resident 1 was admitted from the hospital and her two lower front teeth was missing. RN1 stated Resident 1 ' s MDS was erroneously coded that resident did not have any dental issues and should be amended to indicate Resident 1 had dental issues. During an interview on 10/25/2024 at 1:32 p.m. with the Director of Nursing (DON), the DON stated assessments should be accurate to get a clear representation of the resident if you ' re reading about them from paper. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Assessments and the Care Delivery Process, revised 12/2016 the P&P indicated comprehensive assessments will be (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: 055539 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 055539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701 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)