Health inspection·December 23, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was treated with dignity by not communicating with Resident 1 his (Resident 1's) preferred time to receive activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practiced had the potential to decrease the resident's sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Findings: During a review of Resident 1's admission Record dated 10/25/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), heart failure (a heart condition in which the heart is unable to pump blood efficiently), pneumonia (an infection of one or both of the lungs caused by bacteria or viruses), anemia (a condition where the body does not have enough healthy red blood cells [a type of blood cell responsible for transporting fresh oxygen all over the body), and need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was moderately impaired. Resident 1 required supervision with eating, and was dependent on staff with oral hygiene, toileting, shower/bathing, and dressing. During an interview with Resident 1's responsible party (RP) 1 on 12/20/2024 at 11:10 a.m., RP 1 stated that on 12/7/2024 around 7:00 p.m. RP 1 was informed by Resident 1 that he (Resident 1) had not had a shower that day nor was offered a shower, and it was his (Resident 1) scheduled shower day. RP 1 stated that she met with Registered Nurse (RN) 1, and informed RN 1 that Resident 1 had not had a shower or been offered a shower on 12/7/2024. During an interview with the Director of Staff Development (DSD) on 12/20/2024 at 2:50 p.m., the DSD stated that when Certified Nursing Attendants (CNA) begin their shift, they (CNAs) are instructed to go and introduce themselves to the residents that they are assigned to and discuss with the residents regarding ADL care, including preferred shower times. The DSD stated that she (DSD) was informed that on 12/7/2024 CNA 1 was assigned to Resident 1 and CNA 1 did not discuss with Resident 1 at the beginning of the shift when Resident 1 would like to have a shower. (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: 056149 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 056149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Healthcare and Rehabilitation Center 6700 Sepulveda Blvd. Van Nuys, CA 91411 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)