F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to protect one of three sampled residents (Resident 1) right to
be free from verbal abuse when Certified Nurse Assistant (CNA) 1 cursed (used foul language) in front of
Resident 1 while providing care.This deficient practice placed Resident 1 at risk for psychological harm,
loss of dignity and feeling uncomfortable and had the potential to result in further abuse for Resident 1 and
all residents in the facility. Findings: During a review of Resident 1's admission Record, the admission
Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral
infarction (stroke- loss of blood flow to a part of the brain) and post-traumatic stress disorder (PTSD- a
disorder in which a person has difficulty recovering from experiencing or witnessing a traumatic event).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/26/2026, the
MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and
required maximal assistance (helper does more than half the effort) with toileting, bathing, and dressing.
During a review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a
patient's baseline in physical, cognitive, behavioral, or functional status which without immediate
intervention, may result in complications or death) dated 1/26/2026 at 9:08 p.m., the COC indicated
Resident 1 was concerned about the use of foul language by CNA 1 in her presence. During a review of the
facility's Investigation Summary and Conclusion Report dated 1/30/2026, the Investigation Summary and
Conclusion Report indicated that CNA 1 used an inappropriate word inadvertently (doing something by
accident) towards Resident 1 while inside the resident's room. During an interview on 2/5/2026 at
12:17p.m., with CNA 1, CNA 1 stated when she was in Resident 1's room, she spilled a cup of water and
cursed in front of Resident 1. CNA 1 stated her using foul language in front of Resident 1 could make
Resident 1 feel upset and uncomfortable. During an interview on 2/5/2026 at 3:17 p.m., with the Director of
Nursing (DON), the DON stated CNA 1 used foul language in front of Resident 1 and Resident 1 stated she
did not appreciate CNA 1 blurting that out in front of her. During a review of the facility's P&P titled Abuse
Prevention and Prohibition Report dated 7/9/2024, the P&P indicated, Each resident has the right to be free
from abuse. The P&P indicated the facility is committed to protecting residents from abuse by anyone
including facility staff. During a review of the facility's P&P titled, Definitions: Abuse & Neglect dated
10/2023, the P&P indicated, Verbal abuse means the use of oral, written, or gestured language that willfully
includes disparaging and derogatory terms to residents or to their families, or within their hearing distance,
regardless of their age, ability to comprehend, or disability.
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:
056425
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
056425
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Studebaker Healthcare Center
13226 Studebaker Rd
Norwalk, CA 90650
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F609Based
on interview and record review, the facility failed to report an abuse allegation to the California Department
of Public Health (CDPH), for one of three sampled residents (Resident 2), when Resident 2 reported to the
Director of Staff Development (DSD) that Certified Nurse Assistant (CNA) 2 made a sexually inappropriate
gesture while providing him with personal care.This deficient practice placed Resident 2 at risk of
embarrassment and anger and had the potential to place Resident 2 and all other residents at risk in the
facility for sexual abuse.Findings:During a review of Resident 2's admission Record, the admission Record
indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2
had diagnoses including amyotrophic lateral sclerosis (ALS- a fatal neurological disordered characterized
by progressive degeneration of nerve cells in the spinal cord and brain) and major depressive disorder (a
mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident
2's Minimum Data Set (MDS- a resident assessment tool) dated 11/7/2025, the MDS indicated Resident 2's
cognition (ability to think, understand, learn, and remember) was intact and was dependent on activities of
daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During an
interview on 2/5/2026 at 10:43 a.m., Resident 2 stated CNA 2, made an inappropriate sexual gesture in
front of him. Resident 2 stated CNA 2 made a thrusting gesture with his pelvic area (part of the body
between the legs) on the grey stool in his room, which he stated was offensive to him. Resident 2 stated he
felt CNA 2 was making fun of his sexual orientation and this made him feel angry. Resident 2 stated he told
the DSD what CNA 2 had done and because the DSD was a mandated reporter, the DSD should have
reported it when he told her.During an interview on 2/5/2026 at 11:00 a.m., with the DSD, the DSD stated
Resident 2 did tell her about CNA 2's inappropriate gesture but she did not report it. The DSD stated
Resident 2 told her he felt as if CNA 2 was mocking his lifestyle because he is gay (attracted to one's same
gender). The DSD stated she is a mandated reporter, and this allegation should have been reported for the
resident's safety and to ensure a proper investigation was completed.During an interview on 2/5/2026 at
3:17 p.m., with the Director of Nursing (DON), the DON stated the DSD should have reported Resident 2's
allegations immediately after Resident 2 told her. The DON stated Resident 2's allegation is a form of abuse
and the alleged gesture made by CNA 2 could potentially have made him feel offended and embarrassed.
The DON stated the allegation made by Resident 2 should have been reported so a proper investigation
could have been done and so they could monitor Resident 2 for emotional distress.During a review of the
facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 7/9/2024, the
P&P indicated, The facility will report allegations of abuse immediately, but no later than 2 hours after
forming a suspicion- if the alleged violation involves abuse to the state survey agency, law enforcement,
and the Ombudsman.
Event ID:
Facility ID:
056425
If continuation sheet
Page 2 of 3
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
056425
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Studebaker Healthcare Center
13226 Studebaker Rd
Norwalk, CA 90650
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)
F 0610
Respond appropriately to all alleged violations.
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 implement its abuse policy and procedure (P&P) titled,
Abuse Prevention and Prohibition Program by failing to investigate an allegation of sexual abuse for one of
three sampled residents (Resident 2).This deficient practice had the potential to result in unidentified abuse
in the facility and failure to protect all residents in the facility from abuse.Findings:During a review of
Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the
facility on [DATE] and readmitted on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS- a
fatal neurological disordered characterized by progressive degeneration of nerve cells in the spinal cord
and brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and
loss of interest).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool)
dated 11/7/2025, the MDS indicated Resident 2's cognition (ability to think, understand, learn, and
remember) was intact and was dependent on activities of daily living (ADLs- activities such as bathing,
dressing, and toileting a person performs daily).During an interview on 2/5/2026 at 10:43 a.m., with
Resident 2, Resident 2 stated Certified Nurse Assistant (CNA) 2, made an inappropriate sexual gesture in
front of him. Resident 2 stated CNA 2 made a thrusting gesture with his pelvic area (part of the body
between the legs) on the grey stool in his room which he stated was offensive to him. Resident 2 stated he
felt as if CNA 2 was making fun of his sexual orientation and this made him feel angry. Resident 2 stated he
told the Director of Staff Development (DSD) what CNA 2 had done and because he himself is a mandated
reporter, the DSD should have reported it when he had told her.During an interview on 2/5/2026 at 11:00
a.m., with the DSD, the DSD stated Resident 2 did tell her about CNA 2's inappropriate gesture but she did
not report it. The DSD stated Resident 2 told her he felt as if CNA 2 was mocking his lifestyle because he is
gay (attracted to one's same gender). The DSD stated she is a mandated reporter, and this allegation
should have been reported for the resident's safety and to ensure a proper investigation was
completed.During an interview on 2/5/2026 at 12:11 p.m., with CNA 3, CNA 3 stated any inappropriate
sexual gesture such as a thrusting gesture with their crotch, is considered a form of abuse and should be
reported for the safety of the residents. CNA 3 stated an inappropriate sexual gesture could cause the
residents to feel uncomfortable.During an interview on 2/5/2026 at 3:17 p.m., with the Director of Nursing
(DON), the DON stated the DSD should have reported Resident 2's allegations immediately after Resident
2 told her. The DON stated Resident 2's allegation is a form of abuse and the alleged gesture made by
CNA 2 could potentially have made him feel offended and embarrassed. The DON stated the allegation
made by Resident 2 should have been reported so a proper investigation could have been done and so
they could monitor Resident 2 for emotional distress.During a review of the facility's P&P titled, Definitions:
Abuse & Neglect dated 10/2023, the P&P indicated, Verbal abuse means the use of oral, written, or
gestured language that willfully includes disparaging and derogatory terms to residents or to their families,
or within their hearing distance, regardless of their age, ability to comprehend, or disability. During a review
of the facility P&P titled Abuse Prevention and Prohibition Program dated 7/9/2024, the P&P indicated the
facility promptly and thoroughly investigates reports of resident abuse. The P&P indicated if facility staff
members are accused of committing abuse against a resident, they are suspended until the investigation is
complete and the findings have been reviewed by the Administrator.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056425
If continuation sheet
Page 3 of 3