Health inspection·August 28, 2024

F 0579 Provide information about how to apply for and use Medicare and Medicaid benefits. 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 staff failed to ensure one out of two sampled residents (Resident 1) was informed about her medical coverage during her stay at the facility by: Residents Affected - Few 1. Not informing Resident 1 that she did not have a secondary coverage (insurance that pays after primary coverage, it will cover the remaining costs that the primary insurance did not cover) for the length of her stay at the facility. 2. Not assisting Resident 1 with the process of applying for a secondary coverage. These deficient practices resulted in Resident 1 to live at the facility without being informed she had no medical coverage and Resident 1 received a medical bill for the uncovered amount. 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 depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 1's History and Physical (H&P) dated 3/19/2021, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/25/2021, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for oral hygiene, toileting hygiene, dressing, and shower/bathing. During a review of Resident 1's electronic medical record, the electronic medical record indicated there was no documentation indicating Resident 1 was informed of no secondary coverage for her stay at the facility. The electronic medical record did not indicate the staff attempted to discuss Resident 1's medical coverage. During a review of Resident 1's Medicare Eligibility form, dated 2/19/2021, the Medicare Eligibility form indicated there was no recorded eligibility for requested date of service 2/1/2021. During an interview on 8/28/2024 at 1:12 p.m. with the Administrator, the Administrator stated Resident 1's last day of medical coverage was on 3/18/2021. The administrator stated Resident 1 was (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: 056478 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 056478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lighthouse Healthcare Center 2222 Santa Ana Blvd. Los Angeles, CA 90059 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)