Health inspection·September 10, 2024

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (F, A unit of temperature measurement) for 17 of 17 residents (Resident 1 to Resident 17) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. This deficient practice placed the 17 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On 9/09/2024, at 10:50 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death of a resident) situation for the facility's failure to provide a safe environment to the residents by failing to maintain an acceptable residents' rooms temperature range of 71 to 81 degrees Fahrenheit in the presence of the Chief Nursing Officer (CNO) and the Chief Operational Officer (COO). On 9/10/2024, at 1:30 p.m. the facility submitted an IJ Removal Plan (immediate action that includes all actions the entity has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), which was not accepted. On 9/10/2024, at 4:30 p.m., the survey team conducted an exit conference with the CNO, the assistant CNO (ACNO), the Director of Quality and Risk (DQR), the Director of Plant Operations (DPO), and the Sub-Acute Manager (SAM) and exited the facility, with the IJ situation not removed. Findings: According to an internet article from the California's Governor Office of Emergency Services (Cal OES) https://news.caloes.ca.gov/cal-oes-urges-californians-to-take-precautions-amid-extreme-heat-in-southern-california/ published on September 5th 2024, the article indicated As extreme heat blankets Southern California with high temperatures now expected through Monday evening, Cal OES has moved to Phase II of the Extreme Temperature Response Plan, .Heat can be deadly and it often catches people by surprise, said the Chief Deputy Director of the Governor's Office of Emergency Services. It's important for all Californians to do their part and take steps to stay safe in dangerously hot conditions. (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 6 Event ID: 555874 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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)