Health inspection·December 19, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure privacy during care for three of eight residents (Residents 2, 3, and 4) when certified Nursing Assistants (CNA) 1, CNA 2, and CNA 3 did not fully close the privacy curtains while providing care. This failure had the potential to affect the dignity and self-worth of Residents 2, 3, and 4. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/15/2025 with diagnoses including generalized muscle weakness, difficulty in walking, lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), and morbid obesity (severely overweight). During a review of Resident 2's History and Physical (H&P), dated 9/1/2025, the H&P indicated, Resident 2 had the capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 2 was understood by staff and was able to understand others. The MDS indicated, Resident 2 required partial to moderate assistance for activities of daily living (ADLs-activities such as bathing, dressing, personal/oral hygiene, and toileting). During an observation on 9/22/2025 at 9:00 a.m. in Resident 's room, Certified Nursing Assistant (CNA) 1 was providing ADLs to Resident 2. The privacy curtain was halfway closed while Resident 1 was being provided with incontinent care. Resident 2's bedside window curtains were open, and the resident was visible from the outside of the window. During an interview on 9/22/2025 at 10:05 a.m. with Resident 2, Resident 2 stated having privacy was important to feeling safe. Resident 2 stated feeling embarrassed if exposed to other residents or staff in the room. During an interview on 9/22/2025 at 12:03 p.m. with CNA 1, CNA 1 stated keeping the curtains closed was important for residents' privacy. CNA 1 stated residents would feel embarrassed if curtains were open while receiving care. b. During a review of Resident 3's admission Record, the admission Record indicated, the facilityadmitted Resident 3 on 3/10/2015 with diagnoses including epilepsy (a long-term chronic disease thatcauses repeated seizures due to abnormal electrical signals produced by damaged brain cells), overactivebladder, dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disordercharacterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's H&P, dated 5/28/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severe cognitive (ability to think, learn, remember, use judgement, and make decisions) impairment. The MDS indicated Resident 3 required partial to moderate assistance for ADLs. During a concurrent observation and interview on 9/22/2025 at 9:30 a.m. in Resident 3's room, CNA 2 was providing ADLs to Resident 3. The privacy curtain was halfway closed when Resident 3 was being provided with incontinent care. Resident 3 was observed to be naked. CNA 2 stated the curtains must be closed all the way for residents' privacy. c. During a review of Resident 4's admission Record, the admission Record indicated the Page 1 of 2 055072 055072 12/19/2025 Rosecrans Care Center 1140 West Rosecrans Avenue Gardena, CA 90247

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility admitted Resident 4 on 10/4/2023 with diagnoses including epilepsy, generalized muscle weakness, dementia, hemiplegia (total paralysis ofthe arm, leg, and trunk on the same side of the body), hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), and diabetes mellitus.During a review of Resident 4's H&P, dated 1/26/2024, the H&P indicated, Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE] the MDS indicated Resident 4 had severe cognitive impairment. The MDS also indicated Resident 4 required maximum assistance for ADLs. During a concurrent observation and interview on 9/22/2025 at 9:57 a.m. in Resident 4's room, CNA 3 was providing ADLs to Resident 4. Resident 4 was observed with the entire body exposed. The privacy curtain was only halfway closed. CNA 3 was in the process of cleaning Resident 4 while the resident remained naked. CNA 3 stated curtains needed to be closed all the way to provide privacy. During an interview on 9/22/2025 at 12:16 p.m. with CNA 3, CNA 3 stated closing the curtain was important to provide privacy to Residents. CNA 3 stated residents would feel embarrassed, and uncomfortable if privacy were not provided to them.During an interview on 9/22/2025 at 1:05 p.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated providing privacy such as closing the doors, and curtains were important for respect and dignity purposes. LVN 1 stated residents would feel embarrassed if they were exposed during care. During an interview on 9/22/2025 at 2:45 p.m. with Registered Nurse (RN) 1, RN 1 stated to ensure residents' privacy, staff are expected to knock before entering, introduce themselves, close privacy curtains, and explain the procedures to be performed. RN 1 stated failing to close curtains before providing care can affect a resident's dignity and make them feel embarrassed, which may affect the residents psychologically. During a review of the facility's Policy & Procedure (P&P) titled, Dignity, revised on February 2021, the P&P indicated, Each resident shall be cared for in a manner that respects and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of the facility's P&P titled, Residents Rights Guidelines for all Nursing Procedures, revised on October 2010, the P&P indicated, facility was to close the room entrance door and provide for the resident's privacy. 055072 Page 2 of 2