Health inspection·May 20, 2025

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1 ' s change in condition evaluation form (used to document and report changes in a person ' s health or physical condition) dated 5/8/2025 indicated Resident 1 was not picked up for dialysis due to transportation company reporting that insurance would not cover the transportation. The nurse practitioner (NP) was informed and recommended to transfer Resident 1 to GACH to receive dialysis. During a concurrent interview and record review on 5/20/2025 with The Director of Social Services (DSS), Resident 1 ' s nursing progress note dated 5/8/2025 was reviewed. The Nursing progress note indicated transportation for dialysis did not show up. Resident 2 ' s insurance plan was contacted and verified Resident 2 ' s insurance was no longer active. The DSS contacted the family to manage the insurance. The DSS set up new transport with a different company for wheelchair (WC) pick up at 4:45 a.m. Nursing staff was made aware. The DSS stated, Resident 1 usually went to dialysis via gurney (bed) transport because Resident 1 ' s chair time (scheduled time to be at dialysis to start treatment) was so early in the morning that is what Resident 1 preferred and Resident 1 ' s insurance was able to accommodate. The DSS stated, however when I arranged the new transport, I set it up for WC pick up because Resident 1 sits in the same WC while in the facility. After I made the arrangements, I informed the resident, and I informed nursing staff by placing the new order for WC transport in the communications section (a secure format within the electronic medical record (EMR-digital collection of a patient ' s medical information) that facilitates messaging between care team members). A review of Resident 1 ' s nursing progress note dated 5/8/2025 (Thursday) timed at 3:50 p.m. indicated Resident 1 was sent to GACH for dialysis. A review of Resident 1 ' s nursing progress note dated 5/9/2025 (Friday) indicated Resident 1 returned from GACH at 5:30 p.m. A review of Resident 1 ' s nursing progress note dated 5/10/2025 (Saturday) indicated transportation did not pick up Resident 1 today for dialysis; transport person did not bring a gurney. During an interview on 5/20/2025 at 11:32 a.m. with Resident 1, Resident 1 stated, I missed dialysis on 5/10/2025 (Saturday) because I thought I was going on a gurney, but they showed up with a WC and the nurses did not know it was switched from a gurney to a WC. The night nurse called and got me a new appointment so when another transporter showed up, I asked them if they were taking me to my dialysis place and they said no we are taking you to the GACH. I was shocked and a little upset asking, why, that hospital is not going to put up with me coming there twice in one week. When I arrived at the GACH they said, you were just here yesterday and I said, I tried to tell them. So, I stayed at the GACH all day, had lunch there then they sent me back; I did not get dialysis because they just did it the day before. I made up the session I missed Saturday on 5/12/2025 (Monday). During an interview on 5/20/2025 at 1:04 p.m. with RN 1, RN 1 stated, I work the 11:00 p.m. to 7:00 a.m. shift. The transport guy showed up with a WC not a gurney. I missed in the communications that Resident 1 would be going in the WC. Resident 1 usually went on a gurney so the transportation guy left. After transportation left that is when I saw in communications that Resident 1 was supposed to go by WC. I tried to call them back but there was no answer. I tried to fix the situation by scheduling another chair time for 2:00 p.m . When I left at 3:00 p.m. I endorsed (outgoing nurse completing the shift and handing over patient care information to the incoming shift) to the next RN. I don ' t know how Resident 1 ended up at the GACH. I should have checked the communication before transportation left. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055350 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 055350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Culver West Health Center 4035 Grandview Blvd. Los Angeles, CA 90066 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/20/2025 at 2:58 p.m. with RN 2, RN 2 stated, On 5/10/2025 (Saturday) I came in at 8:00 a.m. and RN 1 told me Resident 1 missed dialysis because the transportation arrived with a WC and not a gurney. RN 2 continued, RN 1 stated WC was not an option because Resident 2 always went by gurney, so RN 1 told me to keep trying to call transportation because RN 1 was trying to call prior to my arrival but was unsuccessful. RN 2 then stated, RN 1 told me the protocol was to send Resident 2 to the GACH for dialysis if I was unable to reach transportation and RN 1 provided the number for the transportation company. RN 2 stated, Previously, I knew Resident 1 was supposed to be transported via WC because I saw it in the communication section on 5/9/2025. Every time I come to work; I check the communication section however I was not here at the time transportation showed up with the WC. I continued to call for transportation with no success. Then I called the dialysis to try to reschedule another chair time and they were booked for the day, and they were closed the following day (Sunday). : At this point, I thought Resident 1 ' s last day she received dialysis was on 5/8/2025 and I did not want Resident 1 to miss it for another two days so I called the doctor and got the order to send Resident 1 to the GACH for dialysis. Resident 1 returned later that same day around 6:00 p.m. A review of the facility's policy and procedures (P&P) titled, Hemodialysis, Care of Resident, revised on 1/12/2025, the P&P indicated, To have pertinent data available for all care givers of dialysis residents to decrease errors and provide quality care. POLICY: It is the policy of this facility to document the information below on the resident's care plan. I. Dialysis order. 2.Transportation - Name, phone number. 3.Dialysis center· Name and phone number. 4.Dialysis days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055350 If continuation sheet Page 3 of 3