Health inspection·February 28, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure, activities of daily living, for three of four residents (Residents 1, 3 and 4), were attended to, promptly. Residents Affected - Few This deficient practice had the potential to result in residents developing skin breakdown and other needs not met. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included difficulty walking, muscle weakness, and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). During a review of Resident 1 ' s history and physical (H&P) dated 1/1/2024, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 1/30/2024, the MDS indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and could understand and be understood by others. The MDS indicated Resident 2 required substantial/ maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s care plan titled, Activity of Daily Living (ADL), dated 1/18/2024, the ADL care plan indicated, Resident 1 needs extensive assistance on ADLs total dependence on staff. One of Resident 1 ' s care plan interventions indicated to place call light within reach, prompt Resident 1 to use call light when assistance is needed and answer promptly. During an interview on 2/27/2024 at 9:08 a.m., Resident 1 stated, he needed assistance from two nurses when getting up from bed. Resident 1 stated, the 11:00 p.m. to 7:00 a.m. nursing staff took 30 minutes to one hour to answer call lights when he needed assistance to get up to use the bathroom or change brief. Resident 1 stated, it was never okay for the nurses to take long to come and assist with care. During a review of Resident 3 ' s admission record, the admission record indicated Resident 3 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included difficulty walking (problems with the joints, bones, circulation) muscle weakness (commonly due to lack of exercise, ageing, muscle injury), and acute osteomyelitis, right ankle, and foot (infection in a bone). Page 1 of 3 056019 056019 02/28/2024 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 3 ' s H&P dated 12/16/2023, the H&P indicated Resident 3 had the mental capacity to understand and make medical decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills (thought process) was independent. The MDS indicated Resident 3 required substantial/ maximal assistance with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 3 ' s activities of daily living (ADL) care plan dated 2/6/2024, the care plan indicated, Resident 3 had an alteration with ADL functions related to generalized weakness requiring assistance with ADLs. Resident 3's care plan interventions indicated, assist with ADLs as needed and maintain call light within easy reach and answer promptly. During an interview on 2/27/2024 at 10:00 a.m., Resident 3 stated he needed nurse's assistance to get up and use the bedside commode at night because he had incontinence episode and would need brief to be changed. Resident 3 stated, when he pressed the call light at night, it took the staff an hour to answer the call light to assist him to use the bedside commode, or changed brief when was wet. Resident 3 stated he does not want to develop a diaper rash because of my wet brief. During a review of Resident 4 ' s admission record, the admission record indicated Resident 4 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis that muscle weakness, alcoholic cirrhosis of liver with ascites (buildup of fluid in your abdomen) and encephalopathy (brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe). During a review of Resident 4 ' s H&P dated 1/11/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognitive skills was independent. The MDS indicated Resident 4 required substantial/ maximal assistance with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 4 ' s ADL care plan for dated 2/6/2024, one of the interventions indicated to assist Resident 4 with ADLs as needed, maintain call light within easy reach and answer promptly. During an interview on 2/27/2024 at 10:30 a.m., Resident 4 stated at nighttime, it took the nurses to answer the call light longer than 30 minutes to empty the urinal. Resident 4 stated, it made me feel bad to wait a long time for the nurses to come. During a record review on 2/27/2024 at 12:30 p.m., the Resident Council Meeting dated 11/2023 and 12/2023 was reviewed. The meeting indicated nursing problems and concerns against 3 p.m.-11 p.m. and 11 p.m. -7 a.m. shifts answering call lights longer. The Resident Council Meeting dated 1/2024 indicated nursing problems and concerns with 11 p.m.-7 a.m. shifts answering call lights longer. During an interview on 2/27/2024 at 1:00 p.m., the Director of Nursing (DON) stated, everybody is responsible in answering the call light. DON stated, it was important to answer the call lights in a timely manner because the resident could fall or have any medical issues. During an interview on 2/27/2024 at 2:52 p.m., CNA 3 stated, it was hard to answer the call lights promptly when you were assigned 16-17 residents. CNA 3 stated, most of the time, residents became so 056019 Page 2 of 3 056019 02/28/2024 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few upset because it took us (CNAs) to answer call lights longer. CNA 3 stated, the call lights should be answered promptly, to respond to emergency situations, like falls. CNA 3 stated it is the facility ' s responsibility to provide the best quality care to residents. During an interview on 2/27/2024 at 3:00 p.m., the Registered Nurses (RN) stated, answering call lights is everybody ' s job at a facility. RN stated, if we do not answer the call light in a timely manner, residents could fall, aspirate, and can have skin issues. RN stated prevention of incidents and complications are important to provide to residents. During an interview on 2/27/2024 at 3:25 p.m., the DON stated, having the right number of nurses is very important so they can attend to residents ' needs promptly, prevent falls, bedsores, and provide good, quality care to the residents. During a review of the facility ' s undated policy and procedure (P/P) titled, Certified Nurse Assistant, the P/P indicated to timely answer call lights of assigned and unassigned residents. During a review of the facility ' s P&P, titled, Resident Call System dated 10/2022, the P&P indicated the facility is adequately equipped to allow residents to call staff assistance through a communication system which relays the call directly to a staff member to respond to the resident ' s request and needs. 056019 Page 3 of 3