Health inspection·January 24, 2025

F 0555 Honor the resident's right to choose his or her attending physician. 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: Residents Affected - Few 1. Ensure resident was involved in decision making and notified in change of physician for one of one sampled resident (Resident 52). This failure had violated Resident 52's resident rights to choose her own physician. Findings: During a review of Resident 52's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 52 was admitted to the facility on [DATE]. The admission Record indicated, Resident 52's diagnoses included left hip osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hypertension ([HTN] - high blood pressure), and hyperlipidemia (a condition where there are high levels of fats, or lipids, in the blood). During a review of Resident 52's History and Physical (H&P), dated 12/21/2024, the H&P indicated, Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/27/2024, the MDS indicated, Resident 52 had the ability to express ideas and wants and ability to understood others. The MDS indicated Resident 52's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 52 required substantial assistance (helper does more than the effort) from staff with toileting hygiene and lower body dressing. During a review of Resident 52's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 52 had a change of physician order on 1/21/2025 due to insurance coverage. During an interview on 1/22/2025 at 1:34 p.m., with Resident 55, Resident 52 stated she was not aware regarding her change of physician. Resident 52 stated she had the right to be informed and choose her own physician since she would be responsible for the care and treatment of her medical condition while at the facility. During a concurrent interview and record review on 1/22/2025 at 2:44 p.m., with the Director of Nursing (DON), Resident 52's clinical records were reviewed. The DON stated there was no documentation by facility staff indicating Resident 52 was notified regarding her change of physician. The DON Page 1 of 36 056019 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the facility did not validate with the resident regarding her new physician. The DON stated the change of physician was made due to change of Resident 52's level of care from skilled care (a type of medical care that requires the expertise of a licensed professional , such as a nurse or therapist) to custodial care (non-medical assistance with daily activities for people who need help with personal care). The DON stated no matter what the reason would be for a change of physician, Resident 52 should had given an opportunity to choose her own physician, and the facility violated Resident 52's rights to be informed of her new physician. During a review of the facility's policy and procedure (P&P), titled Choice of Attending Physician, dated 3/2023, the P&P indicated, The facility supports each resident's right to choose his or her attending physician. The P&P indicated the facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. During a review of the facility's P&P, titled Resident Rights, dated 3/2023, the P&P indicated, Residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 056019 Page 2 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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: Residents Affected - Few 1. Implement the facility's policy and procedures on reporting an unusual occurrence when Resident 58 left the facility and did not return. This deficient practice had the potential to result in serious harm, injuries and death. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of the facility's out on pass log, Resident 58 signed out on 11/19/2024 at 9:54 a.m. and did not return to the facility. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the faciity on [DATE] and did not return. The DON stated the facility did not inform law enforcement nor CDPH within 24 hours of Resident 58 not returning to the facility. The DON stated the risk of not following the facility's policy and procedures could result in serious harm or death for a resident. A review of the facility's policy and procedures, titled Reporting Unusual Occurrences, revised 03/2023, indicated, Our facility will report the following events to appropriate agencies: Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. and Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 056019 Page 3 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to: Residents Affected - Few 1. Report to California Department of Public Health (CDPH) of resident leaving and not returning to the facility on [DATE] for one of two sampled residents (Resident 58). This deficient practice resulted in the delay of investigation by the CDPH. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of the facility's out on pass log, Resident 58 signed out on 11/19/2024 at 9:54 a.m. and did not return to the facility. During an interview, on 01/24/2025 at 2:35 p.m., with the Director of Nursing (DON), the DON stated Resident 58 left the faciity on [DATE] and did not return to the facility. The DON stated Resident 58 did not have a phone and was unable to be contacted. The DON stated Resident 58's housing case worker and nurse practitioner was notified of Resident 58 not returning to the facility by the Social Services Director. The DON stated the facility did not notify Resident 58's primary physician, local law enforcement nor CDPH of Resident 58 not returning the facility. The DON stated there was no documentation by licensed staff on Resident 58 not returning to the facility. The DON stated the risk of not reporting a resident not returning to the facility in a timely manner could result in not knowing whether the resident was safe or alive. We should have been concerned. During an interview, on 01/24/2025 at 3:28 p.m., with the Administrator (ADM), the ADM stated Resident 58 would leave the facility multiple times for hours and would always return. The ADM stated on 11/19/2024. Resident 58 took some of his belongings and did not return to the facility. The ADM 056019 Page 4 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 58 left on his own will. The ADM stated he did not believe Resident 58 not returning to the facility affected the facility operations. The ADM stated law enforcement and CDPH were not notified as Residents have a right to go on pass and have a right to not come back to the facility. The ADM abruptly terminated the interview. A review of the facility's policy and procedures, titled Out on Pass Therapeutic Leave, dated 07/2024, indicated, When a resident has not returned from therapeutic leave as expected. the facility staff shall attempt to contact the resident and resident representative and document such efforts in the medical record. A review of the facility's policy and procedures, titled Abuse Prohibition and Prevention Program, revised March 2023, indicated The facility shall report all alleged violations and all substantiated incidents: (a) To the state agency and to all other agencies as required. And Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. A review of the facility's policy and procedures, titled Reporting Unusual Occurrences, revised 03/2023, indicated, Our facility will report the following events to appropriate agencies: (h) Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 056019 Page 5 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Ensure a smoking safety assessment was completed for one of 6 sampled residents (Resident 48). 2. Ensure an assessment was completed before going out on pass for one of 2 sampled residents (Resident 58). This deficient practice had the potential to result in a safety hazard for Resident 48 and serious harm for Resident 58. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's care plan, dated 12/31/24, indicated Resident 48 was noted to have a care plan for tobacco use. Resident 48's care plan indicated Resident 48 would adhere to the tobacco/smoking policies of the facility. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. During a concurrent interview and record review, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated Resident 48's smoking safety assessment was incomplete. The DON stated Resident 8's smoking safety assessment should've had a progress notes stating Resident 48 was an independent smoker. The DON stated the risk of not completing a smoking safety assessment could result in unsupervised smoke breaks and a safety issue. b. During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted on [DATE] with diagnoses which included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). 056019 Page 6 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 58's History and Physical (H&P), dated 11/4/2024, the H&P indicated Resident 58 had the capacity to understand and make decisions. During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of Resident 58's assessments, there was no assessment found to determine if Resident 58 was able to leave the facility. During an interview, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated the facility did not conduct an assessment to determine nor obtain a physician's order on whether a resident was able to go out on a pass. The DON stated residents who were alert and oriented were able to leave the facility as they wished. The DON stated the risk of not obtaining an assessment for a resident who leaves the facility could result in serious harm or death if a resident wasn't assessed. A review of the facility's policy and procedures, titled Quality of Care, revised 03/2023, indicated, The interdisciplinary Team shall assess risk factors which place the resident at risk for specific conditions and/or problems. A review of the facility's policy and procedures, titled Resident Assessments, dated ?, indicated The facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 056019 Page 7 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0641 Ensure each resident receives an accurate assessment. 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: Residents Affected - Few 1. Ensure the Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 17 sampled residents (Resident 36). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 36. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History and Physical (H&P), dated 12/12/2024, the H&P indicated, Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's MDS assessment, dated 12/19/2024, the MDS indicated, Resident 36's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 36 required moderate assistance (helper does less than half the effort) from staff with upper body dressing and personal hygiene. During a review of Resident 36's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 36's physician prescribed low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer) for wound management. During a concurrent interview and record review on 1/23/2025 at 8:28 a.m., with the Minimum Data Set Nurse (MDSN), Resident 36's MDS assessment, dated 12/19/2024 was reviewed. The MDSN stated Resident 36's MDS assessment was completed inaccurately. The MDSN stated Resident 36 MDS, under section M (Skin Condition) 1200B should have a checked mark on pressure reducing device on bed since Resident 36's had a physician's order for LALM. The MDSN acknowledge he did not encode the use of LALM on the MDS assessment. The MDSN stated by not completing the MDS assessment accurately, the facility is giving wrong information to the facility staff involved with resident and the care and services of resident would be affected. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessments, dated 10/2020, the P&P indicated, The facility ensures each resident receives an accurate assessment reflective of the resident's status at the time of the assessment by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. The P&P indicated the assessment must represent an accurate picture of the resident's status during 056019 Page 8 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0641 the observation period of the MDS. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056019 Page 9 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0644 Level of Harm - Minimal harm or potential for actual harm Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: Residents Affected - Few 1. Submit a Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for one of three sampled residents (Resident 21) which included an existing psychiatric diagnosis. This deficient practice resulted in a delay of Resident 21 receiving a PASSR II evaluation for mental health needs. Findings: During a review of Resident 21's admission Record (Face sheet), the admission Record indicated Resident 21 was re-admitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs) heart disease, hypertension (high blood pressure), and muscle weakness. During a review of Resident 21's Minimum Data Set (a comprehensive assessment and screening tool) dated 12/27/2024, the MDS indicated Resident 21 had severe impairment of cognitive skills for daily decision making. The MDS also indicated Resident 21, was receiving antidepressant medications. During a review of Resident 21's PASRR completed on 12/19/2019, the Level I PASRR indicated Resident 21 did not have a mental illness. During a review of Resident 21's physician's orders dated 12/28/2023, the physician orders stated to give Lexapro (used to treat anxiety and major depressive disorder) oral tablet 10 milligrams (mg, unit of weight) tablet once a day at night for major depressive disorder. During a review of Resident 21's Medical Administration Records (MAR- record that includes the date, time, medication name, dosage, administration method, and the name and signature of the administering healthcare professional), printed on 1/24/2025, the MAR indicated Resident 21 was receiving Lexapro related to major depressive disorder. During a review of the IDT (interdisciplinary team) assessment dated [DATE] indicated Resident 21 was taking Lexapro 10 mg once a day for depression. During an interview, on 1/22/2025 at 10:20 a.m., with the Director of Nursing (DON), the DON stated she was responsible for overseeing PASRR. The DON stated that she did not follow through with a PASRR regarding the need for Resident 21's Level II evaluation. The DON stated that Level II evaluation was to determine appropriate placement and/or the need for specialized services. A review of the facility's revised policy dated March 2023 and titled Preadmission Screening and Resident Review (PASRR) indicated that the facility will ensure individuals with a mental disorder or intellectual disability will continue to receive the care and services they need in the most 056019 Page 10 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0644 Level of Harm - Minimal harm or potential for actual harm appropriate setting when a significant change in their status occur and the facility Shall notify the appropriate state Mental health Authority when a resident with a mental disorder has a significant change in their mental condition. The facility will: 1. Residents Affected - Few Complete a PASRR for all residents on admission and refer those with mental illness or intellectual disability to the state. 2. Facility personnel shall make a referral to Level II resident reviewed evaluation is required individuals previously identified by PASRR to have a mental disorder. 3. Facility will report a resident with behavioral, psychiatric, mood-related symptoms that have not responded to ongoing treatment. 056019 Page 11 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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: Residents Affected - Few 1. Ensure a Level 2 Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) evaluation was obtained for one of six sampled residents (Resident 48). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 48. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Level 1 PASRR, dated 01/07/2025, the Level 1 PASRR indicated Resident 48's required a Level II PASRR evaluation. During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an interview, on 1/23/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated Resident 48's Level 1 PASRR was positive for a mental illness. The DON stated a Level 2 PASRR should had been resubmitted for Resident 48. The DON stated the risk of not resubmitting a PASRR for a resident could result in a delay in necessary mental health care and services. A review of the facility's revised policy, dated 03/2023, titled Preadmission Screening and Resident Review, dated 02/2023, indicated, Facility personnel shall make a referral for Level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. 056019 Page 12 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop an individualized person-centered care plan (a document that summarizes a person's health condition, care needs, and current treatments) with measurable objectives, timeframe, and interventions to meet the residents needs for two of two sampled residents (Residents 58 and 167) by failing to: 1. Ensure a care plan for out on pass was develop for Resident 58. 2. Ensure a care plan with interventions for Peripherally Inserted Central Catheter ([PICC] - a thin flexible tube that is inserted into a vein in the upper arm above the right side of the heart, used to give intravenous fluids, blood transfusions, and medications) line was develop for Resident 167. These deficient practices had the potential to negatively affect the delivery of care and services for Residents 58 and 167. Findings: a. During a review of Resident 58's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 58 was admitted to the facility on [DATE]. The admission Record indicated, Resident 58's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), dysphagia (difficulty swallowing), and acute kidney failure (a sudden loss of kidney function that prevents the kidneys from filtering waste and regulating electrolytes and fluids in the body). During a review of Resident 58's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/13/2024, the MDS indicated Resident 58's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated Resident 58 required moderate assistance (helper does less than the effort) from staff with toileting, showering and upper/lower body dressing. During a review of the facility's out on pass (a temporary permission of a patient to leave the hospital in a specified time) log, Resident 58 was noted signing in and out of the facility multiple times a week. During a review of Resident 58's care plan, there was no care plan in place for Resident 58 to go out on pass. During an interview, on 01/24/2025 at 2:17 p.m., with the Director of Nursing (DON), the DON stated care plans were to be initiated upon admission or during a change of condition for a resident. The DON stated Resident 58 did not have a care plan regarding going out on pass. The DON stated the risk of not having a care plan in place could result in inadequate and incompetent care. b. During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 167 was admitted to the facility on [DATE]. The admission Record indicated, Resident 167's diagnoses included 056019 Page 13 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some atrial fibrillation (irregular heartbeat), hypertension ([HTN] - high blood pressure), and polyneuropathy (a damage or disease affecting peripheral nerves), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 167's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/14/2025, the MDS indicated, Resident 167's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 167 required moderate assistance (helper does less than the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 167 had an Intravenous ([IV] - into or within the vein) access. During a review of Resident 167's Order Summary Report (a document containing active orders), dated 1/23/2025, indicated Resident 167's physician prescribed Ceftriaxone (medication to treat infection) 2 grams ([gm] - metric unit of measurement, used for medication dosage and/or amount) IV daily for right foot osteomyelitis. During a concurrent interview and record review on 1/22/2025 at 3:30 p.m., with Registered Nurse 2 (RN 2), Resident 167's clinical records were reviewed. RN 2 stated Resident 167 had a PICC line on right upper arm and receiving IV medication once a day. RN 2 stated the facility did not formulate an individualized care plan to address Resident 167's PICC line. RN 2 stated Resident 167's PICC line was at risk for complications since facility staff did not develop a care plan that includes care maintenance and interventions. RN 2 stated the purpose of the care plan was to keep track of the progress of the resident and serve as a communication tool among the interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) for resident's continuity of care. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 10/2020, the P&P indicated, The facility develops a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. 056019 Page 14 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Ensure physician orders were carried out for one of 6 sampled residents (Resident 31). 2. Provide services which meet professional standards of quality regarding smoking safety for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in skin breakdown for Resident 31 and a smoking accident for Resident 48. Findings: a. During a review of Resident 31's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 31 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis (a narrowing of the spinal column that occurs over time, putting pressure on the spinal cord and nerves), chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly), acute kidney failure (a sudden loss of kidney function that occurs when the kidneys are no longer able to filter waste from the blood) and embolism (a blockage in an artery caused by a blood clot or other substance) and thrombosis (blood clot) of the left lower extremity. During a review of Resident 31's history and physical (H&P), dated 7/30/2024, the H&P indicated Resident 31 had the capacity to understand and make decisions. During a review of Resident 31's physician orders, dated 12/12/2024, the physician orders indicated Resident 31 was to have a low air loss mattress (a mattress with tiny holes that slowly release air to keep the skin dry and cool, often used to treat and prevent bed sore) for skin management. During a review of Resident 31's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 01/3/2025, indicated Resident 31 cognitive skills were intact. The MDS indicated Resident 31 was dependent with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an observation, on 01/23/2025, at 9:12, in Resident 31's room, Resident 31 did not have an air loss mattress on the bed frame. Resident 31 stated he had been waiting for the facility to provide an air loss mattress since December of 2024 but did not receive one. Resident 31 stated he reported his mattress concerns to different staff members, but his concerns went unheard. During a concurrent interview and record review, on 01/23/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON stated all physician orders were to be carried out by licensed nurses. The DON stated Resident 31 had an order for 'Low Air Loss Mattress for skin management', with a start date 12/12/24. The DON stated Resident 31 did not have a Low Air Loss mattress as ordered. The DON stated the risk of not following the physician order for Resident 31 could had result in providing incomplete care and possible skin breakdown. 056019 Page 15 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0658 Level of Harm - Minimal harm or potential for actual harm b. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). Residents Affected - Few During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's care plan, dated 12/31/24, indicated Resident 48 was noted to have a care plan for tobacco use. Resident 48's care plan indicated Resident 48 would adhere to the tobacco/smoking policies of the facility. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. During a concurrent interview and record review, on 01/23/2025 at 3:30 p.m., with the DON, the DON stated Resident 48 did not have a physician's order for unsupervised smoking. The DON stated Resident 48's Smoking Safety Notes were incomplete. The DON stated the risk of not obtaining a physician's order for a smoking resident could result in a fire hazard. The facility's policy and procedures, titled Physician Medication Orders, dated 03/2023, did not disclose a policy regarding low air loss mattresses nor smoking safety. 056019 Page 16 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice, by failing to: Residents Affected - Few 1. Assess and monitor one of 6 sampled residents smoking safety (Resident 48). This deficient practice had the potential to result in serious harm due to smoking without supervision. 2. Ensure one out of six sampled residents (Resident 49) had their pain management referral processed timely. This deficient practice resulted in a delay in assessing, monitoring (Resident 48) and care to manage the pain of Resident 49. Findings: a. During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking assessment was found incomplete. Resident 48's smoking assessment did not indicate whether supervision was required while smoking. During an observation, on 01/21/25 at 2:34 p.m., Resident 48 was observed smoking a cigarette on the facility's smoking patio, unsupervised. During a concurrent interview and record review, on 01/22/2025, at 3:40 p.m., with the Director of Nursing (DON), the DON stated the protocol for tobacco users was to complete a smoking safety assessment form indicating whether a resident required supervision or was able to smoke independently/unsupervised. The DON stated Resident 48's smoking assessment form was incomplete. The DON also stated there were no Interdisciplinary Team (IDT- a group of healthcare professionals with different areas of expertise who work together to achieve a common goal) meetings in place regarding Resident 48's smoking safety. The DON stated the risk of not having a completed smoking assessment form could result in not knowing whether a resident required supervision and not being able to contract for safety. A review of the facility's policy and procedures, titled Quality of Care, revised 03/2023, 056019 Page 17 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated, The interdisciplinary Team shall assess risk factors which place the resident at risk for specific conditions and/or problems. b. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN-high blood pressure), compression fracture of the spine, and surgical amputation of right lower leg. During a review of Resident 49's History and Physical (H&P), dated 12/27/2024, the H&P indicated Resident 49 has the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS] a resident assessment tool) dated 1/9/2025, the MDS indicated Resident 49's cognition (ability to think and understand) was intact. Resident 49 needed moderate assistance with dressing the lower body, bathing, and toileting. Resident 49 received a scheduled pain management regimen within the last five days. During a review of Resident 49's care plan, dated 12/27/2024, the care plan indicated Resident 49 was at risk for pain and discomfort related to a right below the knee amputation. (During an interview on 1/21/2025 at 11:27 a.m. with Resident 49, Resident 49 stated he is waiting for a pain management referral, and he hasn't seen anyone. Resident 49 stated he feels pissed his pain isn't controlled. During a concurrent interview and record review on 1/23/2025 at 12:19 p.m. with Registered Nurse (RN) 1, Resident 49's order summary was reviewed. The order summary indicated Resident 49 had a physician's order entered on 1/5/2025 to receive a pain management referral. RN 1 stated the referral should be given to the business office right away for processing. RN 1 stated she gave the business office the referral on 1/22/2025. RN1 stated Resident 49's pain is not being managed due to the delayed processing of the pain management referral. During a concurrent interview and record review on 1/23/2025 at 12:25 p.m. with the Admissions Coordinator (AC), Resident 49's pain management referral packet fax was reviewed. The fax indicated the referral was transmitted to the health plan for approval on 1/22/2025 at 1:20 p.m. The AC stated she is notified by nursing staff when a resident needs a physician referral. The AC stated 1/22/2025 is the first time the referral was sent out for processing. During an interview on 1/23/25 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 49's pain medications are not enough to alleviate his pain. LVN 2 stated Resident 49's pain management referral has not been completed. LVN 2 stated it's not acceptable for the resident to wait 18 days for a referral. The resident is in excruciating pain. It seems like he got ignored. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated March 2023, the P&P indicated residents will receive treatment and care in accordance with professional standards of practice. 056019 Page 18 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure the low air loss mattress ([LALM] - a mattress designed to prevent and treat pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) was set and maintained at the correct setting for one of two sampled residents (Resident 36). This deficient practice placed Resident 36 at risk for worsening of pressure ulcer/injury and further skin breakdown. Findings: During a review of Resident 36's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 36 was admitted to the facility on [DATE]. The admission Record indicated, Resident 36's diagnoses included pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (large, triangle-shaped bone in the lower spine that forms part of the pelvis), sepsis (a life-threatening blood infection), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 36's History and Physical (H&P), dated 12/12/2024, the H&P indicated, Resident 36 had the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set ([MDS] - a resident assessment tool) dated 12/19/2024, the MDS indicated, Resident 36's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 36 required moderate assistance (helper does less than half the effort) from staff with upper body dressing and personal hygiene. The MDS indicated, Resident 36 had one unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound is obscured (hidden) by slough (non-viable yellow, tan, ray, green or brown tissue) or eschar (dead tissue that is hard or soft tissue in texture, usually black, brown, or tan in color, and may appear scab-like) and one deep tissue injury ([DTI] persistent non-blanchable deep red, [NAME] or purple discoloration). The MDS indicated, Resident 36 was at risk for developing pressure ulcers or injuries. During a review of Resident 36's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 36's physician prescribed LALM for wound management. During a review of Resident 36's Wound interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) Conference Record, dated 12/18/2024, the Wound IDT Conference Record indicated intervention for offloading measures with use of LALM. During a concurrent observation and interview on 1/21/2025 at 10:48 a.m., with Resident 36's in her room, Resident 36 was observed lying in bed. Resident 36 stated she was very extremely uncomfortable of her air mattress and the springs was so hard and it could touch her tail bone. During a concurrent observation and interview on 1/21/2025 at 10:55 a.m., with Treatment Nurse 1 056019 Page 19 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (TN 1) in Resident 36's room. TN 1 stated Resident 36's was lying on a LALM with a setting of 350 pounds (lbs. - unit of measurement in weight). TN 1 stated Resident 36 did not weigh 350 pounds. TN 1 stated Resident 36 current weight was 132 pounds. TN 1 stated the setting of LALM should be based on Resident 36's current weight. The TN 1 stated incorrect setting of the LALM would cause extra air pressure on the bony prominence that would result in discomfort of the resident and would result in deterioration of the wound. During an interview on 1/21/2025 at 12:02 p.m., with the Director of Nursing (DON), the DON stated LALM setting should be based on the current weight of the resident and the severity of the pressure ulcer as determined by the physician. The DON stated if the LALM was not properly set based on the current resident weight would result in delayed wound healing and possible development of new pressure ulcer. During a review of the facility's policy and procedure (P&P), titled Low Air Loss Mattresses, dated 11/2024, the P&P indicated, The facility has guidelines to provide residents with a low air loss mattress to reduce skin irritation and breakdown and to allow maximal effectiveness of the low air loss mattress when a physician orders such therapy. The P&P indicated for maintenance, settings and care, the facility shall follow the manufacturer's guidelines. During a review of the facility's P&P titled, Treatment Services to Prevent/Heal Pressure Ulcers, dated 3/2023, indicated to provide care and services consistent with professional standards of practice to promote healing of existing pressure ulcers/injuries, including prevention of infection to the extent possible and prevent the development of additional pressure ulcer/injury. 056019 Page 20 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Ensure one out of six sampled residents (Resident 37) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services timely and five days a week as ordered. This deficient practice had the potential to result in Resident 37 having a decline in function or development of contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion). Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of Resident 37's care plan, dated 1/9/2025, the care plan indicated Resident 37 was at risk for decline in the bilateral (both) upper extremities. The care plan intervention indicated the RNA will provide bilateral upper extremity range of motion exercises five times a week. During a review of Resident 37's care plan, dated 1/17/2025, the care plan indicated Resident 37 required the RNA program to maintain and/or improve joint mobility. During a review of Resident 37's care plan, dated 1/17/2025, the care plan indicated Resident 37 was at risk for decline in sit to stand transfers. The care plan intervention indicated the RNA program will help Resident 37 sit to stand with a walker five times a week. During a review of Resident 37's Physical Therapy Discharge Summary for dates of service 12/12/2024 to 1/8/2025, the summary indicated Resident 37's discharge recommendation was to start the RNA program. During a review of Resident 37's Order Summary Report, dated 1/23/2025, the report indicated Resident 37 had an order entered on 1/8/2025 for the RNA program to provide sit to stand exercises with a walker five times a week. The report indicated on 1/9/2025 an order was entered for the RNA to provide bilateral upper extremity range of motion exercises five times a week. 056019 Page 21 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 37's Document Survey Report, dated January 2025, the report indicated RNA services began on 1/16/2025. The report indicated RNA services were provided three days during the week of 1/12/2025 to 1/18/2025. During an interview on 1/23/2025 at 11:12 a.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated RNA services are provided to restore mobility and strength. RNA 1 stated he is informed by the director of rehab when a resident has a new order for RNA services. RNA 1 stated when a resident receives an order for RNA services it should be started the next day. If RNA services are not completed as ordered, the resident can have functional decline. RNA 1 cannot state why Resident 37 only received RNA services three days a week. During an interview on 1/23/2025 at 3:10 p.m. with the Director of Rehab (DOR), the DOR stated when residents are released from rehab and need to start RNA services, she directly gives the RNA the referral form. When RNA services are ordered it is started the next day. The DOR is unable to state why RNA services were ordered on 1/8/2025 and services were not started until 1/16/2025. The DOR stated if a resident does not receive RNA services as ordered they could have a decline in range of motion or mobility. The DOR cannot state why Resident 37 received RNA services only three days. During a review of the facility's policy and procedure (P&P) titled, Restorative Nurse Services, dated March 2023, the P&P indicated each resident shall receive restorative nursing care as needed to help promote optimal safety and independence. The facility will ensure each resident receives restorative nursing services as determined by their comprehensive care plan. 056019 Page 22 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Ensure whether supervision was required during smoke breaks and ensure the environment was free from a fire hazard for one of 6 sampled residents (Resident 48). This deficient practice had the potential to result in an accidental fire in the facility and lead to residents' injuries. Findings: During a review of Resident 48's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 48 was admitted on [DATE] with diagnoses which included epilepsy (seizures), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), nicotine dependence (a chronic disease that causes people to compulsively use nicotine) and encephalopathy (a brain disorder that affects brain function or structure). During a review of Resident 48's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/10/2025, indicated Resident 48 cognitive skills were intact. The MDS indicated Resident 48 required partial to moderate assistance with activities of daily living (ADLs-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During a review of Resident 48's smoking assessment, dated 12/31/24, Resident 48's smoking safety assessment was found incomplete. During a concurrent observation and interview, on 01/21/2025 at 9:25 a.m., with Resident 48, a lighter and empty pack of cigarettes was observed on Resident 48's bedside table. Resident 48 stated the facility allowed him to keep his smoking materials with him. Resident 48 stated he was allowed to freely smoke unsupervised on the smoking patio. During a concurrent interview and record review, on 01/23/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated residents who were alert and oriented were allowed to have their smoking materials in their possession. The DON stated Resident 48 was an independent smoker. The DON stated Resident 48's smoking safety assessment form was incomplete. The DON stated the risk of residents possessing their own smoking materials could result in a fire and safety issue. A review of the facility's policy and procedures, titled Smoking Policy, dated 03/2023, indicated Residents who express a desire to smoke will be assessed for deficits and capabilities to smoke safely. Assessments will be completed on admission and quarterly and as the resident's needs or capabilities change. A review of the facility's policy and procedures, titled Free of Accidents Hazards/Supervision/Devices, dated 12/2024, indicated All staff is involved in observing and identifying potential hazards in the environment. 056019 Page 23 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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: Residents Affected - Few 1. Ensure dental services were provided for one of 6 sampled residents (Resident 110). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 110's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 110 was admitted on [DATE] with diagnoses which included dependence on oxygen, thrombocytopenia, anemia and benign prostatic hyperplasia. During a review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 110 cognitive skills were intact. The MDS indicated Resident 58 required substantial to maximal assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an observation, on 01/21/2025 at 8:40 a.m., Resident 110 was observed receiving oxygen via nasal cannula. Upon observation of Resident 110's oxygen concentrator, the oxygen concentrator showed 1.5 liters of oxygen being delivered via nasal cannula. During a concurrent observation and interview, on 01/23/2025 at 8:23 a.m., with Licensed Vocational Nurse (LVN 2), LNV 2 observed Resident 110's oxygen concentrator. LVN 2 stated Resident 110 was receiving 1.5 liters of oxygen. LVN 2 reviewed Resident 110's physician order and stated Resident 110's physician order indicated he was to receive 2 liters of oxygen continuously via nasal cannula. LVN 2 stated the risk of not administering oxygen per physician order could result in oxygen desaturation (a decrease in the amount of oxygen in your blood). A review of the facility's policy and procedures, titled Oxygen Therapy, revised 03/2023, indicated Residents receiving oxygen therapy will have a physician order outlining administration. 056019 Page 24 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: Residents Affected - Few 1. Ensure a resident who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received care in accordance with standards of practice for one of two sampled residents (Resident 166) by failing to: 2. Ensure Resident 166's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was readily available at the bedside, in case of excessive bleeding from the dialysis site. This deficient practice had the potential to result in staff inability to manage and control the bleeding from Resident 166's dialysis site in the event of an emergency. Findings: During a review of Resident 166's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated 166 was admitted to the facility on [DATE]. The admission Record indicated, Resident 166's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure), hypertension ([HTN] - high blood pressure), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 166's Order Summary Report (a document containing active orders), dated 1/23/2025, the Order Summary Report indicated, Resident 166 was to receive HD treatment every Tuesday, Thursday, and Saturday. The Order Summary Report indicated, to monitor Resident 166's dialysis access site on right upper arm for redness, swelling, and pain. During a concurrent observation and interview on 1/21/2025 at 10:35 a.m., with Licensed Vocational Nurse 1 (LVN 1), in Resident 166's room, LVN 1 acknowledged and confirmed there was no dialysis E-KIT available at bedside. LVN 1 stated dialysis E-KIT consisted of dry gauze, tape, alcohol pads, bandage. LVN 1 stated Resident 166 had arteriovenous graft ([AV] - a surgical procedure that creates a connection between an artery and a vein using a synthetic tube) dialysis access site on right upper arm. LVN 1 stated dialysis E-KIT should be easily accessible and available at bedside at all times in case of an emergency bleeding. LVN 1 stated uncontrolled bleeding on the dialysis access site could cause resident to passed out that would likely require hospitalization and possible death. During an interview on 1/21/2025 at 12:04 p.m., with the Director of Nursing (DON), the DON stated it was the responsibility of the licensed nurses to check the dialysis E-KIT during the start of the shift and huddle meeting between the incoming and outgoing licensed nurses. The DON stated the dialysis E-KIT was a first aid kit that can be used in any emergency signs of bleeding. The DON stated it was a standard of practice to have dialysis E-KIT at bedside to all residents receiving HD treatment. During a review of the facility's policy and procedure (P&P), titled Dialysis Management, dated 3/2023, the P&P indicated, To provide residents who require dialysis care, services, consistent with professional standards of practice, a comprehensive person-centered care plan which meets the 056019 Page 25 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0698 residents goals and preferences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056019 Page 26 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Many 1.Ensure four of six sampled residents' (Residents 15, 30, 37, and 38) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 15, 30, 37, and 38 at risk of not having medication irregularities identified. Findings: A. During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 12/20/2011 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and end stage renal disease (irreversible kidney failure). During a review of Resident 15's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set ([MDS] a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 15's cognition (ability to think and understand) was intact. Resident 15 was dependent on staff with dressing, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). B. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) 056019 Page 27 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0756 Level of Harm - Minimal harm or potential for actual harm impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. Residents Affected - Many During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). C. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 38's History and Physical (H&P), dated 12/27/2024, the H&P indicated Resident 38 does not have the capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set ([MDS] a resident assessment tool) dated 1/8/2025, the MDS indicated Resident 38 was dependent on staff with dressing the lower body, bathing, and toileting. During a review of the facility's MRR binder, dated October 2024 through December 2024, Resident 15 did not have an MRR documented for the months of October through December. During a concurrent interview and record review on 1/22/2025 at 3:40 p.m. with the Director of Nursing (DON), the facility's MRR binder dated October 2024 to December 2024 was reviewed. The binder indicated only five residents received an MRR for the month of October. The DON stated someone should have called the consultant pharmacy to see if the remaining residents were reviewed for October. The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). The DON stated the MRR was needed if the pharmacist provided drug recommendations that the doctor needs to follow up on. The DON stated licensed nurses should follow up on the recommendations as soon 056019 Page 28 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many as possible because if the MRR was not done we would not know if drugs are contraindicated, some drugs could possibly need monitoring to prevent toxicity (state of being harmful). During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, dated March 2023, the P&P indicated the facility's licensed pharmacist shall review at least monthly, each resident's drug regimen to prevent or minimize adverse consequences related to medication therapy. The P&P indicated the pharmacist must review monthly in order to identify irregularities, clinically significant risks; and/or potential adverse consequences which may result from or be associated with medications. D. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted the resident on 8/16/2020 with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs), heart disease (a general term that include many types of heart problems ), hypertension (high blood pressure), and muscle weakness (decreased strength in muscles). During a review of Resident 30's Minimum Data Set (MDS - a resident assessment tool), dated 1/11/2025, indicated Resident 30's cognition and decision-making skills was severely impaired. The MDS indicated the resident required extensive assistance from staff for bed mobility, transfer, dressing, bathing, eating, toilet use, and personal hygiene. During a review of the resident's medical record, indicated there was no documented evidence that the MRR was done for the month of October, November and December 2024. During an interview, on 1/23/2025, at 2:28 p.m., with the Director of Nursing (DON), the DON was unable to provide documented evidence of the MRR report for the months of October 2024, November 2024 and December 2024. The DON stated the practice of the facility was to have MRR done monthly. The DON stated when there was a recommendation from the consultant pharmacist, the DON gives the pharmacist's recommendation to the Registered Nurse (RN) supervisor who faxes the recommendation to the physician, signs and files the recommendation in the resident's chart as evidence this was communicated to the physician. A review of the facility`s policy and procedure, revised on March 2024, titled Drug Regimen Review indicated the facility must ensure that a pharmacist reviews each resident's medical chart every month and perform a drug regimen review, including the following expanded requirements: 056019 Page 29 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure it was free of a medication error rate of five percent (5%) or greater, as evidenced by the identification of two out of 28 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 7.14% for one of two sampled residents (Resident 167) observed during the medication administration facility task by failing to: 2. Administer Resident 167's Calcium Carbonate with Vitamin D (vitamin supplement, a mineral that builds and maintain strong bones and teeth, and for important physical functions such as muscle control and blood circulation) as prescribed by the physician and to monitor pulse rate (measurement of the heart rate, or the number of tines the heart beats per minute) prior to administration of Metoprolol Tartrate (medication used to treat high blood pressure) as ordered by the physician. These deficient practices had the potential to result in harm to Resident 167 by not administering medication and following physician orders to meet resident individual medication needs. Findings: During a review of Resident 167's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 167 was admitted to the facility on [DATE]. The admission Record indicated, Resident 167's diagnoses included atrial fibrillation (irregular heartbeat), hypertension ([HTN] - high blood pressure), polyneuropathy (a damage or disease affecting peripheral nerves), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 167's Minimum Data Set ([MDS] - a resident assessment tool) dated 1/14/2025, the MDS indicated, Resident 167's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 167 required moderate assistance (helper does less than the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 167's Physician's Order, dated 1/11/2025, the order indicated to give Calcium Carbonate 500 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) with Vitamin D 5 micrograms ([mcg] - unit of mass) once a day at 9 a.m. for supplement. During a review of Resident 167's Physician's Order, dated 1/9/2025, the order indicated to give Metoprolol Tartrate 25 mg to give 1 tablet orally once a day at 9 a.m. for HTN, hold for systolic blood pressure ([SBP] the fist number in a blood pressure reading) less than 110 or pulse rate below 60. During a concurrent medication pass observation and interview on 1/22/2025 at 8:13 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed not giving the Calcium Carbonate 500 mg with Vitamin D 5 mcg to Resident 167. LVN 2 stated she did not have the house supply (over the counter medication) of the Calcium Carbonate 500 mg with Vitamin D 5 mcg on her medication cart 1 and that was the reason why she failed to administer the medication to the resident. During a concurrent medication pass observation and interview on 1/22/2025 at 8:27 a.m., with LVN 056019 Page 30 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2, LVN 2 was observed checking the pulse rate of Resident 167 after Metoprolol Tartrate was administered to Resident 167. LVN 2 stated she checked Resident 167's blood pressure but forgot to check the PR prior to the administration of Metoprolol Tartrate. LVN 2 stated she did not follow the physician's order of Metoprolol Tartrate since it has a parameter (specific instructions that you can measure) to hold if SBP less than 110 or pulse rate below 60. LVN 2 stated it was a standard of practice to monitor resident vital signs that includes blood pressure and pulse rate prior to administration of any hypertensive medications. LVN 2 stated Metoprolol Tartrate could cause bradycardia (slows the heart rate) putting Resident 167 at risk for syncopal (loss of consciousness) and dizziness that would likely require hospitalization. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/2023, the P&P indicated, Medications must be administered in accordance with the orders and state and federal guidelines. The P&P indicated the allergies of medication and vital signs must be checked/verified for each resident prior to administering medications. 056019 Page 31 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Label with an opened date one vial (a small container, usually made of glass or plastic used to store liquids) 5 millimeter ([ml] - unit of measurement) of influenza vaccine (a vaccine that protects against the influenza virus) found from the facility's medication storage room [ROOM NUMBER] refrigerator. This deficient practice had the potential for harm to residents due to potential loss of strength of the influenza vaccine. 2. Remove two vials of unopened expired insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) from the facility's medication storage room [ROOM NUMBER] refrigerator for two of two sampled residents (Residents 14 and 15). This deficient practice had the potential to increase the risk of Resident 14 and 15 receiving expired insulin that could be ineffective in treating their blood sugar. Findings: 1. During a concurrent observation and interview on [DATE] at 11:35 a.m., of medication storage room [ROOM NUMBER] refrigerator with Registered Nurse 1 (RN 1), found one 1 vial of influenza vaccine with no opened date. RN 1 stated it was unknown at this time when the influenza vaccine was opened because it was not labeled with an opened date. RN 1 stated it was important to put the date it was opened in the box of the influenza vaccine so the staff would know the validity and when to discard the vaccine. RN 1 stated giving expired flu vaccine would not have the desired effect for the resident. During an interview on [DATE] at 11:44 a.m., with the Infection Preventionist Nurse (IPN), the IPN acknowledged she opened the one vial of influenza vaccine last week and did not put a label with an opened date. The IPN stated it was a standard of practice to label all medications with an opened date During a review of the facility's policy and procedure (P&P) titled, Labeling of Biologicals and Storage of Biologicals, dated 3/2023, the P&P indicated, If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within days unless the manufacturer specifies a different (shorter or loner) date for that opened vial. The P&P indicated the facility, in coordination with the licensed pharmacist provides accurate labeling to facilitate precautions and safe administration of medications, safe, and secure storage. 2. During a review of Resident 14's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 14's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease ([ESRD] - irreversible kidney 056019 Page 32 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0761 failure). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 14's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 14 did not have the capacity to understand and make decisions. Residents Affected - Few During a review of Resident 14's Minimum Data Set ([MDS] - a resident assessment tool) dated [DATE], the MDS indicated, Resident 14's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 14 required substantial assistance (helper does more than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 14's Order Summary Report (a document containing active orders), dated [DATE], indicated Resident 14's physician prescribed insulin lispro (type of insulin medication) to inject subcutaneously ([SQ] - beneath or under the layer of the skin) there times a day before meals at 6:30 a.m., 11:30 a.m., 4:30 p.m., and at bedtime per sliding scale (increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if blood sugar 151-200 = 0, 201-250 = 2 units, 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, if blood sugar above 400 notify medical doctor. During a review of Resident 15's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 15's diagnoses included Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing). During a review of Resident 15's Minimum Data Set ([MDS] - a resident assessment tool) dated [DATE], the MDS indicated, Resident 15's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 15 was totally dependent (helper does all of the effort) from staff with toileting hygiene, upper body dressing, and personal hygiene. During a review of Resident 15's Order Listing Report indicated Resident 15's Levemir insulin (type on insulin medication) was discontinued on [DATE]. During a concurrent observation and interview on [DATE] at 11:55 a.m., of medication storage room [ROOM NUMBER] refrigerator with Registered Nurse 1 (RN 1), found one unopened vial of Lispro insulin expired on [DATE] for Resident 14 and one unopened vial of Levemir insulin expired on [DATE] for Resident 15. RN 1 stated it was the responsibility of the licensed nurses to check each insulin vial for the expiration date. RN 1 stated expired insulin vial should be discarded immediately and placed in the expired disposal bin. RN 1 stated giving expired insulin medication to resident can cause harm by resulting poor blood sugar control and could alter the desired effect of the medication. During a review of the facility's P&P titled, Labeling of Biologicals and Storage of Biologicals, dated 3/2023, the P&P indicated, If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. 056019 Page 33 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0790 Provide routine and 24-hour emergency dental care for each resident. 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: Residents Affected - Few 1. Ensure dental services were provided for one of 6 sampled residents (Resident 6). This deficient practice had the potential to result in tooth decay, gum disease, bad breath and cavities. Findings: During a review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses which included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and insomnia (trouble falling asleep or staying asleep). During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 6 cognitive skills were intact. The MDS indicated Resident 58 required partial to moderate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing. During an interview, on 01/23/2025 at 8:44 a.m., with Resident 6, Resident 6 stated he hadn't had his teeth cleaned by the facility's dentist as requested. Resident 6 stated he was last seen by the dentist in November 2024. Resident 6 stated he had informed the Social Services Director of wanting his teeth cleaned months ago but did not follow up. During an interview, on 01/23/2025 at 3:00 p.m., with the Social Services Director (SSD), the SSD stated she was responsible for setting dental appointments and follow up dental appointments for residents. The SSD stated she wrote Resident 6's name down on a list to have his teeth cleaned but could not find the list. The SSD stated Resident 6 did inform her that he wanted his teeth cleaned. The SSD stated she did not document nor followed up with the teeth cleaning that Resident 6 asked for. The SSD stated the risk of not following up on dental services could result in a resident not being taken care of. A review of the facility's policy and procedures, titled Dental Services, revised on 12/2020, indicated, The facility will ensure the dentist provides dental services in accordance with professional standards of quality and timeliness. 056019 Page 34 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: Residents Affected - Few 1. Provide one out of six sampled residents (Resident 37) with a therapeutic diet at lunch time as ordered. This deficient practice put Resident 37 at risk for further weight loss. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), malnutrition (an imbalance of essential nutrients in the body), and muscle weakness. During a review of Resident 37's History and Physical (H&P), dated 3/23/2024, the H&P indicated Resident 37 does not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/6/2024, the MDS indicated Resident 37 has moderate cognitive (ability to think and understand) impairment. Resident 37 was dependent on staff with dressing, bathing, and toileting. Resident 37 needed maximal assistance rolling left to right, changing from sitting to lying, and transferring from bed. During a review of Resident 37's Order Summary Report, dated 1/23/2025, the report indicated Resident 37 had an order entered on 10/14/2023 for fortified (increased nutrient content) potatoes with lunch. During a review of Resident 37's care plan, dated 3/23/2023, the care plan indicated Resident 37 was at risk for/has altered nutrition. The care plan intervention indicated Resident 37 would receive fortified potatoes at lunch. During a review of Resident 37's care plan, dated 5/16/2024, the care plan indicated Resident 37 was at risk for malnutrition. During a review of Resident 37's Weight Variance Team Update, dated 8/8/2024, the update indicated Resident 37 had poor oral intake. Resident 37 consumed 62% of meals. Resident 37 will receive fortified potatoes with lunch. Resident 37 is underweight. The plan was for gradual weight gain. During a review of Resident 37's Nutrition Task, the task indicated on 1/22/2025 Resident 37 ate 75% of breakfast, 20% of lunch, and 30% of dinner. The task indicated on 1/23/2025 Resident 37 ate 65% of breakfast, 40% of lunch, and 30% of dinner. During a concurrent observation and interview on 1/23/2025 at 12:30 p.m. with the Registered Nurse (RN) 1 at the bedside of Resident 37, Resident 37's lunch tray was observed without fortified potatoes at lunch time. RN 1 stated fortified potatoes are ordered to add nutrition and increase the resident's calorie intake. RN 1 stated if Resident 37 does not receive fortified potatoes as ordered she 056019 Page 35 of 36 056019 01/24/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0808 could have more weight loss or not reach her desired weight. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/23/2025 at 3:19 p.m. with the Dietary Services Supervisor (DSS), the DSS stated fortified potatoes may be ordered to help a resident gain weight. The DSS cannot state why Resident 37 did not receive fortified potatoes today. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet, dated March 2023, the P&P indicated the facility will ensure residents receive and consume foods at the appropriate nutritive content to support the resident's treatment and plan of care. During a review of the facility's policy and procedure (P&P) titled, Weight Management, dated December 2024, the P&P indicated the facility strives to maintain acceptable parameters of nutritional status and they will provide a therapeutic diet for residents with nutritional problems. 056019 Page 36 of 36