Health inspection·January 29, 2025

F 0636 concentration of a substance in a fluid such as blood or urine) at 6:57 a.m. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 1/29/2025 at 12:55 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left out on pass at 1:57 p.m. on 1/20/2025 The Progress Notes indicated Resident 1 had returned to the facility at 1:48 a.m. on 1/21/2025. In addition, Resident 1 ' s Weights and Vital Summary, dated 1/21/2025 the blood sugar was 333 at mm/dl at 6:57 a.m. was reviewed. The DON stated the Resident 1 has diabetes. The DON stated when Resident 1 returned to the facility an assessment (a process where a nurse gathers, sorts, and analyzes of patient ' s health information) was done. The DON stated the blood sugar should have been checked when Resident 1 returned at 1:48 a.m. on 1/21/2025 as part of the assessment. The DON stated the blood sugar was not checked for four hours after the resident had returned. The DON stated Resident 1 was hyperglycemic (a condition in which there is too much glucose (sugar) in the blood) or hypoglycemic (a condition in which there is not enough glucose in the blood) which would have placed the resident at risk for falls, alter level of consciousness (a change in a patient ' s normal state of alertness and awareness), other signs and symptoms of diabetes. Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Diabetes Clinical Protocol, dated 3/2017, the P&P indicated to provide staff with clinical practice guidelines to care for residents with diabetes. The P&P indicated based on the comprehensive assessment, including causes and complications, the physician will order appropriate interventions, which may include treatment of underlying conditions causing impaired glucose tolerance. The P&P indicated monitor as indicated if the individual has returned to the facility after a significant absence. During a review of the facility ' s policy and procedure (P&P) titled, Resident Assessment, dated 3/2023, the P&P indicated the facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident ' s functional capacity. The P&P indicated assessments minimally includes the following special treatments and procedures. The P&P indicated the triggers identifying residents who have or are at risk for developing specific functional problems and require further assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056019 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm 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** During an interview and record review the facility failed to: Residents Affected - Few 1. Ensure one out of three sampled residents (Resident 1) had a care plan for non-compliance (when a patient don't follow the rules, regulations, or advice that ' s been set in place) when out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not developing a care plan (a document that summarizes a person ' s health needs, current treatments, and desired outcomes) for Resident 1 ' s non-compliance had the potential to place the resident at risk for injury and not be continuously monitored for diabetes mellitus([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1's Fall Risk Evaluation, dated 1/19/2025, the Fall Risk Evaluation indicated Resident 1 had one to 2 falls in the past 3 months and was a high fall risk (a person has a significantly increased likelihood of experiencing a fall due to various factors such as poor balance, reduced muscle strength making the more susceptible to losing their footing and falling down). During a review of Resident 1's Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a review of Resident 1's Progress Notes, dated 1/22/2025. The Progress notes indicated Resident 1 left the facility out on pass on 1/22/2025 at 12:19 p.m. and returned to the facility on 1/23/2025 at 8:55 a.m. During a concurrent interview and record review on 1/29/2025 at 1:45 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/202/2025 and 1/22/205 were reviewed. The Progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056019 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notes indicated Resident 1 had left the faciity on 1/20/2025 at 1:57 p.m. and did not return to the facility until 1:48 a.m. on 1/21/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/22/2025 at 12:19 p.m. and returned to the facility on 1/23/2025 at 8:55 a.m. The DON stated when a resident goes OOP the facility requests the resident goes out for four to six hours and return to the facility. The DON stated Resident 1 was OOP for 12 hours on dates 1/20/2025 to 1/21/2025 and was OOP for 21 hours on dates 1/22/2025 to 1/23/2025. The DON stated a care plan should have been done to address his non-compliance for not returning within the recommended time. The DON stated the Resident 1 was a high fall risk and had diabetes. During a review of the facility ' s policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 3/2023, the P&P indicated the facility develops a person-centered comprehensive care plans that address the resident ' s medical, physical, mental and psychosocial needs. The P&P indicated care plans shall include the discipline providing care or services, measurable objectives and timeframes in order to evaluate the resident ' s progress toward his/her goal(s). The P&P indicated when a resident ' s choice to decline care or treatment poses a risk to the resident ' s health or safety, the comprehensive care plan must 1. Identify the care or service being decline 2. The risk the declination poses to the resident 3. Attempts to find alternative means to address the identified risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056019 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 interview and record review the facility failed to: Residents Affected - Few 1. Ensure one out of three sampled residents (Resident1) had a plan in place after being identified as a high risk for falls (a patient has a significantly increased likelihood of experiencing a fall due to various factors like poor balance, muscle weakness, which could potentially cause physical harm if they do fall) for continuous supervision and monitoring while out on pass ([OOP] a patient is temporarily allowed to leave the facility for a specified period of time, with the expectation of returning). This deficient practice of not having a plan in place for continuous supervision and monitoring had the potential risk for Resident 1 to fall while out on pass. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included fall (an unplanned descent to the floor with or without injury to the patient), diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease ([COPD] -a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P), dated 1/16/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 1/22/2025 the MDS indicated, Resident 1 ' s cognition (ability to learn, reason, remember, understand, and make decisions) was cognitively intact. The MDS indicated Resident 1 required supervision for sitting to stand, chair to bed transfers, and walking. The MDS indicated Resident 1 had a history of a fall prior to admission. The MDS indicated Resident 1 required insulin injections (a hormone that lowers the level of sugar in the blood) seven days a week. During a review of Resident 1 ' s Fall Risk Evaluation, dated 1/16/2025, the Fall Risk Evaluation indicated Resident 1 had a history of falls in the past three months and was a high risk for falls. During a review of Resident 1 ' s Progress Notes, dated 1/20/2025. The Progress Notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. During a concurrent interview and record review on 1/29/2025 at 12:24 p.m. with Director of Nursing (DON), Resident 1 ' s Progress Notes, dated 1/20/2025 was reviewed. The Progress notes indicated Resident 1 left the facility OOP on 1/20/2025 at 1:57 p.m. and returned to the facility at 1:48 a.m. on 1/21/2025. The DON stated Resident 1 was OOP for 12 hours on 1/20/2025 and returned 1/21/2025 early morning the next day. The DON stated the recommendation for a resident to be OOP was four to six hours. The DON stated Resident 1 was a high risk for falls and had fallen on 1/18/2025 and prior to admission. The DON stated the staff should have documented the risk factors of safety, supervision, and monitored the resident once the resident didn ' t return within the recommended time. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056019 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056019 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated once the resident left and was gone for long periods of time the staff is no longer able to monitor the resident which would put him at risk for injury. During a review of facility ' s policy and procedure (P&P) titled, Out on Pass Therapeutic Leave, dated 7/2024, the Out on Pass Therapeutic Leave indicated to provide staff with guidelines to ensure residents ' safety when residents choose to leave the facility for social or personal reasons. The P&P indicated the facility ensures that residents are aware of the risks associated with leaving the facility and are provided with necessary information and support to make informed decisions prior to leaving. During a review of facility ' s policy and procedure (P&P) titled, Fall Management Program, dated 3/2023, the P&P indicated to provide each resident with adequate supervision to minimize the risks associated with falls. The P&P indicated identify environmental hazards and individual resident risk of an accident, including the need for supervision. The P&P indicated monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056019 If continuation sheet Page 6 of 6