Health inspection·March 27, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) had the specific competencies, and skill sets necessary to care for one of four residents (Resident 1), by failing to report Resident 1's alleged fall incident. This deficient practice resulted in a delay in Resident 1's treatment/evaluation. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included nondisplaced fracture of the left tibial spine (a break that has not shifted or separated at the top of the tibia bone in the lower leg near the knee), traumatic subdural hemorrhage without loss of consciousness (a serious condition where blood pools between the brain and its outer protective layer (the dura) after a head injury, potentially causing pressure on the brain), and end stage renal disease ([ESRD], is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/2/2025, the MDS indicated Resident 1 was assessed to have clear comprehension (the action or capability of understanding something). The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and maximal assistance for personal hygiene, upper and lower dressing. During an interview on 3/26/2025 at 1:15 p.m. with Resident 1, Resident 1 stated on 3/15/2025, while Certified Nursing Assistant (CNA) 1 was cleaning her, she rolled off the bed and fell to the ground. Resident 1 stated, I think it was an accident. Resident 1 stated CNA 1 picked her up and put her back in the bed. Resident 1 stated she reported to CNA 1 that her head hurt, then CNA 1 left the room. During a review of the facility's CNA job description, dated 10/2021, the job description indicated CNAs were to promptly report any resident changes or concerns, such as injuries or falls, to appropriate licensed nursing personnel. The job description indicated CNAs were to safely lift, reposition, and transport residents, using proper body mechanics or lifting devices, as necessary. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056019 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 03/27/2025 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)