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. Page 1 of 2 056019 056019 03/27/2025 Gardena Convalescent Center 14819 S. Vermont Gardena, CA 90247

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/26/2025 at 2:33 p.m. with CNA 1, CNA 1 stated on 3/15/2025, while cleaning Resident 1 and changing the resident's bed, the resident rolled over and slid off the bed. CNA 1 stated he stopped Resident 1 from falling to the ground. CNA 1 stated after the incident Resident 1 complained of a headache. CNA 1 stated, I went and told the charge nurse that the resident had a headache. I did not tell her about the incident because in my perspective the resident didn't fall, I caught him while he was hanging off the bed and did not touch the ground. CNA 1 stated he should have told the charge nurse about the incident because the resident was hurt. During an interview on 3/26/2025 at 3:48 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was from a registry agency. The DSD stated this was the first time CNA 1 worked at the facility. The DSD stated CNA 1 was placed on a do not return list because of not reporting Resident 1's fall to the charge nurse. The DSD stated not reporting a fall would bring harm to the resident and delay timely medical attention. During an interview on 3/27/2025 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a CNA should always report a fall or near fall to the charge nurse. LVN 1 stated it was not within the CNAs scope of practice to assess the resident to see if they are injured. LVN 1 stated if a fall or accident was not reported immediately the resident would not get the care they would need in a timely manner. During an interview on 3/27/2025 at 12:35 p.m. with LVN 2, LVN 2 stated on 3/15/2025, when she went to pass the pain medication, she noticed a quarter size discolored, slightly raised bump, on the left side above Resident 1's eye. LVN 2 stated Resident 1 reported that he fell off the bed when CNA 1 was cleaning him. LVN 2 stated she was was never told by CNA 1 the resident fell or nearly fell, only that Resident 1 had a headache. During an interview on 3/27/2025 at 1:05 p.m. with CNA 2, CNA 2 stated if you witness a fall or a near fall you must report it to the charge nurse immediately, so they can assess the resident. CNA 2 stated this was for resident's safety. During an interview on 3/27/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated all staff must report a fall or near fall to the charge nurse or supervisor. The DON stated if it is not reported this would harm the resident, which was a safety issue. During a review of the facility's policy and procedure (P&P), titled Fall Management Program , revised 3/2025, the P&P indicated the facility strives to provide each resident with adequate supervision and assistance devices to minimize the risks associated with falls; and to provide an environment which remains as free from accidental hazards as possible. The P&P indicated a fall is unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. The P&P indicated the facility educates employees at the time of hire, annually and as indicated on the facility policy fall management, included intervention to reduce injury and fall related accidents. During a review of the facility's P&P, titled Patient Safety Plan , revised 3/2024, the P&P indicated any employee having knowledge or observation of accidents, including injuries, infections or other of an unknown source, must report to the department supervisor and the charge nurse, and complete an Incident Report Form must be completed on the shift that the incident occurred. 056019 Page 2 of 2