Inspection·April 1, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 4/1/2025 at 4:07 p.m. with the ADM, the ADM stated Resident 1 had scabbed scratches on her left hand. The ADM stated the DON and DSD were notified about the scratches on the resident ' s left hand. The ADM stated it was important to do a skin assessment and notify with the physician so there would be no complications of the resident ' s skin. During a review of the facility ' s policy and procedure (P&P) titled, Nursing Administration, dated 5/2020, the P&P indicated it is the policy of the facility that all changes in resident ' s conditions will be communicated to the physician. The P&P indicated the licensed nurse in charge will notify the physician. Event ID: Facility ID: 056267 If continuation sheet Page 2 of 4 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 056267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camino Healthcare 13922 Cerise Avenue Hawthorne, CA 90250 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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, one of three sampled residents ' (Resident 1), urinalysis ([UA]- a laboratory test that examines a urine sample to detect a urinary tract infection [UTI, infection in the urinary system-kidneys, bladder, urethra]) order was carried out and sent to the laboratory (facility conducting the urine test) per the physician ' s order. Residents Affected - Few This deficient practice had the potential for delayed treatment if Resident 1 had an unidentified UTI. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (a stroke, specifically the death of brain tissue due to a lack of blood flow), bipolar disorder (a mental health condition characterized by significant and persistent mood swings), and aphasia (a language disorder that affects a person ' s ability to communicate). During a review of Resident 1 ' s History and Physical (H&P), dated 4/1/2025, 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 resident assessment tool), dated 2/27/2025, the MDS indicated Resident 1 had cognitive impairment. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, showering, and dressing. During a record review of Resident 1 ' s Change of Condition Evaluation (COC), dated 3/20/2025, the COC indicated Resident 1 had physical aggressive behavior towards staff on 3/20/2025. The COC indicated the physician recommendation was for Resident 1 to have a urinalysis (UA, urine test) done. During a review of Resident 1 ' s Order Summary Report, dated 3/20/2025, the Order Summary Reported indicated an order do UA with culture and sensitivity. During a concurrent interview and record review on 4/1/2025 at 3:31 p.m. with Director of Staff Development (DSD), Resident 1 ' s COC, dated 3/20/2025 was reviewed. The DSD stated theCOC indicated Resident 1 had physical aggressive behavior towards staff on 3/20/2025, and the physician recommended to have a UA done on the resident. The DSD stated Resident 1 ' s UA was not done. The DSD stated the reason for the UA was because Resident 1 had shown signs of aggressive behavior and was confused, which could be a sign of a UTI. The DSD stated it was important the UA was done to check if Resident 1 had an infection and would need treatment. The DSD if the resident had UTI, it had the potential for the resident to become more aggressive and more confused. During a review of facility ' s policy and procedure (P&P) titled, Significant Change of Condition, Response, dated 12/2023, the P&P indicated the facility must ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being. The P&P indicated, any time it is recognized by anyone of the team members that the condition or care needs of the resident have changed, the nurse should perform, document, and implement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056267 If continuation sheet Page 3 of 4 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 056267 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camino Healthcare 13922 Cerise Avenue Hawthorne, CA 90250 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 0770 any new orders or interventions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056267 If continuation sheet Page 4 of 4