Health inspection·November 28, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few alert and oriented times one (person knows who they are but not where they are, what time it is, or what is happening to them). The LAFD report indicated Resident 1 had bilateral (both sides) femur (thigh bone) fractures (broken bone), scrapes and abrasions at various locations of the body. The LAFD report indicated Resident 1 was placed on a stretcher (flat structure covered with cloth which is used to carry someone who is sick or injured) and transferred to a GACH.During a review of Resident 1 ' s Emergency Department (ED) Triage Notes dated [DATE] at 7:43 a.m., the ED Triage Notes indicated Resident 1 was brought in by an ambulance with mild cognitive impairment. The ED Triage Notes indicated Resident 1 was rearended by another vehicle and extricated (process of removing injured or potentially injured people from their vehicles) by Emergency Medical Services (EMS) with lower extremities deformity. The ED Triage Notes indicated Resident 1 had a brief loss of pulses and received one round of cardiopulmonary resuscitation ([CPR] combines rescue breathing (mouth-to-mouth) and chest compressions to temporarily pump enough blood to the brain). The ED Triage Notes indicated on [DATE] at 10:38 a.m. Resident 1 was intubated (a tube inserted through a person's mouth or nose, then down into the airway/windpipe) due to respiratory failure (serious condition that occurs when the lungs can't get enough oxygen into the blood).During a review of Resident 1 ' s GACH History and Physical (H&P) Report dated [DATE] at 9:59 a.m., the H&P indicated Resident 1 sustained 8 left rib fractures (broken bones), 5 right rib fractures, pulmonary contusion (a lung injury that occurs when blunt force trauma to the chest causes bleeding and swelling in the lungs) of the right lung, paraspinal hematoma (collection of blood in the soft tissues around the spine), pubic rami (pelvis) fractures, transverse fracture of through the sacrum (large triangular bone that forms the base of the spine and the back wall of the pelvis - transverse fracture occurs when the bone of the sacrum breaks across its width, running perpendicular to the length of the bone, often resulting from high-impact trauma like falls from a significant height or severe motor vehicle accidents), bilateral fibula (outer and usually smaller of the two bones between the knee and ankle) fractures, left and right tibial (large bone in the lower leg) fractures, bilateral right femoral (thigh bone) fractures, and multiple fractures to the spine. The H&P indicated Resident 1 required 3 units of whole red blood.During a review of Resident 1 ' s Inpatient Progress Notes dated [DATE] at 3:55 p.m., the Progress Notes indicated on [DATE] at 3:47 p.m. Resident 1 was in asystole (no pulse), and unresponsive to painful or verbal stimulation. The Progress Notes indicated Resident 1 did not have any heart and lung sounds and was pronounced dead on [DATE] at 3:51 p.m. The Progress Notes indicated Resident 1 ' s cause of death was multisystem shock (reduced perfusion [flow of bodily fluids] of vital tissue) due to polytrauma (multiple injuries to different parts of the body or organ systems).During a review of Resident 1 ' s Death Record dated [DATE] at 4:28 p.m., the Death Record indicated Resident 1 ' s cause of death was multisystem shock due to polytrauma.During an interview on [DATE] at 10:48 a.m. with CNA 1, CNA 1 stated on [DATE] at 6:55 a.m., she observed the transportation vehicle double parked in front of the facility. CNA 1 stated Transportation Driver (TD) 1 wheeled Resident 1 over the sidewalk through two parked cars to get to the van. CNA 1 stated she did not instruct the transportation driver to move the van before transferring Resident 1 into the van because she was never in-serviced on transportation safety. CNA 1 stated while TD 1 was at the back of the van with Resident 1, she (CNA 1) observed TD 1 use a mechanical lift to transfer Resident 1 into the van. CNA 1 states she walked around to the passenger side to enter the van from the front, and suddenly heard a loud crash, turned around and saw that a car had crashed into the back of the transportation vehicle. CNA 1 stated TD 1 was pinned under the van while Resident 1 was inside the van.During a concurrent observation and interview on [DATE] at 11:17 a.m., with the Social Services Director (SSD), in front of the facility ' s main (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056478 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 056478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lighthouse Healthcare Center 2222 Santa Ana Blvd. Los Angeles, CA 90059 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 entrance, the SSD pointed to the street where Resident 1 ' s accident occurred on [DATE]. The SSD stated the transportation driver doubled parked because there was no street parking at the time. The SSD stated the facility did not have a system in place to for staff to identify potential safety risks, and unsafe work practices.During an interview on [DATE] at 11:54 p.m. with CNA 2, CNA 2 stated transportation vehicles parked on the street when picking up residents all the time. CNA 2 stated the facility did not provide training on transportation safety to staff and staff were not aware not to hand residents to transportation vehicles, when not parked in designated areas.During an interview on [DATE] at 12:21 p.m. with CNA 3, CNA 3 stated when residents were being picked up for medical appointments, she wheeled the residents outside to look for the transportation vehicles . CNA 3 stated the transportation vehicles either parked in the green zone (30-minute parking), red zone (no parking), or regular street parking when loading and unloading residents. CNA 3 stated transportation vehicles did not park in any of the three (3) employee parking lots to pick up or drop off residents. CNA 3 stated the facility did not have a designated resident loading area. CNA 3 stated she witnessed transportation vehicles double park in the street when picking up residents when street parking was not available. CNA 3 stated she had not been trained on safety transportation of residents.During an interview on [DATE] at 12:41 p.m. with CNA 4, CNA 4 stated all transportation drivers should not park on the street when picking up residents but would always double park on the street because all the street parking was taken. CNA 4 stated the facility had not provided any training on transportation safety.During an interview on [DATE] at 1:22 p.m., with the DSD, the DSD stated she had not provided training on escorting residents to appointments and resident safety. The DSD stated she had not provided training on what to look out for during the transportation of a resident into a transportation vehicle. The DSD stated it was important to keep residents safe during transportation. The DSD stated she should have identified potential safety risks regarding resident transportation and in-serviced staff. The DSD stated CNAs must standby as residents were transferred into the transportation vehicle and must enter the vehicle after the resident was safely inside.During an interview on [DATE] at 2:30 p.m., with the transportation company ' s Transportation Service Manager (TSA), the TSA stated his drivers previously informed him all parking spots in front of the facility were always taken by the facility staff. The TSA stated his drivers double parked because the facility did not have a safe designated area to pick up and drop off residents. The TSA stated the facility staff never told his drivers not to double park or to park in the staff parking lot to pick up or drop off residents.During an interview on [DATE] at 1:10 p.m. with RN Supervisor 1, RN Supervisor 1 stated on [DATE] at 6:50 a.m., he heard loud screams and went outside. RN Supervisor 1 stated he observed the back of the transportation van was hit by another vehicle. RN Supervisor 1 stated he observed Resident 1 lying on his abdomen inside the van bleeding from the front of his head. RN Supervisor 1 stated transportation vehicles did not have a designated area to pick up or drop off residents because facility staff took all the street parking. RN Supervisor 1 stated he had never been told not to park in the street to keep open parking spaces for transportation vehicles. RN Supervisor 1 stated transportation vehicles always doubled parked to pick up or drop off residents. RN Supervisor 1 stated it was important not to allow transportation vehicles to double park to prevent accidents. RN Supervisor 1 stated CNA 1 should have said something to the transportation driver about not parking on the street.During an interview on [DATE] at 2:34 p.m., with the ADM, the ADM stated transportation vehicles could park anywhere on the street and in the facility, parking lots to pick up and drop off residents. The ADM stated the best practice was for CNAs to inform transportation drivers to move when they were double park.During an interview on [DATE] at 3:47 p.m., with the ADM, the ADM stated it was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056478 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 056478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lighthouse Healthcare Center 2222 Santa Ana Blvd. Los Angeles, CA 90059 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 FORM CMS-2567 (02/99) Previous Versions Obsolete safe to transfer a resident while the transportation vehicle was parked in the middle of the street. The ADM stated CNA 1 should have informed the RN Supervisor the driver was double parked to prevent accidents.During a review of the facility ' s P&P titled Accidents and Incidents undated, the P&P indicated the facility would comply with current rules and regulations to prevent accidents.During a review of the facility ' s P&P titled Safety Committee-Composition and Duties dated [DATE], the P&P indicated the facility would develop a reporting system for staff to identify potential safety risks, hazardous areas, and unsafe work practices. Event ID: Facility ID: 056478 If continuation sheet Page 4 of 4