Health inspection·August 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the abuse prevention program policy and procedure by not reporting an allegation of abuse for one of four sampled residents (Resident 1) to the California Department of Public Health ([CDPH]- state agency), after Family Member (FM) 1 stated Certified Nurse Assistant (CNA) 1 raised her arm to hit Resident 1. This deficient practice had the potential for under-reporting abuse incidents, delay in investigation of an abuse allegation, and placed Resident 1 and other residents at risk for further abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body), and hemiparesis (weakness or inability to move one side of the body) following intracranial hemorrhage (brain bleed), and syncope (fainting or passing out). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 6/21/2024, indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation form ([SBAR]a communication tool used by licensed staff after a resident has a change in condition), dated 8/17/24 at 12:02 AM, signed by Licensed Vocational Nurse (LVN) 2, the SBAR indicated FM 1 spoke with LVN 2 and told LVN 2 that CNA 1 raised their hand in a motion like they were going to hit Resident 1 but stopped before actually doing so. During a phone interview on 8/28/24 at 10:30 AM with LVN 2, LVN 2 stated she spoke with FM 1 and was informed that CNA 1 made a motion like CNA 1 was going to hit Resident 1. LVN 2 stated she reported the incident to Registered Nurse (RN) 2. LVN 2 stated CNA 1 provided a written statement regarding the events that night and LVN 2 stated RN 2 sent CNA 1 home for the rest of the shift. LVN 2 stated because there was no actual physical contact they did not need to complete and fax the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to notify the state agency. During an interview on 8/28/24 at 11:33 AM with the Administrator (ADM), the ADM stated all allegations of abuse must be reported to the state agency. The ADM stated all staff are trained to report any allegations of abuse to the appropriate agencies and the staff did not report the abuse allegation on the evening of 8/17/2024. (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: 555057 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 555057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Flores Convalescent Hospital 14165 Purche Ave. Gardena, CA 90249 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)