Inspection·July 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few severely impaired. The MDS indicated Resident 2 required moderate assistance from staff with ADLs and did not have the ability to walk. The MDS indicated Resident 2 required the use of a wheelchair for mobility. During a review of Resident 2's COC, dated 7/19/2025, timed at 11:45 a.m., the COC indicated on 7/19/2025 at approximately 10:00 a.m., Resident 2 was observed in the hallway in her wheelchair being pushed by another resident (Resident 1). The COC indicated at 11:00 a.m., the staff could not locate Resident 2 in the facility or the surrounding neighborhood. The COC indicated Resident 2 was brought back to the facility on 7/19/2025 at approximately 3:22 p.m., by a local hospital ambulance. During an interview on 7/29/2025 at 12:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/19/2025 at approximately 10:00 a.m., Resident 1 was observed in the hallway pushing Resident 2 in her wheelchair towards nurses' station near the front exit door. LVN 1 stated Resident 1 was high risk for elopement and had been issued a wander guard bracelet. LVN 1 stated Resident 1 was not on one-to-one monitoring, and instead was being checked during hourly visual rounds. LVN 1 stated Resident 2 was non-ambulatory (able to walk), used a wheelchair, and required staff assistance for mobility. LVN 1 stated at 11:00 a.m., during scheduled visual rounds check, staff were unable to locate Residents 1 and 2. LVN 1 stated she reported the missing residents to the charge nurse and staff initiated a search. LVN 1 stated she did not observe the residents exiting the facility and did not hear the front door alarm which indicated that staff were not monitoring the exit door as required to prevent residents from exiting the facility unsupervised. LVN 1 stated it was the responsibility of the Director of Staff Development (DSD) to ensure such assignments as exit monitoring were reflected in the daily staff assignment. LVN 1 stated the front exit door should be continuously monitored by staff to prevent residents from leaving the facility unsupervised, especially those at high risk for elopement. LVN 1 stated someone should have been watching the exit. During a telephone interview on 7/29/2025 at 1:06 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the charge nurse on duty the morning of 7/19/2025. RN 1 stated she was made aware by LVN 1 that Residents 1 and 2 were missing during the 11:00 a.m. visual check rounds. RN 1 stated Resident 1 had a wander guard bracelet, but she was unaware if the system was active or functioning. RN 1 stated she was not able to recall if Resident 1 was on one-to-one monitoring at the time of the elopement incident on 7/19/2025. RN 1 stated she did not receive any alerts from the wander guard system. RN 1 stated she did not see or hear the residents exiting the facility. RN 1 stated staff should have been assigned to monitor the front exit to prevent residents from leaving unsupervised, especially those with elopement risk. RN 1 stated she believed a staff member (unable to recall name) had been assigned to monitor the front exit on the morning of 7/19/2025, but she was not able to confirm whether that assigned staff was present at the time of the elopement. RN 1 stated I was busy with other duties, and I honestly don't know if they were at the door. RN 1 stated the facility did not have a written policy for monitoring the exit door, it was an informal expectation, and everyone was responsible for the residents' supervision. During a concurrent interview record review on 7/29/2025 at 4:07 p.m., with the Director of Staff Development (DSD), the facility record titled Nursing Staffing Assignment and Sign-in-Sheet, dated 7/19/2025, was reviewed. The staff assignment record indicated Certified Nursing Assistant (CNA) 1 had initially been assigned to monitor the facility's front exit door and observe for any resident attempting to leave unsupervised. The DSD stated all staff were expected to monitor residents by keeping an eye on them, especially those with documented elopement risks. The DSD stated the facility did not have a formal, written protocol requiring staff to be specially assigned to monitor exit doors. The DSD stated she was responsible for preparing the staff assignment sheet for 7/19/2025. The DSD stated CNA 1 was reassigned to provide care to another resident in room [ROOM NUMBER]. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555057 If continuation sheet Page 2 of 3 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 07/29/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DSD stated there was no one to replace CNA 1 after his reassignment and staff at the nurses' station (located near the exit) were to assist with watching and monitoring the exit. The DSD stated this oversight resulted in Residents 1 and 2's elopement on the morning of 7/19/2025. During an interview on 7/29/2025 at 4:50 p.m., with the Administrator (ADM), the ADM stated on the morning of 7/19/2025, while Resident 1 pushed Resident 2 in her wheelchair, the residents exited the facility without staff knowledge. The ADM stated both residents were later located off-site and returned to the facility in the afternoon. The ADM stated Resident 1 had a wander guard bracelet, but the system failed to function at the time of the elopement, and no alarm was received by staff. The ADM stated the facility did not have a specific written policy designating which staff member was responsible for monitoring the front exit. The ADM stated it was an informal facility process that available staff were assigned to monitor the exit. The ADM stated it was expected that all staff would be vigilant and visually monitor the front exit and monitor the residents to prevent the residents from leaving the facility unsupervised. The ADM stated current practices were inadequate and that steps would be taken to create a formal front exit monitoring system. During a review of the facility's policy and procedures (P&P) titled Safety-Resident Monitoring, undated, the P&P indicated:1. The facility would ensure the safety and well-being of all residents by establishing guidelines for effective monitoring, supervision, and timely interventions.2. Staff must ensure resident whereabouts, especially for residents at risk of elopement.3. All staff would be informed of residents under 1:1 observation. During a review of the facility's P&P titled Wandering & Elopement, revised 5/1/2023, the P&P indicated the facility would identify and monitor residents at risk for elopement and facility staff would prevent residents from leaving the facility unsupervised. During a review of the facility P&P titled Safety of Residents, revised 5/1/2023, the P&P indicated the facility would provide a safe environment for residents at the facility. Event ID: Facility ID: 555057 If continuation sheet Page 3 of 3