Health inspection·October 26, 2023

F 0689 10/14/2023 at 6:30 p.m. Level of Harm - Actual harm A review of the GACH H&P, dated 10/15/2023, indicated Resident 1 sustained a fall with head trauma resulting in a hematoma and left parietal scalp laceration. Residents Affected - Few A review of Resident 1's head Computed Tomography ([CT] an imaging test used to detect internal injuries by providing cross-sectional images of bones, blood vessels and soft tissues in the body) scan dated 10/15/2023, indicated Resident 1 had a left parietal scalp hematoma. A review of Resident 1's General Surgeon Consultation report, dated 10/15/2023 indicated Resident 1 had a left parietal occipital (back of head) scalp hematoma measuring 3 centimeters ([cm] a unit of measurement) by 3 cm with a small laceration with scabbing and eschar (dead tissue that forms over healthy skin and then, over time, falls off). During an interview on 10/26/2023, at 12:06 p.m., CNA 2 stated, Resident 1 could not get up by herself or move from side to side on her own and required two people to assist when she was turned and repositioned. CNA 2 stated when two people are required to turn and reposition a resident, a staff member should stand on each side of the resident's bed to prevent the resident from falling off the bed. During a concurrent interview and record review with the MDS Nurse on 10/26/2023 at 1:23 p.m., Resident 1's Activities of Daily Living ([ADL] task required to independently care for oneself such as eating, bathing, dressing, grooming and toileting) Performance Self Care Deficit Care Plan dated 12/21/2020, was reviewed. The Care Plan Indicated Resident 1 had muscle weakness and osteoarthritis (mechanical wear and tear on the joints). The Care plan goals included moving Resident 1, while in bed, using a two-person assist. The MDS Nurse stated the purpose of the Care Plan was to assist the nursing staff in providing individualized care to residents based on their needs. The MDS Nurse stated, if the staff had followed Resident 1's care plan to use two people when moving Resident 1 in bed, Resident 1's fall could have been prevented. During a telephone interview on 10/26/2023 at 1:59 p.m., CNA 1 stated he raised Resident 1's bed to the level of his (CNA 1's) waist (approximately three to four feet from the ground), to change Resident 1's bed linens. CNA 1 stated he was standing behind Resident 1, on the left side of Resident 1's bed, with Resident 1's backside facing him (CNA 1), when Resident 1 leaned to her right side. CNA 1 stated Resident 1 rolled off the bed and hit her head on the bedside dresser before she fell to the floor. CNA 1 stated he was not able to prevent Resident 1 from falling off the bed because he was on the opposite side of the bed from where Resident 1 fell and he did not have enough time to prevent Resident 1 from falling. CNA 1 stated it would have been safer if another staff assisted him when he repositioned Resident 1. CNA 1 stated he was not aware Resident 1 required two people to assist with turning and repositioning Resident 1. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 10/26/2023 at 2:38 p.m., Resident 1's Occupational Therapy Notes for 10/2022 were reviewed. The Occupational Therapy Notes indicated Resident 1 required total assistance with bed mobility and rolling left to right. The DOR stated Resident 1 was a full assist, required two or more persons to roll from left to right because Resident 1 could not roll by herself. The DOR stated Resident 1 does not have a protective reaction (how resident would guard or protect themselves if they were falling) due to her immobility and contractures of her upper and lower extremities. The DOR stated there should have been two staff members assisting with Resident 1's repositioning to prevent her from falling out of bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 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 555410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Gardena Post Acute 16530 S Broadway Street Gardena, CA 90248 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 - Actual harm Residents Affected - Few During a concurrent interview and record review with the Director of Nursing (DON) on 10/26/2023 at 2:56 p.m., Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) notes dated 10/26/2023, and timed at 1:03 p.m., were reviewed. Resident 1's IDT notes indicated Resident 1 had a fall while CNA 1 was turning and repositioning Resident 1 by himself. The IDT notes indicated Resident 1 slid off the bed and hit her head on the dresser that was beside her bed, then landed on the floor. The DON stated CNA 1 reported to her that he was repositioning Resident 1 without assistance when the incident occurred. The DON stated Resident 1's fall should not have happened and could have been avoided if there was another staff member standing with Resident 1 and assisting him (CNA 1) in holding Resident 1 while he (CNA 1) was changing Resident 1's bed linen. During an interview on 10/28/2023 at 12:51 p.m., the Director of Staff Development (DSD) stated when a resident requires two or more people to assist with bed mobility and is totally dependent on staff with moving from side to side in bed, there should always be another CNA assisting to prevent the resident from falling off the side of the bed. A review of the facility's policy and procedure (P/P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, in accordance with the plan of care, including appropriate support and assistance with mobility. A review of the facility's CNA Job Description revised 10/2020, indicated duties and responsibilities include monitoring and evaluating the resident's response to care plan interventions in accordance with facility policies, and to review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan. A review of the facility's P/P, titled Falls and Fall Risk, Managing, revised 3/2018, indicated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 3 of 3