Health inspection·March 22, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure a plan of care was developed and implemented for one of five sampled residents (Resident 1) addressing Resident 1's laceration (a wound that occur when skin or muscle is torn or cut open) on the forehead. This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2024, the MDS indicated Resident 1 was forgetful, made inconsistent decisions and was understood by staff. The MDS indicated Resident 1 required partial/ moderate assistance with one-person assist (helper does less than half the effort) to complete the resident's' activities of daily living such as toileting, personal hygiene, dressing and transferring from bed-to-chair and vice-versa. During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form dated 2/29/2024 at 11:38 p.m., the SBAR Communication Form indicated Resident 1 was found sitting on top of the floor pad beside his bed in his room on 2/29/2024 at 8:03 p.m. with swelling and a laceration to his forehead. During a review of Resident 1's comprehensive care plans, there were no care plans indicating a specific goal and interventions directed to address Resident 1's sustained laceration after an unwitnessed fall. During an interview on 3/21/2024 at 4:32 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated for every resident change of condition, there must be a care plan formulated for continuous monitoring and evaluation such as of Resident 1's laceration. During an interview and record review on 3/22/2024 at 12:50 p.m., with Treatment Nurse 1 (TX 1), Page 1 of 4 555410 555410 03/22/2024 West Gardena Post Acute 16530 S Broadway Street Gardena, CA 90248

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's care plans were reviewed and there were no care plans addressing Resident 1's laceration post fall. TX 1 confirmed there was no specific plan of care formulated for Resident 1's laceration since 2/29/2024. During an interview on 3/22/2024 at 2:17 p.m., with the Director of Nursing (DON), the DON stated the residents' plan of care must be specific to address specific interventions and/or monitoring of Resident 1's laceration every shift to identify any worsening of Resident 1's wound site and escalate care and treatment, if necessary. During a review of the facility's Policy and Procedure (P/P) titled, Care Plans, Comprehensive Person-Centered revised 12/2016, the P/P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented by the facility for each resident. 555410 Page 2 of 4 555410 03/22/2024 West Gardena Post Acute 16530 S Broadway Street Gardena, CA 90248

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) laceration (a wound that occur when soft tissue such as skin or muscle is torn or cut open) on the forehead had documented monitoring for signs and symptoms of infection and complications after the resident sustained a fall on 2/29/2024. Residents Affected - Few This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2024, the MDS indicated Resident 1 was forgetful, made inconsistent decisions and was understood by staff. The MDS indicated Resident 1 required partial/ moderate assistance with one-person assist (helper does less than half the effort) to complete the resident's' activities of daily living such as toileting, personal hygiene, dressing and transferring from bed-to-chair and vice-versa. During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form dated 2/29/2024 at 11:38 p.m., the SBAR Communication Form indicated Resident 1 was found sitting on top of the floor pad beside his bed in his room on 2/29/2024 at 8:03 p.m. with swelling and a laceration to the forehead. During a review of Resident 1's comprehensive care plans, there were no care plans indicating specific goals and interventions of monitoring directed to address Resident 1's sustained laceration after a fall. During a review of Resident 1's Treatment Administration Record (TAR) dated 3/2024, the TAR indicated there was no monitoring of Resident 1's laceration/ wound status every shift. During a telephone interview on 3/21/2024 at 4:10 p.m., with Responsible Party 1(RP1), RP1 stated she was worried of how the staff was monitoring Resident 1's wound because when she visited Resident 1 during the day of 3/7/2024, Resident 1's face was swollen, and the wound looked worse. During an interview on 3/21/2024 at 4:32 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 1's laceration should have had documented monitoring every shift. During an interview and record review on 3/22/2024 at 12:50 p.m., with Treatment Nurse 1 (TX 1), TX 1 confirmed there was no documented monitoring for Resident 1's laceration since 2/29/2024 and TX 1 confirmed there was no order in the TAR indicating to monitor Resident 1's laceration every shift. 555410 Page 3 of 4 555410 03/22/2024 West Gardena Post Acute 16530 S Broadway Street Gardena, CA 90248

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/22/2024 at 2:17 p.m., with the Director of Nursing (DON), the DON stated Resident 1's laceration should have had documented monitoring every shift to identify any worsening of Resident 1's wound site and escalate care and treatment, if necessary. During a review of the facility's Policy and Procedure (P/P) titled, Quality of Care revised 8/2009, the P/P indicated each resident shall be cared for in a manner that promotes and enhances quality care. The P/P indicated quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be: 1. Effective - providing evidence-based healthcare services to those who need them. 2. Safe - avoiding harm to people for whom the care is intended; and 3. Resident-centered - providing care that responds to individual preferences, needs, and values. To realize the benefits of quality health care, health services must be: 1. Timely - reducing waiting times and sometimes harmful delays. 2. Integrated - providing care that makes available the full range of health services throughout the life course. 3. Efficient - maximizing the benefit of available resources and avoiding waste. 555410 Page 4 of 4