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), (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 4 Event ID: 555410 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 03/22/2024 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)