Health inspection·July 29, 2024

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician was notified when the resident had a change of condition (COC) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status. 2. Ensure nursing staff implemented Resident 1's Care Plan titled, Resident at Risk for Constipation, by monitoring the amount, consistency, and frequency of Resident 1's bowel movements. This deficient practice resulted in a delay in care and treatment for Resident 1, who was eventually transferred to a General Acute Care Hospital (GACH) on 7/6/24 where she underwent an emergent total colectomy (a surgical procedure to remove the entire colon), a gastric wedge resection (a surgical procedure in which a wedge shaped portion of the stomach is removed), a partial omentectomy (a surgical procedure to remove a portion of the omentum [a fold of tissue that surrounds the stomach and other organs]), and a temporary abdominal (stomach) closure in the setting of fulminant (something that happens suddenly and with great intensity or severity) clostridoides difficile colitis ([C. Diff- results from the disruption of normal healthy bacteria in the colon, often from antibiotics. Can lead to severe damage to the colon and can be fatal). Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses included hypernatremia (high sodium levels in the blood), hypertensive heart disease (a condition in which the blood vessels have persistently raised pressure), chronic kidney disease ([CKD] kidney damage lasting three months or more) heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following a cerebral infarction ([stroke] lack of oxygen to tissues in the brain). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2024, the MDS indicated Resident 1's cognition (thinking) was moderately impaired. (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 07/29/2024 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)