Health inspection·November 20, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete by paranoia [intense feelings of distrust and suspicion]) and delusional as evident by Staff are conspiring against me (dated 9/5/2025) During a concurrent interview and record review on 11/19/2025 at 3:02 p.m., with the Director of Nursing (DON), it was confirmed that the Risperdal 0.5 mg order was prescribed by Resident 17's attending physician. However, the informed consent for the medication was obtained and signed by the psychiatric nurse practitioner (NP), not the prescribing physician. During a review of the facility policy and procedures (P&P) titled Verification of Informed Consent for Psychotherapeutic Medications (revised June 2024), the P&P indicated Before prescribing a psychotherapeutic drug, the physician must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative. Event ID: Facility ID: 555410 If continuation sheet Page 2 of 33 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 11/20/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report a change of condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) to the physician for one of six sampled residents (Resident 39) when a decline in range of motion (ROM, full movement potential of a joint) of Resident 39's both hands were identified on the Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 3/20/2025. This failure resulted in Resident 39 not receiving the appropriate services and interventions to address and improve ROM, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning.Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility initially admitted Resident 39 on 5/5/2021 and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) and peripheral autonomic neuropathy (disorder that affects then nerves that control the body's processes without conscious effort). During a review of Resident 39's JMA, dated 10/17/2024, the JMA indicated Resident 39 had full ROM of both hands. The Findings section of the JMA indicated Resident 39 had a diagnosis or condition that put him at risk for contracture development. The Comment section of the JMA indicated to continue the RNA program as indicated. During a review of Resident 39's JMA, dated 3/20/2025, the JMA indicated Resident 39 had moderate (26 to 50 percent loss of motion) ROM loss to the right hand and severe (greater than 50 percent loss of motion) ROM loss to the left hand. The JMA indicated under findings section, Resident 39 had minimal to severe loss of passive range of motion (PROM, movement at a given joint with full assistance from another person) to the arms and had a diagnosis or condition that put her at risk for contracture development. The JMA indicated under the comment section, Resident 39 had moderate loss in ROM of the middle finger of the right hand in extension of the proximal interphalangeal (PIP, middle joint of the finger between the knuckle and the fingertip) joint, moderate to maximal loss of ROM of the pointer finger of the left hand in the metacarpal phalangeal (MCP, knuckle joint of the finger) joint and distal interphalangeal (DIP, joint at the tip of the finger closes to the nail) joint, and middle finger of the left hand at the DIP joint. The JMA recommendations indicated no skilled Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation was needed. The JMA under the comment section indicated to continue the RNA program as indicated. During a review of Resident 39's Minimum Date Set (MDS-resident assessment tool) dated 10/16/2025, the MDS indicated Resident 39 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 39 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, sit to stand, and transfers, substantial/maximal assistance (helper does more than half the effort) for toilet hygiene, dressing, and personal hygiene, and was dependent for bathing. The MDS indicated Resident 39 had functional limitations in ROM in both arms. During a concurrent observation and interview on 11/19/2025 at 8:19 am, with Resident 39 in Resident 39's room, Resident 39 was observed lying in bed. All the fingers on Resident 39's left hand were bent downwards into the palm of the hand. Resident 39's middle finger on the left hand and the ring finger on the right hand were bent to about 90 degrees at the middle joints of the fingers between the knuckles and the fingertips. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 3 of 33 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 11/20/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 39 stated he was unable to straighten all the fingers on his left hand and the ring finger of the right hand on his own and needed assistance. During a concurrent observation of Resident 39's RNA session and interview on 11/19/2025 at 10:34 am, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 39 with active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to both hands. Resident 39 stated he was unable to straighten the knuckle joints and middle joints of all fingers of the left hand and the ring finger of the right hand and needed assistance. Resident 39 stated he did not recall when both hands became stiff, but thought it was a long time ago. After assisting with ROM exercises to Resident 39's both hands, RNA 1 applied a splint (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to Resident 39's middle finger of the left hand and subsequently applied an additional resting hand splint (splint secured from the hand to the forearm to position the hand in a functional position) on the same hand to include the other fingers and wrist. During a concurrent record review and interview on 11/19/2025 at 1:16 pm with the Director of Rehabilitation (DOR) and Occupational Therapist 2 (OT 2), the DOR stated the facility monitored for changes in ROM by JMAs completed by the Rehabilitation Department (Rehab) upon admission, re-admission, annually and upon a COC. The DOR stated the purpose of the JMAs was to identify any changes in a resident's ROM such as declines or improvements to ensure the residents received the appropriate care and services to prevent further decline and contracture development. The DOR and OT 2 stated any significant declines noted in the JMAs should be investigated, discussed with nursing, and reported to the physician for further intervention. The DOR and OT 2 reviewed Resident 39's JMAs, dated 10/17/2024 and 3/20/2025, and confirmed Resident 39 had a significant decline in ROM of both hands from full ROM to moderate ROM loss in the right hand and severe ROM loss in the left hand. The DOR and OT 2 stated the decline in Resident 39's ROM of both hands was significant and should have been reported to the doctor when the ROM loss was identified on the JMA on 3/20/2025 but was not. The DOR and OT 2 stated it was important staff notified the physician of any changes of condition to ensure the residents received the appropriate treatment and services to prevent further decline. During a concurrent interview and record review on 11/19/2025 at 4:48 p.m. with the Director of Nursing (DON), the DON stated a COC was any new occurrence observed that was different from a resident's normal baseline. The DON stated a significant decline in a resident's ROM was considered a COC and the physician should be notified. The DON reviewed Resident 39's JMAs, dated 10/17/2024 and 3/20/2025, and confirmed Resident 39 had a significant decline in ROM of both hands from full ROM to moderate ROM loss in the right hand and severe ROM loss in the left hand. The DON stated Resident 39's decline in ROM of both hands was significant and should have been reported to the physician but was not. The DON stated that after identifying Resident 39's decline in ROM of both hands on the JMA on 3/20/2025, Rehab should have informed nursing, notified the physician, and re-evaluated Resident 39 to ensure Resident 39 received the appropriate care and services to improve and prevent further ROM decline. The DON stated it was important facility staff notified the physician of declines in ROM to ensure the physician was able to properly direct medical care and implement appropriate interventions to address the issue. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 7/2024, the P&P indicated The facility shall notify the resident, his or her attending physician, and representative (sponsor) of any changes in the resident's medical/mental condition and/or status. The P&P indicated The nurse would notify the physician when there was a significant change in the resident's physical, emotional, or mental condition. Event ID: Facility ID: 555410 If continuation sheet Page 4 of 33 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 11/20/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a preadmission screening and annual review of a Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was accurately documented for two of four residents (Residents 17 and 45).This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 17 and 45.Findings: A. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and major depressive disorder (a mood disorder that causes a persistent feelings of sadness and loss of interest). During a review of Resident 17's Minimum Data Set (MDS- a resident assessment tool) dated 9/5/2025, the MDS indicated Resident 17 was cognitively (ability to think, understand, learn, and remember) intact. During a review of Resident 17's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for the month of November 2025, the MAR indicated Risperidone 0.5 milligrams (mg- unit of measurement) one tablet by mouth at bedtime for bipolar disorder manifested by paranoia and delusions was ordered on 9/5/2025. During a review of Resident 17's MAR for the month of November 2025, the MAR indicated Trazadone 75 mg at bedtime for depression manifested by the inability to sleep was ordered on 8/19/2025. During a review of Resident 17's Care Plan titled Resident 17 has a behavior problem related to bipolar disorder initiated 3/12/2025, with goals for Resident 17 to have fewer episodes paranoia (a pattern of behavior where a person feels distrustful and suspicious of other people) and delusions (having false or unrealistic beliefs). The Care Plan interventions include approaching him in a calm manner. During a concurrent interview and record review on 11/19/2025 at 12:50 a.m., with the Director of Nursing (DON), Resident 17's PASARR dated 9/5/2025 was reviewed. The PASARR indicated the level one screening was positive and a PASARR level two evaluation was required due to a diagnosis of serious mental illness. The DON stated Resident 17 has bipolar disorder, anxiety, and major depressive disorder and a level two evaluation should have been done but was not because the level two evaluation letter stated Resident 17 does not have a serious mental illness. The DON stated the level two evaluation was documented incorrectly. The DON stated she is responsible for reviewing and completing the PASARR. The DON stated if the PASARR was not documented correctly there will be a delay in resources and care for his mental illness. B. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, anxiety (and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45's cognition was severely impaired. During a review of Resident 17's MAR for the month of November 2025, the MAR indicated:a. Mirtazapine 7.5 mg by mouth at bedtime for depression manifested by poor oral intake ordered on 7/7/2025.b. Quetiapine 50 mg by mouth at bedtime for psychosis manifested by visual and auditory hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) ordered on 7/7/2025. c. Trazadone 100 mg by mouth at bedtime for depression manifested by inability to sleep at night ordered on 7/7/2025.d. Seroquel 50 mg by mouth two times a day for psychosis manifested by visual and auditory hallucinations ordered on 7/7/2025. During a review of Resident 45's Care Plan titled Resident 45 has a behavior problem related to psychosis Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 5 of 33 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 11/20/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete initiated on 10/1/2025 with goals for Resident 45 to have fewer episodes of psychosis. The care plan interventions for Resident 45 include intervening as necessary to protect the rights and safety of others. During a subsequent interview and record review on 11/19/2025 at 1:00 p.m., with the DON, Resident 45's PASARR dated 7/24/2025 was reviewed. The PASARR indicated the level one screening was negative and a PASARR level two evaluation should have been done due to a diagnosis of serious mental illness. The DON stated Resident 45 has psychosis and depression and the PASARR level one evaluation letter was incorrect. The DON stated she will resubmit the PASARR so Resident 45 could receive specialized individualized resources for mental illness. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, dated 3/2019, the P&P indicated, Our facility admits only residents who's medical and nursing care needs can be met. The objectives of our admission criteria policy are to admit residents who can be cared for adequately by the facility. All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disabilities per the PASARR process. The P&P indicated the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. Event ID: Facility ID: 555410 If continuation sheet Page 6 of 33 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 11/20/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 10 and 32) received their scheduled 9:00 a.m. medications within the required one-hour administration window.This failure had the potential to result in delays in treatment, which may affect the residents' health conditions. Findings: During a concurrent observation and interview on 9/30/2025 at 10:16 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed in the hallway of Station 1 with a medication cart. LVN 1 stated that she still had two residents waiting to receive their morning medications and pointed to a nearby resident room, which roomed Residents 10 and 32. During an interview on 9/30/2025 at 10:21 a.m., LVN 1 stated she would begin preparing medications for Resident 10. During an observation on 9/30/2025 at 10:34 a.m., LVN 1 was observed obtaining a blood pressure reading for Resident 32 During an interview on 9/30/2025 at 10:35 a.m., LVN 1 stated that Resident 32 would be the last resident to receive medications during the morning medication pass (medication administration process). During a concurrent observation and interview on 9/30/2025 at 10:41 a.m., LVN 1 completed the medication administration process. LVN 1 stated the morning medication pass ran late because she was trying to be extra careful. During an interview on 9/30/2025 at 2:51 p.m., with the Director of Nursing (DON), the DON stated nurses are expected to administer scheduled medications within a two-hour window of one hour before and one hour after the scheduled time. For medications scheduled at 9:00 a.m., this window would be from 8:00 a.m. to 10:00 a.m. The [NAME] stated the administration of medications to Residents 10 and 32 after 10:00 a.m. was outside the acceptable timeframe. During a review of the facility's policy and procedures (P&P) titled, Administering Medications (revised April 2019), the P&P indicated . Medications are administered within one (1) hour of their prescribed time, . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 7 of 33 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 11/20/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) for one of six sampled residents (Resident 27). The facility failed to: 1.Ensure the Director of Rehab (DOR) who was a Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) of Resident 27's right knee splint. 2.Ensure the Occupational Therapist (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) performed an assessment to determine the appropriateness, fit, and splint wear time tolerance of Resident 27's right elbow and right-hand splints. These failures had the potential to cause Resident 27 to have skin break down (tissue damage caused by friction, shear, moisture, or pressure), pain, discomfort, decreased range of motion (ROM, full movement potential of a joint), joint dislocation (an injury where the joint is forced out of the normal position), deformity (malformation), and/or bone fractures (a crack or break in the bone). Findings:During a review of Resident 27's admission Record, the admission Record indicated the facility initially admitted Resident 27 on 8/20/2024 and re-admitted on [DATE] with diagnoses including right hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), osteoporosis (condition in which the bones become brittle), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/2/2024 with start date of 10/3/2024, for Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) to apply a right knee splint for three (3) to five (5) hours, every day, 5 times a week. During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/2/2024 with start date of 10/3/2024, for RNA to apply a right-hand splint for 3 to 5 hours, every day, 5 times a week. During a review of Resident 27's Order Summary Report, the Order Summary Report indicated a physician's order, dated 9/22/2025 with start date of 9/23/2025, for RNA to apply a right elbow splint for 3 to 5 hours, every day, 5 times a week. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool) dated 10/7/2025, the MDS indicated Resident 27 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 27 was dependent (helper does all the effort) in eating, hygiene, bathing, dressing, and mobility (ability to move). The MDS indicated Resident 27 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) on both arms (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot). During an observation on 11/19/2025 at 10:22 am in Resident 27's room, Resident 27 was lying in bed wearing splints to the right elbow, right hand, and right knee. Resident 27's both knees were bent and rotated to the left side of the body. During a concurrent interview and record review on 11/18/2025 at 2:56 pm with the DOR and Occupational Therapist 1 (OT 1), the DOR stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures. The DOR stated a licensed PT or OT must assess a resident's need for splints if indicated. The DOR stated it was facility's practice for the PTs to assess and determine the necessity of leg splints, while the OTs assessed and determined the necessity of Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 8 of 33 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 11/20/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arm splints. The DOR stated the licensed therapist must determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated that after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing and the RNA program. The DOR and OT 1 stated the standard of practice in therapy for a resident requiring a new splint included: an initial evaluation of the resident's ROM, assessment for the type of splint to issue, application of the splint, periodic splint checks to determine the splint wear schedule, tolerance, and if modification was required, training the patient, caregiver, RNA, and nursing on the use of splint and any precautions and documentation of all findings in the clinical record. The DOR and OT 1 reviewed Resident 27's clinical record and confirmed Resident 27 had physician's orders for RNA to apply splints to Resident 27's right elbow, right hand, and right knee. The DOR and OT 1 reviewed Resident 27's therapy records and confirmed there was no documented evidence to indicate splint assessments for Resident 27's right elbow, right wrist, and right knee were completed and determination of the wear time for all splints were evaluated and established by a therapist. The DOR and OT 1 stated if a resident was not properly assessed for the correct splints and wear time tolerance, the resident could potentially have skin breakdown, pain, discomfort, and ROM decline. During an interview on 11/19/2025 at 4:48 pm with the Director of Nursing (DON), the DON stated the Rehabilitation (Rehab) Department was responsible for splint assessments, determining the correct type of splint to issue, and establishing the splint wear time for all residents in the facility. The DON stated that without proper assessment for the correct type of splint and a safe wear time schedule, residents could potentially experience a functional decline, pain, discomfort, and skin breakdown. During a review of a textbook, titled American Physical Therapy Association. (2003). Guide to physical therapist practice (2nd ed.). American Physical Therapy Association pages 76 to 77, the textbook indicated A physical therapist used tests and measures to assess the need for orthotic ( a medical device, often a specialized insole, that is worn inside a shoe or brace to support, align, or correct a body part's function) devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice indicated Physical Therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device. During a review of a textbook, titled Occupational therapy for physical dysfunction (2014, 7th ed.) pages 429 and 431, the textbook indicated The occupational therapist, as an expert in the adaptive use of upper extremities in occupational performance tasks, has the major responsibility for the recommendation of appropriate orthoses, the testing and training in the use of orthoses, and the selection, design, and fabrication of thermoplastic splints. The Occupational Therapy for Physical Dysfunction indicated The therapist must consider, carefully monitor, and teach the client and caregiver to report any of these problems related to orthotic use: impaired skin integrity, pain, swelling, stiffness, sensory disturbances, increased stress of unsplinted joints, and functional limitations. During a review of the facility's undated policy and procedure (P&P) titled Splinting, the P&P indicated The purpose of splints was to prevent deformity caused by muscle tightness or joint contracture, protect weak muscles from overstretching, prevent increased muscle imbalance, strengthen weak muscles, and provide temporary support for a painful body part. The P&P indicated the charge nurse, or therapist would contact the physician to obtain an evaluation order and treatment sessions for splint application, the monitoring of wear schedule, splint modifications as needed, and instruction for the nursing staff. The P&P indicated the therapist ordered the splints, applied the splint, made any necessary fitting adjustments, placed the resident on a two hour (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 9 of 33 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 11/20/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm trial wearing period to check for pressure points and assessed the resident's tolerance for the splint, increased the splint wear time throughout the course or treatment, in-serviced the nursing staff on proper application, precautions, and wearing schedule once the therapist determined the splint had reached the maximum benefit to the resident, and documented the instructions and recommendations in the plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 10 of 33 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 11/20/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7) who was assessed as being at risk for pressure ulcer ( localized damage to the skin and/or underlying tissue usually over a bony prominence) development was provided a pressure relieving barrier to be placed between Resident 7's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the right foot per facility's policy and procedure titled Prevention of Pressure Injuries. This failure had the potential for Resident 7 to develop pressure ulcers on the right foot. Findings: During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in range of motion (ROM (ROM, full movement potential of a joint [limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury]) in both arms and both legs. The MDS indicated Resident 7 was at risk for pressure ulcer development. During a review of Resident 7's Braden Scale (pressure ulcer risk assessment tool), dated 10/7/2025, the Braden Scale indicated Resident 7 was at very high risk for pressure ulcer development due to very limited sensory perception (unable to communicate discomfort, needs to be turned, or had limited ability to feel pain or discomfort in one or two arms or legs), occasionally moist skin, complete immobility (inability to move), and very poor food intake. During a review of Resident 7's care plan, titled Resident 7 was at high risk for impairment to skin integrity due to contractures of both hands, both knees, both elbows, and limited mobility, the care plan indicated a goal for Resident 7 to be free from skin injury. The care plan interventions indicated to identify/document potential causative factors and eliminate/resolve where possible. During a concurrent observation of a Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session and interview on 10/1/2025 at 10:42 am, in Resident 7's room, Resident 7 was lying in bed wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, right wrist, and right hand, a rolled up towel in the left hand, and soft boots (specialized boots placed on the feet and ankles used to treat and prevent pressure sores) on both feet. Restorative Nursing Aide 1 (RNA 1) and Certified Nursing Assistant 2 (CNA 2) removed Resident 7's both knee splints and both soft boots from Resident 7's legs and assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both knees, both ankles, and all the toes of both feet. Resident 7's middle toe, fourth toe, and small toe of the right foot were hyperextended (extension of a body part beyond its normal limits) at the knuckle joint and overlapping. Resident 7's small toe on the right foot overlapped the fourth toe, and the fourth toe overlapped the middle toe. RNA 1 and CNA 2 stated Resident 7's middle toe, fourth toe, and small toe on the right foot were Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 11 of 33 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 11/20/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete overlapping and needed to be physically separated by staff because they were on top of each other and creating points of pressure. During a concurrent observation and interview on 10/1/2025 at 11:04 a.m., with Licensed Vocational Nurse 2 (LVN 2) in Resident 7's room, LVN 2 confirmed Resident 7 had contractures of the toes on the right foot causing the middle toe, fourth toe, and small toe to overlap. LVN 2 stated Resident 7's soft boots helped prevent skin breakdown (tissue damage caused by friction, shear [occurs when the skin is pulled in one direction while the underlying bone is pulled in the opposite direction], moisture, or pressure) and pressure ulcers of both heels and feet but caused the overlapping toes to further press against each other when the straps of the soft boots were fastened. LVN 2 stated Resident 7 was at high risk for pressure sore development because she had diabetes and required total assistance for mobility. LVN 2 stated Resident 7's toes on the right foot were overlapping and required staff to physically separate and consistently reposition the toes to prevent areas of pressure. During a concurrent observation and interview on 10/1/2025 at 11:13 am with the Director of Nursing (DON) in Resident 7's room, the DON assessed Resident 7's right foot and confirmed Resident 7 had contractures of the right foot causing the middle toe, fourth toe, and small toes to overlap. The DON stated Resident 7 required a barrier or device to separate the overlapping toes of Resident 7's right foot to offload (reducing or removing pressure) the pressure and prevent pressure ulcers but did not have one. The DON stated the lack of repositioning, prolonged areas of pressure, poor nutrition, and immobility put residents at risk for skin breakdown and pressure ulcers. The DON stated Resident 7 was at high risk for developing skin breakdown and pressure ulcers because Resident 7 required total care for mobility and repositioning and had multiple contracted toes causing areas of constant pressure between the middle toe, fourth toe, and small toe of the right foot with no barrier in-between to offload the pressure. During a review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/2020, the P&P indicated Staff were to review the care plan and identify the risk factors as well as the interventions designed to reduce or eliminate pressure injuries. The P&P indicated staff inspected skin daily when performing or assisting with personal care or activities of daily living (ADLs) which included the inspection of pressure points, repositioning the resident, and providing support devices and assistance as needed. The P&P indicated skin care and prevention of pressure injuries included the use of facility-approved protective dressings for at risk individuals. The P&P indicated staff were to review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and to consult with current clinical practice guidelines for prevention measures associated with specific devices. Event ID: Facility ID: 555410 If continuation sheet Page 12 of 33 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three of six sampled residents (Residents 7, 9, and 39) with ROM concerns by failing to: 1.Objectively measure Resident 7's limited ROM in both hips and both knees during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 11/24/2024. 2.Objectively measure Resident 39's limited finger ROM of the right hand during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 5/14/2025. 3.Provide ROM exercises to Resident 9's right hand and right wrist during a Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session in accordance with physician's orders. These failures had the potential for Residents 7, 9, and 39 to experience a further decline in ROM resulting in contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) development and have a decline in physical functioning, mobility (ability to move), and activities of daily living (ADL, basic activities such as eating, dressing, toileting). Findings:1. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's PT Evaluation, dated 11/25/2024, the PT Evaluation indicated Resident 7's ROM of both legs were impaired. The PT Evaluation indicated Resident 7's ROM of the right hip, right ankle, left hip, and left ankle were impaired. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation of a RNA session on 10/1/2025 at 10:42 am, in Resident 7's room, observed Resident 7 was lying in bed wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, the right wrist, and right hand, a rolled up towel in the left hand, and soft boots (specialized boots placed on the feet and ankles used to treat and prevent pressure sores) on both feet. Restorative Nursing Aide 1 (RNA 1) and Certified Nursing Assistant 2 (CNA 2) removed Resident 7's both knee splints and both soft boots from Resident 7's legs. Resident 7's both legs were bent at the knees. RNA 1 and CNA 2 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both knees, both ankles, and all the toes of both feet. RNA 1 and CNA 2 were unable to straighten Resident 7's both hips and both knees. RNA 1 and CNA 2 assisted with ankle ROM and stated both ankles felt stiff during ROM. CNA 2 stated Resident 7's left leg felt stiffer than the right leg. At the end of the session, RNA 1 and CNA 2 replaced both knee splints and soft boots, positioned Resident 7 on the right side of the body and placed pillows in between Resident 7's both knees. During (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 13 of 33 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a concurrent interview and record review on 11/18/2025 at 1:42 pm with the Director of Rehabilitation (DOR), the DOR who was a Physical Therapist (PT), stated PTs and OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively (unbiased, based on facts) determine a resident's baseline ROM and detect changes in joint ROM. The DOR reviewed Resident 7's PT Evaluation, 11/24/2024, and confirmed Resident 7's ROM of both hips, both knees, and both ankles were impaired. The DOR stated Physical Therapist 1 (PT 1) completed Resident 7's PT Evaluation and did not use a goniometer to measure the joints of both hips and both ankles but should have because Resident 7 had ROM limitations. The DOR stated Resident 7's baseline ROM of both hips and both ankles were not determined because the ROM limitations were not measured with a goniometer. The DOR stated lack of objective ROM measurements had the potential to negatively impact the staff's ability to detect changes such as improvements or declines in Resident 7's ROM. The DOR stated it was important to provide objective measurements of a limited joint in the PT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During an interview on 11/19/2025 at 4:48 pm with the Director of Nursing (DON), the DON stated the facility provides RNA and Rehabilitation (Rehab) services to maintain, improve, and prevent declines in ROM for the residents in the facility. The DON stated the facility monitored changes in ROM by joint mobility assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), report from Rehab and/or nursing, and observations during daily care. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. The DON stated if residents who had ROM limitations did not receive the appropriate treatment and services to maintain their ROM, it could result in a functional decline. 2. During a review of Resident 39's admission Record, the admission Record indicated the facility initially admitted Resident 39 on 5/5/2021 and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing) and peripheral autonomic neuropathy (disorder that affects then nerves that control the body's processes without conscious effort). During a review of Resident 39's OT Evaluation, dated 5/14/2025, the OT Evaluation indicated Resident 39's ROM of both hands were impaired. The OT Evaluation indicated the ROM of Resident 39's ring finger on the right hand was impaired. The OT Evaluation indicated Resident 39's left hand ROM was impaired and described as follows:Index finger: Impaired - tightness and increased risk of deformity, metacarpal phalangeal (MP, knuckle joint) tightness and mild loss of motion notedMiddle finger: Impaired - tightness and increased risk of deformity, distal interphalangeal joint (DIP, joint at the tip of the finger closes to the nail) contracture and loss of motion, proximal interphalangeal joint (PIP, middle joint of the finger between the knuckle and the fingertip) hyperextended (the extension of a body part beyond it's normal limits), MP tightness and mild loss of motion notedRing finger: Impaired - tightness and increased risk of deformity, MP tightness and mild loss of motion notedLittle finger: Impaired - tightness and increased risk of deformity, MP tightness, and mild loss of motion noted. The OT evaluation indicated a goal for Resident 7 to maintain/increase current ROM, decrease stiffness on both hands. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 had moderate cognitive impairment. The MDS indicated Resident 39 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) for eating and oral hygiene, partial/moderate assistance (helper does less than half the effort) for rolling to both sides, sit to stand, and transfers, substantial/maximal assistance (helper does more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 14 of 33 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some than half the effort) for toilet hygiene, dressing, and personal hygiene, and was dependent for bathing. The MDS indicated Resident 39 had functional limitations in ROM in both arms. During a concurrent observation and interview on 11/19/2025 at 8:19 am, with Resident 39 in Resident 39's room, observed Resident 39 lying in bed. All the fingers on Resident 39's left hand were bent downwards into the palm of the hand. Resident 39's middle finger on the left hand and the ring finger on the right hand were bent to about 90 degrees at the middle joints of the fingers between the knuckles and the fingertips. Resident 39 stated he was unable to straighten all the fingers on his left hand and the ring finger of the right hand on his own and needed assistance. During a concurrent interview and record review on 11/18/2025 at 2:56 pm with the DOR and Occupational Therapist 1 (OT 1), the DOR stated PTs and OTs used goniometers to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR and OT 1 reviewed Resident 39's OT Evaluation, dated 5/14/2025, and confirmed Resident 39's ROM of both hands were impaired. OT 1 stated he completed Resident 39's OT Evaluation and did not use a goniometer to measure the joints of Resident 39's fingers but should have because Resident 39 had ROM limitations. OT 1 and the DOR stated Resident 39's baseline ROM of the fingers of both hands were not determined because the ROM limitations were not measured with a goniometer. OT 1 confirmed the OT Evaluation indicated a goal for Resident 39 to maintain and increase joint ROM. OT 1 stated he was unable to determine if Resident 39 made progress and/or met the goal since the evaluation lacked objective ROM measurements of both hands to indicate if Resident 39 maintained, declined, or improved in ROM. OT 1 and the DOR stated the lack of objective ROM measurements in the OT Evaluation had the potential to negatively impact Resident 39's plan of care and staff's ability to detect changes such as improvements or declines in ROM and monitor a resident's progress toward therapy goals. The DOR stated it was important to provide objective measurements of a limited joint in the OT evaluation to ensure subtle changes of ROM could be detected which would in turn guided the treatments and services provided. During an interview on 11/19/2025 at 4:48 pm with the DON, the DON stated the facility provides RNA and Rehab services to maintain, improve, and prevent declines in ROM for the residents in the facility. The DON stated the facility monitored changes in ROM by JMAs, report from Rehab and/or nursing, and observations during daily care. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines. The DON stated if residents who had ROM limitations did not receive the appropriate treatment and services to maintain their ROM, it could result in a functional decline. 3. During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted Resident 9 on 9/21/2013 and re-admitted on [DATE] with diagnoses including quadriplegia (weakness or paralysis to all four extremities), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) of an unspecified side of the body. During a review of Resident 9's Order Summery Report, the Order Summary Report indicated a physician's order, dated 8/25/2025, for RNA to provide active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to Resident 9's right arm, five times a week as tolerated. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was cognitively intact. The MDS indicated Resident 9 required set up or clean-up assistance (helper sets or cleans up and assists only prior to or following the activity) for eating, partial/moderate assistance for rolling to both sides, sit to stand, and transfers, and substantial/maximal assistance for hygiene, dressing, and bathing. The MDS indicated Resident 9 had functional limitations in ROM in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 15 of 33 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 11/20/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete both arms. During an observation of Resident 9's RNA session on 10/1/2025 at 10:09 am, in Resident 9's room, observed Resident 9 lying in bed. Restorative Nursing Aide 1 (RNA 1) verbally cued Resident 9 to perform active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) exercises to the right shoulder, right elbow, right wrist, and right hand. Resident 9 actively moved the right shoulder and right elbow independently with effort. Resident 9 minimally bent and straightened the right wrist and could not extend all the fingers of the right hand which were bent and curled in toward the palm of the hand. Resident 9 stated he was unable to move his right wrist and fingers well. RNA 1 did not assist with ROM exercises to Resident 9's right wrist and hand. During an interview on 10/1/2025 at 10:31 am with RNA 1, RNA 1 confirmed Resident 9 had RNA orders for AAROM exercises to Resident 9's right arm which meant assisting Resident 9 with ROM exercises to the entire arm, including the shoulder, elbow, wrist, and hand. RNA 1 confirmed she did not assist with ROM exercises to Resident 9's right wrist and hand as ordered. RNA 1 stated Resident 9 required assistance with ROM exercises to the right wrist and hand due to weakness. RNA 1 stated she should have assisted Resident 9 with right wrist and hand ROM exercises as ordered but did not. RNA 1 stated Resident 9 could have a decline in ROM if RNA exercises were not provided as ordered. During an interview on 11/18/2025 at 2:56 pm with OT 1 and the DOR, the DOR stated the purpose of the RNA program was to maintain and improve a resident's functional level and ROM. The DOR stated Rehab determined the types of exercises RNAs were to perform when creating an RNA program. The DOR and OT 1 stated if an RNA order was written for ROM exercises to the right arm, it was expected the RNA provide ROM to the entire arm, which included the shoulder, elbow, wrist, and fingers. The DOR and OT 1 stated if RNA did not provide RNA services as ordered, it could potentially result in a decline in ROM and contracture development. During an interview on 11/19/2025 at 4:48 p.m., the Director of Nursing (DON) stated the purpose of the RNA program was to ensure the residents in the facility maintained their function and mobility and to prevent functional declines. The DON stated it was important for RNA to provide exercises as ordered to prevent potential declines in ROM, function, and to avoid delaying a resident's progress towards goals. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, the P&P indicated Residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive the treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated The care plan would be developed by the interdisciplinary team based on comprehensive assessment and include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P&P indicated The care plan would include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Event ID: Facility ID: 555410 If continuation sheet Page 16 of 33 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 11/20/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 31) humidifier bottle (a medical device used with oxygen therapy to add moisture to dry oxygen) was dated with the last change date.This failure had the potential for Resident 31 to receive oxygen through equipment that may not have been maintained according to infection control standards.Findings:During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, difficulty in walking, acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), and dependence on supplemental oxygen.During a review of Resident 31's quarterly Minimum Data Set (MDS - assessment tool) dated 9/5/2025, the MDS indicated Resident 31 needed oxygen therapy.During a review of Resident 31's Order Summary dated 10/3/2025, the Order Summary Report indicated Resident 31 had an order to change pre-filled humidifier every (Q) seven days and as needed (PRN) when oxygen (O2) was in use. The Order Summary indicated to change the pre-filled humidifier Q seven days starting on 6/13/2025. The Order Summary indicated to change the humidifier every Friday on the day shift, starting 6/20/2025, and PRN when O2 was in use. During an observation on 9/30/2025 at 9:27 a.m. in Resident 31' room, Resident 31 was observed lying in bed with eyes closed, with oxygen at 3 liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). The pre-filled humidifier attached to the oxygen setup was not dated. During an observation 10/01/2025 at 10:16 a.m. in Resident 31's room, Resident 31's pre-filled humidifier bottle attached to the oxygen setup was not dated.During a concurrent observation and interview on 10/01/2025 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 31's room, the oxygen tubing and pre-filled humidifier were observed. LVN 1 stated the pre-filled humidifier was not dated. LVN 1 stated the pre-filled humidifier(s) were supposed to be changed weekly. LVN 1 stated if humidifier(s) and oxygen tubing(s) were not dated, there would be a potential for risk for infection.During a concurrent observation and interview 10/01/2025 at 10:21 a.m. with the Director of Nursing (DON) in Resident 31's room, the oxygen tubing and pre-filled humidifier were observed. The DON stated the pre-filled humidifier was not dated. The DON stated the oxygen tubing and humidifier should be changed weekly by the treatment nurse and as needed by charge nurse if they were noticeably soiled or damaged. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration revised October 2010, the P&P indicated .Steps in the Procedure.8. Change and label oxygen tubing weekly and as indicated. The facility's P&P did not indicate procedure for labeling pre-filled humidifier(s). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 17 of 33 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 11/20/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 5 diluted potassium chloride oral solution (a medication used to treat and prevent low potassium levels) prior to administration per physician order for one of three sampled residents (Resident 22).This failure had the potential to cause adverse effects, which may impact the resident's health condition.Findings: During an observation on 9/30/2025 at 9:24 a.m., LVN 5) was preparing medications for Resident 22. LVN 5 poured 30 milliliters (ml, unit to measure volume) of potassium chloride 20 milliequivalents (mEq, unit to measure mass) per 15 ml into a medication cup to a line marked 30 ml. During a medication administration observation on 9/30/2025 at 9:59 a.m., Resident 22 was observed having difficulty taking 30 ml of potassium chloride oral solution directly from a medicine cup. Observed Resident 22 displayed an unpleasant facial expression. During an observation on 9/30/2025 at 10:03 a.m., Resident 22 was observed consuming 30 ml of potassium chloride oral solution. The resident had not yet finished the dose and was observed taking small sips of the potassium chloride, followed by sips of water after each. During a concurrent interview and record review on 9/30/2025 at 10:11 a.m., with LVN 5, reviewed medication label instruction on Resident 22's potassium chloride oral solution bottle. LVN 5 stated the potassium solution bottle label indicated Give 40 mEq by mouth one time a day for hypokalemia (low potassium level in the body), 30ml= 40 mEq. Dilute with four ounces (oz, unit to measure volume) of water (120 ml) before taking medication. LVN stated she did not dilute the potassium chloride solution before administering Resident 22. LVN 5 stated that potassium chloride solution should be diluted before administration due to the taste of the medication. LVN 5 stated that Resident 22 exhibited an unpleasant facial expression while sipping the undiluted solution. During a review of Resident 22's Physician Order, dated 7/19/2025 at 7:27 p.m., the Physician Order indicated Potassium chloride liquid 20 mEq/15 mL, give 40 mEq by mouth one time a day for hypokalemia, 30 mL = 40 mEq. Dilute with 4 oz (120 mL) of water before taking medication. During an interview on 9/30/2025 at 2:55 p.m. with the Director of Nursing (DON), the DON stated nurses should follow the directions on the physician's orders. During an interview on 11/18/2025 at 4:01 p.m., with the DON, the DON stated taking potassium chloride oral solution without diluting it first could cause stomach irritation. During a review of the facility's policy and procedures (P&P) titled Administering Medications (revised in April 2019), the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. Event ID: Facility ID: 555410 If continuation sheet Page 18 of 33 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 11/20/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to maintain an organized medication storage system in the medication room. Medications were found stored in buckets labeled for different medications, and the overall storage lacked a systematic organization (example: alphabetical or by drug class). This deficient practice had the potential to result in medication errors and/or delays in administration if licensed staff were unable to locate the correct medication promptly.Findings: During an interview on 11/18/2025 at 11:05 a.m., with the Director of Nursing (DON), the DON stated the facility had two (2) nursing stations and 1 medication room. During a concurrent observation and interview on 11/18/2025 at 11:30 a.m., with the Licensed Vocational Nurse (LVN 2) in the medication (med) room located between the two nursing stations, observed to contain two walls of shelving with gallon sized buckets. A posted sign read Charge nurses please make sure to maintain organization and cleanliness of this med room. LVN 2 stated the buckets contained over the counter medications and inventory were maintained by central supply personnel. One bucket had two labels: Calcium (a mineral supplement that is essential to our body function) 600 milligrams (mg, an unit to measure mass) and vitamin D3 (an over-the-counter supplement that contained both ingredients in one tablet) and Calcium 500 plus D (a supplement tablet that contained both calcium 500 mg and unspecified amount of vitamin D). Upon closer look at the contents inside the bucket, LVN 2 confirmed there were at least 5 bottles of calcium 500 mg (without vitamin D) and 2 bottles of vitamin D3 50 mg. During a concurrent observation and interview with LVN 2 on 11/18/2025 at 11:38 a.m., with LVN 2, observed another bucket with 4 labels indicated the bucket contained Vitamin D 10 micrograms (mcg, unit to measure mass), Thiamin B-1 (a form of vitamin B) 100 mg, Vitamin D3 10000 international units (IU, an unit to measure concentration of certain vitamins), and Vitamin D3 400 IU. LVN 2 confirmed there were at least 5 bottles of Vitamin D 25 mcg (1000 IU) in this bucket. LVN 2 stated it would be time-consuming to search for a particular medication when there were several types of medications stored in one bucket. LVN 2 stated the buckets system of storing medications were not in any order, not alphabetically, nor by class. During a concurrent observation and interview on 11/18/2025 at 11:40 a.m., LVN 2 confirmed there were three boxes of loperamide HCl (medication to treat diarrhea) 2 mg tablets found in the bucket that was labeled for diphenhydramine (generic for Benadryl, a medication to treat allergies 25 mg and loratadine (a medication to treat allergies) 10 mg. LVN 2 stated the loperamide boxes were misplaced. There was a bucket labeled for loperamide on the top shelf. During an interview on 11/18/2025 at 11:53 a.m., with the DON in the med room the DON stated the current medication storage system in the med room was not organized. The DON stated if nursing could not find the medication they were looking for, nurse would submit a requisition for central supply to order. The DON stated if LVN (in general) could not find the medication, there could be a potential delay in medication administration. During an interview on 11/18/2025 at 3:41 p.m., the DON acknowledged it would be difficult to rotate stocks and prevent expired medications from remaining in circulation. During a review of the facility's policy and procedures P&P) titled Medication Labeling and Storage (revised February 2023), the P&P indicated . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications are stored in an orderly manner. Event ID: Facility ID: 555410 If continuation sheet Page 19 of 33 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 11/20/2025 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dental services for one of two sample residents (Resident 62) in a timely manner by failing to:1. Refer Resident 62 to the dentist for recurrent toothache.2. follow up Resident 62 dental x-rays (a special camera that takes pictures of the inside of the mouth, teeth and jaw) result.These failures had the potential to put Resident 62 for unnecessary pain and increased risk of gum disease.Findings:During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses including myocardial infarction (MI- heart attack), angina pectoris (chest pain caused by reduced blood flow to the heart muscle), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and hyperlipidemia (high level of fats in the blood).During a review of Resident 62's History and Physical (H&P) dated 10/8/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 10/14/2025, the MDS indicated the resident had an intact cognition (ability to think, learn, understand and remember) and required set-up or clean up assistance (helper sets up or cleans up ; resident completes activity and helper assists only prior to or following the activity) with oral hygiene and eating. The MDS indicated the resident had an obvious or likely cavity or broken natural teeth.During a review of Resident 62's Order Summary Report (a comprehensive document that outlines a resident's current medical orders, medications and treatments) dated 10/7/2025, the Order Summary Report indicated an order of dental consult and follow treatment as needed.During a review of Resident 62's Onsite Mobile Dental Note dated 10/24/2025, the Onsite Mobile Dental Note indicated Resident 62's chief complaint was broken teeth on his upper and lower mouth. The Onsite Mobile Dental Note indicated Resident 62 had mostly broken teeth, low oral hygiene (neglecting the practices of keeping teeth and gums clean) and high plaque (a sticky, colorless film that forms on teeth and contributes to tooth decay and gum disease) and tartar (hardened dental plaque). The Onsite Mobile Dental Note indicated teeth extractions and evaluation with dental x-rays for treatment recommendations. The Onsite Mobile Dental Note indicated an order of Amoxiclavunate (medicine used to treat infection) 875 milligrams (mgs. -unit of measurement) by mouth every 6 hours as needed for mild to moderate pain) and Ibuprofen (medicine to treat pain and inflammation) 600 mg for pain.During a review of Resident 62's Order Summary Report dated 10/24/2025, the Order Summary Report indicated a physician order of Amoxicillin-Pot Clavunate 875 mgs - 125 mgs. one tablet by mouth every 12 hours for tooth infection for 10 days.During a review of Resident 62's Order Summary Report dated 10/24/2025, the Order Summary Report indicated an order for Ibuprofen 600 mg 1 tablet for mild to moderate pain (1-7 out of 10 pain levels).During a review of Resident 62's Care Plan titled, Resident noted with broken natural teeth and at risk for oral pain/ discomfort, initiated on 10/8/2025, the Care Plan indicated the resident experienced pain related to toothache to left upper side on 10/12/2025. The Care Plan goal indicated Resident 62 will not exhibit mouth pain through the next review date. The Care Plan interventions included dental consultation due to toothache to the left upper side, and dental evaluation and intervention as needed.During a concurrent observation and interview on 11/18/2025 at 9:40 a.m. with Resident 62, Resident 62 grimaced and pointed to the left upper side of his face. Resident 62 stated he had a toothache 9 out of 10 pain scale (severe pain).During a review of Resident 62's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 11/18/2025 and 11/19/2025, the MAR indicated on 11/18/2025 at 9:52 a.m. Resident 62 had 7 out of 10 on a 0 to 10 numeric pain scale(0= no pain, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 20 of 33 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 11/20/2025 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 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1-to 3 numeric pain , 4 to 6 = moderate pain and 7 to 10 = severe pain) and received Ibuprofen 600 mgs one tablet. The MAR indicated on 11/19/2025 at 12:34 p.m. the resident received one tablet of Ibuprofen 600 mgs for 7 out of 10 pain level.During a concurrent interview and record review on 11/19/2025 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 62 ‘s MAR, dated 11/18/2025 and 11/19/2025 and Onsite Mobile Dental Note, for the month of October 2025 were reviewed. LVN 3 stated Resident 62 received Ibuprofen 600 mgs. on 11/18/2025 at 9:52 a.m. and on 11/19/2025 at 12:34 p.m. for toothache of 7 out of 10 pain level. LVN 3 stated there was a dental x-ray performed on 11/12/2025 but there was no result in the chart and no staff followed up the result of Resident 62's dental x-rays. LVN 3 stated the licensed nurses should have followed up the Resident 62's dental x-rays and obtained an order from the physician for a dental consultation because of resident's recurrent toothache. LVN 3 stated licensed nurses would call the physician to obtain a dental consultation, and the social worker would schedule an appointment for the dentist to see the resident. LVN 3 stated Resident 62's could develop a tooth infection, and his toothache could get worse if not addressed.During a concurrent interview and record review on 11/19/2025 at 4:45 p.m. with the Director of Nursing (DON), Resident 62's Order Summary Report, dated 10/24/2025 and Onsite Mobile Dental Note dated 10/2025 were reviewed. DON stated the resident was seen by the dentist and was prescribed an antibiotic (Amoxicillin Pot Clavunate) for tooth infection dated 10/24/2025. DON stated the resident had a dental x-ray on 11/12/2025 and result was not on the electronic chart. DON stated licensed nurses are responsible in following up Resident 62's dental x-ray result and should have notified the physician about the recurrent toothache to obtain a dental consultation. DON stated tooth pain could be an indication of infection and could result in worsening pain if not addressed in a timely manner. DON stated licensed nurses not following up Resident 62's dental x-ray result and not notifying the physician about his toothache could cause delay of care and treatment for Resident 62.During a review of facility's policy and procedure (P&P) titled Dental Services, revised 12/2016, the P&P indicated routine, and emergency dental services are available to meet the resident's oral health services according to the resident's assessment and plan of care.During a review of facility's P&P titled, Quality of Care, revised 8/2009, the P&P indicated quality healthcare should be effective, safe, resident centered (providing care that responds to individual needs) and timely. Event ID: Facility ID: 555410 If continuation sheet Page 21 of 33 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 11/20/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the lunch meal for one of six sampled residents (Resident 3) was fortified (foods have protein, carbohydrates, and/or fats added to increase the total nutritional value of the food) as ordered by the physician.This failure had the potential to result in inadequate caloric and nutritional intake which could lead to unplanned weight loss, decreased strength, and a decline in overall health status.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] and was readmitted on [DATE] with diagnoses including encephalopathy (any disorder that affects the brain's function or structure), muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified protein-calorie malnutrition (poor nutrition).During a review of Resident 3's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/15/2025, the MDS indicated Resident 3's had moderate cognitive impairment. The MDS indicated Resident 3 needed supervision or touching assistance with eating. The MDS indicated Resident 3 was dependent on staff for toileting, showering, dressing, and putting on or taking off footwear. The MDS indicated Resident 3 needed partial to moderate assistance from staff with oral and personal hygiene.During a review of Resident 3's Care Plan Report initiated on 2/28/2024 and revised on 11/13/2025, the Care Plan Report indicated The resident has potential nutritional problem and dehydration risk r/t advancing age, mechanically altered diet, on therapeutic diet. The Care Plan indicated interventions included Fortified diet 4-Pureed texture, 2-mildly thick consistency, use plate guard (assistive device used to prevent food from falling off the plate) for meals initiated on 11/3/2025. The Care Plan goals included The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs and symptoms) of malnutrition daily through review date.During a review of Resident 3's Order Summary Report (a comprehensive document that outlines a resident's current medical orders, medications and treatments), dated 11/19/2025, Resident 3 had an order for Fortified diet 4-Pureed texture, 2 - mildly thick consistency, provide inner lip plate for every meal ordered on 11/18/2025 and started on 11/18/2025.During an observation on 11/19/2025 at 12:30 p.m. in Resident 3's room, Resident 3's lunch tray was observed with no sauce, gravy, or margarine.During an interview on 11/19/2025 at 1:52 p.m. with Dietary Aid (DA) 1, DA 1 stated she was responsible for announcing the fortified diet to the cook, but she did not read the diet out loud. DA 1 stated she should have read the meal card carefully and told the cook the diet for Resident 3 was fortified.During an interview on 11/19/2025 at 2:04 p.m. with the Dietary Manager (DM), the DM stated fortified diets were for resident(s) who are losing weight and were ordered by the physician for the resident(s) to gain weight. The DM stated if fortified diet orders were not followed, there would be potential for weight loss.During an interview on 11/19/2025 at 4:15 p.m. with the Director of Nursing (DON), the DON stated the purpose of diet fortification was to add calories to the diet. The DON stated if diets were not fortified, the resident would not meet the additional calorie needs.During a review of the facility's policy and procedure (P&P) titled FORTIFIED DIET dated 2025, indicated .The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. SAMPLED FORTIFIED MEAL PLAN:. Lunch: Extra sauce or gravy on meat extra margarine on potatoes, rice, or pasta extra margarine on hot vegetables, whipped topping on gelatin, pie, cobblers, and pudding. Event ID: Facility ID: 555410 If continuation sheet Page 22 of 33 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 11/20/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and served in a sanitary manner by failing to:Ensure the freezer's temperature was not greater than zero degrees Fahrenheit (F-unit of measurement) while frozen items were stored.Ensure an open bag of popsicles was dated and labeled with open date and use by date.Ensure an open bag of frozen burritos was dated with open date and stored in a sealed bag.Ensure the cook performed hand hygiene after the removal of used gloves and before removing the baked burritos from the oven.These failures had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).Findings:1. During an initial tour of kitchen observation and interview on 9/30/2025 at 8:30 a.m. with [NAME] (CK)1, the reach in freezer had a temperature of 39 degrees F. CK 1 stated the kitchen staff were restocking frozen items in the freezer that was why the freezer's temperature was high.During a concurrent observation and interview on 9/30/2025 at 10:52 a.m. with the Dietary Manager (DM), the reach in freezer had a temperature of 12 degrees F. The DM stated the temperature of freezer should be -10 degrees to 0-degree F to keep the frozen meats and vegetables away from danger zone (temperature range between 40 degrees and 140 degrees F where bacteria can multiply quickly causing food borne illness).During an observation on 9/30/2025 at 2:45 p.m. with the DM in the kitchen, the reach in freezer temperature read 20 degrees F. There was an observation of frozen deep pizza started to defrost, and an ice cream container had beads of water on the surface. The DM stated the administrator called for a repairman to fix the freezer today.During an interview on 9/30/2025 at 3:38 p.m. with the DM, the DM stated she did not know the freezer's temperature was greater than zero degrees. The DM stated the facility will discard the frozen food items that were defrosting like pizza and ice-cream and will not leave any food items in the freezer. The DM stated defrosted frozen food cannot refroze because defrosted food items had the potential to promote bacterial growth which can cause food borne illnesses if consumed by residents.During a telephone interview on 9/30/2025 at 3:33 p.m. with the Registered Dietician (RD), the RD stated the frozen meats can be thawed in the refrigerator and can still be used for two days. The RD stated the rest of the food will be discarded and whatever the kitchen staff can thaw will be used. The RD stated residents could get food borne illness if the frozen food items are not stored in a freezer with a temperature of 0-degree F.2.During a concurrent observation and interview on 9/30/2025 at 8:33 a.m. with Dietary Aid (DA) 2, an open box of popsicles not labeled with open date and use by date was observed. DA 2 stated the box of popsicles came from the activity department and should have been labeled and dated with open date and by use date.During an interview on 9/30/2025 at 8:41 a.m. with the DM, the DM stated the dietary staff should have put an open date to determine if the popsicles would still be good to be consumed by the residents.3. During a concurrent observation and interview on 9/30/2025 at 2:45 p.m. and subsequent interview on 9/30/2025 at 4:21 p.m. with the DM, an open, not labeled with date open of burritos was stored in an unsealed bag in the freezer. The DM stated the bags of bean and beef burritos should be stored in a sealed container or bag to prevent freezer burns which can affect the quality of food. The DM stated labeling and dating open food items in the freezer and refrigerator are important so the kitchen staff will know when to discard expired food and to ensure food safety.During an interview on 11/20/2025 at 12:00 p.m. with the Administrator (ADM), the ADM stated labeling and dating of open frozen food is important so the dietary staff would know when the food was open, and is still good to be consumed by residents to ensure food safety.4. During an observation on 11/19/2025 at 12:10 p.m. in the kitchen with [NAME] (CK) 1of the tray line (assembly-line system for preparing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 23 of 33 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 11/20/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and assembling meal trays), CK 1 turned off the stove and removed the bean cheese burritos from the oven with gloves used in plating food. CK 1 was observed removing used gloves and putting on a new pair of gloves without hand hygiene and then proceeded to plate food for the tray line.During an interview on 11/19/2025 at 1:38 p.m. with CK 1, CK 1 stated hand hygiene is practiced before and after preparing food, before putting on a new pair of gloves to avoid cross contamination (unintentional transfer of harmful bacteria, viruses from one food or surface to another). CK 1 stated she should have washed her hands to prevent residents from getting sick of food-borne illnesses.During an interview on 11/19/2025 at 4:15 p.m. with the Director of Nursing (DON), the DON stated not practicing hand hygiene in the kitchen during tray line, and in between tasks can put residents at risk for foodborne illness caused by cross contamination.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated foods will be received and stored in a manner that complies with safe food handling practices. The P&P indicated all foods stored in the refrigerator or freezer are covered, labeled and dated with use by date. The P&P indicated frozen foods are maintained at a temperature to keep the food frozen solid.During a review of facility's P&P titled, Procedure for Refrigerated Storage, undated, the P&P indicated the freezer's temperature is 0 degree or lower.During a review of facility's P&P titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, revised 11/2022, the P&P indicated employees should wash hands during food preparation, as often as necessary to remove soil and contamination, to prevent cross contamination when changing tasks and after engaging in other activities that contaminate the hands. The P&P indicated the use of disposable gloves does not substitute for proper handwashing, and handwashing should be practiced after gloves are removed Event ID: Facility ID: 555410 If continuation sheet Page 24 of 33 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aides (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) accurately documented RNA services provided for two of six sampled residents (Residents 7 and 9) in 5/2025, 6/2025, and 7/2025. This failure had the potential to negatively impact the provision of necessary care and services due to the inaccurate reflection of services provided. Findings: 1. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, and chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot. During a review of Resident 7's 5/2025 RNA flowsheet (daily record of RNA services provided for each month), the RNA flowsheet indicated two RNA orders for: 1. RNA to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025. During a review of Resident 7's 6/2025 RNA flowsheet the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The squares on the RNA flowsheet were blank on 6/4/2025 and 6/5/2025 for both RNA orders. The square on the RNA flowsheet was blank on 6/26/2025 for the RNA splinting order. During a review of Resident 7's 7/ 2025 RNA flowsheet the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 7's both arms and both legs, five times a week and 2. RNA to apply splints to Resident 7's right hand, both elbows, both knees, and a towel roll to Resident 7's left hand for four hours, five times a week. The square on the RNA flowsheet was blank on 7/29/2025 for both RNA orders. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 10/7/2025, the MDS indicated Resident 7 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 7 was dependent (helper does all the effort) in oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and transfers. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation on 11/18/2025 at 11:53 am in Resident 7's room, Resident 7 was lying in bed with both eyes closed and blankets covering the body from the waist down. Resident 7 was wearing splints to both elbows and holding a rolled-up towel in the left hand. Resident 7's both legs appeared to be bent and rotated to the left side of the body. 2. During a review of Resident 9's admission Record, the admission Record indicated the facility initially admitted Resident 9 on 9/21/2013 and re-admitted on [DATE] with diagnoses including quadriplegia (weakness or paralysis to all four extremities), hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) of an unspecified side of the body. During a review of Resident 9's 5/ 2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 25 of 33 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a front wheeled walker (FWW, mobility device with two wheels in the front used for support when standing or walking) for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. During a review of Resident 9's 6/2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a FWW for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on the following days: 6/4/2025, 6/5/2025, 6/12/2025, 6/13/2025, 6/16/2025 to 6/20/2025, 6/23/2025 to 6/26/2025, and 6/30/2025 for both RNA orders. During a review of Resident 9's 7/2025 RNA flowsheet, the RNA flowsheet indicated two RNA orders for: 1. RNA to perform PROM exercises to Resident 9's left arm, three times a week and 2. RNA to assist Resident 9 with walking exercises using a FWW for approximately 30 feet with one person assistance, five times a week. The squares on the RNA flowsheet were blank on 7/2/2025 and 7/4/2025 for the RNA PROM exercises order. The squares on the RNA flowsheet were blank on 7/17/2025 and 7/29/2025 for the RNA walking exercises order. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was cognitively intact. The MDS indicated Resident 9 required set up or clean-up assistance (helper sets or cleans up and assists only prior to or following the activity) for eating, partial/moderate assistance for rolling to both sides, sit to stand, and transfers, and substantial/maximal assistance for hygiene, dressing, and bathing. The MDS indicated Resident 9 had functional limitations in ROM in both arms. During a concurrent observation and interview on 9/30/2025 at 2:28 p.m., with Resident 9 in Resident 9's room, Resident 9 was lying in bed. Resident 9's left elbow was bent, and the fingers of the left hand were in a loose fist. Resident 9 stated he was unable to independently move the fingers of the left hand and the left shoulder and needed assistance. Resident 9 lifted his right arm to shoulder height, partially bent and straightened the right elbow, and was unable to actively move all the fingers of the right hand. Resident 9's both legs were straight and resting on a cushion at the end of the bed. Resident 9 minimally bent both knees, bent and straightened both ankles and wiggled all toes. Resident 9 stated staff assisted with exercises almost every day. During an interview on 9/30/2025 at 3:29 p.m., with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated she was the primary RNA for all the residents on an RNA program in the facility. RNA 1 stated two other RNAs, Certified Nursing Assistant 2 (CNA 2) and Restorative Nursing Aide 2 (RNA 2) assist as needed to ensure all residents on the RNA program were seen daily, Monday through Friday. RNA 1 stated that she was able to see all residents in her daily caseload and rarely required assistance. During a concurrent interview and record review on 11/19/2025 at 10:57 a.m., with RNA 1, RNA 1 reviewed Resident 7 and Resident 9's RNA flowsheets for the month of 5/2025, 6/ 2025, and 7/ 2025. RNA 1 stated blank squares on the RNA flowsheet either meant she forgot to document, or she did not provide treatment that day. RNA 1 stated she did not know why there were blank squares in 5/2025, 6/2025, and 7/2025 because there was always RNA coverage Monday through Friday since she had been working. RNA 1 stated that she had not called in sick at any time during the past year she worked at the facility and that coverage was always arranged for days she was scheduled to be off. RNA 1 stated she provided treatment to all residents on the RNA program on the days she worked but forgot to document. RNA 1 stated it was important she documented daily to ensure the facility could monitor if the residents on the RNA program were being seen as ordered. During a concurrent interview and record review on 11/19/2025 at 2:51 p.m., with the Director of Staff Development (DSD), the DSD stated he supervised the RNAs. The DSD stated the facility provided RNA services to the residents in the facility Monday through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 26 of 33 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 11/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Friday. The DSD stated RNA 1 was the primary RNA on the floor and CNA 2 and RNA 2 provided back up assistance as needed if RNA 1 was scheduled off or called out sick. The DSD stated RNA 1's daily caseload was very manageable and all residents on the RNA program were seen as ordered. The DSD reviewed Resident 7 and Resident 9's RNA flowsheets for 5/2025, 6/2025, and 7/2025. The DSD stated a blank square on the RNA flowsheet indicated RNA either did not document for the day or RNA treatment was not provided. The DSD reviewed Resident 7's 5/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. The DSD reviewed Resident 7's 6/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 6/4/2025 and 6/5/2025 for both RNA orders and blank on 6/26/2025 for the RNA splinting order. The DSD reviewed Resident 7's 7/ 2025 RNA flowsheet and confirmed the square on the RNA flowsheet was blank on 7/29/2025 for both RNA orders. The DSD reviewed Resident 9's 5/2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 5/5/2025 and 5/21/2025 for both RNA orders. The DSD reviewed Resident 9's 6/ 2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank on 6/4/2025, 6/5/2025, 6/12/2025, 6/13/2025, 6/16/2025 to 6/20/2025, 6/23/2025 to 6/26/2025, and 6/30/2025 for both RNA orders. The DSD reviewed Resident 9's 7/ 2025 RNA flowsheet and confirmed the squares on the RNA flowsheet were blank 7/2/2025 and 7/4/2025 for the RNA PROM exercises order and on 7/17/2025 and 7/29/2025 for the RNA walking exercises order. The DSD stated there was always at least one RNA on staff Monday through Friday in 5/2025, 6/2025, and 7/2025, and the blank squares likely indicated the RNAs forgot to document the treatments that were provided. The DSD stated the lack of RNA documentation could be mistaken for missed RNA treatments. The DSD stated it was important that RNAs documented accurately to ensure the facility could correctly monitor a resident's progress and tolerance to the RNA program and to ensure all residents on the RNA program were seen as ordered to prevent any functional declines. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated the purpose of the RNA program was to ensure the residents in the facility maintained their function and mobility and to prevent functional declines. The DON stated accurate RNA documentation was important to ensure the facility had an accurate assessment of the type and frequency of services provided, the status of the resident's function, and the resident's tolerance to the RNA program. During a review of the facility's Job Description, titled Restorative Nursing Assistant, dated 5/2017, the Job description indicated one of the responsibilities of the RNA was to maintain accurate restorative progress and documentation records on all patients participating in the restorative program. During a review of the facility's policy and procedure (P&P), titled Charting and Documentation, revised 7/2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the medical record. The P&P indicated treatment or services performed was to be documented in the medical record. The P&P indicated documentation in the medical record would be objective, completed, and accurate. Event ID: Facility ID: 555410 If continuation sheet Page 27 of 33 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 11/20/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and observe infection control measures for two of six sampled residents (Residents 6 and 7) by failing to:1.Ensure Certified Nursing Assistant (CNA) 4 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 6's both knees and both ankles which required direct contact with Resident 6 who was on Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms [microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents]). 2.Ensure CNA 2 wore an isolation gown while assisting with range of motion to Resident 7's both hands and repositioning Resident 7's both legs which required direct contact with Resident 7 who was on EBP. These failures had the potential to transmit infectious microorganisms and increase the risk of infection among the residents and staff members. Findings:1. During a review of Resident 6's admission Record, the admission Record indicated the facility initially admitted Resident 6 on 11/21/2020 and re-admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and osteoarthritis (loss of protective cartilage that cushions the ends of your bones). During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order, dated 4/8/2024, for Resident 6 to be on EBP due to the presence of a gastrostomy tube (G-tube - a tube placed directly into the stomach for long-term feeding). During a concurrent observation and interview on 11/18/2025 at 11:05 a.m., with Resident 6 in Resident 6's room, Resident 6 was lying in bed with blankets covering both legs. CNA 4 entered Resident 6's room, put on gloves and did not put on an isolation gown. CNA 4 removed Resident 6's blankets. Resident 6's both knees and hips were bent and rotated to the right side of the body. Resident 6 stated she was unable to straighten her legs on her own and needed assistance. CNA 4 touched Resident 6's both legs and attempted to straighten Resident 6's both hips, knees, and ankles multiple times. CNA 4 replaced Resident 6's blankets, removed both gloves, performed hand hygiene, and exited the room. During an interview on 11/18/2025 at 11:34 a.m., with CNA 4, CNA 4 confirmed he did not wear an isolation gown while providing care which required direct contact with Resident 6 who was on EBP. CNA 4 stated he should have worn an isolation gown while assisting Resident 6 with ROM of both legs because he had direct contact with Resident 6 who was on EBP. CNA 4 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 11/19/2025 at 2:22 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with non-healing wounds (injury to the body that typically involves a laceration or breaking of a membrane) and indwelling devices (medical devices inside the body) such as g-tubes and foley catheters (thin, flexible rube inserted into the bladder to drain urine). The IPN stated all staff providing direct patient care which included repositioning a resident and assisting with ROM to residents on EBP must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated it was important for staff to follow the proper infection control protocols to prevent the spread of infection. 2. During a review of Resident 7's admission Record, the admission Record indicated the facility initially admitted Resident 7 on 12/7/2020 and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus ( a disorder characterized Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 28 of 33 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 11/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete by difficulty in blood sugar control and poor wound healing), contractures of both knees, both elbows, and both hands, chronic a chronic diabetic ulcer (persistent open wound that fails to show significant healing) of the left foot and Parkinsons disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). During a review of Resident 7's Order Summary Report, the Order Summary Report indicated a physician's order, dated 1/10/2025, for Resident 7 to be on EBP due to the presence of a G-tube and diabetic ulcers (open sore or wound caused by nerve damage and poor blood flow) on the bottom of Resident 7's left foot and on the fifth metatarsal bone (outer side of the ball of the foot) of Resident 7's right foot. During an observation on 9/30/2025 at 11:01 a.m., in Resident 7's room, Resident 7 was lying in bed with blankets covering the entire body. CNA 2 entered Resident 7's room, put on gloves and did not put on an isolation gown. CNA 2 removed Resident 7's blankets. Resident 7 was wearing splints (a device used to restrict, protect, or immobilize a part of the body to support function and increase ROM) to both elbows, both knees, and the right wrist and hand. Resident 7 had a rolled-up towel in the left hand and was wearing soft boots to both ankles. Resident 7's both knees were bent and rotated to the right side of the body. CNA 2 touched and repositioned Resident 7's both legs. CNA 2 stated Resident 7's left side of the body was stiffer than the right side of the body. CNA 2 removed Resident 7's left towel roll and tried to straighten the fingers of Resident 7's left hand. CNA 2 touched Resident 7's right hand splint and tried to straighten the fingers of the right hand which were wrapped around the splint. CNA 2 removed both gloves, performed hand hygiene, and exited the room. During an interview on 9/30/2025 at 11:10 a.m., with CNA 2, CNA 2 confirmed she did not wear an isolation gown while providing care which required direct contact for Resident 7 was on EBP. CNA 2 stated she should have worn an isolation gown while assisting Resident 7 with ROM and repositioning Resident 7 because she had direct contact with Resident 7 who was on EBP. CNA 2 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 11/19/2025 at 2:22 p.m., with the IPN, the IPN stated the purpose of EBP precautions was to reduce the transmission of infection for residents with non-healing wounds and indwelling devices. The IPN stated all staff providing direct patient care, including repositioning residents and assisting with range of motion (ROM) exercises for residents on EBP, must wear appropriate personal protective equipment (PPE), which includes an isolation gown and gloves, to prevent the spread of infection. During an interview on 11/19/2025 at 4:48 p.m., with the DON, the DON stated it was important for staff to follow the proper infection control protocols to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions, revised 5/20/2025, the P&P indicated EBP was the use of gloves and gowns for specific high contact care activities based on the resident's characteristics that are associated with high risk of MDRO colonization which included the presence of indwelling medical devices such as G-tubes and chronic and open non-healing wounds. The P&P indicated gowns and gloves would be used while performing high contact tasks associated with the greatest risk for MDRO contamination of the healthcare provider's hands, clothes, and the environment which included any care activity where close contact with the resident is expected and any care activity involving contact with environmental surfaces. Event ID: Facility ID: 555410 If continuation sheet Page 29 of 33 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 11/20/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for one of two sampled residents (Resident 64). This deficient practice had the potential for Resident 64 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.Findings:During a review of Resident 64's admission Record, the admission Record indicated Resident 64 was admitted to the facility 10/14/2025 with diagnoses including dementia (a progressive state of decline in mental abilities) and Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 64's Minimum Data Set (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 64's cognition (ability to think, understand, learn, and remember) was moderately impaired and was dependent (helper does all the effort) with activities of daily living (ADLs-activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 64's progress note dated 11/6/2025, at 1:33 p.m., the progress note indicated Resident 64 did not have sediment (solid particles found in urine caused by a UTI), hematuria (blood in urine), pain, or foul-smelling odor of the urine. During a review of Resident 64's order details dated 11/6/2025 at 2:26 p.m., the order details indicated an order for Nitrofurantoin (medication to treat urinary tract infections). During a concurrent interview and record review on 11/20/2025 at 7:34 a.m., with the Infection Prevention Nurse (IPN), the IPN indicated Resident 64 was started an oral antibiotic Nitrofurantoin 100 milligrams (mg- unit of measurement) twice a day for 10 days. The IPN stated there was no documentation to determine if there was a urine infection or urine culture done prior to Resident 64's starting on oral antibiotics. The IPN stated I missed this one and the importance of screening residents prior to initiation of antibiotic therapy is to prevent antibiotic resistance and potentially killing good bacteria. During an interview on 11/20/2025 at 9:51 a.m., with the Director of Nursing (DON), the DON indicated the IPN should have done a time-out (a brief pause) when Resident 64 was prescribed the oral antibiotic. The DON stated Resident 64 did not have any symptoms of a UTI and therefore the antibiotic was unnecessary and could lead to resistance if prescribed again in the future. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 11/2019, the P&P indicated, To optimize use of antibiotics by improving prescribing practices and to reduce inappropriate antibiotic use. The facility will implement an antibiotic stewardship program to promote appropriate use of antibiotics, optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improving outcomes for residents. The P&P indicated the infection preventionist will track whether the resident met Criteria when the antibiotic is ordered. The P&P indicated the infection preventionist will track if cultures were ordered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 30 of 33 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 11/20/2025 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 0907 Provide enough space and equipment to meet each resident's needs Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that the therapy mat (a padded surface used for therapeutic treatment) in the Rehabilitation Gym (Rehab Gym) was maintained in a clean and unobstructed condition. The mat was observed to be cluttered with various miscellaneous items, including multiple cardboard boxes, a cushion pad, inflatable balls, a large paper towel roll, bags, splints (rigid devices used to support and immobilize a broken bone or impaired joint), a wooden device with plastic rings, folded linen, and personal belongings of staff. This failure had the potential to limit the availability and use of therapeutic equipment, reduce usable treatment space for residents during rehab therapy. Findings: During an observation of the Rehab gym on 9/30/2025 at 4:10 p.m., observed four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two sets of leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, cell phone, eye glasses, and an eyeglass case were observed on top of the therapy mat. During a concurrent observation and interview on 9/30/2025 at 4:30 p.m., with the Director of Rehabilitation (DOR) in the Rehab gym, the DOR stated the therapy mat was used for residents to work on transfers (moving from one surface to another), sitting balance, and various exercises. The DOR confirmed there were four cardboard boxes, a blue cushion pad, two inflatable balls, a large paper towel roll, a large bag containing splints, two leg splints, a wooden device with plastic rings, folded linen, a personal carrying bag, cell phone, eyeglasses, and an eyeglass case on the therapy mat. The DOR stated the miscellaneous items stored on the therapy mat limited the amount of usable space for residents during therapy sessions. The DOR stated the items on the therapy mat should be stored in their designated areas and not on the therapy mat for resident safety and to ensure the equipment was clear and accessible for resident use. During an interview on 11/19/2025 at 4:48 p.m., with the Director of Nursing (DON), the DON stated all therapy equipment should be accessible for resident use. The DON stated the therapy mat should always be clear and free of clutter to prevent accidents and to ensure residents could access the equipment during therapy. During a review of the facility's undated policy and procedures (P&P), titled, Rehab Space Requirements, the P&P indicated the rehabilitation team would provide skilled rehabilitation services in a safe and suitable environment that encouraged the residents to participate and enabled the treating clinician to address the modalities listed on the plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 31 of 33 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 11/20/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the reach in freezer for frozen vegetables and frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to:1. Follow their policy and procedure titled Freezer Storage which indicated to maintain a temperature of zero-degree Fahrenheit (F- unit of measurement) or lower.This failure had the potential to put residents at risk for food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).Findings:During an initial tour of kitchen observation and interview on 9/30/2025 at 8:30 a.m. with [NAME] (CK)1, the reach in freezer had a temperature of 39 degrees F. CK 1 stated the kitchen staff was restocking frozen items in the freezer that was why the freezer's temperature was high.During a concurrent observation and interview on 9/30/2025 at 10:52 with the Dietary Manager (DM), the reach in freezer had a temperature of 12 degrees F. The DM stated the temperature of freezer should be -10 degrees to 0 degrees F to keep the frozen meats and vegetables away from danger zone (temperature range between 40 degrees and 140 degrees F where bacteria can multiply quickly causing food borne illness).During a concurrent observation and interview on 9/30/2025 at 2:45 p.m. with the DM in the kitchen, the reach in freezer temperature read 20 degrees F. There was an observation of frozen deep pizza that started to defrost and an ice cream container that had beads of water on the surface and appeared to be melting. The DM stated the administrator called for a repairman to fix the freezer today.During an interview on 9/30/2025 at 8:41 a.m. and 3:38 p.m. with the DM, the DM stated she did not know the freezer's temperature was greater than zero degrees this morning. The DM stated the facility will discard the frozen food items that were defrosting like pizza, and ice-cream will not be left in the freezer. The DM stated the defrosted frozen food cannot refreeze because defrosted food items had the potential to promote bacterial growth which can cause food borne illnesses if consumed by residents.During a telephone interview on 9/30/2025 at 3:33 p.m. with the Registered Dietician (RD), the RD stated the frozen meats can be thawed in the refrigerator and can still be used for two days. The RD stated the rest of the food will be discarded and whatever the kitchen staff can thaw, will be used. The RD stated residents could get food borne illness if the frozen food items are not stored in a freezer with a temperature of zero degrees F.During an interview on 9/30/2025 at 4:03 p.m. with the Administrator (ADM), the ADM stated she was notified about the freezer not functioning properly on 9/30/2025 at 11:00 a.m. The ADM stated she called the company to fix the freezer, and the kitchen staff will empty the contents of the freezer. During an interview on 11/19/2025 at 2:04 p.m. with the DM, the DM stated maintaining the correct temperature of freezer will keep the freshness and quality of food.During a review of facility's policy and procedure (P&P) titled, Freezer Storage, undated, the P&P indicated the freezer should be maintained at a temperature of zero degrees F.During a review of facility's P&P titled, Food Receiving and Storage, revised 11/2022, the P&P indicated frozen foods are maintained at a temperature to keep the food frozen solid and wrappers of frozen foods must stay intact until thawing. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555410 If continuation sheet Page 32 of 33 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 11/20/2025 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 24 residents' rooms met 80 square feet (sq. ft- a unit of area measurement) per residents in multibed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,14,15,16,17,18,19, 20, 21, 22, 23, 25, and 26 were occupied with at least two residents. rooms [ROOM NUMBERS] were occupied with three residents per room. This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents. Findings: During an observation on 9/30/2025 at 10:17 a.m. an initial tour of the facility was done. Residents' rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15,16,17, 18, 19, 20, 21,22. 23, 25, and 26, did not meet the requirement of 80 sq. ft per resident. During an observation on 11/19/2025 at 2:31 p.m., some residents were in their rooms, able to move freely, and open drawers on their nightstand. Nurses were able to perform patient care, and the resident size of room did not affect the privacy of the residents. During a review of the facility's Room Waiver letter, dated 9/15/2025, provided by the Administrator (ADM), the Room Waiver letter indicated that rooms had enough space to provide for each resident's care, dignity. and privacy. The Room Waiver letter indicated the lack of space on the new building code has no adverse effect on the residents' health and safety or on maintaining the wellbeing of the residents. The following rooms were included in the Room Waiver request: Rooms 1, 2, 3, 4, 5, 6, 7. 8, 9, 10, 11, 12, 14, 15,16, 17, 18,19, 20, 21, 22, 23, 25, and 26. During an interview on 11/20/2025 at 12:27 p.m. with the ADM, the ADM stated a letter was sent out every year to ensure the California Department of Public Health was aware of the residents' room sizes. The ADM stated at this time there were no concerns from residents about room size. The ADM stated we can accommodate the residents' needs, provide care and environmental cleaning on a daily basis. During a review of the facility's policy and procedures (P&P), titled Bedrooms, undated, the P&P indicated, .Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. Event ID: Facility ID: 555410 If continuation sheet Page 33 of 33