Health inspection·March 10, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm patient/ resident's dignity and respect in full recognition of his or her individuality. The P&P indicated promoting resident's independence and dignity in dining such as by avoidance of staff standing over patients/residents while assisting them to eat. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 - Some 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 staff failed to inform and consult with the resident's physician when a resident experienced a significant change of condition ([COC] a clinical deviation from a resident's baseline) for two of eight sampled residents (Resident 27 and 258): 1. Resident 27, who had a suprapubic urinary catheter (a urinary drainage device inserted into the bladder through the lower abdominal wall), had a temperature of 101.8 degrees Fahrenheit (F), with sediments (happens when crystals, bacteria, or blood exit through the urine) and cloudy urine noted. Resident 27 was not assessed and monitored for signs and symptoms (S&S) of a urinary tract infection ([UTI] an infection that affects part of the urinary tract.) 2. Resident 258's indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was leaking from the insertion site and the physician was not notified of the changes of condition for proper and timely intervention. These deficient practices of not notifying the physician of Resident 27's and Resident 258's COC resulted in a delay in evaluation, care, and treatment for both Resident 27 and 258. Cross Reference F690. Findings: a. During a review Resident 27's admission Record (Face Sheet), the admission Record indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), type 2 diabetes mellitus [(DM) a chronic condition that affects the way the body processes sugar in the blood], encephalopathy (a broad term for any brain disease that alters brain function or structure), and quadriplegia (refers to the inability to move from the neck down, including the trunk, legs and arms). During a review of Resident 27's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 1/29/2023, the MDS indicated Resident 27 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 27 required total dependence from staff with all activities of daily living (ADLs, self-care activities performed daily, such as dressing, eating, bathing, and personal hygiene). During a concurrent observation and interview on 3/8/2023 at 10:10 a.m., with Licensed Vocational Nurse (LVN) 5, Resident 27 was observed lying in the bed with a suprapubic urinary catheter. There was no gauze dressing to the surgical site nor a dated statlock (a strap free device, which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull). There was no indication when the urine drainage bag had last been changed. The urine output was observed to be amber-colored (between yellow and orange) with cloudy sediments observed in the indwelling catheter tubing. LVN 5 stated she was not sure when was the last time the indwelling catheter tubing and urine drainage bag had been changed. LVN 5 stated it should have been changed every month. LVN 5 stated the suprapubic catheter's surgical site should be covered with gauze dressing to prevent contamination and a UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 During a review of Resident 27's Progress Note (PN) dated 3/6/2023, the PN indicated Certified Nurse Assistant (CNA) 5 informed Registered Nurse (RN) 4 Resident 27 had temperature of 101.8 degrees Fahrenheit (?). The note indicated RN 4 administered Acetaminophen (medication to reduce fevers), however there was no documentation Resident 27's physician and responsible party (RP) were notified regarding the change of condition. Residents Affected - Some During a review of Resident 27's Genitourinary (GU, relating to the genital and urinary organs) daily assessments dated 3/4/3023 to 3/7/2023, the GU assessments had incomplete documentation indicating Resident 27's urine was assessed. During an interview with RN 2 on 3/8/2023 at 2:38 p.m., RN 2 stated urine output should be assessed and documented accurately to provide proper care to Resident 27 who had a history of UTIs. RN 2 stated there was no Urologist consult order (a physician who specializes in the study or treatment of the function and disorders of the urinary system) for Resident 27's suprapubic urinary catheter. RN 2 stated the Urologist should see Resident 27 for proper care of the suprapubic urinary catheter because Resident 27 had history of UTIs and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues). RN 2 stated due to insurance coverage issues the Urologist could not see Resident 27. During a review of Resident 27's Physician's Order for the month of March 2023. The order indicated to change the suprapubic catheter as needed for leaking and blockage, and to change the urine drainage bag as needed for heavy sediment. During a concurrent interview with RN 2 and record review on 3/8/2023 at 2:38 p.m., Resident 27's Laboratory (lab) result: Culture urine reflex dated 2/1/2023 was reviewed. The lab result indicated there were three or more organisms isolated greater than (>)100,000 colony-forming unit (CFU, a unit commonly used to estimate the concentration of microorganisms in a test) each, indicating probable contamination or colonization. The lab result indicated a repeat lab test was requested on 2/3/2023. RN 2 stated there was no repeat lab test done on 2/3/2023. During a review of Resident 27's Treatment Administration Record (TAR) for the months of January, February, and March 2023. The TARs indicated the following orders: 1. Secure suprapubic catheter with statlock twice a day (BID). 2. Suprapubic urinary catheter change as needed for leaking and blockage. 3. Change urine drainage bag as needed for heavy sediment. There was no documentation Resident 27's suprapubic catheter was assessed and monitored. During a review of Resident 27's care plan titled, Risk for UTI and skin breakdown related to (R/T) use of suprapubic catheter, initiated on 12/7/2022, the care plan indicated the need for the suprapubic catheter was for wound management, neurogenic bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems), and frequent UTI. The goals of the care plan indicated the following: 1. Resident 27 will remain clean, dry, and odor free daily for 3 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 2. Resident 27 will remain and free from UTI daily for 3 months. Level of Harm - Minimal harm or potential for actual harm 3. Resident 27 will have no skin breakdown daily for 3 months. 4. Resident 27 will have no further complications from catheter use daily for 3 months Residents Affected - Some The staff's interventions indicated the following: 1. Monitor catheter urinary bag and document the following every shift: color, consistency, odor, hematuria (blood in the urine), bladder distention, and burning sensation. 2. Provide adequate fluids as ordered. 3. Intake and output monitoring every shift per protocol. 4. Provide good peri care (the cleaning of a person's private areas). 5. Monitor labs as ordered. 6. Monitor for urinary retention. 7. Provide catheter care every shift and as needed (PRN) as ordered. 8. Change catheter as needed when clogged, soiled, or pulled out. 9. Change catheter drainage bag as needed. 10. Keep catheter patent (free from clogs) and in proper position. 11. Secure catheter with statlock at all times every shift. 12. Medication as ordered. 13. Urology consult as needed. During a review of the facility's policy and procedures (P&P) titled, Change in resident condition, revised on 4/2013, the P&P indicated to clearly define the guidelines for timely notification of a change in resident's condition by LVN and RN. The P&P indicated it is the policy of this facility that all changes in resident conditions and responses to treatments will be communicated to the physician and family or legal representative. The P&P indicated the following: A. Acute Medical Change 1. Any sudden or serious change in resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician immediately. The licensed nurse in charge will notify the physician. 2. If unable to contact attending physician or alternate physician notify the Medical Director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 - Some 3. The responsible party for making medical decisions regarding the resident will be notified that this has been a change in the resident's condition, and what steps are being taken. (The resident may be the responsible party). 4. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. B. Routine Medical Changes/Need to Alter Treatment Significantly. 1. All symptoms and unusual signs will be communicated to the physician promptly. This includes a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening, weight loss or gain, and response to treatments. 2. The nurse in charge is responsible for notification of physician and family or legal representative prior to end of assigned shift when a change in a resident's condition is noted. 3. If unable to contact attending physician or alternate TIMELY, notify Medical Director for response and follow-up to change in resident's status. 4. Document resident change in condition and response in Nursing Progress Notes, and update resident care plan as indicated. 5. All attempts to reach the physician and responsible party will be documented in the Nursing Progress Notes in the electronic record. Documentation will include time and response. b. During a review of Resident 258's admission Record, the resident was admitted to the facility on [DATE], with diagnoses including acute tubular necrosis (a kidney disorder involving damage to the tubule cells of the kidneys, which can lead to the kidneys not working), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids) and hemodialysis [(dialysis), a treatment to filter wastes and water from the blood when the kidneys are not able to function]. During an interview on 3/7/2023, at 6:50 a.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 258 was being monitored because he attempts to pull out his indwelling catheter [(Foley catheter) a flexible tube that a clinician inserts into the bladder to drain urine]. During an observation and concurrent interview with Certified Nursing Assistant 4 (CNA 4), on 3/8/2023, at 7:43 a.m., CNA 4 stated that Resident 258's catheter sometimes leaked. Resident 258 was observed to be wet with urine, with saturated disposable pads under the buttocks, and having towels under the scrotum, penis, and catheter insertion site. During an interview with the Director of Nursing (DON), on 3/8/2023, at 1:47 p.m., the DON stated Resident 258 was on dialysis but had fluid shifts where the resident will produce urine at times. The DON stated she was not aware that Resident 258's Foley catheter was leaking. The DON stated upon reviewing Resident 258's medical record, there were no notes regarding notifying the physician of Resident 258's leaking Foley catheter. During an interview with Licensed Vocational Nurse 7 (LVN 7), on 3/9/2023, at 8:30 a.m., LVN 7 stated he never received any report that Resident 258's Foley catheter was leaking. LVN 7 stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 - Some was a physician's order for the Foley catheter to be changed when there was leakage (of urine) or blockage. During a review of a document titled Progress Note for Resident 258, dated 3/6/2023, CNA 4 documented Resident 258's chucks (a disposable absorbent pad that is placed underneath a resident with the intent to absorb urine or feces moisture), was wet upon doing patient care, and CNA 4 reported the incident to LVN 7. During a record review of Resident 258's document titled Intake/Output Inquiry, dated 3/6/2023, at 2:35 p.m., indicated urine output was 200 ml, and there was urine leaking at the catheter site. During a review of the active admission Physician's Orders, dated 2/23/2023, indicated the following: 1. Urinary catheter for wound management. 2. Change Urinary Catheter FR 16/ 10 milliliters (ml, unit of measure), PRN (as needed) when leaking/ blockage. During a review of Resident 258's medical record from the time of admission on [DATE], the medical record had no documentation of notification to physician, or any change in catheter due to leaking urine. During a review of Resident 258's care plan titled, Care plan: Catheter Use, indicated Resident 258 was at risk for UTI [(urinary tract infection), an infection in any part of the urinary system] and would remain clean and dry daily for 3 months. The care plan indicated the resident would remain free from UTI and complications for 3 months by monitoring catheter urinary bag, and documenting and the catheter would be changed when clogged, soiled, or pulled out. During a review of the facility's P&P titled, Change in Residents Condition, indicated any sudden or serious change in resident's condition will be notified to the physician immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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: Residents Affected - Some a. Ensure three of seven sampled residents were free from physical restraints (Resident 7, 25, and 33). b. Obtain physician order, and consent for the use of four (4) side rails for Resident 7, 25 and 33. c. Assess residents for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the enclosure of bed rails) and create a care plan for use of four side rails for Resident 7, 25 and 33. These deficient practices resulted in unnecessary restraint use, absence of continued assessment/ monitoring and placed the residents at potential risk for physical injuries. Findings: During a review of Resident 7's admission Record (face sheet), the face sheet indicated Resident 7 was initially admitted to the facility on [DATE] with diagnoses including respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), s/p tracheostomy ( an opening created at the front of the neck so a tube can be inserted into the windpipe [traches] to help you breathe ),gastroparesis ( delayed gastric emptying ) , S/P gastrotomy ( an opening into the stomach from the abdominal wall, made surgically for the introduction of food.) During a review of Resident 7's Minimum Data Set ([MDS], resident assessment and care-screening tool), dated 1/8/2023, the MDS indicated Resident 7 was comatose (persistent vegetative state/ no discernible consciousness). The MDS indicated Resident 7 required total assistance with one person assist bed mobility, dressing, transfer, locomotion on and off the unit, toilet use, personal hygiene, and bathing. During a review of Resident 25's face sheet, the face sheet indicated Resident 33 was initially admitted to the facility on [DATE] with diagnoses including respiratory failure, s/p tracheostomy, anemia (a condition in which the body does not have enough healthy red blood cells). During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 was unable to speak, rarely understands and rarely understand others. MDS indicated Resident 25 was totally dependent on all activities of daily living (ADL) like bed mobility, dressing, transfer, locomotion on and off the unit, toilet use, personal hygiene, and bathing. During a review of Resident 33's face sheet, the face sheet indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including respiratory failure, s/p tracheostomy, multiple fracture, epilepsy. During a review of Resident 33's MDS dated [DATE], the MDS indicated Resident 33 sometimes able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be understood and sometimes understands other. The MDS indicated Resident 33 required extensive assistance with bed mobility, dressing, total assistance with transfer, locomotion on and off the unit, toilet use, personal hygiene, and bathing. During an initial tour of the facility on 3/7/2023 at 7:37 a.m., Residents 7, 25 and 33 were observed with four side rails up. During an interview on 3/8/2023 at 8:20 a.m., with Minimum Data Set Coordinator (MDSC 2), the MDSC 2 stated that restraint (a measure or condition that keeps someone or something under control or within limits) needed to have a physician's order, consent, assessment, and a care plan. MDSC 2 stated there was no resident at the facility who was on restraint. MDSC 2 stated that nurses should have put the side rails down when they saw that the four side rails was up. MDSC stated that three side rails were not considered a restraint but if it was four it would be a restraint. During a concurrent interview and record review on 3/8/2023 at 9:46 a.m., with MDSC 2, Resident 7, 25 and 33's medical records were reviewed. MDSC 2 stated that he cannot find a physician order, consent, care plan and assessment for four siderails for Resident 7, 25 and 33. During a concurrent interview and record review on 3/8/2023 at 2:15 p.m. with the Director of Nursing (DON), Resident 7, 25 and 33's medical records were reviewed. The DON stated she was not aware that the staff at the facility put all the 4 siderails up because there were no physician orders, assessment, care plan and most importantly consent for the use of restraint. During a record review of the facility's policy and procedure (P&P) titled, Restraints- Physical, Guidelines for Use and Assessment, dated 3/2020, the P&P indicated to assure that physical restraint will only be utilized for treatment, safety, and protection of the resident when medical symptoms warrant their use and less restrictive measures have been unsuccessful. The Physician will obtain informed consent pertaining to the use of restraints from the resident or resident's representative. The facility will not use restraints in violation of the regulation solely based on a legal surrogate or representative's request or approval. All restraints will require a physician order and order and restraint use will be reflected in the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality of care for three of four sampled residents (Resident 37, 26, and 32), by failing to ensure: Residents Affected - Some a. To check Resident 37's gastrostomy tube [(g-tube), tube inserted through the abdomen that brings nutrition directly to the stomach] for placement (ensuring the tube was still inserted into the stomach) prior to medication administration and check the residuals (measuring the amount of liquid contents in stomach) prior to gastrostomy tube medication administration. b. Licensed Vocational Nurse (LVN) 1 flushed Resident 50's feeding tube ([F-tube] tube inserted directly to the stomach for medications) after each medication was administered during medication pass for Resident 50. c. Resident 32's intravenous ([IV] administering medicines and fluids into the bloodstream via a vein) antibiotic (medication that inhibits the growth or destroys germs) was infused with an anti-free flow device (prevents the medication from flowing freely into the patient, or infusate [given over a period of time] from freely entering the patient). These deficient practices placed Resident 37, 26, and 32 at risk for pulmonary aspiration (when food, liquids, saliva, or vomit enters into the airways) due to the stomach reaching content capacity causing pressure on the digestive tract, resulting in pneumonia (an infection affecting the lungs), and ineffective medication therapy. Findings: a. During a review of Resident 37's admission records, the admission records indicated the resident was admitted to the facility on [DATE], with diagnoses including status post tracheostomy (an opening at the front of the neck so a tube can be inserted into the windpipe to help with breathing) due to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), percutaneous endoscopic gastrostomy (a medical procedure where a tube is passed into the stomach through the abdominal wall, to provide nutrition when oral intake is not adequate or possible), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). During a review of Resident 37's Minimum Data Set Assessment (MDS), a standardized assessment and care screening tool dated 3/6/2023, indicated Resident 37 required total assistance for all care needs, and that was unable to communicate or make needs known. During an observation on 3/7/2023 at 8:40 a.m., Licensed Vocational Nurse 8 (LVN 8) administered Resident 37's medications via g-tube without checking for placement, or residual. During an interview on 3/7/2023, at 8:50 a.m., LVN 8 stated she forgot to check for placement or residual prior to administering medications but was aware she should always check prior to administering medications via a g-tube. During an interview with the Director of Nursing (DON), on 3/8/2023, at 1:45 p.m., the DON stated staff must always check for placement and check for excessive fluids by aspirating (pulling fluid out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 to measure amount) prior to administering medications. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P/&P) titled, Medication Administration Through a Feeding Tube, indicated prior to administering medication through a gastrointestinal tube, to check for placement and residual. Residents Affected - Some b. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted Resident 50 on 4/24/2022 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 50's Minimum MDS, dated [DATE], the MDS indicated Resident 32's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 50 required extensive assistance with bed mobility and was totally dependent on staff with transfers, dressing, walking, toilet use, and personal hygiene. During a record review of Resident 50's Physician's Orders for the month of March 2023, the orders indicated Resident 50 had a feeding tube. The orders indicated starting on 4/21/2022, flush (to wash out) 5 milliliters (ml, unit of measurement) to 10 milliliters of fluids in between medication administration via F-tube. During a medication pass observation with LVN 1 on 3/7/2023 at 8:47 a.m., LVN 1 was observed administering Resident 50's medications through the F-tube without flushing the F-tube with fluids in between each medication. During an interview with LVN 1 on 3/8/2023 at 2:09 p.m., LVN 1 stated she forgot to flush each medication with 5 to 10 ml of fluid in between each medication. During an interview with Registered Nurse (RN) 1 on 3/8/2023 at 2:25 p.m., RN 1 stated when administering several medications using the F-tube, the F-tube needed to be flushed with 5 ml to 10 ml of fluid in between each medication. During a record review of the facility's P&P titled, Medication Administration through a Feeding Tube, approved 4/2017, the P&P indicated to use a minimum of 5-15 milliliters of water for each medication and do not mix with each other or with formula. c. During a review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 4/15/2019 with diagnoses that included respiratory failure. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making was severely impaired. The MDS indicated the resident was totally dependent on staff for all activities of daily livings (ADLs, self-care activities performed daily such as dressing, eating, toileting, and personal hygiene). During a record review of Resident 32's Medication Administration History Report, dated from 3/1/2023 to 3/8/2023, the report indicated an order for Piperacillin-tazobactam (antibiotic medication that kills germs) every six hours around the clock, via IV, infuse over thirty minutes, for five days. During a medication pass observation and concurrent interview with Registered Nurse (RN) 1 on 3/7/2023 at 8:24 a.m., RN 1 was observed administering Resident 32's IV Piperacillin-tazobactam. RN 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observed infusing the medication via gravity using IV tubing that did not have an anti-free flow device; the medication was infused via gravity and not via an IV pump (device used to infuse the medication at a prescribed rate). RN 1 stated she was not using the medication an IV pump because the medication was infusing through the resident's midline access (IV access inserted in the upper arm with the tip located just below the axilla [armpit]). RN 1 stated the drip rate was estimated and not calculated to infuse in 30 minutes. The medication administration was initiated on 3/7/2023 at 8:28 a.m. During a follow up observation of Resident 32's IV medication infusing on 3/7/2023 at 9:16 a.m., the IV medication was still observed to be infusing via gravity (approximately 48 minutes later). During a follow up observation of Resident 32's IV medication infusing and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 3/7/2023 at 9:33 a.m., the IV medication was observed to have completed and the medication container and the IV tubing was completely dry. LVN 1 stated the IV medication was completed on 3/7/2023 at 9:33 a.m., more than thirty minutes after the dose was initiated. LVN 1 stated the medication infused with regular IV tubing and it was completely empty. During a record review of the facility's P&P titled, Sterile Products: IV Therapy Administration, (approved 10/2017), the P&P indicated the policy was established to ensure safe administration of IV fluids and medication. The P&P indicated administration of IV solutions containing medications shall use anti-free flow infusion control devices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents with urinary catheters (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services for two of eight sampled residents (Resident 27 and Resident 258): 1. Resident 27, who had a suprapubic urinary catheter (a urinary drainage device inserted into the bladder through the lower abdominal wall), had a temperature of 101.8 degrees Fahrenheit (F), with sediments (happens when crystals, bacteria, or blood exit through the urine) and cloudy urine noted. Resident 27 was not assessed and monitored for signs and symptoms (S&S) of a urinary tract infection ([UTI] an infection that affects part of the urinary tract.) 2. Resident 258's indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was leaking from the insertion site and the physician was not notified of the changes of condition for proper and timely intervention. This deficient practice had the potential for delayed UTI identification, delayed treatment, and UTI reoccurrence for Resident 27 and Resident 258. Findings: a. During a review Resident 27's admission Record (Face Sheet), the admission Record indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), type 2 diabetes mellitus [(DM) a chronic condition that affects the way the body processes sugar in the blood], encephalopathy (a broad term for any brain disease that alters brain function or structure), and quadriplegia (refers to the inability to move from the neck down, including the trunk, legs and arms). During a review of Resident 27's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 1/29/2023, the MDS indicated Resident 27 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 27 required total dependence from staff with all activities of daily living (ADLs, self-care activities performed daily, such as dressing, eating, bathing, and personal hygiene). During a concurrent observation and interview on 3/8/2023 at 10:10 a.m., with Licensed Vocational Nurse (LVN) 5, Resident 27 was observed lying in the bed with a suprapubic urinary catheter. There was no gauze dressing to the surgical site nor a dated statlock (a strap free device, which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull). There was no indication when the urine drainage bag had last been changed. The urine output was observed to be amber-colored (between yellow and orange) with cloudy sediments observed in the indwelling catheter tubing. LVN 5 stated she was not sure when was the last time the indwelling catheter tubing and urine drainage bag had been changed. LVN 5 stated it should have been changed every month. LVN 5 stated the suprapubic catheter's surgical site should be covered with gauze dressing to prevent contamination and a UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 27's Progress Note (PN) dated 3/6/2023, the PN indicated Certified Nurse Assistant (CNA) 5 informed Registered Nurse (RN) 4 Resident 27 had temperature of 101.8 degrees F. The note indicated RN 4 administered Acetaminophen (medication to reduce fevers), however there was no documentation Resident 27's physician and responsible party (RP) were notified regarding the change of condition. Residents Affected - Some During a review of Resident 27's Genitourinary (GU, relating to the genital and urinary organs) daily assessments dated 3/4/3023 to 3/7/2023, the GU assessments had incomplete documentation indicating Resident 27's urine was assessed. During an interview with RN 2 on 3/8/2023 at 2:38 p.m., RN 2 stated urine output should be assessed and documented accurately to provide proper care to Resident 27 who had a history of UTIs. RN 2 stated there was no Urologist consult order (a physician who specializes in the study or treatment of the function and disorders of the urinary system) for Resident 27's suprapubic urinary catheter. RN 2 stated the Urologist should see Resident 27 for proper care of the suprapubic urinary catheter because Resident 27 had history of UTIs and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues). RN 2 stated due to insurance coverage issues the Urologist could not see Resident 27. During a review of Resident 27's Physician's Order for the month of March 2023, the order indicated to change the suprapubic catheter as needed for leaking and blockage, and to change the urine drainage bag as needed for heavy sediment. During a concurrent interview with RN 2 and record review on 3/8/2023 at 2:38 p.m., Resident 27's Laboratory (lab) result: Culture urine reflex dated 2/1/2023 was reviewed. The lab result indicated there were three or more organisms isolated greater than (>)100,000 colony-forming unit (CFU, a unit commonly used to estimate the concentration of microorganisms in a test) each, indicating probable contamination or colonization. The lab result indicated a repeat lab test was requested on 2/3/2023. RN 2 stated there was no repeat lab test done on 2/3/2023. During a review of Resident 27's Treatment Administration Record (TAR) for the months of January, February, and March 2023. The TARs indicated the following orders: 1. Secure suprapubic catheter with statlock twice a day (BID). 2. Suprapubic urinary catheter change as needed for leaking and blockage. 3. Change urine drainage bag as needed for heavy sediment. There was no documentation Resident 27's suprapubic catheter was assessed and monitored. During a review of Resident 27's care plan titled, Risk for UTI and skin breakdown related to (R/T) use of suprapubic catheter, initiated on 12/7/2022, the care plan indicated the need for the suprapubic catheter was for wound management, neurogenic bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems), and frequent UTI. The goals of the care plan indicated the following: 1. Resident 27 will remain clean, dry, and odor free daily for 3 months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 2. Resident 27 will remain and free from UTI daily for 3 months. Level of Harm - Minimal harm or potential for actual harm 3. Resident 27 will have no skin breakdown daily for 3 months. 4. Resident 27 will have no further complications from catheter use daily for 3 months Residents Affected - Some The staff's interventions indicated the following: 1. Monitor catheter urinary bag and document the following every shift: color, consistency, odor, hematuria (blood in the urine), bladder distention, and burning sensation. 2. Provide adequate fluids as ordered. 3. Intake and output monitoring every shift per protocol. 4. Provide good peri care (the cleaning of a person's private areas). 5. Monitor labs as ordered. 6. Monitor for urinary retention. 7. Provide catheter care every shift and as needed (PRN) as ordered. 8. Change catheter as needed when clogged, soiled, or pulled out. 9. Change catheter drainage bag as needed. 10. Keep catheter patent (free from clogs) and in proper position. 11. Secure catheter with statlock at all times every shift. 12. Medication as ordered. 13. Urology consult as needed. During a review of the facility's policy and procedure (P&P) titled, Indwelling catheter use, revised on 10/2014, the P&P indicated the purpose was for the use and management of residents with an indwelling urinary catheter and to prevent urinary tract infections in residents with an indwelling urinary catheter. 1. Generally, urinary catheterization is indicated for the following and left in place only as long as needed: a. To relieve urinary tract obstruction. b. To permit urinary drainage in patients with neurogenic bladder dysfunction and urinary retention. c. To aid in urologic surgery or other surgery on contiguous structures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 d. To obtain accurate measurements of urinary output. Level of Harm - Minimal harm or potential for actual harm 2. Clinical conditions in the resident population demonstrating the necessity of an indwelling catheter may include: Residents Affected - Some a. Urinary retention causing persistent overflow incontinence, symptomatic infections and/or renal dysfunction. b. Urinary retention that cannot be corrected surgically. c. Urinary retention that cannot be managed with intermittent catheterization. d. Skin conditions such as wounds, pressure sore or irritations irritated by presence of urine e. Terminal illness or severe impairment causing discomfort to the resident when bed and clothing changes are performed. 3. Handwashing must be performed immediately before and after any manipulation of the catheter site or apparatus. 4. Specimen collection: a. Cleanse the sampling port with disinfectant and aspirate urine with a sterile syringe. b. Larger volumes of urine for special analysis, should be obtained aseptically from the drainage bag. (i.e., 24-hour urine studies.) 5. Urinary flow: a. Unobstructed flow must be maintained. (Occasionally, it is necessary to temporarily obstruct the catheter for specimen collection or other medical purposes.) b. To achieve free flow of urine: c. The catheter collection should be kept from kinking d. The collecting bag should be emptied regularly using a separate collecting container for each patient. e. The draining spigot and non-sterile collecting container should never come in contact. f. Properly functioning of obstructed catheters should be irrigated or if necessary, replaced. 6. Catheters will only be changed prn when deemed necessary due to obstruction or formation of concretions. 7. Regular bacteriologic monitoring of catheterized patients/residents as an infection control measure is NOT recommended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 Level of Harm - Minimal harm or potential for actual harm b. During a review of Resident 258's admission Record, the resident was admitted to the facility on [DATE], with diagnoses including acute tubular necrosis (a kidney disorder involving damage to the tubule cells of the kidneys, which can lead to the kidneys not working), renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids) and hemodialysis [(dialysis), a treatment to filter wastes and water from the blood when the kidneys are not able to function]. Residents Affected - Some During an interview on 3/7/2023, at 6:50 a.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 258 was being monitored because he attempts to pull out his indwelling catheter [(Foley catheter) a flexible tube that a clinician inserts into the bladder to drain urine]. During an observation and concurrent interview with CNA 4, on 3/8/2023, at 7:43 a.m., CNA 4 stated Resident 258's catheter sometimes leaked. Resident 258 was observed to be wet with urine, with saturated disposable pads under the buttocks, and having towels under the scrotum, penis, and catheter insertion site. During an interview with the Director of Nursing (DON), on 3/8/2023, at 1:47 p.m., the DON stated Resident 258 was on dialysis but had fluid shifts where the resident will produce urine at times. The DON stated she was not aware that Resident 258's Foley catheter was leaking. The DON stated upon reviewing Resident 258's medical record, there were no notes regarding notifying the physician of Resident 258's leaking Foley catheter. During an interview with Licensed Vocational Nurse 7 (LVN 7), on 3/9/2023, at 8:30 a.m., LVN 7 stated he never received any report that Resident 258's Foley catheter was leaking. LVN 7 stated there was a physician's order for the Foley catheter to be changed when there was leakage (of urine) or blockage. During a review of a document titled Progress Note for Resident 258, dated 3/6/2023, CNA 4 documented Resident 258's chucks (a disposable absorbent pad that is placed underneath a resident with the intent to absorb urine or feces moisture), was wet upon doing patient care, and CNA 4 reported the incident to LVN 7. During a record review of Resident 258's medical document titled Intake/Output Inquiry, dated 3/6/2023, at 2:35 p.m., indicated urine output was 200 ml, and there was urine leaking at the catheter site. During a review of the active admission Physician's Orders, dated 2/23/2023, indicated the following: 1. Urinary catheter for wound management. 2. Change Urinary Catheter FR 16/ 10 milliliters (ml, unit of measure), PRN when leaking/ blockage. During a review of Resident 258's medical record from the time of admission on [DATE], the medical record had no documentation of notification to physician, or any change in catheter due to leaking urine. During a review of Resident 258's care plan titled, Care plan: Catheter Use, indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 258 was at risk for UTI and will remain clean and dry daily for 3 months. The care plan indicated the resident would remain free from UTI and complications for 3 months by monitoring catheter urinary bag, and documenting and the catheter will be changed when clogged, soiled, or pulled out. During a review of facility policy and procedure titled, Indwelling Foley Catheter Use, indicated Unobstructed flow must be maintained .and that poorly functioning or obstructed catheters should be irrigated or if necessary, replaced. It further indicates that catheters will be changed when deemed necessary due to obstruction. Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Resident 13 and 30) tube feeding (a way of delivering nutrition, hydration, and medication directly to the stomach through a surgically inserted tube) formulas were changed every twenty-four hours as indicated by the facility's policy and procedure (P&P). This deficient practice had the potential to result in bacterial contamination for Resident 13 and Resident 30. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 4/19/2017 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 13's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/5/2023, the MDS indicated Resident 13's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 13 was totally dependent on staff for all activities of daily living (ADLs, self-care activities performed daily such as dressing, bathing, toileting, and personal hygiene). During a record review of Resident 13's Physician's Orders for the month of March 2023, the orders indicated Resident 13 had a feeding tube. The orders indicated starting on 4/19/2017, the resident to receive gastrostomy tube ([G tube] tube inserted through the wall of the abdomen directly into the stomach) feeding of Jevity 1.5 (type of tube feeding formula providing nutrition), 60 cubic centimeters (cc, unit of measurement) per hour for eighteen hours to provide 1080 cc/ 1620 kilocalorie per day. During a record review of Resident 13's Medication Record for the month of March 2023, the record indicated starting on 8/27/2020, the resident to receive G tube feeding of Jevity 1.5, 60 cc per hour via pump for eighteen hours to provide 1080 cc/ 1620 kilocalorie per day. The records indicated Resident 13 had been receiving the ordered tube feeding from 3/1/2023 to 3/8/2023. During an observation of Resident 13's tube feeding and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 3/7/2023 at 9:03 a.m., the Jevity 1.5 label was dated 2/19/2023. LVN 1 stated the date on the bottle indicated it was changed on 2/19/2023. b. During a review of Resident 30's admission Record, the admission Record indicated the facility admitted Resident 13 on 5/23/2018 with diagnoses that included respiratory failure. During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 30 was totally dependent on staff for all ADLs. During a record review of Resident 30's Physician's Orders for the month of March 2023, the orders indicated Resident 30 had a feeding tube. The orders indicated starting on 5/23/2018, resident to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some receive a G tube feeding of Jevity 1.5, 45 cc per hour for eighteen hours to provide 810 cc/ 1215 kilocalorie per day. During a record review of Resident 30's Medication Record for the month of March 2023, the record indicated starting on 3/4/2023, the resident to receive G tube feeding of Jevity 1.5, 45 cc per hour via pump for eighteen hours to provide 1080 cc/ 1620 kilocalorie per day. The records indicated Resident 30 had been receiving the ordered tube feeding from 3/4/2023 to 3/8/2023. During an observation of Resident 30's tube feeding and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 3/7/2023 at 9:03 a.m., the Jevity 1.5 label was dated 3/5/2023. LVN 1 stated the date on the bottle indicated it was changed on 3/5/2023. LVN 1 stated the bottle should have been changed sooner. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/8/2023 at 2:14 p.m., LVN 1 stated tube feeding formulas need to be changed at least every twenty-four hours. During an interview with the Director of Nursing (DON) on 3/8/2023 at 2:44 p.m., the DON stated tube feeding formulas need to be changed every twenty-hours to ensure it did not get spoiled. During a record review of the facility's policy and procedure (P&P) titled, Enteral Feeding Tube Via Gastrostomy Tube/Jejunostomy Tube, (approved 4/2017), the P&P indicated change feeding bag and tubing every twenty four hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 a resident who received hemodialysis [(HD) process of removing waste products and excess fluid from the body] received treatment in accordance with standards of practice for one of six sampled residents (Resident 45) by failing to: Residents Affected - Some 1.Ensure to accurately assess and monitor HD access site of Resident 45. 2.Followed physician order to weigh Resident 45 before and after HD treatment. 3.Ensure the HD emergency kit was always available at bedside for safety measures for HD complications for Resident 45. 4.Ensure to develop and implement individualized resident-centered care plans for Resident 45 on HD treatment. These deficient practices had the potential to delay or lack of identifying complications (such as pain, infection, trauma, and bleeding) of the HD access site, and can lead to a delay provision of HD treatment. Findings: During a review Resident 45's admission Record (Face Sheet), the admission Record indicated Resident 45 was admitted on [DATE] with diagnoses including end stage renal disease ([ESRD] stage when the kidneys can no longer support the body's needs of removing waste and excess water from the body) and dependence on HD, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), type 2 diabetes mellitus [(DM) a chronic condition that affects the way the body processes blood sugar]. During a review of Resident 45's Minimum Data Set ([MDS]a comprehensive standardized assessment and care-screening tool), dated 2/19/2023, the MDS indicated Resident 45's severely impaired cognition (ability to think and reason). The MDS indicated Resident 45 required total dependence with all activities of daily living (ADL) assistance. During concurrent observation and interview on 3/8/2023 at 10:00 a.m., with Licensed Vocational Nurse (LVN) 5, Resident 45 was seen lying on bed with tracheostomy tube connected to ventilator machine. Resident 45 had HD access of right internal jugular (IJ) permacath (a special IV line into the blood vessel in your neck or upper chest just under the collarbone). Resident 45 was seen crying with tears, however unable to say words. LVN 5 stated Resident 45 was schedule for HD that day. LVN 5 stated that she does not know what type of HD access Resident 45 has. LVN 5 also stated that she was not able to find Resident 45's HD emergency kit at bedside. LVN 5 stated HD kit was necessary for emergency use in the event of complication such as continuous bleeding. During an interview with HD nurse on 3/8/2023 at 3:00 p.m. HD Nurse stated that resident on HD treatment will benefits from having an emergency kit, in case of complication such as bleeding due accidental pulling out of HD access. During an interview with RN 2 on 3/8/2023 at 3:36 p.m. RN 2 stated that regardless of what type of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0698 Level of Harm - Minimal harm or potential for actual harm HD access, Resident 45 should have an emergency kit at bedside at all times for any complications such as profuse bleeding. During a review of physician order (PO) on 11/7/2022, PO indicated HD order: bedside every Monday, Wednesday, Friday. Dialysis access: right IJ Permacath. Residents Affected - Some During a review of PO on 11/7/2022, PO indicated fluid restriction: water flush 25 milliliters (ml) every hour. During a review of PO on 11/7/2022, PO indicated weigh the resident before and after HD. During a review of PO on 11/7/2022, PO indicated to inspect HD site for color, warmth, redness, edema, and drainage every shift, leave the dressing in place for 24 hours, if dressing was used after the HD has occurred unless contraindicated. Closely inspect dressing for drainage. Dressing change every week on Mondays and as needed soiled and dislodged. During a review of medication administration record (MAR) for February 2023, MAR indicated bedside HD order Monday, Wednesday, Friday, however documentation was done every shift. During a review of MAR for February 2023, MAR indicated to inspect total shunt site area for the following every shift. Resident 45 has right IJ permacath and not shunt. During a review of MAR for February, MAR indicated weigh resident on HD days pre and post. Resident 45 has no record of weights on the following dates: 2/6/2023 no post weight 2/10/2023 no pre and post weights 2/15/2023 no pre and post weights 2/24/2023 no pre and post weights 3/1/2023 no pre and post weights During a review of care plans (CP) initiated on11/7/2023, titled Hemodialysis: Right Intrajugular permacath at risk for injury, clotting, bleeding, and infection, CP indicated goals: will have no signs and symptoms of injury from HD daily, will maintain patent vascular access every shift daily, and will be free of infection every shift daily. Interventions was not applicable to current HD access of Resident 45 instead for resident with atrioventricular (AV) shunt. During a review of facility's policy and procedures (P&P) revised on 3/2023 titled Care of Dialysis Resident, indicated that employee of will be familiar with the hospital infection control policies and procedures, including but no limited to, standard precautions, medical waste handling and disposal, hazardous material considerations, hand washing and general safety considerations. Provide nursing care that maintains the patency of HD access, prevents complications, and identifies specific measures to be followed if complications occur. Promote the removal of toxic substances and wastes, regulations of fluid balance, and control blood pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0698 Dialysis patient data and documentation: Level of Harm - Minimal harm or potential for actual harm 1. Dialysis order 2. Dialysis written consent Residents Affected - Some 3. Dialysis center providing the bedside dialysis-Name and phone number 4. Dialysis days 5. Renal Diet 6. When to feed resident on dialysis days 7. Fluid restrictions as indicated 8. Intake and output as indicated for fluid restrictions, or MD order 9. Hepatitis Panel laboratory result every 28 days 10. Weight frequency- pre and post dialysis weight 11. Dressing changes every week and as needed by RN or Dialysis nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. 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 one of seven sampled residents (Resident 25) was being followed up by a wound care Nurse Practitioner (NP, a registered nurse who has additional education and training in how to diagnose and treat disease) as ordered in October 2022. Residents Affected - Few This deficient practice had the potential for delay of necessary services, poor continuity of care and followup on Resident 25's status. Findings: During a review of Resident 25's face sheet, the face sheet indicated Resident 25 was initially admitted to the facility on [DATE] with diagnoses including respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), gastroparesis (delayed gastric emptying), and anemia (condition in which the body does not have enough healthy red blood cells). During a review of Resident 25's Minimum Data Set ([MDS], resident assessment and care-screening tool) dated 2/9/2023, the MDS indicated Resident 25 was unable to speak, was rarely understood and rarely understands others. The MDS indicated Resident 25 required total dependence on all activities of daily living (ADL's, daily self-care activities such as dressing, eating, and bathing). During an interview with Licensed Vocational Nurse (LVN) 3 and concurrent record review on 3/8/2023 at 10:45 a.m., Resident 25's medical record was reviewed. LVN 3 stated her regular role was as treatment nurse on the floor. LVN 3 stated every time she had a resident with a big wound, the Nurse Practitioner (NP) would visit and LVN 3 would follow up with the NP if the treatment was appropriate for the resident for healing. LVN 3 stated she called and followed up and documented that the NP would visit the next day after the physician's order. During a record review of Resident 25's Progress Note dated 10/08/2022, the progress note indicated while doing patient care, noted blanchable redness (redness that goes away when the skin is pressed) at the resident's left temporal (area at the sides of the skull) area at his old scalp scar. Treatment initiated. Wound consult ordered for evaluation. Resident on 72-hour monitoring for any significant changes noted to modify treatment if needed. Responsible Party made aware. During an interview with the Director of Nursing (DON) and concurrent record review on 3/8/2023 at 11:10 a.m., Resident 25's Physician's Visits were reviewed. The DON stated she could not locate the Physician's Visit notes. The DON stated if the notes were not there, it probably was not done. During an interview on 3/8/2023 at 11:25 a.m. with LVN 3 and the DON, the DON stated she remembered the facility changed the NP wound consultant during the time of Resident 25's wound. LVN 3 stated she remembered calling and the Wound Consultant and the NP stated she would come the next week. The DON stated it should have been followed up and should have been documented. During a record review of the facility's policy and procedure (P&P) titled, Notification of Physician Consultant, dated 9/2021, the P&P indicated Physician services requested by an attending physician will be provided to patients in a timely manner. When the attending physician wishes the nurses to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete make the call to the consultant, the nurse will: Try to contact the consultant and document each attempt on the nurses' notes. If the consultant cannot be reached or has not seen the patient within 48 hours, contact the attending physician for further orders or alternative consultant to call. If consultant does not respond to see the patient within 48 hours and the attending physician wishes to continue with the same consultant, the DON and Medical Director must be notified for further resolution. All communication must be documented on nurses' and physician progress notes as well. Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to perform a gradual dose reduction ([GDR] an attempt to reduce the dose of a medication in order to find the lowest effective dose or to discontinue the medication) or provide documentation the attempt would be clinically contraindicated (likely to cause harm to the resident) for Zoloft (medication use for treating several different mood and behavioral conditions) for one of seven sampled resident (Resident 45). This deficient practice had the potential to negatively impact Resident 45's quality of life by increasing the risk of experiencing adverse effect (an undesired harmful effect) from Zoloft. Findings: During a review of Resident 45's admission Record (face sheet), the face sheet indicated Resident 45 was initially admitted to the facility on [DATE] with diagnoses including respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), anemia (a condition in which there was lack of enough healthy red blood cells to carry adequate oxygen to body's tissues), diabetes mellitus (a disorder in which the body does not produce enough or respond normally to hormone, causing blood sugar levels to be abnormally high). During a review of Resident 45's Minimum Data Set ([MDS], resident assessment and care-screening tool), dated 2/12/2023, the MDS indicated Resident 45 has unclear speech but able to be understood and understands other. The MDS indicated Resident 45 required extensive assistance with bed mobility, dressing, transfer, locomotion on and off the unit, toilet use, personal hygiene, and total dependence on bathing with limited assistance on eating. During an initial tour to the facility on 3/7/2023 at 7:10 a.m., Resident 45 stated he was not feeling sad or depressed and he was very happy during his stay in the facility. During a record review of Resident 45's physician order (order) dated 11/20/2022, the order indicated Resident 45 was on Zoloft 75 mg ([milligram]unit of measurement) via tube feeding (a flexible plastic tube placed into stomach or bowel to help get nutrition when unable to eat) daily for depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a record review of Resident 45's Psychotropic medication sheet dated 1/21/2022, the medication sheet indicated that Resident 45 was on Zoloft 50 mg via tube feeding daily for depression manifested by (m/b) feeling of hopelessness. During a concurrent interview and record review on 3/8/2023 at 11:02 a.m., with Minimum Data Set Coordinator (MDSC 1), Resident 45's medical chart record was reviewed, MDSC 1 stated Resident 45 was on anti-depressant medication (Zoloft) since January 2022 and that the Zoloft was not tapered since the time it was ordered. MDSC 1 stated that Zoloft was increased to higher dosage because according to Psychiatric note, Resident 45 verbalized that he was sad or depressed. MDSC 1 stated that from February 2022-October 2022 there was no attempt for GDR and no recommendation found. MDSC 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0758 Level of Harm - Minimal harm or potential for actual harm facility should try to do GDR or tapering as often as possible to prevent residents to have unnecessary medication. During a record review of the GDR medication review dated 11/17/2022, the GDR review indicated Resident 45 was last seen by Psychiatrist on 02/2022 and a Psychiatric consult was needed. Residents Affected - Few During an interview on 3/8/2023 at 3:00 p.m. with the Director of Nursing (DON), the DON stated that Pharmacist should report any irregularities to the Medical Doctor (MD), if the concern was about the Psychotropic medication, either the Psychiatrist or Nurse Practitioner (NP) that comes to the facility will review the medication and respond to the Pharmacist recommendation. The DON stated that GDR needed to be done or at least attempted to be performed once in 6 months after start of the medication. The DON further stated that she couldn ' t find any Psychiatric notes visit during the Month of March to November 2022. During an interview on 3/8/2023 at 3:50 p.m. with the Pharmacist (Pharm), Pharm stated that she was not assigned to attend the IDT meeting and she was not aware about the guidelines when to start the GDR. During a record review of the facility verification of informed consent dated 11/19/2022, the consent indicated Resident 45 was taking Zoloft 75 mg daily via Gastrostomy Tube (GT- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluid, and medications) signed by Resident 45 wife. During a record review of the facility's policy and procedure (P&P) titled Psychoactive Medication dated 06/2022, the P&P indicated alternative behavioral management programs are a continuing part of the resident ' s plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was less than five (5) percent, due to improper medication administration for two of four randomly selected residents (Resident 26 and 32) during the medication pass observation. Residents Affected - Some The outcome was two medication errors out of twenty-five opportunities for errors, which resulted in a medication administration error rate of eight (8) percent, that exceeded the five percent threshold. Findings: a. During a review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 4/15/2019 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 32's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/31/2023, the MDS indicated Resident 32's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 32 was totally dependent on staff for all activities of daily living (ADLs, self-care activities performed daily such as dressing, eating, toileting, and personal hygiene). During a record review of Resident 32's Medication Administration History report, dated from 3/1/2023 to 3/8/2023, the report indicated an order for Piperacillin-tazobactam (antibiotic medication that kills germs) every six hours around the clock intravenous (IV, medication administered directly to the bloodstream through the vein), infuse over thirty minutes, for five days. During a medication pass observation and concurrent interview with Registered Nurse (RN) 1 on 3/7/2023 at 8:24 a.m., RN 1 was observed administering Resident 32's IV piperacillin-tazobactam. RN 1 was observed infusing the medication to gravity using an IV tubing that did not have an anti-free flow device (prevent blood from draining from the patient, or infusate [given over a period of time] from freely entering the patient). RN 1 confirmed she was not using an IV pump (device used to infuse the medication at a prescribed rate) to infuse the IV medication. RN 1 stated the drip rate was estimated and not calculated to infuse in 30 minutes. The medication administration was initiated at on 3/7/2023 at 8:28 a.m. During a follow up observation of Resident 32's IV medication infusing on 3/7/2023 at 9:16 a.m., the IV medication was still observed to be infusing approximately 48 minutes later. During a follow up observation of Resident 32's IV medication infusing and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 3/7/2023 at 9:33 a.m., the IV medication was observed to be completed and the medication container and the IV tubing was completely dry. LVN 1 stated the IV medication completed on 3/7/2023 at 9:33 a.m., more than thirty minutes after the dose was initiated. b. During a review of Resident 26's admission Record, the admission Record indicated the facility admitted Resident 26 on 4/10/2021 with diagnosis that included respiratory failure. During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26's cognitive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some skills for daily decision making was severely impaired. The MDS indicated Resident 26 was totally dependent on staff for all ADLs. During a record review of Resident 26's Physician's Orders for the month of March 2023, the orders indicated on 9/5/2022, to administer Dilantin (medication for seizure [sudden uncontrolled burst of electrical activity in the brain] 250 milligrams (mg) per 10 milliliters (ml), via feeding tube ([F-tube] tube connected directly to the stomach for medication) to be given twice a day. During an observation on 3/7/2023 at 8:30 a.m., Resident 26's tube feeding was observed to be infusing as ordered. During a medication pass observation and concurrent interview with LVN 2 on 3/7/2023 at 8:42 a.m., Resident 26's tube feeding was observed to be infusing. LVN 2 was then observed administering Dilantin 250 mg/10 ml via the F-tube without holding the tube feeding for one hour as ordered. After the medication pass, the tube feeding was noted to be continuously infusing and it was not held for one hour after the Dilantin was administered. During an interview with the Director of Nursing (DON) on 3/8/2023 at 11:08 a.m., the DON stated when Dilantin was administered through the F-tube, the feeding should be held one (1) hour before and 1 hour after it was administered. During an interview with LVN 2 on 3/8/2023 at 2:25 p.m., LVN 2 stated LVN 2 did not recall turning the tube feeding off one hour before the medication administration of Dilantin and for one hour after Dilantin was administered via the feeding tube. During a record review of Resident 26's Medication Record for the month of March 2023, the record indicated an order to hold the tube feeding one hour prior to and after Dilantin medication administration. During a record review of the facility's policy and procedure (P&P) titled, Medication Error Reduction Plan (approved 7/2019), the P&P indicated the facility planned to eliminate or substantially reduce medication errors and improve patient safety. The P&P defined medication errors as any event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professional. The P&P indicated wrong rate of infusion and dose administered outside of parameters were examples of medication error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 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 store and prepare food under sanitary conditions in one of one kitchen, by failing to: Residents Affected - Some a. Ensure Freezer 4's temperature was at or below 0 degrees Fahrenheit (F, unit of measurement); b. Ensure the breads were labeled with an expiration or received by date; and c. Ensure the ice machine was clean. These deficient practices had the potential to result in contamination of food items placing residents at high risk for food borne illness that could lead to hospitalization and a decline in health. Findings: a. During an observation of the facility's kitchen Freezer 4 with the Kitchen Supervisor (KS) on 3/7/2023 at 6:28 a.m., the freezer thermometer indicated a temperature reading of 28 degrees Fahrenheit. (F, unit of measurement). The KS stated the temperature should be at 0 degrees or lower. The chicken nuggets were observed to be not solid frozen. During record review of the facility's kitchen Freezer 4 log, the log indicated the freezer temperatures must be below 0 degrees F. The log indicated the freezer's temperature to be above 0 degrees F from 3/1/2023 to 3/7/2023. During a record review of the facility's policy and procedure (P&P) titled, Food Purchasing and Handling (revised 9/2021), the P&P indicated frozen foods shall be stored at equal or less than 0 degrees Fahrenheit. Frozen foods were kept frozen at all times until they are removed from the freezer for preparation. b. During an observation of the facility's kitchen with the KS on 3/7/2023 at 6:28 a.m., the breads were all not labeled with an expiration or received date. The KS stated he knew when the bread was stocked but the bread should have a label on each item. During a record review of the facility's P&P titled, Freshness Dating and Labeling (revised 2021), the P&P indicated all foods will be dated for freshness and food safety. The P&P indicated upon delivery of items, if not already dated, it was the responsibility of the purchasing agent (or individual checking the delivery foods) to date the items with the current date. c. During an observation of the facility's ice machine and concurrent interview with the KS on 3/7/2023 at 6:28 a.m., the KS opened the cover to the ice machine and wiped the bin cover over the ice machine. Black residue was observed. The KS stated the ice machine was dirty. The KS stated the ice machine should be clean. During a record review of the facility's P&P titled, Cleaning of Ice Machine (revised 7/2019), the P&P indicated the Environmental Services Department will clean ice machines on a daily basis. During an interview with the facility's Director of Food and Nutrition (DFN) on 3/8/2023 at 12:48 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 p.m., the DFN stated the ice machine should always be clean, the freezer temperature should be below 0 degrees F, and the bread should be dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Many 1. Ensure the Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) committee meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance Performance Improvement QAPI ([QAPI] a data driven and proactive approach to quality improvement) program. 2. Ensure the Infection preventionist (IP) and the Medical Director participated on the facility's QAA/QAPI meeting. These deficient practices had the potential to result in a lack of oversight for infection prevention practices, overall medical care being provided by the facility, and ensuring that resident care policies were implemented appropriately. Findings: During a concurrent interview and record review on 3/8/2023 at 3:46 p.m., with the Director of Nursing (DON), the DON stated that the IP does not attend the QAA/QAPI meeting, the DON stated that they had the meeting held for a while since there were some changes in the committee. The DON verified that the last two QAA/QAPI meeting was held last June 2022 and was recently restarted in February 2023. During an interview on 3/9/2023 at 9:05 a.m., with IP, IP stated she never attended the QAA or QAPI meeting because she was never invited to attend the meeting, IP added that it was the DON who attends the monthly meeting. During a concurrent interview and record review on 3/9/2023 at 9:45 a.m., with the Quality Assurance (QA), QAA meeting sign in sheet dated February, April, June 2022, and February 2023 were reviewed. QAA meeting sign in sheet indicated there were no infection preventionist from the sub-acute unit and no medical director signature present in the sign in sheet. The QA also stated that she reviewed and listened to the video recorded for the last QAA meeting held on February 2023, but the Medical Director and the IP did not attend the meeting. During a record review of the sub-acute facility assessment for the year 2022 Roles and responsibilities of Performance Improvement (PI) committee the assessment indicated PI leaders to oversee and hold monthly committee meetings to address all PI indicators. PI team members to attend or send a designee to all meetings to discuss and present data. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 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 555441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial Hospital of Gardena D/P Snf 1145 W. Redondo Beach Gardena, CA 90247 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a coronavirus disease 2019 ([COVID-19] highly contagious respiratory infection) vaccine (produce immunity against a specific disease) administration policy and procedure was developed for staff and 69 of 69 residents. Residents Affected - Some This deficiency had the potential to increase the risk of spreading COVID-19 to residents and staff. Findings: During a record review of the facility's policy and procedures (P&P), the facility was unable to provide a P&P to address COVID-19 vaccination for staff and residents. During an interview with the Infection Preventionist Nurse (IP) on 3/8/2023 at 4:12 p.m., the IP stated the facility had no P&P addressing the staff and residents' COVID-19 vaccination. The IP stated the facility used the COVID-19 Mitigation Plan (document that outlines the skilled nursing facility's plan in mitigating COVID-19). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 33 of 33