Health inspection·February 9, 2024

F 0580 developing pressure ulcers. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, the Wound Photographic Documentation-Nursing indicated, Resident 163 had stage 3 pressure ulcer on right buttock, not present on admission, wound size is 2.5 centimeters (cm, unit of measurement) in length, 3 cm in width, and 0.1 cm in depth, scanty amount of serosanguineous (type of wound drainage), and no odor. Residents Affected - Few During a concurrent observation and interview on 2/9/2024 at 9:21 a.m. with Treatment Nurse 1 (TN 1) in Resident 163's room, TN1 observed doing wound care treatment on Resident 163's pressure ulcer on right buttock. The wound bed was observed with adherent yellow slough, dark gray skin and pink tissue, wound margins indistinct. Peri wound noted with deep purple skin discoloration. TN 1 stated Resident 163's stage 3 pressure ulcer on right buttock was acquired in the facility and identified the pressure ulcer on 2/7/2024 and did not document and notify the Medical Doctor (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and that was the reason why she did not document and called MD 1. TN 1 stated she did not follow the standard of practice by not reporting the pressure ulcer stage 3 on right buttock to the physician in a timely manner. During an interview on 2/9/2024 at 4:48 p.m. with MD 1, MD 1 stated he was notified Resident 163's new stage pressure ulcer on right buttock by TN 1 on 2/8/2024 and not on 2/7/2024. MD 1 stated he thinks Resident 163's new stage 3 pressure ulcer on right buttock had been there but he doesn't want to speculate. During a review of facility's policy and procedure (P&P) titled, 'Change in Residents Condition, dated 11/2023, the P&P indicated, Any sudden or serious change in residents 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 2 of 29 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 02/09/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1.Ensure the comprehensive Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for one of fifteen sampled residents (Resident 51) was completed within the required timeframe. This deficient practice had the potential to result in Resident 51 not receiving proper care and treatment. Findings: During a review of Resident 51's Face Sheet, the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), hypoxia (not enough oxygen), and hypercapnia (when you have too much carbon dioxide in your blood). During a review of Resident 51's MDS assessment, dated 8/21/2023, the MDS assessment, indicated Resident 51's had a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident 51's cognitive skills for daily decision making was moderately impaired. During a concurrent interview and record review on 2/7/2024 at 3:27 p.m. with MDS 1, Center for Medicare/Medicaid Services (CMS) Validation Report, dated 8/21/2023 was reviewed. The CMS Validation Report of Resident 51's MDS assessment indicated a warning message of assessment completed late for this admission assessment (A0310A, coded as 1), Z0500B (The data on this column contains the date that the Registered Nurse Assessment Coordinator signed the assessment as complete), was more than 13 days after A1600 (Recent admission entry date). MDS 1 stated Resident 51's MDS admission assessment should had been completed on 8/21/2023 since Resident 51 was admitted to the facility on [DATE] but the facility completed Resident 51's admission assessment on 8/26/2023. MDS 1 stated residents MDS assessment should be completed 14 days, quarterly, yearly and if there is a significant change in residents health status. MDS 1 stated she follows the Resident Assessment Instrument ([RAI] is the official instructional guide for completing MDS) manual for completing the MDS assessment. MDS 1 stated it was very important to submit and complete MDS assessment in a timely manner as required by law in order to formulate appropriate plan of care to residents. During a review of facility's policy and procedure (P&P) titled, CMS's RAI Version 3.0 Manual, dated September 2010, the P&P indicated, Federal statute and regulations require that residents are assessed promptly upon admission (but not later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 3 of 29 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 02/09/2024 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 0641 Ensure each resident receives an accurate assessment. 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 provide accurate information in the Minimum Data Set ([MDS] resident assessment and care screening tool) assessment for two of fifteen sampled residents (Resident 10 and Resident 36). Residents Affected - Few This deficient practice had the potential to result inaccurate care and services for the residents due to inappropriate MDS care screening and assessment tool practices. Findings: a. During a review of Resident 10's Face Sheet, the Face Sheet indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), Diabetes (a serious condition where your blood glucose level is to high), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a review of Resident 10's MDS entry assessment, dated 8/24/2023, the MDS assessment under A1000 (Race/Ethnicity) indicated, Resident 10 was Black or African American. During a review of Resident 10's MDS discharge assessment, dated 9/2/2023, the MDS assessment under A1000 (Race/Ethnicity), did not code the race or ethnicity of Resident 10. During a concurrent interview and record review on 2/7/2024 at 3:27 p.m. with MDS 1, Center for Medicare/Medicaid Services (CMS) Validation Report, dated 9/2/2023 was reviewed. MDS 1 stated the CMS Validation Report had a warning message of resident information mismatch. MDS 1 stated Resident 10's discharge assessment on 9/2/2023 was coded and assessed inaccurately due to missing information of Resident 10's race/ethnicity. MDS 1 stated it was essential to submit and complete MDS assessment accurately because it would affect the plan of care of residents. During a review of facility's policy and procedure (P&P) titled, Assessment-Minimum Data Set and Care Area Assessment, dated 2/2019, the P&P indicated, To conduct initial and periodical comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 4 of 29 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 02/09/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 36's admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not have mouth discomfort or difficulty with chewing. During an observation and interview on 2/8/2023 at 9:40 a.m. with Resident 36, in resident room, Resident 36 opened mouth and had missing and broken teeth. Resident 36 stated he had not seen a dentist for a few years. Resident 36 stated now that he can eat food it is uncomfortable to chew the food because of his broken teeth. Resident 36 stated it makes him feel sad that he had not been seen by a dentist to correct his broken and missing teeth. During a concurrent interview and record review on 2/9/2024 at 10:25 a.m. with Minimum Data Set Coordinator (MDS) 1, Resident 36's Dental Service Note, dated 4/30/2022 was reviewed. The Dental Service Note indicated, on 4/30/2022 dentist recommendation to have Resident 36 to be referred to an oral surgeon to remove teeth and pain medication when needed. MDS 1 stated a care plan should have been set up to address the dentist recommendations. MDS 1 stated the care plan would have consisted of interventions to address the missing teeth and comfort. MDS 1 stated Resident 36 's care plan would be implemented. MDS 1 stated after the care plan is implemented to check if the interventions were effective. MDS 1 stated Resident 36 had missing teeth and difficulty chewing it could had affected his nutrition and put Resident 36 at risk for weight loss. During a concurrent interview and record review on 2/9/2024 at 10:25 a.m. with Infection Preventionist (IP) 1, Resident 36's Dental Service Note, dated 4/30/2022 was reviewed. The Dental Service Note indicated, on 4/30/2022 dentist recommendation to have Resident 36 to be referred to an oral surgeon to remove teeth and pain medication when needed. IP 1 stated Resident 36 had missing and broken teeth. IP 1 stated a care plan needed to be set up to address if Resident 36 were to have discomfort and difficult chewing. IP 1 stated it is important to have a care plan for Resident 36 to make sure the Resident is comfortable and not having issues with chewing his food. During a review of the facility's policy and procedure (P&P) titled, Assessment and Care Planning, dated 2/2019, the P&P indicated, To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet resident's individual needs and to assist the resident reaching high level of independence possible .The assessment identifies risk factors associated with possible functional decline and the resident's objective for maintaining or improving. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 5 of 29 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 02/09/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Revise tube feeding (a way to give medications or liquid food through a small tube placed into the stomach) care plans for two out of five sampled Residents (Resident 40, and 18). These deficient practices had the potential for repeat occurrences for not revising residents care plans. Findings: a. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/30/2023, the MDS indicated, Resident 40's cognition (ability to learn reason, remember, understand, and make decisions) skills were severely impaired. The MDS indicated, Resident 40 activities of daily living ([ADL] activities related to personal care) Resident 40 was dependent with toileting, hygiene, and showering. During a review of Resident 40's Physician Orders, dated 8/18/2023, the Physician Orders indicated, Resident 40 was to receive Glucerna (liquid food) via gastrostomy tube (G-tube) at 60 milliliters ([ml] to measure fluid volume). During a concurrent interview and record review on 2/8/2024 at 11:26 a.m. with Infection Preventionist (IP) 1, Resident 40's Care Plan: Tube Feeding, dated 8/18/2023 was reviewed. The care plan: tube feeding indicated, the approach for tube feeding was to give Glucerna at 65 ml per hour for 22 hours and Glucerna at 70 ml per hour for 22 hours. IP 1 stated the care plan should match the physician orders. IP 1 the care plan should have been revised. IP 1 stated not revising the care plan could affect the medical treatment for Resident 40 and cause confusion. b. During a review of Resident 18's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own). During a review of Resident 18's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 18 is lethargic and unresponsive. During a review of Resident 18's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/23/2023, the MDS indicated, Resident 18s cognition (ability to learn reason, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 6 of 29 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 02/09/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few remember, understand, and make decisions) skills were severely impaired. The MDS indicated, Resident 18 activities of daily living ([ADL] activities related to personal care) Resident 18 was dependent with eating, toileting, hygiene, and showering. During a review of Resident 18's Physician Orders, dated 1/17/2017 the Physician Orders indicated, Resident 18 was to receive Nepro (liquid food) at 50ml via gastrostomy tube (G-tube) at 60 ml per hour. During a concurrent interview and record review on 2/8/2024 at 11:36 a.m. with Infection Preventionist (IP) 1, Resident 18's Care Plan: Tube Feeding, dated 5/22/2022 was reviewed. The care plan: tube feeding indicated, the approach for tube feeding was to give Nepro at 45 ml per hour for 18 hours and change the rate to 40 ml per hour for 18 hours. IP 1 stated the care plan does not match the doctor orders. IP 1 stated the care plan need to be revised to match the doctor orders. IP 1 stated its important to have revised the care plan to prevent harm. IP 1 stated if the nurse looked at the care plan instead of the doctor orders it had the potential for the nurse to set up the tube feeding at the wrong rate per hour. During a review of the facility's policy and procedure titled, Assessment and Care Planning, dated 2/2019, the P&P indicated, To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet resident's individual needs and to assist the resident reaching high level of independence possible .Physician admission order for immediate care such as diet, medications and routine care are obtained until staff can conduct a comprehensive assessment an develop the resident care plan .The resident assessment information is used to establish, review and update the resident care plan post admission and no less than every three months thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 7 of 29 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 02/09/2024 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 0679 Provide activities to meet all resident's needs. 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 medical record review, the facility failed to: Residents Affected - Few 1. Provide an ongoing activity program to meet the needs and interests for one of 5 sampled residents (Residents 40) to ensure residents maintained their highest physical, mental, and psychosocial well-being. This failure had the potential of not enhancing Resident 40's quality of life. Findings: During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/30/2023, the MDS indicated, Resident 40's cognition (ability to learn reason, remember, understand, and make decisions) skills were severely impaired. The MDS indicated, Resident 40 activities of daily living ([ADL] activities related to personal care) Resident 40 was dependent with toileting, hygiene, and showering. During an interview and record review on 2/9/2024 at 1:09 p.m. with Activity Coordinator (AC) 2, Resident 40's Care Plan Activities, dated 8/20/2023 was reviewed. The Care Plan Activities indicated, the approach was to take Resident 40 out of bed to Geri-chair. AC 2 stated the process is to plan in the morning with the Registered Nurse (RN) and schedule for the Residents to go to the activity room. AC 2 stated Resident 40 had not been out of bed to Geri-Chair during the week of 2/4/2024 and could not provide any documents nor arrangements for Resident 40 to go to the activity room. AC 2 stated putting Resident 40 in a Geri-chair is important to have movement even if Resident 40 is not fully alert. AC 2 stated if Resident 40 is in the bed all day everyday he is missing out on social interaction. During an interview on 2/9/2024 at 1:29 p.m. with Respiratory Therapist (RT) 1, RT 1 stated the process is I will assist with making sure the resident is ventilated (a form of life support that helps you breathe when you can't breathe on your own) and bring the ventilator (a machine that moves air in and out of the lungs) to the activity room when the resident is placed in a Geri-chair. RT 1 stated I have not seen Resident 40 out of bed to Geri-chair nor in the activity room. RT 1 stated it is important to take Resident 40 out of bed to help with circulation (the flow of blood through the heart and blood vessels), pressure relief to skin, and helps with mentality (a person way of thinking about things). During an interview and record review on 2/9/2024 at 1:40p.m. with Registered Nurse (RN) 1, Resident 40's Care Plan Activities, dated 8/20/2023 was reviewed. The Care Plan Activities indicated, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 8 of 29 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 02/09/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm approach was to take Resident 40 out of bed to Geri-chair. RN 1 stated Resident 40 had not been in the activity room and had not been in the Geri-chair. RN 1 stated Resident 40 should be in the Geri-chair at least twice a week. RN 1 stated Resident 40 was stable to be out of bed to chair. RN 1 stated it is important to place Resident 40 in the Geri-chair and take him to the activity room so it could motivate Resident 40 to feel better and interact with other people. Residents Affected - Few During a review of the facility's policy and procedure titled, Activities Program-Requirements, dated 1/2022, the P&P indicated, The Residents shall be encouraged to participate in activities planned to meet their individual needs .A written, planned schedule of social and other purposeful individual and group activities shall be designed with its purpose to enable each resident to maintain the highest attainable social, physical and emotional functioning .The activities program shall consist of social activities .activities shall be available on a daily basis .The Activity Coordinator develop, implement and supervise the program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 9 of 29 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 02/09/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). Residents Affected - Few During a review of Resident 40's Minimum Data set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated, Resident 40's cognitive (ability to learn reason, remember, understand, and make decisions) skills for daily decision making were severely impaired. The MDS indicated Resident 40 was dependent on staff for activities of daily living (ADL) including toileting, hygiene, and showering. During a review of Resident 40's admission assessment dated [DATE], the admission Assessment indicated the resident had the following: 1. Left heel undetermined (UTD) skin injury. 2. Sacral pressure ulcer Stage III. 3. Right lateral malleolus UTD skin injury. 4. Right buttock UTD skin injury. During a review of Resident 40 's care plan for Impaired Skin Integrity dated 8/18/2023, the care plan indicated a goal for the resident was to maintain intact skin daily for the next three months (until next care plan evaluation). One of the care plan interventions was to reposition the resident every two hours. During a review of Progress Note Inquiry dated 9/21/2023 completed by a Wound Consultant, the Progress Note Inquiry indicated Resident 40's left heel was assessed as unstageable pressure ulcer and measured 1.0 cm by 0.8 cm. The Wound Consultant documented recommendation for intervention to promote pressure ulcer healing included heel off loading, heel protector, and turning and repositioning the resident. During a review of Resident 40's Physician's Orders, dated 2/1/2024, Physician's Orders indicated the order to cleanse left heel DTPI with Normal Saline solution, pat dry. Apply Betadine and cover with dry dressing daily. During a review of Wound Photographic Documentation/Nursing dated 2/1/2024, the Wound Photographic Documentation indicated Resident 40 had DTPI to left heel measured 1.0 cm in length by 1.5 cm in width. During an observation on 2/6/2024 from 11:09 a.m. until 4:00 p.m. (a total of five hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/7/2024 from 9:17 a.m. until 4:15 p.m. (a total of seven hours), Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 10 of 29 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 02/09/2024 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 0686 40 was observed in bed on a left side facing the window. Level of Harm - Actual harm During an observation on 2/8/2024 from 8:15 a.m. until 12:15 p.m. (four hours) Resident 40 was observed lying on the left side facing the window. Residents Affected - Few During a concurrent observation and interview on 2/8/2024 at 12:15 p.m. with Restorative Nurse Assistant (RNA 1) in Resident 40's room, Resident 40 was observed in bed lying on a left side facing the window. Resident 40 was observed to have a heel protector (a soft cushion covering the heel) on the left heel. Resident 40's left heel had a sock on inside the heel protector. RNA 1 confirmed Resident 40 was facing the window and lying on the left side of his body. RNA 1 stated Resident 40 should be facing the door at 12:00 p.m. RNA 1 stated Resident 40 should be repositioned from side to side every two hours to prevent a pressure ulcer from developing, to help with blood circulation (the flow of blood through the heart and blood vessels), and to prevent DTPI to have a recurrent pressure ulcer. During a review of Resident 40's Repositioning Schedule, date unknown, the Repositioning Scheduled indicated Resident 40 should be turned (repositioned) every two hours. During a concurrent observation and interview on 2/8/2024 at 12:30 p.m. with Infection Preventionist (IP 1), in Resident 40's room, Resident 40 was lying on the left side facing the window. IP 1 stated Resident 40 had a sock on and a heel protector. IP stated if the resident is not turned every two hours, even though there is a heel protector on the heel, the resident can develop a pressure ulcer to the skin. IP 1 stated it was 30 minutes passed the time for Resident 40 to be repositioned on the right side and facing the door. IP 1 stated we should be following the reposition schedule every two hours. IP 1 stated it was important to reposition Resident 40 as scheduled to prevent a pressure ulcers development. During a concurrent interview and record review on 2/8/2024 at 3:54 p.m. with the Director of Nursing (DON 2) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 had to have heels offloading (not bearing weight) as one of the interventions to promote DTPI healing. The DON 2 stated its important to reposition a resident every two hours to prevent pneumonia (a condition that inflames the air sacs in one or both lungs). The DON 2 stated repositioning Resident 40 every two hours and offloading the left heel would help healing proceed of Resident 40's left heel DTPI. During a concurrent interview and record review on 2/9/2024 at 2:02 p.m. with the Registered Nurse (RN1) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 interventions to promote healing to a left heel included offloading. RN 1 stated the left heel had DTPI. RN 1 stated the recommendation were to offload the left heel. RN 1 stated it was important to offload the left heel to prevent skin breakdown and to promote DTPI healing. RN 1 stated by not following the Wound Consultant's recommendations to offload Resident 40's left heel the pressure ulcer on a heel can continue to breakdown further and could become infected. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Assessment, Treatment and Prevention, dated 7/2019, the P&P indicated, preventive measures used to prevent further breakdown of the skin and did not disclose to offload heels. The P&P did not disclose to turn the Residents every two hours. During a review of the facility's P&P titled, Pressure Ulcer Assessment, Treatment and Prevention, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 11 of 29 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 02/09/2024 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 0686 Level of Harm - Actual harm dated 7/2019, the P&P indicated that upon admission to the facility each resident shall have a total body check by a licensed nurse for the presence of pressure injuries or risk to develop a pressure injury. The resident care plan will include preventive equipment used to help prevent further ulcer breakdown. DTI is a skin injury resulted from intense or prolonged pressure and shear force at the bone muscle interface. Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the residents who were admitted to the facility with intact skin did not develop a pressure ulcer ([PU], injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for three of three sampled residents (Residents 163, 40, and 38). The facility failed to: 1. Ensure Resident 163's did not develop a Stage III PU (Full thickness tissue loss) to the right buttocks after the admission to the facility. 2. Ensure the nursing staff monitored Resident 163 skin condition to identify development of a PU to the right buttock at the earlier stage to prevent development of a Stage III PU. 3. Ensure the nursing staff implemented Resident 163's care plan titled Skin Integrity by ensuring the resident will not have a skin breakdown. 4. Ensure nursing staff turned and repositioned Resident 40 every two hours to prevent a deep tissue pressure injury ([DTPI] a serious form of pressure injuries defined as purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) from reopening. 5. Ensure the nursing staff turned and repositioned Resident 38 every two hours as care planned to prevent the resident from developing a Stage II pressure ulcer to the left gluteal fold (a horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). These deficient practices resulted in Resident 163 acquiring a Stage III PU, the reopening of Resident 40's DTPI, and Resident 38 developing Stage II pressure ulcer to the left gluteal fold. Findings: a. During a review of Resident 163's Face Sheet (admission Record), the Face Sheet indicated, Resident 163 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (a 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), multiple fractures (partial or complete break of a bone), and gunshot wound. During a review of Resident 163's Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment, dated 1/4/2024, the MDS indicated, Resident 163 had severely impaired cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 163 was dependent to staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS Section M (Skin Conditions) indicated, Resident 163 was at risk for developing a pressure ulcer and had one unhealed Stage III to a sacral (tailbone) area. The MDS indicated Resident 163 was incontinent of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 12 of 29 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 02/09/2024 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 0686 bowel and had a condom catheter (sheath-like device that is placed around the penis and secured with adhesive or a strap) for a sacral ulcer management. Level of Harm - Actual harm Residents Affected - Few During a review of Resident 163's admission Assessment, dated 12/23/2023, the admission Assessment indicated Resident 163 was admitted with a Stage III pressure ulcer to a sacral area. During a review of Resident 163's Occupational Therapy Evaluation form, dated 12/23/2023, the Occupational Therapy Evaluation Form indicated Resident 163 was totally dependent for bed mobility. During a review of Resident 163's Braden Scale (tool commonly used in healthcare to assess and document a resident's risk for developing pressure ulcers) form, dated 12/24/2023, 12/30/2023, 1/7/2024, and 1/14/2024, the Braden Scale form indicated Resident 163 had very limited sensory perception (ability to respond meaningfully to pressure-related discomfort), was constantly moist, bedfast (confined in bed), completely immobile, was receiving nutrition via a gastrostomy tube ([GT] a soft tube surgically inserted into the stomach through the abdomen) and had a problem in friction and shear. The Braden Scale indicated, Resident 163 had a score of nine (total score of 12 or less represent high risk), indicating the resident was high risk for developing a pressure ulcer. During a review of Resident 163's Daily Assessment Inquiry under Certified Nursing Assistant (CNA) Documentation from 12/23/2023 to 2/7/2024, the Daily Assessment Inquiry indicated there were no documentation of Resident 163 having a pressure ulcer on a right buttock. During a review of Resident 163's Progress Notes Inquiry from 12/23/2023 to 2/6/2024, the Progress Notes Inquiry, indicated there were no documentation of Resident 163 having a pressure ulcer to a right buttock. During a review of Resident 163's Sub-Acute Nursing Weekly Summary dated 12/25/2023, 1/1/2024, 1/8/2024, 1/22/2024, 1/29/2024, and 2/5/2024, the Sub-Acute Nursing Weekly Summary, indicated there were no documentation of Resident 163's having a pressure ulcer to a right buttock. During a review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, the Wound Photographic Documentation-Nursing indicated Resident 163 had a Stage III pressure ulcer to the right buttock, which was not present on admission. Resident 163's Stage III pressure ulcer to the right buttock was measured 2.5 centimeters ([cm] unit of measurement) in length, 3.0 cm in width, and 0.1 cm in depth, and documented to have a scant (minimal) amount of serosanguineous (fluid containing both blood and blood serum [clear liquid part of the blood after blood cells have been removed]) fluid with no odor. During a concurrent observation and interview on 2/9/2024 at 9:21 a.m. with Treatment Nurse 1 (TN 1) in Resident 163's room, TN 1 was observed conducting a wound care treatment to Resident 163's pressure ulcer on the right buttock. The wound bed was observed to have an adherent yellow slough (dead tissue, usually cream or yellow in color) dark gray skin and pink tissue, with indistinct (not sharply outlined or separable) wound margins (edge). The Peri wound (tissue surrounding the wound) was noted to have deep purple skin discoloration. TN 1 stated Resident 163's Stage III pressure ulcer to the right buttock was acquired at the facility. TN 1 stated she identified Resident 163 having a Stage III pressure ulcer to the right buttock on 2/7/2024. TN 1 stated she did not document about it and did not notify Resident 163's physician (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and that was the reason why she did not document about newly identified Resident 163's pressure ulcer and did not called MD 1. TN 1 stated she did not follow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 13 of 29 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 (X3) DATE SURVEY COMPLETED A. Building 02/09/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few the standard of practice by not reporting Resident 163's Stage III pressure ulcer to the right buttock to MD 1 in a timely manner. TN 1 stated she had seen Resident 163's on several occasions soiled (dirty) with urine because his condom catheter was dislodged. TN 1 stated Resident 163 had only one Stage III pressure ulcer to the sacral area upon admission. TN 1 stated she did not observe Resident 163's developing redness, blister, or any skin damage to his right buttock until 2/7/2023 when he developed a Stage III pressure ulcer to his right buttock. TN 1 stated Resident 163 had no skin maintenance treatment order to the right buttock prior to identification of a Stage III pressure ulcer. During an interview on 2/9/2024 at 10:23 a.m. a Certified Nursing Assistant 2 (CNA 2) stated she was giving a bed bath (bathing a patient who is confined to bed and cannot have the physical and mental capability of self-bathing) to Resident 163 every time she was assigned to care for Resident 163. CNA 2 stated, she did not observe Resident 163 had a new pressure ulcer. CNA 2 stated she documents in the flowsheet of a resident's electronic health record if a resident noted with skin issues including bed sore, redness, and skin tear. During an interview on 2/9/2024 at 10:33 a.m. the Registered Nurse 2 (RN 2) stated protecting and monitoring the condition of Resident 163's skin was important for preventing development of a pressure ulcer and identifying a pressure ulcer earlier so it can be treated at the early stage and not to let it to get worse. RN 2 stated she was not aware Resident 163 developed a Stage III pressure ulcer to his right buttock. RN 2 stated the licensed nurses need to check resident's skin when completing the Nursing Weekly Summary and report it to the supervisor when areas of concern identified. During a concurrent interview and record review on 2/9/2024 at 2:25 p.m. with Infection Preventionist Nurse (IP 1), Resident 163's Subacute Pressure Injury Weekly Report dated 12/24/2023 and 1/28/2024 were reviewed. IP 1 stated Resident 163 had only one pressure ulcer Stage III to the sacral area. IP 1 stated it was important to identify the presence of a pressure ulcer and its stages early so nurses can implement the necessary interventions. During a concurrent interview and record review on 2/9/2024 at 3:00 p.m. with Director of Nursing 1 (DON 1), Resident 163's care plan titled Skin Integrity, dated 12/27/2023, was reviewed. The care plan problem indicated, Potential for impaired skin integrity related to impaired mobility, incontinence, fragile skin, history, or current pressure ulcer, and on anticoagulant therapy. The care plan goals included the following: 1. To maintain Resident 163's skin integrity as evidenced by intact skin daily for next three months. 2. Resident 163 will be free from skin breakdown daily for next three months. 3. There will be no further sacral pressure ulcer deterioration daily for the next three months. The DON stated the facility failed to prevent Resident 163's pressure ulcer development to the right buttock and failed to identify this pressure ulcer prior its progression to a Stage III. The DON stated a Stage III pressure ulcer can develop fast but not right away. The DON stated with proper care treatment and interventions and early detection of a pressure ulcer Resident 163's new Stage III pressure ulcer to the right buttock could had been avoided. During a review of facility's policy and procedure (P&P) titled, Dignity, Patient/Resident, dated 9/2023, the P&P indicated, the facility will provide, in accordance with Federal law requirement, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 14 of 29 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 02/09/2024 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 0686 every resident with the care and quality of life sufficient for them to attain and maintain their highest practicable physical, emotional, and social well-being. Level of Harm - Actual harm Residents Affected - Few During a review of facility's policy and procedure (P&P) titled, 'Change in Residents Condition, dated 11/2023, the P&P indicated, the licensed nurse in charge will notify the physician immediately of any sudden or serious change in residents condition manifested by a marked change in physical or mental behavior. c. During a review of Resident 38's Face Sheet, the Face Sheet indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, persistent vegetative state (condition of not being aware), respiratory failure (unable to breath on your own), and diabetes (high blood sugar). During a review of Resident 38's admission assessment dated [DATE], the admission Assessment indicated the resident had intact skin. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 was dependent on staff to reposition from side to side. The MDS indicated Resident 38 was at risk for pressure ulcer development. During a review of Resident 38's care plan for Impaired Skin Integrity (date illegible), the care plan indicated Resident 38 had the potential for impaired skin integrity related to impaired mobility, weight loss, and steroid therapy. The care plan indicated the staff would reposition the resident every two hours and assess skin condition daily. During a review of Resident 38's Braden Scale Highest (a lower score represents a higher risk), dated 10/18/2022, indicated Resident 38 scored 10. During a concurrent interview and record review on 2/8/24 at 12:05 p.m. with TN 1, Resident 38's Wound Management form dated 8/31/23 was reviewed. The Wound Management indicated Resident 38 had a new pressure ulcer to the left gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) acquired on 8/31/23. TN 1 stated Resident 38 acquired a pressure ulcer because the resident was immobile. TN 1 stated Resident 38 had to be repositioned every two hours and there was no medical reason why the resident could not be repositioned. During a review of Resident 38's Physician's Orders Report dated 8/31/2023, the Physician's Orders Report indicated an order for Hydrogel (medication that promotes wound healing) with dry dressing to the left gluteal fold pressure ulcer to be done daily. During a review of Resident 38's Physician's Orders Report dated 2/1/2024, the Physician's Orders Report indicated an order to continue Hydrogel with dry dressing to the left gluteal fold pressure ulcer daily. During an interview on 2/8/24 at 12:28 p.m. CNA 1 stated residents were turned every two hours to prevent a pressure ulcer development. CNA 1 stated bed sores (pressure ulcers) are preventable. During an observation on 2/9/24 from 8:10 a.m. until 2:07 p.m. (six hours) Resident 38 was in bed in a supine (on the back) position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 15 of 29 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 02/09/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few During an observation on 2/9/24 at 8:20 a.m. TN 2 observed performing wound care and measuring the pressure ulcer of the left gluteal fold. The pressure ulcer measured 1.5 cm x 1.5 cm and assessed as a Stage II pressure ulcer. During a concurrent interview and record review on 2/9/24 at 11:25 a.m. with RN 2, a wound evaluation (pressure ulcer) order dated 9/1/2023 was reviewed. RN 2 stated it was the responsibility of the treatment nurse to notify the wound nurse of a new pressure ulcer by entering a wound evaluation order. During a review of the facility's P&P titled, Turning and Repositioning, dated 6/2018, the P&P indicated staff will turn and reposition residents every two hours and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 16 of 29 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 02/09/2024 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 interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluids from the body) received treatment in accordance with standard of practice for one of one sampled resident (Resident 164) by failing to implement the physician's order for fluid restriction accurately. Residents Affected - Few This deficient practice placed Resident 164 at risk for fluid overload, swelling, shortness of breath and discomfort. Findings: During a review of Resident 164's Face Sheet, the Face Sheet indicated, the facility originally admitted Resident 164 on 12/19/2023 and was readmitted on [DATE], with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach to provide nutrition and medication), and end stage renal disease (a condition in which the kidneys no longer function normally). During a review of Resident 164's Minimum Data Set ([MDS] resident assessment and care screening tool) assessment, dated 1/12/2024, the MDS indicated, Resident 164 was severely impaired with cognitive skills for daily decision making (ability to think and reason). The MDS indicated, Resident 164 was dependent to staff in eating, oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a concurrent interview and record review on 2/8/2024 at 1:21 p.m. with Registered Nurse 3 (RN 3), Resident 164's Physician's Orders for February 2024 was reviewed. RN 3 stated, Resident 164 had an active order of fluid restriction of 200 cubic centimeter (cc, unit of measurement) every 6 hours. RN 3 stated Resident 164 is on tube feeding and receiving Nepro at 35 cc/hour to provide 770 cc/1386 kilocalorie (kcal, unit of measurement). RN 3 stated charge nurse was responsible for monitoring the intake and recorded in the flow sheet and Certified Nursing Assistant (CNA) was responsible for monitoring the output and recorded in the flowsheet. RN 3 stated Resident is on bedside dialysis treatment every Monday and Friday. RN 3 stated it was very important to follow the physician's order for fluid restriction of Resident 164 consistently and accurately since she is on dialysis treatment and too much fluid would cause shortness of breath, edema and cardiac complications. During a concurrent interview and record review on 2/8/2024 at 1:30 p.m. with Registered Dietitian 1 (RD 1), Resident 164's Intake/Output Report milliliter (ml, unit of measurement), from 1/17/2024 to 2/8/2024, was reviewed. The Intake/Output Report ml, 24-hour total intake indicated as follow: 1/17/2024: 1566 ml 1/18/2024: 1755 ml 1/19/2024: 1910 ml 1/20/2024: not recorded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 17 of 29 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 02/09/2024 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 1/21/2024: 1999 ml Level of Harm - Minimal harm or potential for actual harm 1/22/2024: 1050 ml 1/23/2024: 2733 ml Residents Affected - Few 1/24/2024: 1575 ml 1/25/2024: 1860 ml 1/26/2024: 900 ml 1/27/2024: 2630 ml 1/28/2024: 1960 ml 1/29/2024: 1860 ml 1/30/2024: 1300 ml 1/31/2024: 950 ml 2/1/2024: 2360 ml 2/2/2024: 1170 ml 2/3/2024: 1215 ml 2/4/2024: 1165 ml 2/5/2024: 1390 ml 2/6/2024: 1536 ml 2/7/2024: 1400 ml RD 1 Stated based on the 24-hour total intake of Resident 164 from 1/17/2024 to 2/7/2024, Resident 164 was exceeding the 800 ml in 24 hours fluid restriction ordered by the physician. RD 1 stated the free water of the Nepro formula is 560 ml and the fluid restriction of 800ml in 24 hours ordered by the physician was on the low side. RD stated I could not tell you the complications of giving too much fluid to a dialysis resident since I am not a physician. RD 1 stated she will inform the Director of Nursing 1 (DON 1) immediately to address Resident 164's fluid restriction. During a review of facility's policy and procedure (P&P) titled, 'Fluid Restriction, dated 4/2017, the P&P indicated, To provide a method to ensure fluid intake is restricted as ordered by the physician while maintaining optimum hydration to the extent possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 18 of 29 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 02/09/2024 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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure the treatment nurse was competent in wound site identification. This failure had the potential for a resident receiving treatment at the wrong site. Findings: During a concurrent interview and record review on 2/8/24 at 12:05 p.m. with LVN 2, Resident 38's Photographic Documentation, dated 2/1/24 was reviewed. The Photographic Documentation indicated Resident 38 had a wound in the left glutei fold. The actual picture indicated the wound was on the left buttock. LVN 2 agreed the wound was not in the left gluteal fold. LVN 2 stated he continued to write what the previous nurse wrote. LVN 2 could not verbalize what he would document the site as. LVN 2 stated he was trained in wound care by the facility over a two week orientation. LVN 2 stated he had no prior nursing experience before being hired as a treatment nurse. LVN 2 stated he became a nurse in February 2023 and was hired by the facility in June 2023. During a concurrent observation and interview on 2/9/24 at 8:20 a.m. with LVN 2, LVN2 performed wound care on the left buttock. The wound was observed on the left buttock, not the left gluteal fold. LVN 2 was unable to state what site he would document as the wound site. During a concurrent interview and record review on 2/9/24 at 11:25 a.m. with RN2, Resident 38's Photographic Documentation, dated 2/1/24 was reviewed. RN2 stated the wound site is the left buttocks. During a concurrent interview and record review on 2/9/24 at 2:20 p.m. with IP, Resident 38's Photographic Documentation, dated 2/1/24 was reviewed. IP stated the wound site is the left buttock. IP stated it is not the left gluteal fold because the wound is not in the fold. During an interview on 2/9/24 at 2:57 p.m. with DSD1, DSD1 stated the facility does in-services monthly on wound care. New Treatment Nurses are required to review the nursing policy binder and follow a lead treatment nurse for two weeks before working independently. During a review of the facility's job description titled, LVN/LPT/Treatment Nurse (no date), the job description indicated the nurse will have a minimum of one year of current experience in the area applying for. The nurse will provide accurate written communication of clinical information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 19 of 29 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 02/09/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure expired medications were removed from the medication cart for 1 out of 5 sampled Residents (Resident 40). This failure resulted in Resident 40 receiving expired medications. Findings: During an observation on 2/7/24 at 4:19 p.m. at the 7th floor Team 2 medication cart, a packet of expired Atorvastatin (medication that lowers cholesterol) was noted. The packet had an expiration date of 1/31/24. Six pills were removed from the packet for 2/1/24 to 2/6/24. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/30/2023, the MDS indicated, Resident 40's cognition (ability to learn reason, remember, understand, and make decisions) skills were severely impaired. The MDS indicated, Resident 40 activities of daily living ([ADL] activities related to personal care) Resident 40 was dependent with toileting, hygiene, and showering. During an interview on 2/7/24 at 4:25 p.m. with LVN 3, LVN 3 stated the medication cart should be checked every shift for expired medication. LVN3 stated she did not check the medication cart for the day. LVN 3 states the resident received six doses of the expired medication. LVN 3 states if a resident receives an expired medication they could have and adverse reaction (bad response) such as fever, upset stomach, or diarrhea. During an interview on 2/8/24 at 12:22 p.m. with LVN4, LVN4 stated, the expiration date should be checked prior to giving a medication. If an expired medication is given to a resident, you must complete an incident report, notify the doctor, and monitor for adverse reactions (bad response). During a review of the facility's policy and procedure (P&P) titled, Medication Storage-Patient Care Areas, dated 10/2018, the P&P indicated any expired medication is to be returned to the pharmacy or wasted per facility protocol. During a review of the facility's policy and procedure (P&P) titled, Medication Areas-Inspection, dated 6/2017, the P&P indicated the pharmacy department will inspect all medication areas at least monthly. Expired drugs are removed and returned to pharmacy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 20 of 29 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 02/09/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: 1. Ensure potassium levels were checked prior to administering a potassium supplements. Residents Affected - Few This failure had the potential to result in the resident having a high potassium level, which can be life threatening. Findings: During an observation of medication pass on 2/8/24 at 11:06 a.m., LVN 1 failed to check the potassium level before giving Effer K (a medication that increases the potassium level). During an interview on 2/8/24 at 11:06 a.m. with LVN 1, LVN 1 stated, you need to check the potassium level before giving the dose. If the level is greater than 5 and you give the dose the patient can be hyperkalemic (condition of having a high potassium level) and you need to call the doctor. A high potassium level can make the heart go fast. It can hurt your heart. During an interview on 2/8/24 at 12:39 p.m., with LVN 2, LVN 2 stated, before giving a dose of potassium you should check the potassium level to ensure it's not above five. If you give the dose without checking the potassium level and the level is above five, the patient could have complications with the heart. They could have a heart attack and die. During a review of the medication administration record on 2/8/24, the doctor's comment states to notify the doctor if the potassium level is five or greater so the dose can be decreased or removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 21 of 29 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 02/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure all medication carts were secured after a nurse left the keys on the side of the medication cart. This failure had the potential to result in an unauthorized person obtaining the keys and taking medication from the cart. Findings: During an observation on 2/7/24 at 2:55 p.m. at the Team 1 medication cart, a key with a blue wrist cord was noted on the side of the cart. During an interview on 2/7/24 at 2:55 p.m. with LVN 5, LVN 5 stated the key is for the medication cart. LVN 5 stated the key was left on the cart in an attempt to prevent losing them. LVN 5 stated if someone gets the key they can open the medication cart. That person can then take drugs from the cart and overdose. LVN 5 states she was trained to keep the keys in a secure place. LVN 5 states the location where the keys were observed is not a secure place. During an interview on 2/7/24 at 3:02 p.m. with LVN 6, LVN 6 stated the medication cart key should be kept on your body. If someone gets access to the key they can open the cart and steal the medications. The person who takes the medication can have a medical problem because they don't know the right dose or information about the medication. The person could take too much medication or use it for another purpose. During a review of the facility's policy and procedure (P&P) titled, Medication Storage-Patient Care Areas, dated 10/2018, the P&P indicated all medications are stored in a secure environment that limits access to authorized personnel only. During a review of the facility's policy and procedure (P&P) titled, Medication Storage-Authorized Access, dated 6/2017, the P&P indicated a secure area means that drugs are stored in a manner to prevent unmonitored access by unauthorized individuals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 22 of 29 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 02/09/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 36 admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Residents Affected - Few During a review of Resident 36 Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not address Resident 36 had mouth discomfort or difficulty with chewing due to missing and broken teeth. During an observation and interview on 2/8/2023 at 9:40 a.m. with Resident 36, in resident room, Resident 36 opened mouth and had missing and broken teeth. Resident 36 stated he had not seen a dentist for a few years. Resident 36 stated now that he can eat food it is uncomfortable to chew the food because of his broken teeth. Resident 36 stated it makes him feel sad that he had not been seen by a dentist to correct his broken and missing teeth. During an interview on 2/28/2024 at 10:24 a.m. with Director of Nursing (DON) 1, DON 1 stated I am the one responsible for the dental screenings. DON 1 stated it is standard practice for the Residents to be screen for dental services. DON 1 stated it had been one year since the last time Resident 36 had been seen by a dentist since there had been no dental services. DON 1 stated if I was a resident at the sub-acute and not receiving dental services; I would feel like I am not being cared for. During an interview on 2/8/2024 at 11:42 a.m. with Infection Preventionist (IP) 1, IP 1 stated we had a dental group that would check the Residents every 6 months and as needed. IP 1 stated the dental contract ended in 10/2022. IP 1 stated Resident 36 had not been seen by the dentist since 4/30/2022. IP 1 stated this put Resident 36 at risk for cavities, gingivitis (gum inflammation), and infection. IP 1 stated if I was a resident and not being seen by a dentist it would make me feel ignored and frustrated. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 4/2021, the P&P indicated, To assure residents dental services needs are assessed and provided as needed .Director of Nursing or designee is responsible for the following procedures .Ascertain that dental problems are addressed, when present in their resident's Plan of Care .Maintains a dental log of all complaints and/or appointments for residents and kept with social services. Based on observation, interview and record review, 1. The facility failed to provide periodic dental screening and evaluation for two out of two sampled residents (Residents 48 and 36). This deficient practice had the potential to put Resident 36 and Resident 48 at risk for tooth decay, oral infection and other life-threatening health conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 23 of 29 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 02/09/2024 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 0790 Findings: Level of Harm - Minimal harm or potential for actual harm a. During a review of Resident 48's Face Sheet, the Face Sheet indicated, Resident 48 was admitted to the facility on [DATE], with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), s/p tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), and diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated). Residents Affected - Few During a review of Resident 48's MDS assessment, dated 1/10/2024, the MDS assessment, indicated Resident 48's had a Brief Interview for Mental Status (BIMS) total score of 15 (intact cognitive response). During a review of Resident 48's Physician's Order, the Physician's Order indicated, Resident 48 had an order for dental consult and treatment as needed (PRN) for dental problems. During a review of Resident 48's Oral/Dental Assessment, dated 1/10/2024, the Oral/Dental Assessment indicated, Resident 48 had a missing upper teeth. During a concurrent observation and interview on 2/7/2024 at 3:01 p.m. with Resident 48 in his room. Resident 48 was observed with missing upper teeth. Resident 48 stated she had never seen by a dentist since he was admitted to the facility. Resident 48 stated he requested to Director of Staff Development 1 (DSD 1) about 3 months ago for routine dental check-up. During an interview on 2/8/2024 at 9:28 a.m. with DSD, DSD 1 stated she was fully aware of Resident 48's request for dental referral and she already informed her Director of Nursing (DON 1). DSD 1 stated the facility is still looking for a dentist that could come in the facility. DSD 1 stated routine dental screening and work-up are important for all residents in the facility so they could be screened for dental cavities that could lead to oral infection. During an interview on 2/8/2024 at 9:49 a.m. with Social Service Director 1 (SSD1), SSD 1 stated she is responsible for arranging ancillary services such as dental and podiatry. SSD 1 stated it is the facility's policy for dental screening for all residents initially upon admission, yearly and as needed. SSD 1 stated the management are still looking for a dental provider. SSD 1 stated the last time the dentist came in the facility was October 2022. During an interview on 2/8/2024 at 10:23 a.m. with Director of Nursing 1 (DON 1), DON 1 stated it is a must for all residents to be seen by a dentist for dental screening and it is one of the services they provide. DON 1 stated the management is still in the process for negotiating a contract for a new dental provider. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 4/2021, the P&P indicated, The facility shall maintain an agreement with an advisory dentist to advise and assist the facility in providing proper dental care to all residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 24 of 29 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 02/09/2024 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 Residents Affected - Few 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: 1. Ensure the inside compartment of the ice machine was to be maintained in a sanitary manner for nine out of 59 residents. This deficient practice had the potential to result in an outbreak of foodborne illness that could affect all or most of the residents who reside in the facility. Findings: During a concurrent observation and interview on 2/6/2024 at 9:45 a.m. with Dietary Service Supervisor 1 (DSS 1) in the kitchen, found inside compartment of the ice machine was dirty. DSS 1 used a clean paper towel to swipe the inside compartment of the ice machine, produced black residue with hard water deposits. DSS 1 stated it was their engineering department who was responsible for the maintenance of the ice machine every month. DSS 1 stated the ice machine compartment was dirty and not safe for consumption. During a review of Ice Machine Cleaning Schedule 2024, the Ice Machine Cleaning Schedule indicated the ice machine was last cleaned on 1/12/2024. During an interview on 2/6/2024 at 11:50 a.m. with Registered Dietitian 1 (RD 1), RD 1 stated residents can get sick because of food-borne illness if the ice machine was not maintained in a sanitary manner. During a review of the facility's policy and procedure titled, Equipment Use and Sanitation-Ice Machine, dated 4/2019, the P&P indicated, The ice machine in the food and nutrition department will be maintained and sanitized on a regular basis so as to prevent food-borne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 25 of 29 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 02/09/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Accurately document fluids (the amount of liquid going into the body) that were infused intravenously ([IV]a method of putting fluids, including drugs, into the bloodstream) into the body for one out of five sampled Residents (Resident 40). This deficient practice had the potential to result in confusion in the care and services rendered to Residents and inaccurate information could be entered into the resident's clinical record. Findings: During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's History and Physical (H&P), dated 8/18/2023, the H&P indicated, Resident 40 unable to review systems due mental condition. During a review of Resident 40's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/30/2023, the MDS indicated, Resident 40's cognition (ability to learn reason, remember, understand, and make decisions) skills were severely impaired. The MDS indicated, Resident 40 activities of daily living ([ADL] activities related to personal care) Resident 40 was dependent with toileting, hygiene, and showering. During a concurrent interview and record review During an interview and record review on 2/8/2024 at 1:30 p.m. with Registered Nurse (RN) 1, Resident 40's Intake/Output Inquiry, dated 2/5/2024 was reviewed. The Intake/Output Inquiry indicated, Resident 40 had blood products (any therapeutic substance derived from human blood) for a total amount of 350 milliliters ([ml] a measure of volume that is equal to one-thousandth of a liter) and Resident 40 received intravenous fluids (IVFs) of Dextrose 5% ½ Normal Saline including potassium chlorine (KCL) 20 milliequivalent (meq) ( [D5 1/2NS + 20meq KCL] a solution is used to treat dehydration) at 100ml per hour. RN 1 stated the blood products and the D51/2NS + 20MEQ KCL should not be infused at the same time in the same (IV). RN 1 stated I charted the intake as 1200mls for the D5 ½NS + 20meq KCL at 100ml per hour and the blood product at 100ml an hour. RN 1 stated Resident 40 had one IV. RN 1 stated I did stop the intravenous fluids (IVF) while the blood products were infusing. RN 1 stated I should have charted 850ml for the IVFs and 350mls for the blood products to equal 1200mls for 12 hours I worked. RN 1 stated I charted the fluid input incorrectly and it reflected the blood products and the IVF infused at the same time. RN 1 stated if the IVFs and the blood product were given together Resident 40 could have had a reaction to the blood transfusion. RN 1 stated its important to chart correctly to provide so when someone is reviewing can see the fluids Resident 40 received. During a concurrent interview and record review During an interview and record review on 2/8/2024 at 1:30 p.m. with Director of Nursing (DON) 2, Resident 40's Intake/Output Inquiry, dated 2/5/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 26 of 29 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 02/09/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was reviewed. The Intake/Output Inquiry indicated, Resident 40 had blood products (any therapeutic substance derived from human blood) for a total amount of 350 milliliters ([ml] a measure of volume that is equal to one-thousandth of a liter) and Resident 40 received intravenous fluids (IVFs) of Dextrose 5% ½ NS + 20meq KCL. DON 2 stated RN 1 should have charted 850ml for the IVFs and 350mls for the blood products to equal 1200mls for 12 hours RN 1 worked. DON 2 stated RN 1 had a documentation error and gave the appearance that the blood products and IVFs were infused at the same time. DON 2 stated it was important to document the correct fluids to prevent the misinterpretation of fluids infusing into Resident 40's body. During a review of the facility's policy and procedure (P&P) titled, Administration of Medications-Medication Administration Record (MAR), dated 6/2017, the P&P indicated, MAR recording procedure properly record every dose of every medication administered in the patient's record after administration .For every hour's dosing document clearly with adequate space for documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 27 of 29 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 02/09/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to: 1. Identify facility dental services and care issues for one of one sampled residents (Resident 36). The failure to fulfill and fully implement an active QAPI process had the potential to result in resident harm by not having a system in place to identify significant resident safety issues, develop a plan to correct identified issues, and implement the plan or monitor the results of the facility plan. Findings: During a review of Resident 36 admission Record (Face Sheet), the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a condition that makes it difficult to breathe on your own), renal failure (one or both kidneys no longer function well on their own), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 36 Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 11/12/2023, the MDS indicated, Resident 36's cognition (ability to learn reason, remember, understand, and make decisions) skills Resident 36 was oriented to year, month, year, and could recall questions that were previously asked. The MDS indicated, Resident 36's oral and dental status did not address Resident 36 had mouth discomfort or difficulty with chewing due to missing and broken teeth. During an observation and interview on 2/8/2023 at 9:40 a.m. with Resident 36, in resident room, Resident 36 opened mouth and had missing and broken teeth. Resident 36 stated he had not seen a dentist for a few years. Resident 36 stated now that he can eat food it is uncomfortable to chew the food because of his broken teeth. Resident 36 stated it makes him feel sad that he had not been seen by a dentist to correct his broken and missing teeth. During an interview on 2/28/2024 at 10:24 a.m. with Director of Nursing (DON) 1, DON 1 stated I am the one responsible for the dental screenings. DON 1 stated it is standard practice for the Residents to be screen for dental services. DON 1 stated it had been one year since the last time Resident 36 had been seen by a dentist since there had been no dental services. DON 1 stated if I was a resident at the sub-acute and not receiving dental services; I would feel like I am not being cared for. During an interview on 2/8/2024 at 11:42 a.m. with Infection Preventionist (IP) 1, IP 1 stated we had a dental group that would check the Residents every 6 months and as needed. IP 1 stated the dental contract ended in 10/2022. IP 1 stated Resident 36 had not been seen by the dentist since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 28 of 29 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 02/09/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/30/2022. IP 1 stated this put Resident 36 at risk for cavities, gingivitis (gum inflammation), and infection. IP 1 stated if I was a resident and not being seen by a dentist it would make me feel ignored and frustrated. During an interview on 2/9/2024 at 2:25 p.m. with Risk Management 1, Risk Management 1 stated there had not been dental services for eights months. Risk Management 1 stated there had been eight QAPI meetings and the dental services was not mentioned. Risk Management 1 stated dental services should have been addressed in the QAPI meetings with an action plan. Risk Management 1 stated the impact of not having dental services for the Residents it could cause the Residents to be uncomfortable and have pain. Risk Management 1 stated it can be difficult for the Residents to chew their food, restrict the type of food they could have, and eat due to having an infected tooth. During an interview on 2/09/2024 at 3:03 p.m. with Director of Nursing (DON) 1, DON 1 stated there were no mentioned of dental service issues in the QAPI meetings. DON 1 stated we have not had dental services since 10/2022. DON 1 stated when there were no longer dental services, we should have realized this was an issue of not having dental services. DON 1 stated dental services should have been included in the QAPI action plan. DON 1 stated there should have been a followed to make sure dental services were in the goods and services for our Residents. DON 1 stated not having an action plan in place had placed the Residents at risk for infection and pain. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 4/2021, the P&P indicated, To assure residents dental services needs are assessed and provided as needed .Director of Nursing or designee is responsible for the following procedures .Ascertain that dental problems are addressed, when present in their resident's Plan of Care .Maintains a dental log of all complaints and/or appointments for residents and kept with social services. During a review of the facility's policy and procedure (P&P) titled, Organizational Performance Improvement Plan, dated 6/2022, the P&P indicated, The Plan for Performance Improvement at Memorial Hospital of Gardena reflects the evolution of our efforts to ensure the highest quality, cost efficient and safest care for our patients .Our resources, which are managed carefully, are dedicated to delivering high quality care for our patients .continuously improve outcomes related to the quality of care and service .Design reliable systems and processes that reduce the likelihood of harm for our patients . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555441 If continuation sheet Page 29 of 29