Other·December 14, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of a Complaint during an Abbreviated Standard Survey. Complaint Number: CA00604365 and CA00604134 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 37393 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Three deficiencies was issued for CA604365 and CA00604134

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 12/06/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 1 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 2 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to follow its policy and procedure for change of condition (COC) when one of three sample residents (Resident 1) had significant change in clinical condition and a need to alter treatment. For Resident 1, who had a fall with injuries, Licensed Vocational Nurse 1 (LVN 1) failed to immediately notify and consult the resident's physician (Cross referenced F684). This deficient practice resulted in a delay in diagnosis, care and services and a decline in Resident 1's health. Resident 1 sustained a subdural hematoma (a collection of blood outside the brain caused by severe head injuries) after the fall due to blunt head trauma (BHT) and was transferred to a general acute care hospital (GACH) where the resident died the next day, on 9/16/18. Findings: A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on 8/6/18. Resident 1's diagnoses included atrial fibrillation (heart rhythm abnormality in which the heart quivers or has an irregular heartbeat), right hip fracture secondary to a fall, syncope (dizziness or temporary loss of consciousness caused by a fall in blood pressure), history of falls with contusion (bruise) of scalp, and difficulty walking. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 8/15/18, indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and be understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for transferring, dressing, toileting, personal hygiene and bed mobility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 3 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The MDS indicated Resident 1 was impaired of range of motion (ROM) of bilateral (both) lower extremities. According to the MDS, Resident 1 sustained a fall in the last month. A review a facility's Situation, Background, Assessment and Recommendation ([SBAR] internal communication form) written by LVN 1, dated 9/15/18 and timed at 3:30 a.m., indicated Resident 1 had an unwitnessed fall that resulted on a bump to the left side of the forehead. The SBAR indicated Resident 1 was alert, verbal, and was placed back in bed. A neurological check (an assessment of sensory neuron and motor responses, especially reflexes, to determine if the nervous system was impaired) were initiated. A review of a Progress Note written by LVN 1, dated 9/15/18 and timed at 3:30 a.m., indicated Certified Nursing Assistant 1 (CNA 1) responded to Resident 1's call light and upon entering the room, Resident 1 was found on the floor next to the bed after an unwitnessed fall. The progress note indicated Resident 1 was alert and verbally responsive, with no signs of distress and was able to move upper and lower extremities, no dizziness, no headache, or nausea and vomiting. According to the progress note, Resident 1 had a large bump on left side of the forehead and a bluish discoloration to the right side of the chin, but denied pain. A review of the "Licensed Progress Notes" written by LVN 1, dated 9/15/18 and timed at 4:05 a.m., indicated LVN 1 notified Resident 1's physician of the unwitnessed fall. The note indicated Physician 1 ordered an x-ray of the skull and left hip. A review of Physician 1's telephone order (T/O), dated 9/15/18 and timed at 4:05 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 4 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE written by LVN 1, indicated STAT (instantly or immediately) X-ray of the right hip, left side of forehead and skull. The T/O indicated to apply an ice pack to the left forehead every shift for 15 minutes for three days and do neuro checks per protocol for 48 hours. A review of a Licensed Progress note, dated 9/15/18 and timed at 5 a.m., indicated Resident 1 was awake, with no complaints of pain, and/or discomfort. A review of the 48 hours Neuro-Checklist, dated 9/15/18 and timed at 5 a.m., written by LVN 1 indicated Resident 1's vital signs were blood pressure 144/84 (normal reference range [NRR] 120/80), body temperature was 97.8 Fahrenheit (F) (NRR = 97.9 to 99), and heart rate was 74 (NNR = 60-100), with respirations of 18 (NRR = 12-20). Resident 1 was alert, verbal, and had no change of LOC. A review of a Licensed Progress note, dated 9/15/18 and timed at 6 a.m., indicated LVN 1 notified Resident 1's Family member (FM 1) about the resident's fall, x-rays were ordered, and that Resident 1 denied pain/discomfort denial. The note further indicated that Resident 1 was administered omeprazole (a medication to treat heartburn) without any problem. A review of the 48 hours Neuro-Checklist, dated 9/15/18 and timed at 6 a.m., written by LVN 1, indicated Resident 1's vital signs were as follows: blood pressure 148/78, body temperature was 97.8 F, and heart rate was 72 with respirations of 20. Resident 1 was alert, verbal, and had no change of level of consciousness (LOC). A review of the Licensed Nurses Progress Note, dated 9/15/18 and timed at 7:10 a.m., indicated CNA 2 reported to Registered Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 5 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1 (RN 1) that Resident 1's unidentified Family member came to visit and Resident 1 was not responding or opening her eyes when FM 1 attempted to talk to resident. The note indicated RN 1 was unable to wake up Resident 1. Resident 1's vital signs were documented as follows: blood pressure 172/84, body temperature 101.6 F, heart rate 85, respirations of 18, and Oxygen saturation (measurement of how much oxygen is in the blood) was 96 percent (%) (NRR 92 to 100). RN 1 called 911 paramedics to transport Resident 1 for medical evaluation to the nearest GACH due to unresponsiveness. A review of a Physicians' Telephone Order, dated 9/15/18 and timed at 7:15 a.m., written by RN 1 indicated for Resident 1 to be transferred to the nearest GACH via 911 (emergency response number) for medical evaluation due to unresponsiveness. A review of the facility's Record of Termination, dated 9/28/18, indicated that LVN 1 was terminated after Resident 1's fall incident that occurred on 9/15/18. The termination record indicated that the nursing home lost confidence in LVN 1's abilities due to in-accurately assessing the resident, documenting assessment, and practicing out of her scope of practice by writing a physician's orders without confirming the order with the physician. On 9/20/18 at 10:03 a.m., during an interview, an associate physician of the primary care provider (Physician 2) stated, "I am not sure who wrote the phone order, the Physician assistant (PA 1) who works with the primary care provider (Physician 1) was off. Another provider was on call, not the primary care provider." On 9/20/18 at 10:12 a.m., during a phone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 6 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interview the diagnostic lab representative stated, "We do not have an order for an x-ray of the skull from this facility; we usually do not x-ray skulls." On 9/20/18 at 1:42 p.m., during a phone interview Physician 2 stated, "No provider gave that order from our office. Another provider was on duty, and did not receive a call from the facility." On 9/21/18 at 9:59 a.m., during a concurrent interview and record review, LVN 1 stated and she confirmed that on 9/15/18, she did not receive orders for x-ray of the skull and neuro check from Resident 1's physician. LVN 1 stated that she left a message, but did not receive orders or made a second attempt to notify the physician of Resident 1's fall with injury. LVN 1 stated that Resident 1 suffered a fall that resulted in an elevated bump to the left side of the forehead that appeared slight green in color and measured 3 to 4 centimeters (cm) in diameter. LVN 1 stated that she wrote the order for the x-ray because she believed Resident 1 would benefit from it and that it would not hurt her. A review of the facility's policy and procedures titled, "Change of Condition, Physician Contact," revised 3/31/06, indicated to notify the physician of any significant change in patient's condition, or to report an incident. In case of an emergency, call the attending physician if physician not available, call the alternative, or the medical director if any of the physicians are available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 7 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F684 Quality of Care CFR(s): 483.25

F684 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/06/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy when a resident had a change of condition and provide the necessary care and services when one of three sampled residents had a change of condition (Resident 1). Resident 1 had a fall with injuries and Licensed Vocational Nurse 1 (LVN 1) failed to notify the physician for the necessary care and interventions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 8 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This deficient practice resulted in a delay in diagnosis, care and services and a decline in Resident 1's health. During the fall, Resident 1 had blunt head trauma (BHT) and sustained a subdural hematoma (a collection of blood outside the brain caused by severe head injuries) and was transferred to a general acute care hospital (GACH) and died the next day, on 9/16/18. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 8/6/18. Resident 1's diagnoses included atrial fibrillation (heart rhythm abnormality in which the heart quivers or has an irregular heartbeat), right hip fracture secondary to a fall, syncope (dizziness or temporary loss of consciousness caused by a fall in blood pressure), history of falls with contusion (bruise) of scalp, and difficulty walking. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 8/15/18, indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and be understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for transferring, dressing, toileting, personal hygiene and bed mobility. The MDS indicated Resident 1 was impaired of range of motion (ROM) of bilateral (both) lower extremities. According to the MDS, Resident 1 sustained a fall in the last month. A review a facility's Situation, Background, Assessment and Recommendation ([SBAR] an internal communication form) written by LVN 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 9 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 9/15/18 and timed at 3:30 a.m., indicated Resident 1 had an unwitnessed fall that resulted in a bump to the left side of the forehead (BHT). The SBAR indicated Resident 1 was alert, verbal, and was placed back in bed. A neurological check (an assessment of sensory neuron and motor responses, especially reflexes, to determine if the nervous system was impaired) were initiated. A review of a Progress Note written by LVN 1, dated 9/15/18 and timed at 3:30 a.m., indicated Certified Nursing Assistant 1 (CNA 1) responded to Resident 1's call light and upon entering the room, Resident 1 was found on the floor next to the bed after an unwitnessed fall. The progress note indicated Resident 1 was alert and verbally responsive, with no signs of distress and was able to move upper and lower extremities, no dizziness, no headache, or nausea and vomiting. According to the progress note, Resident 1 had a large bump on left side of the forehead and a bluish discoloration to the right side of the chin, but denied pain. A review of the "Licensed Progress Notes" written by LVN 1, dated 9/15/18 and timed at 4:05 a.m., indicated LVN 1 notified Resident 1's physician of the unwitnessed fall. The note indicated Physician 1 ordered an x-ray of the skull and left hip. A review of Physician 1's telephone order (T/O), dated 9/15/18 and timed at 4:05 a.m., written by LVN 1, indicated STAT (instantly or immediately) X-ray of the right hip, left side of forehead and skull. The T/O indicated to apply an ice pack to the left forehead every shift for 15 minutes for three days and do neuro checks per protocol for 48 hours. A review of a Licensed Progress note, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 10 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9/15/18 and timed at 5 a.m., indicated Resident 1 was awake, with no complaints of pain, and/or discomfort. A review of the 48 hours Neuro-Checklist, dated 9/15/18 and timed at 5 a.m., written by LVN 1 indicated Resident 1's vital signs were blood pressure 144/84 (normal reference range [NRR] 120/80), body temperature was 97.8 Fahrenheit (F) (NRR = 97.9 to 99 F), and heart rate was 74 bpm [beats per minute] (NRR = 60100), with respirations of 18 (NRR = 12-20). Resident 1 was alert, verbal, and had no change of LOC. A review of a Licensed Progress note, dated 9/15/18 and timed at 6 a.m., indicated LVN 1 notified Resident 1's Family member (FM 1) about the resident's fall, x-rays were ordered, and that Resident 1 denied pain/discomfort denial. The note further indicated that Resident 1 was administered omeprazole (a medication to treat heartburn) without any problem. A review of the 48 hours Neuro-Checklist, dated 9/15/18 and timed at 6 a.m., written by LVN 1, indicated Resident 1's vital signs were as follows: blood pressure 148/78, body temperature was 97.8 F, and heart rate was 72 with respirations of 20. Resident 1 was alert, verbal, and had no change of level of consciousness (LOC). A review of the licensed nurses progress note, dated 9/15/18 and timed at 7:10 a.m., indicated CNA 2 reported to Registered Nurse 1 (RN 1) that Resident 1's unidentified Family member came to visit and Resident 1 was not responding or opening her eyes when FM 1 attempted to talk to resident. The note indicated RN 1 was unable to wake up Resident 1. Resident 1's vital signs were documented as follows: blood pressure 172/84, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 11 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE body temperature 101.6 F, heart rate 85, respirations of 18, and Oxygen saturation (measurement of how much oxygen is in the blood) was 96 percent (%) (NRR 92 to 100). RN 1 called 911 paramedics to transport Resident 1 for medical evaluation to the nearest GACH due to unresponsiveness. A review of a physicians' telephone order, dated 9/15/18 and timed at 7:15 a.m., written by RN 1 indicated for Resident 1 to be transferred to the nearest GACH via 911 (emergency response number) for medical evaluation due to unresponsiveness. A review of the facility's Record of Termination, dated 9/28/18, indicated that LVN 1 was terminated after Resident 1's fall incident that occurred on 9/15/18. The termination record indicated that the nursing home lost confidence in LVN 1's abilities due to in-accurately assessing the resident, documenting assessment, and practicing out of her scope of practice by writing a physician's orders without confirming the order with the physician. On 9/20/18 at 10:03 a.m., during an interview, an associate physician of the primary care provider (Physician 2) stated, "I am not sure who wrote the phone order, the Physician assistant (PA 1) who works with the primary care provider (Physician 1) was off. Another provider was on call, not the primary care provider." On 9/20/18 at 10:12 a.m., during a phone interview the diagnostic lab representative stated, "We do not have an order for an x-ray of the skull from this facility; we usually do not x-ray skulls." On 9/20/18 at 1:42 p.m., during a phone interview Physician 2 stated, "No provider gave FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 12 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that order from our office. Another provider was on duty, and did not receive a call from the facility." On 9/21/18 at 9:59 a.m., during a concurrent interview and record review, LVN 1 stated and she confirmed that on 9/15/18, she did not received orders for x-ray of the skull and neuro check from Resident 1's physician. LVN 1 stated that she left a message, but did not received orders or made a second attempt to notify the physician of Resident 1's fall with injury. LVN 1 stated that Resident 1 suffered a fall that resulted in an elevated bump to the left side of the forehead that appeared slight green in color and measured 3 to 4 centimeters (cm) in diameter. LVN 1 stated that she wrote the order for the x-ray because she believed Resident 1 would benefit from it and that it would not hurt her. A review of the facility's policy and procedures titled, "Change of Condition, Physician Contact," revised 3/31/06, indicated to notify the physician of any significant change in patient's condition, or to report an incident. In case of an emergency, call the attending physician if physician not available, call the alternative, or the medical director if any of the physicians are available.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) FORM CMS-2567(02-99) Previous Versions Obsolete

F842 Event ID: SR9P11 12/06/2018 Facility ID: CA910000033 If continuation sheet 13 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 14 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that residents' clinical records were accurately documented as per physician orders and prevent Licensed Vocational Nurse 1 (LVN 1) from altering residents' vital signs (clinical measurements of the pulse rate, temperature, respiration rate, and blood pressure, that indicates the state of the body functions), neurological checks (assessment conducted after a head injury to check for level of consciousness) and physician orders for one of three sampled residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 15 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Resident 1). These deficient practices resulted in Resident 1 not receiving emergency treatment after sustaining a head injury following a fall. Resident 1 was transferred to a general acute care hospital (GACH) on 9/15/18 and died of a subdural hematoma (a collection of blood outside the brain caused by severe head injuries) on 9/16/18 (26 hours after). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on 8/6/18. Resident 1's diagnoses included atrial fibrillation (heart rhythm abnormality in which the heart quivers or has an irregular heartbeat), right hip fracture secondary to a fall, syncope (dizziness or temporary loss of consciousness caused by a fall in blood pressure), history of a fall with contusion (bruise) of scalp, osteoporosis (condition in which the bones become brittle and fragile from deficiency of calcium), and difficulty walking. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 8/15/18, indicated Resident 1 had no memory problems or decision-making, was able to make needs known and be understood by others. The MDS indicated Resident 1 required an extensive assistance of a one-person physical staff assist for transferring, dressing, toileting, personal hygiene and bed mobility. The MDS indicated Resident 1 was impaired of range of motion (ROM) of bilateral (both) lower extremities. The MDS indicated that Resident 1 sustained a fall in the last month. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 16 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's Situation, Background, Assessment and Recommendation ([SBAR] internal communication tool) written by LVN 1, dated 9/15/18 and timed at 3:30 a.m., indicated Resident 1 had an unwitnessed fall that resulted in a bump to the left side of the forehead. The SBAR indicated Resident 1 was alert, verbal, was placed back in bed, and neurological checks were to be initiated. A review of the 48 hours Neuro-Checklist, dated 9/15/18 and timed at 3:30 a.m., written by LVN 1 indicated Resident 1's vital signs were documented as follows: blood pressure 145/96 ([NRR] 120/80), body temperature was 98.0 Fahrenheit (F) (NRR = 97.9 to 99), and heart rate was 68 (NRR = 60 to 100) with respirations of 20 (NRR = 12 to 20). Resident 1 was alert, verbal, and had no change of level of consciousness (LOC). LVN 1 documented that Resident 1's right and left pupil were PERRLA (pupils equal, round, react to light, accommodation {while performing an assessment of the eyes, an evaluation of the size and shape of the pupils, reaction to light, and the ability to accommodate]) and that the right and left hand grip were good. A review of a physician's telephone order (T/O), dated 9/15/18 and timed at 4:05 a.m., written by LVN 1, indicated STAT (instantly or immediately) x-ray of the right hip and left side of the forehead and skull, icepack to left the forehead every shift for 15 minutes for three days and indicated neuro-check per protocol for 48 hours. A review of the facility's Record of Termination, dated 9/28/18, indicated that the facility was terminating LVN 1 after Resident 1's fall incident that occurred on 9/15/18. The termination record indicated that the facility lost confidence in LVN 1's abilities by not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 17 of 18 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555706 (X3) DATE SURVEY COMPLETED 11/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEL AMO GARDENS CARE CENTER 22419 Kent Ave Torrance, CA 90505 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accurately assessing the resident, documenting assessments, and practicing out of her scope of practice by writing a physician's order without confirming the order. On 9/21/18 at 8:55 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated and confirmed that physician orders should be carried out after received from the physician. On 9/21/18 at 9:59 a.m., during a concurrent interview and record review, LVN 1 stated and she confirmed that on 9/15/18, she did not receive orders for x-ray of the skull and neuro check from Resident 1's physician. LVN 1 stated that she left a message, but did not receive orders or made a second attempt to notify the physician of Resident 1's fall with injury. LVN 1 stated that Resident 1 suffered a fall that resulted in an elevated bump to the left side of the forehead that appeared slight green in color and measured 3 to 4 centimeters (cm) in diameter. LVN 1 stated that she wrote the order for the x-ray because she believed Resident 1 would benefit from it and would not hurt her. A review of the facility's policy and procedures (P/P) titled, "Physician Orders and Telephone orders," dated 11/2017, indicated that physician orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorization to prescribe for and treat human illness. All orders must be specific and complete and no standing orders shall be accepted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SR9P11 Facility ID: CA910000033 If continuation sheet 18 of 18