Other·February 6, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Ammended as of 1/17/2019 The following reflects the findings of The Department of Public Health during the Recertification survey. Representing the Department of Public Health: Surveyor ID: 19096 RN, HFEN Surveyor ID: 36356 RN, HFEN Surveyor ID: 36385 RN, HFEN Total Census: 62 Total Sampled Residents: 17 Highest Severity and Scope: E

F550 SS=E Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of 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: 70Q811 Facility ID: CA910000275 If continuation sheet 1 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to treat two of 17 sampled residents (Resident 9, 12) with dignity. These deficient practices resulted in Resident 12 not feeling good because the facility failed to provide an underwear to meet his needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 2 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 Findings: a. During an interview with Resident 12 on 1/4/18 at 6:59 p.m., stated the facility did not provide him with an underwear. The resident stated he wore incontinent pads (diapers) which made him feel bad. The resident stated wearing diapers made him feel "effeminate" (like a woman and made to feel unmanly). A review of Resident 12's admission records (facesheet) indicated admitted on 4/7/17 with diagnoses that included injuries sustained in a motor vehicle accident with muscle weakness and dysphagia (difficulty swallowing). A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 10/13/17 indicated Resident 12 was always continent (able to control) of bowel and bladder (urine) functions. A review of Resident 12's assessment of bowel and bladder functions, dated 10/13/17 indicated Resident 12 was continent of both bowel and bladder functions. During an interview with certified nurse assistant (CNA 1) on 1/7/18 at 9:00 a.m., stated Resident 12 was alert and "not confused". CNA 1 stated the resident used his wheelchair for mobility, was able to transfer from bed to wheelchair on his own and was able to use the toilet by himself. Upon further questioning, CNA 1 stated the resident was continent of both bowel and bladder functions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 3 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 CNA 1 stated she used pull-up diapers on the resident because that was the underwear provided by the facility which had been found in his closet. During an interview with the social service designee (SSD) on 1/7/18 at 9:06 a.m., stated Resident 12 did not have any underwear and did not not know the reason why the resident wore pull-ups. The SSD stated if a resident did not have a family, she was responsible for purchasing the items they needed. During an interview with the MDS nurse on 1/7/18 at 9:31 a.m., stated Resident 12 was continent of both bowl, and bladder functions. The MDS RN stated that he was able to go to the toilet using a walker. However, MDS RN stated she did not know why he wore a diaper. The MDS nurse stated the residents who wear diapers are usually incontinent. During an observation with the MDS nurse on 1/7/18 at 11:00 a.m., one dark colored men's underwear was found in Resident 12's bottom closet drawer. The MDS nurse verified the underwear did not look clean. There were no other underwear found in the resident's closet or drawers. b. During a tour of the facility on 1/6/18 at 9:20 am., Resident 9 was observed riding through the hallway of the facility in his motorized wheelchair. The resident's inner left leg pants was observed to have a tear in the inseam about the length of half a ruler. The resident was asked the reason he had a tear in his pants, and stated he had not had the pants washed or seamed up. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 4 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 Resident 9's clinical records indicated he was originally admitted to the facility on 11/28/08 and re-admitted on 9/9/17, with diagnoses which include quadriplegia (have significant paralysis below the neck, and many are completely unable to move), contracture of left/right wrist, and contracture of the left/right hand (shortening of certain tendons, muscles or other connective tissues causing loss of full extension of the affected joints). A review of Resident 9's Minimum Data Set (MDS), a standardized assessment and care screening tool indicated Resident 9 was alert, oriented, able to make his need known and required extensive assistance in his activities of daily living.

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

F580 §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 psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 5 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 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, one of 17 sampled residents (Resident 210) had coughed all night long, the staff took all night to notify the physician before any interventions were provided because the physician did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 6 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 call back in a timely manner. This deficient practice had delayed in the doctor being notified in order to receive the care/treatment needed for his cough. Findings: During a interview on 1/7/18 at 1:30 pm., Resident 210 stated recently he had a bad cough and notified the facility staff who attempted to call his physician. Resident 210 stated he had to wait all day and almost coughed his lungs out because the staff were unable to reach his physician. Resident 210 stated staff informed him they could not do anything until the physician called back. During a review of Resident 210's Face Sheet and Admission Information indicated admitted to the facility on 11/29/17, with diagnoses of Rhabdomyolysis (rapid destruction of skeletal muscle which can cause muscle pain and weakness), Gullian-Barre Syndrome (a rare disorder in which the body's immune system attacks the nerves), and hypertension (high blood pressure).

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 7 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 8 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 review, one of 17 sampled residents (Resident 22) complained of uncomfortable noise levels within the facility. The deficient practice of loud noises had the potential to cause the resident distress. Findings: During an interview on 1/04/18 06:26 PM Resident 22 stated staff are noisy all times. The resident also stated he did not bother with the noise now because the facility did not do anything to stop it. On a concurrent observation, staff were observed wheeling the linen and trash containers. The wheels of the containers were loud. The back exit door also banged loudly when staff entered and exited the building.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to do a thorough investigation for two of 17 sampled residents (Resident 33, 205). Resident 33 sustained a fall and it was not thoroughly investigated to decrease the of further falls and injuries. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 9 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 205's sustained a lump on right elbow which was not thoroughly assessed. This deficient practice caused the residents not to get adequate care, pain medication and treatment as needed. Findings: a. During an observation of the medication pass on January 6, 2018 at 9:00, am Resident 205 was observed lying in bed on his left side. Resident 205 was observed with facial grimacing while trying to turn on his back and a large swollen lump was observed on his right elbow. During an interview with a Licensed Vocational Nurse (LVN 1) was asked about the resident's pain level was for his elbow and he stated 10 on a 0 (zero) to 10 pain rating scale (zero meaning no pain and 10 meaning the worst pain experienced). When asked how long did he have this lump on his right elbow, Resident 25 stated," I don't know but I've had it when I came here." During a review of the clinical records for Resident 205 on 1/6/18 at 11:49 am., the face sheet indicated the resident was admitted to the facility on December 20, 2017, with diagnoses of urinary tract infection (infection in any part of the urinary system), hypertension (high blood pressure), muscle weakness and difficulty in walking. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 27, 2017, indicated Resident 205 was able to make daily decision making and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 10 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 required limited extensive assistance in performing activities of daily living. A review of Resident 205's clinical record indicated a history and physician examination dated December 22, 2017, indicated Resident 205 had a soft lump on the right elbow. Review of the physical Therapist evaluation/plan of treatment, dated 12/22/17 at 3:28 pm, for the certification period of 12/21/17 to 1/17/18, stipulated Resident 205 to receive physical Therapy (PT) therapy five times a week for 4 weeks for therapeutic exercise, gait training therapy, neuromuscular re-education and therapeutic activities. However, there was no documentation from nursing staff or physical therapy regarding Resident 205's lump/pain range on his right elbow. During an interview with the physical therapy supervisor regarding Resident 205's lump on right elbow on 1/7/18 at 4;30pm, stated he was not aware of the lump on the elbow but was only aware of the resident's severe headaches. During an interview with the Director of Nursing (DON) on 1/8/17 at 4 pm., stated Resident 205 should have been assessed completely. b. A review of Resident 33's undated record titled, "Face Sheet," indicated Resident 33 was readmitted to the facility on 1/26/15, with diagnoses including left side hemiplegia (one sided paralysis) and hemiparesis (muscle weakness and partial loss of movement on one side of the body). A review of Resident 33's record titled, "Rehabilitation Screen," form dated 8/9/16 indicated Resident 33 was observed to have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 11 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 decline in current RNA program (restorative nursing programs, provide specific treatments to restore and maintain the strength, coordination and skills to ambulate and perform functional activities of daily living). The Rehabilitation Screen form also planned for Physical Therapy (PT) and Occupational Therapy (OT) to pick up (take over) the resident for services. A review of Resident 33's record titled, "PT Therapist Progress and Updated Plan of Care," dated 9/7/2016 indicated Resident 33 displayed decreased strength and range of motion (ROM) which limited safe transfer and gait. A review of Resident 33's record titled, "Occupational Therapy (OT)," dated 9/8/16 to 9/29/16, indicated Resident 33 continued to require assistance with activities of daily living (ADLs) due to loss of movement on the left upper extremity (LUE), and impaired dynamic (act of moving) skills in sitting and standing tolerance. The Occupational Therapy indicated Resident 33's functional deficits and underlying impairments included loss of movement on the LUE with contracture (shortening and hardening of muscles and tendons) on the wrist and fingers. During an interview on 1/04/18 at 06:58 PM, Resident 33 stated she fell a month ago from the sit to stand lift machine when two nurses were transferring her from her wheelchair to the bed. Resident 33 stated she fell right through the machine and did not know how it happened. Resident 33 stated she fell on her side. Resident 33 stated someone from rehabilitation came and checked to see if she was alright. On a concurrent observation, there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 12 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 was no manufacturer's guidelines attached to the sit to stand machine as an easy access and referral source during the use of the machine for the staff. During an interview on 1/06/18 at 11:57 AM, and concurrent review of Resident 33's records, Physical Therapist (PT 2) was not able to locate the PT assessment of Resident 33's ability to safely use the sit to stand machine before and after the fall in Resident 33's electronic medical records (EMR). During an interview on 1/06/18 at 11:57 AM, the Director of Staff Development (DSD) stated the company changed hands and had asked the Administrator to search for the records. The DSD stated in order to use the sit to stand machine, the resident must be able to firmly hold the handles of the machine with both hands, and be able to stand and bear weight on both legs. The DSD stated two nurses must always be with the resident when the sit to stand machine was in use. The DSD stated all nursing staff were in-serviced on how to safely transfer residents using the sit to stand machine upon hire. During the same interview, both Quality Assurance Registered Nurse (QARN) and DSD were unable to state if PT had assessed Resident 33 prior to using the sit to stand machine. The DSD stated the two Certified Nurse Assistants (CNAs) who were with Resident 33 when the resident fell from the sit to stand machine were not able to recall if Resident 33 was safely secured to the machine prior to the resident's transfer. During the same interview, in the presence of QARN, Resident 33 stated she was unable to use her left arm, hand, and fingers. Resident 33's left hand and fingers were observed to be contracted; left ankle was rotated outward, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 13 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 unable to move the left leg. The QARN stated the fall incident happened in October 2017. During an interview on 1/06/18 at 12:12 PM, PT 2 stated the residents who had fractures (broken bone) on lower extremities, were on weight bearing precautions (non- weight bearing), or had decreased or poor strength on the upper and lower extremities must not be placed on the sit to stand machine. PT 2 stated the residents must first be assessed for safety and ability to stand and maintain standing before the sit and stand machine could be used to transfer. PT 2 stated she never evaluated Resident 33. PT 2 stated to ensure the resident's safety, PT should always document on the resident's medical records when a resident could safely use the sit to stand machine. PT 2 stated she was not aware Resident 33 fell from the sit to stand machine. During an interview on 1/06/18 at 03:12 PM, PT 1 stated the only assessment he made on Resident 33 was when the resident complained of pain or condition change after the fall. PT 1 stated he had checked with medical records and was not able to locate Resident 33's and Resident 10's initial assessment for safe use of the sit to stand machine. PT 1 stated nurses were responsible when they use the sit to stand machine on the residents. During an interview on 1/06/18 at 05:06 PM, the DSD stated both PT 1 and DSD were not able to find any in-services provided to the staff on the safe use of sit to stand machine. During an interview 1/07/18 08:25 AM, CNA 3 stated the first in-service on the sit to stand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 14 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 machine was provided a couple of months ago after Resident 33 fell. CNA 3 stated the nurses were instructed to strap the padding around the back and abdomen and one around both legs on the sit to stand machine before transferring a resident. CNA 3 stated, "We strap the residents on the machine so they don't fall and two nurses must be present when using the machine." CNA 3 stated that residents who were able to use the machine were supposed to help stand up, support body weight, and be able to hold the machine rails to help with the transfer. During an interview on 1/07/18 at 08:39 AM, CNA 1 stated an in-service was provided on sit to stand machine when the facility first bought the machine in 2013 and never received another in-service after that. CNA 1 stated two nurses must be with a resident before the sit to stand machine could be used to transfer a resident. CNA 1 stated it was important to strap the resident's abdomen. CNA 1 stated the sit to stand machine only had one strap for the abdomen. CNA 1 stated she only used the abdominal strap when transferring a resident on the machine. CNA 1 stated the resident must be able to hold and get a good grip onto the machine and put weight on their feet for safe transfer. CNA 1 stated the abdominal pads must be safely secured on the sit to stand machine hooks. A review of Resident 33's record titled, "Fall Care Plan," dated 8/24/17, indicated Resident 33 was at high risk for fall due to generalized weakness. The fall care plan indicated to perform regular checks, remove clutter from patient environment, place call light within reach, and assist during transfers as needed. The document did not indicate how to safely FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 15 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 transfer the resident. A review of Resident 33's record titled, "Progress Notes," dated 10/22/17, at 9:45 PM, indicated licensed nurse was summoned to Resident 33's room where the resident was found on the floor lying on the right side. The Progress Notes indicated head to toe assessment completed and the resident had no injuries. A review of Resident 33's record titled, "Short Term Care Plan," dated 10/22/17, indicated to check function of sit and stand machine. The care plan indicated to assess Resident 33 for function level before transfer and two person to assist. A review of Resident 33's record titled, "InService Meeting Minutes," dated 10/23/17, indicated Sit to Stand Machine needs two (2) CNAs at all times. The in-service meeting minutes indicated CNA 2 had attended the inservice. During an observation on 1/07/18, at 09:16 AM, CNA 4 was observed standing outside Resident 33's room and was holding the door closed. CNA 4 stated she was waiting for the sit to stand machine and stated CNA 2 had probably completed transferring Resident 33. CNA 2 was observed alone in the room and Resident 33 was observed seated on a wheelchair. The sit to stand machine was observed next to Resident 33. During an interview on 1/07/18 at 09:30 AM, CNA 2 stated she had transferred Resident 33 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 16 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 by herself using the sit to stand machine. CNA 2 stated Resident 33 was in a hurry to go to church and did not have time for CNA 2 to find for help transfer the resident. CNA 2 stated she knew two nurses were supposed to be present during resident transfer using the sit and stand machine. During an interview on 1/07/18 at 10:50 AM, when asked for the fall incident investigation, the Administrator provided Resident 33's and CNA involved interview statements, an inservice dated 1/15/13, and record titled, "EZ Sit-To-Stand Demonstration of Proper Use of This Machine." The Administrator stated, "This is all l have." The in-service was provided by a consultant from the Sit-To-Stand Machine Company. There was no indication that licensed nurses attended the in-service meeting.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide the following care and services to two of 17 sampled residents (Residents 33 and10), who used the sit to stand machine: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 17 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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. Assess residents' ability to safely use the sit to stand machine. 2. Thoroughly investigate fall incidents related to sit to stand machine (Resident 33) to reduce the risk of further occurrences. 3. Provide ongoing training of all nursing staff on safe use and safe transfer of residents using the sit to stand machine in accordance with manufacturer's guideline. 4. Ensure licensed nursing staff provided supervision to ensure safety of the residents when using the sit to stand machine. 5. Develop a policy and procedures on the use of the sit to stand machine. 6. Ensure manufacturer's guideline for the sit to stand machine was readily available as a referral source to the staff. These deficient practices had the potential to cause repeated falls and could result in serious injury to the residents. Findings: a. A review of Resident 33's undated record titled, "Face Sheet," indicated Resident 33 was readmitted to the facility on 1/26/15, with diagnoses including left side hemiplegia (one sided paralysis) and hemiparesis (muscle weakness and partial loss of movement on one side of the body). A review of Resident 33's record titled, "Rehabilitation Screen," form dated 8/9/16 indicated Resident 33 was observed to have decline in current RNA program (restorative nursing programs, provide specific treatments to restore and maintain the strength, coordination and skills to ambulate and perform functional activities of daily living). The Rehabilitation Screen form also planned for Physical Therapy (PT) and Occupational FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 18 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 Therapy (OT) to pick up (take over) the resident for services. A review of Resident 33's record titled, "PT Therapist Progress and Updated Plan of Care," dated 9/7/2016 indicated Resident 33 displayed decreased strength and range of motion (ROM) which limited safe transfer and gait. A review of Resident 33's record titled, "Occupational Therapy (OT), " dated 9/8/16 to 9/29/16, indicated Resident 33 continued to require assistance with activities of daily living (ADLs) due to loss of movement on the left upper extremity (LUE), and impaired dynamic (act of moving) skills in sitting and standing tolerance. The Occupational Therapy indicated Resident 33's functional deficits and underlying impairments included loss of movement on the LUE with contracture (shortening and hardening of muscles and tendons) on the wrist and fingers. During an interview on 1/04/18 at 06:58 PM, Resident 33 stated she fell a month ago from the sit to stand lift machine when two nurses were transferring her from her wheelchair to the bed. Resident 33 stated she fell right through the machine and did not know how it happened. Resident 33 stated she fell on her side. Resident 33 stated someone from rehabilitation came and checked to see if she was alright. On a concurrent observation, there was no manufacturer's guidelines attached to the sit to stand machine as an easy access and referral source during the use of the machine for the staff. During an interview on 1/06/18 at 11:57 AM, and concurrent review of Resident 33's records, Physical Therapist (PT 2) was not able to locate the PT assessment of Resident 33's ability to safely use the sit to stand machine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 19 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 before and after the fall in Resident 33's electronic medical records (EMR). During an interview on 1/06/18 at 11:57 AM, the Director of Staff Development (DSD) stated the company changed hands and had asked the Administrator to search for the records. The DSD stated in order to use the sit to stand machine, the resident must be able to firmly hold the handles of the machine with both hands, and be able to stand and bear weight on both legs. The DSD stated two nurses must always be with the resident when the sit to stand machine was in use. The DSD stated all nursing staff were in-serviced on how to safely transfer residents using the sit to stand machine upon hire. During the same interview, both Quality Assurance Registered Nurse (QARN) and DSD were unable to state if PT had assessed Resident 33 prior to using the sit to stand machine. The DSD stated the two Certified Nurse Assistants (CNAs) who were with Resident 33 when the resident fell from the sit to stand machine were not able to recall if Resident 33 was safely secured to the machine prior to the resident's transfer. During the same interview, in the presence of QARN, Resident 33 stated she was unable to use her left arm, hand, and fingers. Resident 33's left hand and fingers were observed to be contracted; left ankle was rotated outward, and unable to move the left leg. The QARN stated the fall incident happened in October 2017. During an interview on 1/06/18 at 12:12 PM, PT 2 stated the residents who had fractures (broken bone) on lower extremities, were on weight bearing precautions (non- weight bearing), or had decreased or poor strength on the upper and lower extremities must not be placed on the sit to stand machine. PT 2 stated the residents must first be assessed for safety and ability to stand and maintain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 20 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 standing before the sit and stand machine could be used to transfer. PT 2 stated she never evaluated Resident 33. PT 2 stated to ensure the resident's safety, PT should always document on the resident's medical records when a resident could safely use the sit to stand machine. PT 2 stated she was not aware Resident 33 fell from the sit to stand machine. During an interview on 1/06/18 at 03:12 PM, PT 1 stated the only assessment he made on Resident 33 was when the resident complained of pain or condition change after the fall. PT 1 stated he had checked with medical records and was not able to locate Resident 33's and Resident 10's initial assessment for safe use of the sit to stand machine. PT 1 stated nurses were responsible when they use the sit to stand machine on the residents. During an interview on 1/06/18 at 05:06 PM, the DSD stated both PT 1 and DSD were not able to find any in-services provided to the staff on the safe use of sit to stand machine. During an interview 1/07/18 08:25 AM, CNA 3 stated the first in-service on the sit to stand machine was provided a couple of months ago after Resident 33 fell. CNA 3 stated the nurses were instructed to strap the padding around the back and abdomen and one around both legs on the sit to stand machine before transferring a resident. CNA 3 stated, "We strap the residents on the machine so they don't fall and two nurses must be present when using the machine." CNA 3 stated that residents who were able to use the machine were supposed to help stand up, support body weight, and be able to hold the machine rails to help with the transfer. During an interview on 1/07/18 at 08:39 AM, CNA 1 stated an in-service was provided on sit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 21 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 to stand machine when the facility first bought the machine in 2013 and never received another in-service after that. CNA 1 stated two nurses must be with a resident before the sit to stand machine could be used to transfer a resident. CNA 1 stated it was important to strap the resident's abdomen. CNA 1 stated the sit to stand machine only had one strap for the abdomen. CNA 1 stated she only used the abdominal strap when transferring a resident on the machine. CNA 1 stated the resident must be able to hold and get a good grip onto the machine and put weight on their feet for safe transfer. CNA 1 stated the abdominal pads must be safely secured on the sit to stand machine hooks. A review of Resident 33's record titled, "Fall Care Plan," dated 8/24/17, indicated Resident 33 was at high risk for fall due to generalized weakness. The fall care plan indicated to perform regular checks, remove clutter from patient environment, place call light within reach, and assist during transfers as needed. The document did not indicate how to safely transfer the resident. A review of Resident 33's record titled, "Progress Notes," dated 10/22/17, at 9:45 PM, indicated licensed nurse was summoned to Resident 33's room where the resident was found on the floor lying on the right side. The Progress Notes indicated head to toe assessment completed and the resident had no injuries. A review of Resident 33's record titled, "Short Term Care Plan," dated 10/22/17, indicated to check function of sit and stand machine. The care plan indicated to assess Resident 33 for function level before transfer and two person to assist. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 22 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 Resident 33's record titled, "InService Meeting Minutes," dated 10/23/17, indicated Sit to Stand Machine needs two (2) CNAs at all times. The in-service meeting minutes indicated CNA 2 had attended the inservice. During an observation on 1/07/18, at 09:16 AM, CNA 4 was observed standing outside Resident 33's room and was holding the door closed. CNA 4 stated she was waiting for the sit to stand machine and stated CNA 2 had probably completed transferring Resident 33. CNA 2 was observed alone in the room and Resident 33 was observed seated on a wheelchair. The sit to stand machine was observed next to Resident 33. During an interview on 1/07/18 at 09:30 AM, CNA 2 stated she had transferred Resident 33 by herself using the sit to stand machine. CNA 2 stated Resident 33 was in a hurry to go to church and did not have time for CNA 2 to find for help transfer the resident. CNA 2 stated she knew two nurses were supposed to be present during resident transfer using the sit and stand machine. During an interview on 1/07/18 at 10:50 AM, when asked for the fall incident investigation, the Administrator provided Resident 33's and CNA involved interview statements, an inservice dated 1/15/13, and record titled, "EZ Sit-To-Stand Demonstration of Proper Use of This Machine." The Administrator stated, "This is all l have." The in-service was provided by a consultant from the Sit-To-Stand Machine Company. There was no indication that licensed nurses attended the in-service meeting. b. On 1/07/18, at 10:09 AM, CNA 4 and Restorative Nurse Assistant (RNA 1) were observed transferring Resident 10 from the bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 23 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 to the wheelchair using the sit to stand machine. Resident 10's left hand and fingers were contracted and left ankle rotated outward. CNA 4 and RNA 1 placed the back padding on Resident 10's both arms and upper back. The leg straps were observed at the bottom of the sit to stand machine. Resident 10's legs were not strapped in. A review of Resident 10's record titled, "Face Sheet," undated, indicated Resident 10 was readmitted to the facility on 11/1/13, with diagnoses that included obesity (over weight), left sided hemiplegia, and contracture of the left hand. The MDS, dated 10/1/17, indicated Resident 10 was cognitively intact, needed extensive assistance with bed mobility, totally dependent on staff for transfers, and was not able to walk. The MDS indicated Resident 10 had impairment on one side on both upper and lower extremities, and was not steady on surface to surface transfer. During an interview on 1/7/18 at 10:20 AM, both RNA 1 and CNA 4 stated during a resident transfer while using a sit to stand machine, they made sure the bed and machine were in locked position, safety belt applied, placed pillow between the knee and leg rest, and made sure both feet were firmly secured on the sit to stand machine. Both CNA 4 an RNA 1 stated Resident 10's left foot was twisted outward when the resident stood on the machine. CNA 4 and RNA 1 stated it was important to make sure the resident could grab the machine handles and the sling was properly secured on two hooks on either side of the machine. On 1/7/18, at 10:30 AM, during an observation of the machine, CNA 4 and RNA 1 were not able to identify the leg straps until it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 24 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 pointed out to them. CNA 4 then stated, "Oh now l see the straps for the legs." CNA 4 stated she had worked at the facility for three months but had never been trained on how to use the sit to stand machine. RNA 1 stated she had worked at the facility for one year and had never been trained on how to use the sit to stand machine. During an interview on 1/07/18, 11 AM, the QARN, Licensed Vocational Nurse (LVN)1, LVN 2, and LVN 3, all stated only CNAs and RNAs assisted residents with transfer using the sit to stand machine. The QARN stated licensed nurses never supervised or assisted non- licensed nursing staff with resident transfer using the sit to stand machine. During an interview on 1/07/18, at 11:51 AM, RNA 1 stated she did not know what to look for on the sit to stand machine because she never been in-serviced on it. During an interview on 1/07/18, at 12:21 PM, the Administrator stated the facility did not have a policy on the use of the sit to stand machine. The Administrator stated he would develop a sit to stand machine policy and procedures that clearly indicate how to safely transfer residents using the sit to stand machine. A review of the manufacturer's guide titled, "EZ Way Smart Stand: Your Total Patient Lift Solution," revised 6/17/14, indicated for safe operation of the EZ Way Smart Stand, operators should watch the training video, read through the manual, complete the competency checklist, and practice on fellow staff members before use with patients. The document in big and blotted warning sign, indicated for safe operation of the EZ Way Smart Stand, the stand must be used by trained personnel in accordance with operators manual, video, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 25 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 training checklist to avoid injury to patient. A review of the facility's policy titled, "Fall Accident Mitigation and Intervention," revised 10/2017 indicated the facility nursing staff and or the Interdisciplinary Team (IDT) would update the resident's plan of care accordingly to reduce the risk of further occurrences of a fall or other event. A review of the facility's document titled, "Licensed Vocational Nurse Position Description," dated 12/20/2004, indicated to monitor assigned personnel to ensure they follow established safety regulations in the use of equipment and supplies. The document indicated to participate in the development and implementation of procedures for the safe operation of all supplies and equipment. To ensure all personnel operate nursing service supplies and equipment in a safe manner. A review of the facility's document titled, "Registered Nurse (RN) Position Description," dated 12/20/2004, indicated the RN would maintain a safe, comfortable, and therapeutic environment for residents and families in accordance with facility's standards.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 26 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to label open date for one multi vial tuberculin skin test (a tool for screening for tuberculosis [a potentially serious infectious bacterial disease that mainly affects the lungs] and for tuberculosis diagnosis) and one multi dose vial of influenza vaccine (to protect against respirator infection). These deficient practices placed the residents at risk of receiving expired tuberculin skin test and influenza vaccines. Findings: On 01/06/18 08:09 AM accompanied by an Registered Nurse, the tuberculin skin test and and influenza vaccine multi dose vial was observed undated as to when it was opened. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 27 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 During a concurrent interview the RN stated the multi-dose vials should be labeled when opened.

F800 SS=E Provided Diet Meets Needs of Each Resident CFR(s): 483.60

F800 §483.60 Food and nutrition services. The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This REQUIREMENT is not met as evidenced by: Based on observation and interview, during a group meeting the residents complained of facility not honoring their food preferences, not considering food allergies for five of 8 alert and oriented resident and one of 17 sampled resident (Resident 210). These deficient practices had the potential to cause food allergies and not honor the residents food preferences. Findings: a. During the group council meeting on 1/7/18 at 1:30 pm., five of 8 alert residents in attendance stated the facility did not honor their food preferences. Some of the residents stated since they have been in the facility, their blood sugar had been up and down and the reason FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 28 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 was the facility served them either not enough food or foods they could not eat. They stated they have spoken to staff in the kitchen all the time but nothing has been done. One alert resident stated he was allergic to cooked tomatoes, and though it also documented on his food card, he still got tomatoes soup. b. During the tour of the facility and dining observation on 1/7/18 at 8:30 am, Resident 210 was observed sitting in his room in his wheelchair talking with the dietary supervisor. The resident wanted to know the reason why he was only fed french toast that morning. The resident wanted some meat and eggs with his breakfast meal. Resident 210 stated even though he did not eat pork, he should still be given meat with his breakfast. The dietary supervisor was observed informing Resident 210 that he could not sway from the menu but he could serve from the substitute menu, which was a sandwich. Resident 210 asked the dietary supervisor if he had a substitute breakfast menu not a sandwich in which the supervisor replied, no. When asked if the facility could provide turkey or ground beef in addition to the breakfast meal to the resident who did not eat pork, the dietary supervisor stated he would look into it and that was a good suggestion.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 §483.60(i) Food safety requirements. The facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 29 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to separate the food plate covers from the residents already served with food from trays awaiting distribution to other residents. The deficient practice had the potential for food contamination. Findings: During dining observation on 1/06/18 at 07:39 AM, several Certified Nurse Assistants (CNAs) were observed returning the food plate covers that was removed from the residents rooms and placed them inside the food cart with food trays waiting to be distributed to other residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 30 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 During an interview on 1/06/18 07:42 AM, the Director of Staff Development (DSD) stated used food plate covers were not supposed to be returned and placed inside the same food cart with food trays waiting distribution. DSD also stated this was to prevent potential spread of food contamination and infection.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 31 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to observe hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 32 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 hygiene and infection control practices during a resident care for one of 17 sampled residents (Resident 22). The deficient practice had the potential to spread infection. Findings: During a clinical record review Resident 22 was admitted to the facility with diagnoses not limited to spinal stenosis (narrowing of the spaces in the spine). A review of the Minimum Data Set (MDS), a standardized comprehensive assessment and care screening tool, dated 11/2017 indicated Resident 22 needed extensive assistance for surface to surface transfer, bed mobility, and was dependent on nurses for personal hygiene. During an observation on 1/06/18 at 08:49 AM, a Restorative Nursing Assistant (RNA 1) and Certified Nurse Assistant (CNA 2) were observed preparing Resident 22 for a shower . The Licensed Vocational Nurse (LVN 1) was also observed covering the resident's left arm that was in a soft cast with a clear plastic bag. All three staff transferred the resident to a shower chair using a Hoyer lift (mechanical lift) with the resident's bottom and private parts exposed through the opened curtain and hallways main door. CNA 2 was observed removing her used gloves, without washing her hands or using a hand sanitizer, picked up linen from clean linen cart. During an interview on 1/6/18 at 9:30 AM, CNA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 33 of 34 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: _______________ 056019 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARDENA CONVALESCENT CENTER 14819 S Vermont Ave Gardena, CA 90247 (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 2 stated she should have sanitized her hands after removing gloves and before touching clean linen to prevent spread of infection. A review of the facility's policy titled "Hand Washing" indicated all staff must wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent to the extent possible, the spread of nosocomial (hospital acquired) infections. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 70Q811 Facility ID: CA910000275 If continuation sheet 34 of 34