Other·March 14, 2019

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 (DPH) during the investigation of a complaint. Complaint number: CA00616804 Representing the DPH: HFEN #19152 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA000616804

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. 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: UPI911 Facility ID: CA910000275 If continuation sheet 1 of 8 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 02/12/2019 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 §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 2 of 8 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 02/12/2019 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 intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility's staff failed to ensure a notice of transfer/discharge was issued to one resident (Resident A) when it was determined they were no longer able to provide care to her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 3 of 8 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 02/12/2019 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 Subsequently, Resident A was transferred to a general acute care hospital (GACH) on December 11, 2018, because of a change in condition (COC). When the GACH was ready to discharge the resident back to the facility, the facility refused to readmit her. This deficient practice resulted in Resident A being held at the hospital for longer than anticipated, did not allow her and/or her responsible (RP) to appeal the transfer/discharge and forced the RP to find another facility to care for her. Findings: A review of Resident A's Admission Records indicated she was readmitted to the facility on 2 -21-2018, with diagnoses including Parkinson's disease (a degenerative disorder of the central nervous system that belongs to a group of conditions called movement disorders), Alzheimer's disease (a form of dementia [a progressive loss of mental ability), syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse. A Minimal Data Set (MDS) Assessment, dated 10-13-2018, indicated Resident A's speech was clear but she was rarely/never able to express ideas and wants and she was rarely/never able understand verbal content. Resident A's cognitive skills for daily decisionmaking were severely impaired and she required extensive one person assistance in transferring, walking in her room, the corridor and on the unit. She required extensive one person assistance in completing most of her activities of daily living ([ADL] the things we normally do such as eating, bathing, dressing, grooming and toileting), was incontinent of both bowel and bladder functions (involuntary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 4 of 8 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 02/12/2019 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 voiding of urine and stool) and had other behavioral symptoms not directed toward others. Progress Notes, dated 12-11-2018, at 10:30 p.m., indicated Resident A was non-responsive with shallow breathing and periods of apnea and fluctuating vital signs. Emergency services (911) were called and the resident was transferred to a GACH via 911. A Physician's Order, dated 12-11-18, indicated to transfer Resident A to the GACH via 911. On 12-20-2018, a complaint to the Department of Public Health (DPH) indicated the facility refused to readmit Resident A. On 12-21-2018, at 11:10 a.m., during an interview, the Director of Nursing (DON) stated on 12-12-2018, they received a call from the GACH saying they were ready to transfer Resident A back to the facility. The DON stated prior to the resident's change of condition (COC) and transfer to the hospital on 12-11-2018, the business office manager (BOM) called the resident's RP to inform him the resident no longer had medical coverage. On 12-21-2018, at 11:36 a.m., during an interview, the BOM stated on 12-3-2018 she received a call from their corporate office telling her to get in contact with Resident A's RP. She called the resident's RP on 12-4-2018 and, informed him that "Medical" was not covering the resident's skilled nursing cost. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 5 of 8 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 02/12/2019 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 On 12-21-2018, at 12:03 p.m., during an interview, the facility's admission's staff stated she called the discharge planner (DP) at the GACH to let her know that Resident A did not have any "Medical" benefits and they would not be readmitting the resident to the facility. At that time the resident was not ready to come back but later the same day the DP called again to say they had an order to discharge the resident from the GACH and readmit her to the facility, she transferred the DP to the administrator. On 12-21-2018, at 12:14 p.m., during an interview, the Administrator stated on 12-122018, he contacted Resident A's RP to inform him that Resident A's "Medical" was no longer eligible and they would not take her back. He then told the RP if the resident was readmitted to the facility she would have to pay privately (from her own pocket), pay for the bed hold period and pay for a private care giver. He stated there were more issues than just the "Medical" ineligibility. He stated the resident was not safe to be left alone and needed 1:1 care. In the past they provided 1:1 care for her and paid for it but would not be doing so if she was readmitted. He stated he spoke to the GACH on Monday 12-17-2018, and told them the resident had no medical insurance and they would not be readmitting her because of that reason. He acknowledged that a notice of transfer/discharge had not been given to the resident and/or her RP. He stated if the resident had not had a COC that required her to be transferred, he would have talked to the son to try to rectify the "Medical" issue, put her on private pay if the "Medical" issue was not resolved and issued a notice of transfer/discharge. In a subsequent interview at 1:35 p.m., the Administrator stated at this time he had no intention of accepting Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 6 of 8 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 02/12/2019 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 back to the facility. Continued review of Resident A's clinical records indicated there was no written documentation that a notice of transfer/discharge had been given to Resident A and/or her RP. On 1-15-2019, at 12:17 p.m., during a telephone interview, the Complainant stated the facility refused to readmit the resident and he had to find another facility that would take her. On 1-15-2018, at 3:15 p.m., during a telephone interview, the Case Manager (CM), from the GACH, stated Resident A was admitted to the GACH on 12-11-18, and there was an order to discharge her back to the facility on 12-132018. She stated the facility contacted them to inform them they could not accommodate the resident because she was no longer eligible for Medicare and had no secondary insurance. She stated the resident's RP really wanted the resident to go back to the facility but the facility said they could not hold a bed for her unless the GACH filed for insurance. The CM stated she contacted their admission's coordinator who told her it would take a few weeks to process an application. She stated the resident was finally discharged to another facility on 1226-2018, 13 days following her discharge order back to the facility she originally came from. A facility policy, titled "Transfer and Discharge Notice" dated 11-20-2017, indicated the facility shall permit each resident to remain in the facility, and not transfer, and not transfer or discharge the resident unless: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 7 of 8 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 02/12/2019 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. The transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. b. The transfer and discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services by the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of the individuals in the facility would otherwise be endangered e. The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility or f. The facility ceases to operate. The resident and, if known, a family member or resident representative shall be notified in writing and in a language and manner they understand, of the transfer or discharge and the reasons for the move before a transfer or discharge takes place. A written notice of transfer or discharge shall be provided to the resident and the resident's representative(s) as outlined: Facility decides to discharge resident while the resident is still hospitalized: a written notice of discharge must be sent to the resident and resident representative and a copy to be sent to the Office of the State LTC Ombudsman at the time the notice of discharge is provided to the resident and resident representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UPI911 Facility ID: CA910000275 If continuation sheet 8 of 8