Other·May 11, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of a complaint. Complaint: CA00677556 Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 36206 The investigation was limited to the complaint investigated and does not represent the findings of a full inspection. Two deficiencies were issued for complaint CA00677556.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and 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: TF4V11 Facility ID: CA930000904 If continuation sheet 1 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement an abuse policy which indicated that injuries of unknown origins (a sign of abuse) must be reported to the Department of Public Health within 24 hours. Resident 1 developed an injury to the head during her residence at the facility. This deficient practice resulted in the facility's failure to report an injury of unknown origin and possible delay in investigation. Findings: On 2/27/2020, at 10:10 AM, an announced visit was made to the facility to investigate a complaint which alleged that Resident 1 developed a head injury on 9/21/2019 during the night. A review of the undated admission record indicated the facility originally admitted Resident 1 on 4/28/2014 and readmitted on 9/20/2020. Resident 1's diagnoses included respiratory failure, hypertension (high blood pressure), and diabetes mellitus (a disease which may result in high-blood sugar). Resident 1 had a history of tracheostomy (an opening in the neck in order to place a breathing tube in the windpipe) and G-tube placement (a feeding tube placed through the abdomen into the stomach). A review of the Minimum Data Set, (MDS) a standardized resident assessment and carescreening tool, dated 11/9/2019, indicated Resident 1 had difficulty communicating some FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 2 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 words or finishing thoughts. Resident 1 misses some parts of the message when understating others. Resident 1 required total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of a progress note, dated 9/21/2019 at 4:20 PM, indicated Resident 1 noted today with a bump on the head with maroon/purple skin discoloration, no open area. FM at bedside. Physician made aware with order to do a computer tomography (CT - a x-ray that takes images in several sections to look at the bones and tissues inside the body) scan without contrast and neurological checks. A review of the Photographic Documentation Nursing, dated 9/21/2019, indicated Resident 1 had a right-sided, occipital (back of the head) area, bump with discoloration, size 7 x 6 centimeters (cm - a unit of measure). A review of the results of a CT scan, dated 9/21/2019, indicated Resident 1 had posterior right parietal scalp (upper back area of the head) swelling. A review a physician's order dated 9/21/2019 at 4:00 PM, indicated to provide treatment to the right side, occipital area bump with discoloration, cleanse with normal saline (salt water), pat dry daily, for 21 days. On 2/27/2020, at 11:25 AM, Resident 1 was observed in bed, awake. Resident 1 was nonverbal. A nickel-size bald spot was observed on the right side of the head. Resident 1 had a tracheostomy and G-tube in place. Resident 1 was unable to reposition self. On 2/27/2020, at 11:30 AM, during an interview, a registered nurse (RN 1) stated Resident 1 had a scar to the right side of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 3 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 head from an injury. RN 1 stated the injury was discovered to the right side of Patient 1's head on 9/21/2019 during bedside care with a family member (FM). The area was covered in dried blood but was not actively bleeding. RN 1 stated she informed the Charge Nurse (CN), the Treatment Nurse, the Director of Nursing (DON), and the physician on 9/21/2019 about the injury. RN 1 stated that the injury to the head was not endorsed by the previous nurse. RN 1 stated she saw Resident 1 on the morning of 9/21/2019 but did not notice the injury. RN 1 stated she had no previous knowledge of the bump or how it occurred. On 2/27/2020 at 11:51 AM, during an interview, the CN stated she became aware of the bump to Resident 1's head on 9/21/2019. The CN stated she notified the physician and he ordered a CT of the head. The CN stated she notified the DON. The CN stated she interviewed the treatment nurse RN 1, she assessed Resident 1 that morning, and neither the treatment nurse or RN 1 were aware of the bump or knew how the it originated. On 2/27/2020 at 11:59 AM, during an interview, the DON stated that none of the staff knew how Resident 1's injury happened. The DON stated she assisted with the investigation, and the cause of the injury was never determined. The DON stated the injury was not reported to the Department. The DON stated that the facility did not report the injury to the state agency because they felt the injury was not a result of abuse. The DON, however, confirmed that the facility could not rule out abuse. A review of the policy, Abuse/Neglect/Exploitation Reporting (Child, Dependent Adult/Elder and Domestic), effective September 2018, indicated all staff members are responsible for the reporting of any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 4 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 reasonable suspicion or of any witnessed or alleged abuse. Written reports will be completed within 24 hours of the incident and sent via fax. Telephone, and regular mail to the Los Angeles Department of Public Health, Health Facilities Inspection Division at 3400 Aerojet Avenue, Suite #323, El Monte, CA 91731; phone number (800) 228-1019 using form SOC 341. Physical indicators of abuse included but were not limited to, bruises, welts, discoloration, swelling, and absence of hair/bleeding scalp.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 5 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to report a bump (an injury of unknown origin or sign of abuse) to Resident 1's head to the Department of Public Health (Department) within 24 hours of becoming aware of the injury for one of three sampled residents. This deficient practice delayed the Department's investigation with the potential for on-going abuse. Findings: On 2/27/2020, at 10:10 AM, an announced visit was made to the facility to investigate a complaint which alleged that Resident 1 developed a head injury on 9/21/2019 during the night. A review of the undated admission record indicated the facility originally admitted Resident 1 on 4/28/2014 and readmitted on 9/20/2020. Resident 1's diagnoses included respiratory failure, hypertension (high blood pressure), and diabetes mellitus (a disease which may result in high-blood sugar). Resident 1 had a history of tracheostomy (an opening in the neck in order to place a breathing tube in the windpipe) and G-tube placement (a feeding tube placed through the abdomen into the stomach). A review of the Minimum Data Set, (MDS) a standardized resident assessment and carescreening tool, dated 11/9/2019, indicated Resident 1 had difficulty communicating some FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 6 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 words or finishing thoughts. Resident 1 misses some parts of the message when understating others. Resident 1 required total dependence with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of a progress note, dated 9/21/2019 at 4:20 PM, indicated Resident 1 noted today with a bump on the head with maroon/purple skin discoloration, no open area. FM at bedside. Physician made aware with order to do a computer tomography (CT - a x-ray that takes images in several sections to look at the bones and tissues inside the body) scan without contrast and neurological checks. A review of the Photographic Documentation Nursing, dated 9/21/2019, indicated Resident 1 had a right-sided, occipital (back of the head) area, bump with discoloration, size 7 x 6 centimeters (cm - a unit of measure). A review of the results of a CT scan (a x-ray that takes images in several sections to look at the bones and tissues inside the body), dated 9/21/2019, indicated Resident 1 had posterior right parietal scalp (upper back area of the head) swelling. A review a physician's order dated 9/21/2019 at 4:00 PM, indicated to provide treatment to the right side, occipital area bump with discoloration, cleanse with normal saline (salt water), pat dry daily, for 21 days. On 2/27/2020, at 11:25 AM, Resident 1 was observed in bed, awake. Resident 1 was nonverbal. A nickel-size bald spot was observed on the right side of the head. Resident 1 had a tracheostomy and G-tube in place. Resident 1 was unable to reposition self. On 2/27/2020, at 11:30 AM, during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 7 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 interview, a registered nurse (RN 1) stated Resident 1 had a scar to the right side of the head from an injury. RN 1 stated the injury was discovered to the right side of Patient 1's head on 9/21/2019 during bedside care with a family member (FM). The area was covered in dried blood but was not actively bleeding. RN 1 stated she informed the Charge Nurse (CN), the Treatment Nurse, the Director of Nursing (DON), and the physician on 9/21/2019 about the injury. RN 1 stated that the injury to the head was not endorsed by the previous nurse. RN 1 stated she saw Resident 1 on the morning of 9/21/2019 but did not notice the injury. RN 1 stated she had no previous knowledge of the bump or how it occurred. On 2/27/2020 at 11:51 AM, during an interview, the CN stated she became aware of the bump to Resident 1's head on 9/21/2019. The CN stated she notified the physician and he ordered a CT scan of the head. The CN stated she notified the DON. The CN stated she interviewed the treatment nurse RN 1, she assessed Resident 1 that morning, and neither the treatment nurse or RN 1 were aware of the bump or knew how the it originated. On 2/27/2020 at 11:59 AM, during an interview, the DON stated that none of the staff knew how Resident 1's injury happened. The DON stated she assisted with the investigation, and the cause of the injury was never determined. The DON stated the injury was not reported to the Department. The DON stated that the facility did not report the injury to the state agency because they felt the injury was not a result of abuse. A review of the policy, Abuse/Neglect/Exploitation Reporting (Child, Dependent Adult/Elder and Domestic), effective September 2018, indicated all staff members FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 8 of 9 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: _______________ 555441 (X3) DATE SURVEY COMPLETED 04/10/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MEMORIAL HOSPITAL OF GARDENA D/P SNF 1145 W Redondo Beach Blvd 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 are responsible for the reporting of any reasonable suspicion or of any witnessed or alleged abuse. Written reports will be completed within 24 hours of the incident and sent via fax. Telephone, and regular mail to the Los Angeles Department of Public Health, Health Facilities Inspection Division at 3400 Aerojet Avenue, Suite #323, El Monte, CA 91731; phone number (800) 228-1019 using form SOC 341. Physical indicators of abuse included but were not limited to, bruises, welts, discoloration, swelling, and absence of hair/bleeding scalp. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TF4V11 Facility ID: CA930000904 If continuation sheet 9 of 9