Health inspection·June 18, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one out of three sampled residents (Resident 1) resident rights were accommodated when Resident 1 refused a blood draw. This deficient practice of not allowing Resident 1 to refuse blood draw had the potential for the resident to feel discomfort when the staff attempted to draw the blood. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1 diagnoses included dementia (a serious disturbance in a person's metal abilities that results in a decreased awareness of one's environment and confused thinking), anxiety (a feeling of worry, nervousness, or unease), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Resident 1's History and Physical (H&P), dated 6/20/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/21/2025, the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 had not exhibited rejection of care including, blood work. The MDS indicated Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) on staff for toilet hygiene and dressing. During an observation of on 6/18/2025 at 4:20 p.m. in Resident 1's room, there was a sign posted above the bed and indicated if resident refused blood draw, please call family so the family could encourage the resident. Resident 1 had bruising (a type of injury that causes the skin to become discolored caused by rupturing under the blood vessels) to the left and right wrist. During a review of Resident 1's physician orders titled, Physician Order Report, dated 8/27/2024, the physician order indicated if resident refused blood drawn, please call family. During a review of Resident 1's Observation Detail List Report, dated 6/16/2025, the Observation Detail List Report indicated Resident 1 was noted to have discoloration of the left wrist. The Observation Detail List Report indicated Resident 1 had blood draw was attempted on 6/13/2025 and Resident Page 1 of 2 055526 055526 06/18/2025 Inglewood Health Care Center 100 S. Hillcrest Blvd Inglewood, CA 90301

F 0550 1 had refused blood drawn attempt. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's care plan titled, Behavioral Symptoms with rejection of care, dated 4/14/2025, the care plan interventions were to encourage resident to verbalize feelings, offer understanding, and empathy. Residents Affected - Few During a review of Resident 1's Patient Service Log dated 6/13/2025, the Patient Service Log indicated and attempt to obtain a blood draw on 6/13/2025 and the phlebotomist was unable to obtain blood. During a concurrent observation and interview on 6/18/2025 at 4:20 p.m. with Resident 1, in Resident 1's room, Resident 1 stated the staff wanted to draw my blood. Resident 1 stated, I told the staff to stop, they held me down and drew the blood anyway. Resident 1 stated the bruising on her left and right wrist came from the staff trying to draw blood. Resident 1 stated the staff did not listen to her request to refuse the blood draw. Resident 1 stated the staff drawing the blood it was painful and after the staff drew the blood her both her wrist had hurt. During a telephone interview on 6/20/2025 at 10:15 a.m. with Registered Nurse (RN) 1, RN 1 stated she went into Resident 1's room with the phlebotomist (). RN 1 stated the phlebotomist attempted to draw the blood. RN 1 stated Resident 1 was making sounds during the blood draw but could not describe what sounds the resident was making. RN 1 stated after the blood draw the Resident 1 was rubbing both wrist and I had asked her to stop rubbing her wrist, RN 1 stated was not aware of the signage above Resident 1's bed. RN 1 stated when a resident refuses the staff is not to force them to do care. During a concurrent interview and record review on 6/24/2025 at 2:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's physician orders titled, Physician Order Report, dated 8/27/2024, the physician order indicated if resident refused blood drawn, please call family. LVN 1 stated there was a sign above Resident 1's bed that states to call the family if the resident refuse blood draws. LVN 1 stated she had noticed the bruised left and right wrist the start of the morning shift on 6/13/2025. LVN 1 stated she had checked Resident 1 's chart records and there was an attempt to draw her blood. LVN 1 stated she had called the laboratory company for lab results and the lab company stated Resident 1 had resisted and they were not able to obtain the blood work. LVN 1 stated if Resident 1 resisted then would be considered refusing care. LVN 1 stated the protocol when Resident 1 resisted the staff were to call the family. LVN 1 stated Resident 1 had a history of refusals of care and at times we do need to call the family to assist Resident 1. LVN 1 stated Resident 1 had the right to refuse the care and her rights were violated. During a review of facility's policy and procedures (P&P) titled, Resident Rights, date unknown, the P&P indicated the company protects and promotes the rights of each resident. The P&P indicated company staff will assist residents in exercising their rights. The P&P indicated company staff will not hamper or compel by force. The P&P indicated Residents had freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care. During a review of facility's policy and procedures (P&P) titled, Refusal of Treatment, date unknown, the P&P indicated refusal of treatment included treatments. The P&P indicated the resident is not forced to accept any medical treatment and may refuse specific treatment even thou a physician prescribes it. 055526 Page 2 of 2