Health inspection·September 1, 2023

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 interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 treat two of five sample residents (Resident 1 and Resident 5) with dignity and respect. These deficient practices violated the resident's right to be treated with respect and dignity and had the potential to affect the self-esteem, cause emotionally distress, and psychosocial well-being of the residents. Findings: a.During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with a diagnosis that included Parkinson disease (brain disorder that causes unintended or uncontrollable movements), obstructive and reflux uropathy (disorder characterized by blockage of the normal flow of contents of the urinary tract), and other specifies disorders of bladder (medical classification of a range -Other diseases of the urine). During a review of Resident 1 ' s history and physical (H&P) dated 5/12/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 8/16/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was capable and could understand and be understood by others. The MDS indicated Resident 1 required total dependence with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During an interview on 9/1/2023 at 12:05 p.m., with Resident 1 complainant, the complainant stated, I am a friend of Resident 1 but sometimes resident 1 calls me family. Complainant stated, on 8/21/2023 I called Resident 1 and he put me on a speaker phone, when I heard a nurse coming to his room. Complainant stated, LVN 1 did not noted, I was on the speaker phone and LVN 1 started to talk to Resident 1 in a rude tone. Complainant stated, LVN 1 was telling Resident 1 to take his medications and If he does not take the medications, LVN1 was going to leave and not give him anything. Complainant stated, then I talked to LVN 1 on the phone, and I told her that she should not be rude with him and talk loud at him. Complainant stated it is unrespectful to treat resident 1 that way. During an interview on 9/1/2023 at 1:06 p.m., with LVN 1 stated, I had talked to resident 1 family member, via phone when I was passing medications to resident 1. LVN 1 stated, I told the family Page 1 of 4 056143 056143 09/01/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member that I was showing resident 1 the medications. LVN stated, I remember I told the family, that I was doing the right thing LVN 1 stated, I did not report to the Director of Nursing (DON) about the miss understanding of words because, I tough was not serious. LVN 1 stated, when nurses talked to residents in a loud tone of voice, it can be disrespectful. b. During a review of Resident 5 ' s admission record, the admission record indicated Resident 5 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (airflow blockage and breathing-related problems.), diabetes (DM-high blood sugar), and hypertension (HTN-high blood pressure). During a review of Resident 5 ' s history and physical (H&P) dated 7/16/2023, the H&P indicated Resident 5 had the capacity to understand and make medical decisions. During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 8/15/2023, the MDS indicated Resident 5 ' s cognitive skills (thought process) was capable and could understand and be understood by others. The MDS indicated Resident 1 required total dependence with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During an interview on 9/1/2023 at 12:05 p.m., with Resident 5, Resident 5 stated, LVN 1 had a rude attitude towards passing medications. Resident 5 stated, LVN 1 come this morning and just tossed the medications cup on the table and in a demanding way, she asked me to take the medications fast. Resident 5 stated, I take time taking medications, I like to see what I am taking. Resident 5 stated, LVN 1 has a hard mode when giving medications and said take it. Resident 1 stated, I just think her voice sounds rude toward me. Resident 5 stated, I do not like it. Resident 5 stated, LVN 1 should be softer and not rush me. During an interview on 9/1/2023 at 1:06 p.m., with LVN 1 stated, I had Resident 5, I gave his medications this morning. LVN 1 stated, resident 5 never refused medications. LVN 1 stated, resident 5 likes to take his medications slowly and check all the medications. LVN 1 stated, I do not remember, I rush him taking the medications. LVN 1 stated, sometimes resident 5 asked me to put the medications on the table and I told him to take it. LVN 1 stated yes, we need to be patience with residents, so they do not feel we are rushing them. During an interview on 9/1/2023 at 1:06 p.m., with DON stated, the communications with resident should be in polite mode and listen to resident and allow time to speak. DON stated, some nurses tone of voice can be stronger and can appeared to resident that is harsh. DON stated, we must communicate patently and nicely as we can, with residents. DON stated resident 1 can be affected emotionally. DON stated, it is important to use a controlling tone of voice, so resident cannot be emotionally disturbed. A review of the facility ' s policies and procedures (P&P) titled Residents Right- Quality of Life, dated 3/2017 the P&P indicated Facility staff speaks respectfully to residents at all times, procedures are explained to resident before they are performed. The P&P LVN Job Descriptions undated, the P&P indicated LVN treats resident/family member with dignity and respect. 056143 Page 2 of 4 056143 09/01/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services as indicated in the physician orders by failing to: 1. Assess and document color and sediments (consistsof biological elements such as leukocytes, erythrocytes, epithelial cells, casts, bacteria, fungi, parasites) in Resident 2 ' s urine. 2. Notify the physician of color and sediments in Resident 2's urine output. This deficient practice resulted in delayed identification of Urinary Tract Infection [UTI- an infection in any part of the urinary system, the kidneys, bladder, or urethra)] delayed in necessary care and treatment and had the potential to lead to worsening infection. Findings: During a review of Resident 2 ' s admission record, the admission record indicated Resident 2 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included unspecified dementia (mild memory disturbance due to known physiological condition), pressure ulcer of sacral region stage 4 (full thickness skin and tissue loss), muscle weakness (a lack of muscle strength). During a review of Resident 1 ' s history and physical (H&P) dated 8/30/2023, the H&P indicated Resident 1 was unable to follow commands. During a review of Resident 2 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 8/16/2023, the MDS indicated Resident 2 ' s cognitive skills (thought process) usually understand and be understood by others. The MDS indicated Resident 2 required total dependence with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 2 ' s physician orders dated, 7/31/2023 the physician orders indicated Resident 2 had an order for Assess urinary drainage for sign and symptoms of infection, noting cloudiness, color, sediments, blood, odor, and amount of urine output every day shift, every evening and night shift. During concurrent observation and interview on 9/1/2023 at 9:45 a.m., in Residents 2 ' s room, Resident 2 unable to answer questions. Observed Resident 2 with a foley catheter to gravity on the left side of the bed, catheter off floor with privacy bag. Foley catheter tubing with white sediments. Certified Nurse Assistance (CNA) 1 stated I did observe the sediments on the tubing. CNA 1 stated, when I see sediments, I informed the charge nurses. CNA 1 stated, I had not informed the charge nurse. During concurrent observation and interview on 9/1/2023 at 11:28 a.m., in Residents 2 ' s room with Licensed Vocational Nurse (LVN) 1, observed Resident 2 ' s foley catheter tubing with sediments and urine amber in color and cloudy. LVN 1 stated, I did not see it this morning. LVN 1 stated, yes the 056143 Page 3 of 4 056143 09/01/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urine is amber and cloudy. LVN 1 stated, I just noted the sediments this morning while surveyor in residents 2 ' s room. LVN 1 stated, I had not called the doctor or documented finding until now. LVN 1 stated, I will call the doctor now. LVN 1 stated, I usually do my assessment in resident 2 when I pass medications, but I did not see it. LVN 1 stated, it is not acceptable wait to inform the doctor of Residents 2 ' urine findings. LVN 1 stated, it can be an infection and the doctor will give us orders for medications or urine sample. LVN 1 stated, the sediments and cloudiness can be a sign of infection or dehydration (loss of total body water). LVN 1 stated Resident 2 can be in danger of having UTI and be transfer to the hospital. During an interview on 9/1/2023 at 1:50 p.m., with Treatment Nurse (TN), TN stated, I oversee changing the foley catheter bag if order by doctor. TN stated, the foley catheter is change every two weeks or as needed. TN stated, if sediments or blood or discharge noted, the bag is change, and the doctor is notified. TN stated, if we see the urine amber and sediment, the doctor may order urinalysis and a change of catheter. LVN 1 stated, nurses must inform the doctor because if can be a possible UTI. TN stated resident 2 can be at risk for dehydration, sepsis (body's extreme response to an infection), and cause resident to go to the hospital. During an interview on 9/1/2023 at 2:20 p.m., with Director of Nursing (DON), DON stated, it is important to do a catheter care because is a porter of infection and can cause a lot of issues such as infections, sepsis, kidney failure (condition in which one or both of your kidneys no longer work on their own), pain (an unpleasant signal that something hurts), and can cause hospitalization. DON stated, Resident 2 has a foley catheter for wound management. DON stated, I was not aware of residents 2 foley catheter with sediments. DON stated, when urine is amber and sediments, nurses must call the doctor for orders to find out if there is an infection. DON stated, if nurses delay in notifying the doctor, resident 2 can get sicker and develop an illness or infection. A review of the facility ' s policies and procedures (P&P) dated 6/10/2021 titled Catheter Care, the P&P indicated Nursing Staff will assess urinary drainage for signs and symptoms of infection, nothing cloudiness, color, sediments, blood, odor, and amount of urine. A Licensed Nurse will notify the Attending Physician of any signs and symptoms of infection for clinical interventions. 056143 Page 4 of 4