Health inspection·November 3, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure the resident's clinical records were updated for advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (1) out of 42 sampled residents (Resident 1) by failing to maintain a current signature and adequate dates that match dates on the copy of the resident's advance directives in the resident's clinical record. Based on interview and record review, the facility failed to ensure one of 42 sampled residents advance directive was updated by failing to maintain a current signature and dates that matched the dates on the copy of the residents advance directives in the resident's clinical record. This deficient practice had the potential to result in conflict with the resident's wishes regarding health care (Resident 1). Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility with hemiplegia and hemiparesis (hemiplegia, a patient experiences weakness on one side of the body hemiparesis refers to partial weakness) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Muscle weakness (due to lack of exercise, ageing, muscle injury). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/27/2023, indicated the resident had severe cognitive impairment and needed extensive assistance with bed mobility, dressing, and total dependence with locomotion on and off unit, eating, toilet use and personal hygiene. During an interview and record review on 11/2/2023 at 9:16 a.m. with the SSD, the SSD read the policy and procedure (P&P) titled Advance Directives, dated 7/2018, the policy and procedure indicated .The Interdisciplinary Team will annually review the resident or responsible party, to ensure that the directive still reflects the wishes of the resident. The SSD acknowledged there are no checks indicating the resident's understanding of their rights as set. The SSD also indicated there was no signature of the resident's representative, and the dates observed on the advance healthcare directive indicated different dates. The LVN's signature is different from the date of 11/5/2021. The SSD stated it is her responsibly to check the advance director for accuracy. The SSD indicated Medical Records did not conduct an audit or quarterly review of the advance healthcare directive. During an interview and record review on 11/2/2023 at 9:51 a.m. with LVN/Charge Nurse, the Charge Page 1 of 9 056143 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse stated the advance directive was not correctly filled out and there is no signature from the resident or resident representative. There were different dates on the incomplete form. The Charge Nurse stated the dates should have been the same unless it was a weekend, and not three months apart. The Charge Nurse stated the facility failed to properly document the advance directive. During an interview and record review on 11/2/2023 at 12:49 p.m. with the DON, the DON stated the advance directive is the responsibility of the SSD. The DON stated Resident 1's advance directive is not completed, and there are two different dates on the document. The DON states the facility failed to offer the resident or representative an opportunity to complete the advance directive. 056143 Page 2 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise the care plan for one of four Residents (Resident 39). This deficient practice had the potential to result in Resident 39 to receive inappropriate interventions and treatment. Findings: During a review of Resident 39s admission record facesheet, the face sheet indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic embolism and thrombosis (is a blockage or obstruction in the pulmonary arteries in the lungs), respiratory failure (a serious condition that makes it difficult to breathe on you own), left and right hand contractures (a fixed tightening of muscle, ligaments, or skin), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 39's history and physical (H&P), dated 5/9/2023, the H&P indicated Resident 39 does not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/10/2023, the MDS indicated Resident 39's cognition (ability to learn, reason, remember, understand, and make decisions) was not able to recall information when ask to repeat information. The MDS indicated Resident 39 was total dependence for bed mobility, dressing, eating, toilet use, and person hygiene. During an observation on 10/31/2023 at 9:14 a.m. in Resident 39's room, Resident 39 was lying in bed and had contractures to the left and right hand with no splints on the left and right hand. During a review of Resident 39's Care Plan (CP), dated 8/18/2022 and revised on 11/1/2023, the CP indicated, the RNA was to apply a resting splint on the right hand and on the left hand. The CP interventions indicated, the RNA was to apply a splint as ordered and to provide gentle range of motion and splinting as needed. During a review of Resident 39's Order Summary Report, dated 10/1/2023, the Order Summary Report indicated, the Restorative Nursing Assistant (RNA) was to apply a resting hand splint on the left and right hand for five hours as tolerated daily three times a week. During a concurring interview and record review on 11/2/23 at 11:02 a.m. with Occupational Therapist (OT), Resident 39's Oder Summary Report, dated 10/1/2023 was reviewed, the Order Summary Report indicated, on 10/1/2023 the RNA was to apply a resting hand splint on the left and right hand for five hours as tolerated daily three times a week. The OT stated the Resident 39 should not have splints due to the discontinuation of the order. The OT stated the orders to place the splints to the left and right hand is still showing as active and should have been discontinued. The OT stated the order was not to continue with the splints by RNA 1 but it was not discontinued on the Order Summary Report. The OT stated it was important to follow the physician orders and the physician orders still 056143 Page 3 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated to place the splints according to the Order Summary Report. The OT stated it was important to follow the physician orders and to make sure the orders are up to date so that residents can receive the correct care. During a concurrent interview and record review on 11/2/2023 at 1:25 p.m. with Registered Nurse Supervisor (RNS) 1 of Resident 39's Care Plan (CP), dated 8/18/2022 and revised on 11/1/2023, the CP indicated, the RNA was to apply a resting splint on the right hand and on the left hand. The CP interventions indicated, the RNA was to apply a splint as ordered and to provide gentle range of motion and splinting as needed. RNS 1 stated the CPs are updated every three months and Resident 39's CP was not updated because the physician orders were not updated. RNS 1 stated if the physician orders were correct then the CP would have been correct with no splints for Resident 39. RNS 1 stated its important to make sure the CP is up to date so the Resident 39 could get the correct medical treatment. During a concurrent interview and record review on 11/2/2023 at 1:25 p.m. with the Minimum Data Set (MDS) Coordinator of Resident 39's Care Plan (CP), dated 8/18/2022 and revised on 11/1/2023, the CP indicated the RNA was to apply a resting splint on the right hand and on the left hand. The CP interventions indicated, the RNA was to apply a splint as ordered and to provide gentle range of motion and splinting as needed. The MDS Coordinator stated there is an active physician order for Resident 39 to have the splints in place, therefore there must be a CP in place for the interventions related to the splints. The MDS Coordinator stated the order for the splints should have discontinued from the physician list set and I would have removed the splint placements from the CP. The MDS Coordinator stated it is important to have an updated CP so the Resident 39 would be provided adequate care. During a concurrent interview and record review on 11/2/2023 at 1:25 p.m. with the Director of Nursing (DON) of Resident 39's Care Plan (CP), dated 8/18/2022 and revised on 11/1/2023, the CP indicated, the RNA was to apply a resting splint to the right hand and on the left hand of Resident 39. The CP interventions indicated, the RNA was to apply a splint as ordered and to provide gentle range of motion and splinting, as needed. The DON stated the CP is updated every three months and to have the correct CP the physician order needed to be discontinued for the splints to the hands. The DON stated since no one knew there was a change in the physician orders (When was the physician order changed? Do not see it in the findings?) there was no change in the care plan. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program Guidelines, dated 9/19/2019, the P&P indicated, The program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning unless a decline is unavoidable based on the resident's clinical condition .The Care Plan to each resident will be updated with any changes to the Restorative Nursing Program when they occur and reviewed quarterly or as needed by the Interdisciplinary Team. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, the P&P indicated, To ensure that a comprehensive person-centered care plan is developed for each resident .The comprehensive care plan will be reviewed and revised by IDT (interdisciplinary team) after each assessment which means after each MDS assessment . to address changes in behavior and care. 056143 Page 4 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage, food preparation practices in the kitchen by failing to: Residents Affected - Few 1. Ensure one bag of breaded potato hash browns were not stored in the reach in freezer with no date and label and one large plastic wrapped bacon was open. 2. Ensure Dishwasher 1 (DW 1) knew how to use the proper sanitizer test strip for the dish machine sanitizer (competency - cross reference F802). 3. Ensure DW 1 did not take clean food trays out of the dishwasher and place them on the floor, then pick up the trays up and place the food trays that was on the floor in the rack with other clean trays. And ensure DAS did not place trays on top of clean dishes. 4. Ensure Employee's food was not stored in the resident food refrigerator without a label, date, and temperature log. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 42 out of 42 residents who received food from the kitchen and who stored and consumed personal foods from the resident refrigerator. Findings: 1. During an observation in the kitchen on 10/31/2023 at 8:46 a.m. there were a large bag of breaded hash brown potatoes with an open date of 10/31/2023 in the reach in freezer with no used by date. During an interview 10/31/2023 at 8:46 am, with the DS regarding their food storage process, the DS stated all foods should be dated upon receipt, when opened and used by date on label for every open item in the freezer. DS stated the hash brown potatoes and open bacon will be discarded. A review of the facility policy titled Food Storage poly No.DS-52 revised 7/25/2019, indicated, All items will be correctly labeled and dated. 2. During an observation on 10/31/2023 at 8:46 am, the DW1 did not know the process for checking dish machine sanitizer concentration when requested. DW 1 was observed being provided a test strip by DS and still could not demonstrate how to use the test strip. During an interview with the DS on 10/31/2023 at 8:48 a.m. the DS states DW 1 was trained on how to use the sanitizer strips, and DW 1 is nervous when demonstrating proper use of sanitizer strips. 3. During an observation on 11/3/2023 at 8:35 a.m. DA1 removed trays from the dish washer and placed the clean trays on the floor, then picked the trays up off the floor and placed them in rack with other clean trays. The DAS took the trays off the floor and placed the trays on top of the clean dishes and proceeded to place the trays that were on the floor with other clean dishes and proceeded to place trays that were on the floor with other clean dishes. 056143 Page 5 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0812 Level of Harm - Minimal harm or potential for actual harm A review of facility P&P titled Pot and Pan Cleaning with a revised of 6/22/2023 and an effective date of 7/13/2023, indicated .Allow the items to air dry, when items are dry, store them in the proper storage area. During an interview with DS 1, DS 1 stated DW 1 should not have placed the trays on the floor and DAS should not have placed trays on top of clean dishes. Residents Affected - Few 4. During an observation and interview on 11/3/2023 at 2:47 p.m. with DS, the resident nutrition snack/nourishment refrigerator had employees' snack in the resident nourishment refrigerator with no label and there was no temperature log posted on the outer refrigerator door. The DS stated the staff's food should not be in the resident's refrigerator and proceeded to discard several items including drinks. A review of the Policy and Procedure (P&P) titled Food Brought in by Visitors dated 1/1/2012, indicated perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. 056143 Page 6 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0826 Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician orders to discontinue use of splints for one out of four Residents (Resident 39). Residents Affected - Few This deficient practice had the potential to result in Resident 39 to receive the inappropriate medical treatment as ordered by the physician. Findings: During a review of Resident 39s admission record, the admission record indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included chronic embolism and thrombosis (is a blockage or obstruction in the pulmonary arteries in the lungs), respiratory failure (a serious condition that makes it difficult to breathe on you own), left and right hand contractures (a fixed tightening of muscle, ligaments, or skin), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 39's history and physical (H&P) dated 5/9/2023, the H&P indicated Resident 39 does not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 8/10/2023, the MDS indicated Resident 39 was impaired cognitively (ability to learn, reason, remember, understand, and make decisions) and not able to recall information when asked to repeat information. The MDS indicated Resident 39 required total dependence for bed mobility, dressing, eating, toilet use, and personal hygiene. During a review of Resident 39's Order Summary Report dated 10/1/2023, the Order Summary Report indicated, the Restorative Nursing Assistant (RNA) was to apply a resting hand splint on left and right hand for five hours as tolerated daily three times a week. During an observation on 10/31/2023 at 9:14 a.m. while in Resident 39's room, Resident 39 was lying in bed and had contractures to the left and right hand with no splints on the left and right hand. During a concurring interview and record review on 11/2/23 at 11:02 a.m. with Occupational Therapist (OT), Resident 39's Oder Summary Report, dated 10/1/2023 was reviewed, The Order Summary Report indicated, on 10/1/2023 the RNA was to apply a resting hand splint on the left and right hand for five hours as tolerated daily three times a week. The OT stated Resident 39 should not have splints due to the discontinuation of the order. The OT stated the orders to place the splints to the left and right hand is still showing as active and should have been discontinued. The OT stated the order was verbalize not to continue with the splints to RNA 1, but not discontinued on the Order Summary Report. The OT stated it was important to follow the physician orders and the physician orders still stated to place the splints from the Order Summary Report. The OT stated it was important to follow the physician orders and to make sure the orders are up to date so the Residents can receive the correct care. During a concurring interview and record review on 11/2/23 at 11:28 a.m. with RNA 1 Resident 39's 056143 Page 7 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0826 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Oder Summary Report, dated 10/1/2023 was reviewed. The Order Summary Report indicated, on 10/1/2023 the RNA was to apply a resting hand splint on the left and right hand for five hours, as tolerated, daily three times a week. RNA 1 stated the OT verbalized to discontinue the left- and right-hand splints for Resident 39. RNA 1 stated when the orders were verbalized to discontinue the splints, it should have been documented on the Oder Summary Report to discontinue the splints. RNA 1 stated the Order Summary Report had the incorrect order and if another RNA was taken care of Resident 39 were to see the order the RNA would apply the hand splints. During a concurring interview and record review on 11/2/23 at 11:28 a.m. with the Director of Nursing (DON) Resident 39's Oder Summary Report, dated 10/1/2023, was reviewed. The Order Summary Report indicated, on 10/1/2023, the RNA was to apply a resting hand splint on the left and right hand for five hours, as tolerated, daily three times a week. The DON stated Resident 39 was to wear the hand splints to the left and right hand and there were no current orders to discontinue the splints. The DON stated the orders were not being followed and when there is a verbal order to discontinue the order should be removed from the Order Summary Report. The DON stated it is important for all spectrum of the staff to follow the physician orders so we can take care of the Residents. During a review of the facility's policy and procedure (P&P) titled, Restorative Aide Job Description, date unknown, the P&P indicated, A nursing assistant designated to perform restorative nursing measures on a resident under the supervision of the Director of Nursing Services .Follow Physician's orders as written. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 8/21/2020, the P&P indicated, To have a process to verify that all physician orders are complete and accurate .The licensed nurse will confirm that physician orders are clear, complete, and accurate as needed .Treatment orders will include a description of the treatment, frequency, and duration of the order. 056143 Page 8 of 9 056143 11/03/2023 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two of 12 sampled resident rooms (room [ROOM NUMBER] and 18) accommodated no more than four residents per room. This deficient practice had the potential to result in and or create safety hazards, lack of privacy and care issues for the residents. Findings: During observations of rooms [ROOM NUMBERS] from 10/31/2022 through 11/3/2023, there were no noted concerns with the privacy, care issues and or safety to the residents. During a review of the Client Accommodations ' Analysis form completed by the facility on 10/31/2023, the form indicated room [ROOM NUMBER] beds (A, B, C, D, and E) and room [ROOM NUMBER] beds (A, B, C, D, and E) accommodated five residents. During an interview with the Administrator (ADM), on 11/3/2023 at 9:20 a.m., the ADM stated the facility had a request for a waiver, that included two rooms to accommodate more than four residents. The facility's plan was to request another waiver for the current year 2024. The ADM stated Each resident in room [ROOM NUMBER] and 18 has an adequate amount of space, bedside tables and closet space. Everything is adequate. Every year, I must write a letter requesting for a waiver, submit the waiver form and get the approval from CMS. ADM provided letter requesting for waiver form to CDPH. 056143 Page 9 of 9