Health inspection·August 27, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 4) was transferred from chair to bed using an appropriate technique.This deficient practice resulted in Resident 4 feeling discomfort when being transferred.Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 4's History and Physical (H&P), dated 8/14/2025, the H&P indicated Resident 4 was able to make needs known, but could not make medical decisions. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 8/18/2025, the MDS indicated Resident 4 had the ability to make himself understood and ability to understand others. Resident 4 was not able to stand or transfer from bed to chair.During a review of Resident 4's Physical Therapy PT Discharge Summary for Dates of Service 8/11/2025-8/24/2025, the summary indicated Resident 4 was dependent (helper does all the effort, two or more helpers are required for the resident to complete the activity). During a review of Resident 4's care plan, dated 8/15/2025, the care plan indicated Resident 4 had paraplegia related to trauma. The goal indicated Resident 4 would remain free of complications or discomfort related to paraplegia. The interventions indicated staff would assist with locomotion as required. During an interview on 8/26/2025 at 3:17 p.m. with Resident 4, Resident 4 stated there is a guy that picks me up and throws me in the bed. He hurt my foot one time. Resident 4 told the guy he doesn't have to move him like that. Resident 4 stated when this happens It makes me want to pick him up and rough him up. Resident 4 stated the guy picks him up under his arms, then throws him in the bed. No one helps the guy; he does it by himself. During an interview on 8/27/2025 at 1:21 p.m. with the Director of Physical Therapy (DOP), the DOP stated Resident 4 was assessed on 8/11/2025. Resident 4's ability to stand was not assessed on that date because it wasn't medically safe. The DOP stated Resident 4 is dependent for transfers and should be transferred using 2-person assist for safety. It would be difficult for one person. For safety it's best to use two people otherwise you might injure the resident. During an interview on 8/27/2025 at 4:13 p.m. with CNA 3, CNA 3 stated he transferred Resident 4 from wheelchair to bed on 8/25/2025. CNA 3 stated he transferred Resident 4 to bed by himself. CNA 3 placed his right arm under Resident 4's right arm and placed him into bed. CNA 3 cannot state exactly how he was able to transfer Resident 4 using one arm. CNA 3 was reminded Resident 4 was paraplegic and did not stand, CNA 3 was silent and could not explain how he transferred Resident 4 to bed. CNA 3 could not state if Resident 4 required one or 2-person assist. CNA 3 did not respond when asked how he knew it was okay to transfer Resident 4 by himself. CNA 3 did not respond when asked how he is made aware of what type of assistance residents under his care require. During a review of the facility's policy and procedure (P&P), titled Resident Rights - Residents Affected - Few Page 1 of 3 056143 056143 08/27/2025 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Quality of Life, dated March 2017, the P&P indicated each resident shall be cared for in a manner that enhances their quality of life, dignity, respect, individuality, and receives services in a person-centered manner. During a review of the facility's P&P, titled Transfer, dated January 2012, the P&P indicated safe and efficient transfers are a combination of the resident's physical ability, perceptual capacity, appropriate techniques, and good planning. During a review of the Certified Nursing Assistant Job Description, no date, the description indicated the CNA will perform all duties as assigned and in accordance with facility's established protocols and procedures, nursing care procedures and safety rules/regulations. 056143 Page 2 of 3 056143 08/27/2025 Osage Healthcare & Wellness Centre 1001 South Osage Ave Inglewood, CA 90301

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to: 1. Ensure one of four sampled employees (Certified Nursing Assistant 2) had an annual skills competency completed.This deficient practice had the potential to result in residents receiving a decreased quality of care.Findings:During a concurrent interview and record review on 8/27/2025 at 2:30 p.m. with the Director of Staff Development (DSD), Certified Nursing Assistant (CNA) 2's employee file was reviewed. The DSD stated CNA 2's new hire competency was completed on 2/21/2024. CNA 2 should have had an annual competency completed in February of 2025. The DSD stated the annual competency was not completed because she forgot. The annual competency is needed to ensure staff have up to date skills and check if retraining is needed. If staff don't know what they are doing it will affect the quality of the care the resident receives. During a review of the facility's policy and procedure (P&P), titled Staff Competency Validation, dated June 2024, the P&P indicated competency validation is completed to evaluate an individual's performance, meet standards set by regulatory agencies, and address problematic issues. The purpose is to protect the health, safety, and well-being of residents. 056143 Page 3 of 3