Health inspection·June 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its' abuse policy and procedures for two of nine sampled residents (Residents 2 and 3). This failure resulted in an employee-to-resident allegation of abuse incident not being reported to state licensing/certification office, police, and ombudsman, and the incident not investigated in a timely manner. Findings: During a review of Resident 2's admission Record, dated 6/11/25 indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN—high blood pressure), insomnia (inability to sleep), hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and abnormalities of gait and mobility. During a review of Resident 2 ' s History and Physical (H&P), dated 1/20/25 indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS—a resident assessment tool), dated 3/25/25, indicated, Resident 2 had intact cognition (ability to think, understand and make daily decisions). The same MDS further indicated Resident 2 required setup or cleaning assistance to supervision from staff for eating, personal hygiene, toileting, bathing, dressing and bed mobility. During a review of Resident 3's admission Record, dated 6/11/25 indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD—a group of lung diseases that block airflow and make it difficult to breath), heart failure (a condition where the heart can't pump enough blood to meet the body's needs), chronic kidney disease (CKD—a condition where the kidneys are damaged and cannot filter blood as well as they should) muscle weakness, and lack of coordination. During a review of Resident 3 ' s H&P, dated 1/13/25 indicated, Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], indicated, Resident 3 had severe cognitive (ability to think, understand and make daily decisions) impairment. The same MDS further indicated Resident 3 required substantial/maximal to total dependance on staff for eating, personal hygiene, (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056174 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056174 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mid-Wilshire Health Care Cntr 676 S. Bonnie Brae Street Los Angeles, CA 90057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)