Inspection visit

InspectionJune 21, 2021

HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LPCMS #55567717 citations on this visit

17 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 17 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** b) During a review of Resident 62's Face Sheet, the face sheet indicated Resident 62 was admitted to the facility on [DATE]. Resident 62's diagnoses included muscle weakness, obesity, absence of left leg below the knee, and osteoarthritis (joint disease that results from breakdown of joint cartilage and underlying bone). During a review of Resident 62's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/12/2021, the MDS indicated Resident 62 had no cognitive (thought) impairment. The MDS indicated Resident 62 required extensive assist of one-person physical assist for moving to and from lying position, turning side to side, moving from the bed to a wheelchair, moving to a standing position and toileting. During a review of Resident 62's care plan titled, Activities of Daily living (ADL) Functional and Rehab Potential, dated 5/11/2021, the care plan indicated Resident 62 should be provided assistance with ADL care as needed and to bed turned and repositioned as ordered. During a concurrent observation and interview on 6/16/2021 at 8:46 a.m., Resident 62 was observed lying in bed, covered in a sheet from the neck to below the waist. Resident 62 stated I'm waiting to be changed. I have been waiting here since breakfast, which was served about 8:00 a.m., This is not good. I feel they should get some help. During an interview on 6/21/2021 at 8:11 a.m., Resident 62 stated, It's a long wait for the call lights to be answered. Staff answers the call lights and then goes to call someone else to come back and help me, but it takes a while for them to get back to me. It's a better idea for the nurse to say I'll come back later because I'm busy and that way I can understand that they may take w while. They don't give me a time that they will return. Sometimes I think they forget to tell the nurse that I need help. The person who answers the call light is not the one performs the task, so I do not get my needs met. Sometimes it takes about 10 minutes to get help if it's your actual nurse that answers the call light. If it's not my nurse, then it takes about 15 to 30 minutes to get help. Sometimes I'm not satisfied. Sometimes I'm soiled during mealtime for about 15 or 30 minutes. I wait 15 minutes the press the light again. It makes me feel horrible. It makes me want to cry because I can't do anything. This happens on all shifts. During an interview on 6/21/2021 at 10:19 a.m., the DSD stated call lights should be positioned within reach of the resident and all staff was responsible for answering. The DSD stated CNAs were instructed during in-service to inform the resident the time they will be back if they are not able to address the resident's concerns immediately. The DSD stated it was not acceptable for staff not to give a time frame or for the Resident to have to repeatedly press the call light for help. (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 37 Event ID: 555677 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P/P) titled, Communication-Call System, revised 1/1/2012, the P/P indicated nursing staff would answer call bells promptly and in a courteous manner. The P/P also indicated, In answering to request, nursing staff will return to resident with the item or reply promptly. Based on observation, interview, and record review, the facility failed to ensure staff treated four out of four (4) sampled residents (Residents 8, 62, 382, and 385) with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life as evidenced by the following: a) For Resident 8, a nursing staff was observed standing while providing feeding assistance, instead of sitting at the same level, for Resident 8. b) For Resident 62, nursing staff did not answer the call light in a timely manner, resulting in the resident eating while soiled because she had to wait over 30 minutes for assistance to use the restroom. c) For Resident 385, nursing staff did not provide a dignity bag (a cover to conceal contents) for an indwelling foley catheter (a thin sterile tube inserted through the urethra and into the bladder to collect urine) and failed to ensure the catheter bag did not touch the floor. d) For Resident 382, nursing staff did not notify the physician regarding the resident's refusal of a laboratory blood draw (a procedure in which a needle is used to take blood for testing). These deficient practices resulted in Residents 8, 62, 382, and 385 not being treated with dignity and respect as their rights were violated and had the potential to cause the residents to experience a loss of dignity and self-esteem. Resident 62 felt unwanted, embarrassed, horrible, and crying at times; Resident 382 feeling angry and missing his blood draw; Resident 385 feeling embarrassed; and Resident 8 had the potential to feel disrespected. Findings: a. During a review of Resident 8's admission Record (Face Sheet), dated 6/22/2021, the face sheet indicated the resident was admitted to the facility on [DATE]. Resident 8's diagnoses included unspecified lack of expected normal physiological development in childhood. During an observation, on June 15, 2021, at 12:25 p.m., of the dining room during lunch, Licensed Vocational Nurse (LVN) 5 was observed standing in front of Resident 8 while assisting him to eat. During an interview, on June 15, 2021, at 2:17 p.m., Licensed Vocational Nurse 5 (LVN 5) confirmed she was assisting Resident 8 with feeding because he required feeding assistance. LVN 5 stated she was standing while providing feeding assistance because her arms could not reach the resident because he is tall and because the resident was sitting up in a ger- chair (clinical recliner), but could have sat with him if he had sat in a wheelchair. LVN 5 stated it is important to sit with residents while providing feeding assistance so the residents understand staff are with them to watch their chewing and swallowing. During an interview, on 6/21/2021, at 11:48 a.m., with the Director of Staff Development (DSD), the DSD stated she educates both licensed and unlicensed staff on how to assist residents with feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 2 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DSD stated certified nursing assistants (CNAs) should sit down with the residents while assisting with feeding so residents do not feel uncomfortable; it assures residents that staff are not superior, nor are in a hurry. During a review of the facility's policy and procedure (P&P), entitled, Restorative Dining Program, revised January 1, 2012, indicated, Staff member should sit while assisting or feeding resident. c) During an observation of Resident 385's foley catheter bag, on 6/15/2021 at 12:54 p.m., Resident 385's foley catheter was observed without a dignity bag. During a review of Resident 385's admission Record (Face Sheet), the face sheet indicated Resident 385 was admitted to the facility on [DATE]. Resident 385's diagnoses included generalized muscle weakness and reduced mobility. During a review of Resident 385's comprehensive care plan titled, Foley Catheter, dated 6/3/2021, the care plan indicated a revision occurred on 6/15/21, urinary catheter bag changed to maintain infection control and dignity bag attached to drainage bag. During a concurrent observation and interview, on 6/16/2021 at 11:25 a.m., Certified Nurse Assistant 1 (CNA 1) confirmed Resident 385's foley catheter bag was uncovered and stated the foley catheter drainage bag should be placed in a dignity bag per facilities policy and procedures (P/P). CNA 1 stated the dignity bag was the licensed job and not her to do. CNA 1 stated Resident 385 was at risk for feeling embarrassed and uncomfortable for not having a dignity bag to provide her with privacy. During an interview on 6/15/2021 at 12:54 p.m., Charge Nurse 1 (CN 1) stated it was everyone's job to maintain a resident's dignity. CN 1 stated he was notified by CNA 1 Resident 385's catheter bag was on the floor and with no dignity bag. During an interview 6/15/2021 at 3 p.m., CNA 3 stated the facility's process for caring for resident's with foley catheter was for the foley bag to be off the floor with a dignity bag to concealing Resident 385's urine content and prevent embarrassment. During an interview on 6/17/ 2021 at 3:24 p.m., Director of Staff Development (DSD) stated it was the CNAs role to ensure the foley catheter bag was off the floor and with a dignity bag. The DSD stated, it is everyone's responsibility to ensure patient's maintain respect and dignity and maintenance of resident's rights are always protected. During an interview on 6/18/2021 at 9:00 a.m., Resident 385 stated he would be embarrassed for his family to visit and see the color of his urine. During a review of the facility's undated policy and procedure (P/P), titled Indwelling Catheter, the P/P indicated the resident's privacy and dignity would be protected by placing a cover over the drainage bag. d) During a review of Resident 382's admission Record (Face Sheet), the face sheet indicated Resident 382 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 382's diagnoses included fracture (broken bone) of left femur (the bone of the thigh or upper hind limb), history of Type 2 diabetes mellitus (abnormal blood sugar) and Cerebrovascular Accident ([CVA], a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired.) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 3 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 382's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/9/2021, the MDS indicated Resident 382's had no cognitive impairment (ability to think, understand and make decisions of daily living). During a review of Resident 382's progress notes for 6/2021, the progress notes had no indication a Resident 382's primary physician was notified of the blood drawn refusal. During a review of Resident 382's laboratory requisition dated 6/4/2021, the laboratory requisition indicated Resident 382 refused to have labs drawn. During an interview on 6/21/2021 at 11:44 a.m., Resident 382 stated the laboratory technician (skilled workers that perform highly technical, mechanical and diagnostic tests in medical or scientific laboratories) attempted to perform a blood draw from his left hand, when he had refused to have it drawn from the left arm. Resident 382 stated feeling angry and frustrated because they did not respect his decision when he asked not to use the left hand. During a review of facility's policy and procedure (P/P) titled, Resident Rights dated 1/1/2012, the P/P indicated residents had the freedom of choice about how they wish to receive care and employees were to treat all residents with kindness, respect, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 4 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, facility failed to provide appropriate bed size in length and width for one of 18 sample residents (Resident 46). Resident 46 was lying down in bed with left leg hanging over bed frame. with redness on the area even when moved. Residents Affected - Few This deficient practice resulted in Resident 46's left leg to have redness on the area of the leg hanging over the bed frame and had the potential to impede blood circulation to the resident's foot, skin breakdown and ulceration (break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis [death skin]). Findings: During a review of Resident 46's admission Record (Face sheet), the face sheet indicated Resident 46 was initially admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 46's diagnoses included complete traumatic amputation (action of surgically cutting off a limb) of unspecified great toe, hyperlipidemia (elevated level of fat in the blood), acquired absence of right upper limb. During a review of Resident 46's History and Physical (H/P), dated 4/29/2020, the H/P indicated Resident 46 did not have the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/7/2021, the MDS indicated Resident 46 had severe cognitive (ability to make decisions, understand, learn) impairment for skills for daily decision making. The MDS assessment indicated Resident 46 required extensive assistance of one-person physical assist for activities of daily living ([ADL]) bed mobility, transfer, locomotion on unit and off unit, dressing, eating, toilet, and personal hygiene. During a review of Resident 46's Podiatry consult dated 4/21/2021, the consult indicated non-palpable pulses (absence of pulses), amputation of right foot toes 2-5. During a concurrent observation of Resident 46 and interview, on 6/16/2021 at 10:44 a.m., Resident 46 was observed lying down in bed with left leg hanging over the foot of the bed board frame and the right leg dangling out of the bed touching the floor. The left foot was observed with reddened on the area and with scattered scars on the foot. Certified Nurse Assistant 15 (CNA 15), confirmed Resident 46's leg hanging on bedframe board and attempted to move the resident up in bed and yet the left leg was hanging over the foot of bed frame. CNA 15 stated Resident 46 need a bigger and longer bed to avoid developing ulcer on the foot as prolonged hanging of the foot over the bed frame could impede blood circulation. During a concurrent observation and interview, on 6/16/21 at 10:55 a.m., Social Service Director (SSD) stated she acknowledged Resident 46' legs were hanging over the bed frame. The SSD stated the residents were provided with beds and mattress based on their height and weight. During an interview on 6/16/2021 at 2:05 p.m., the Maintenance Supervisor (MS) stated the facility's bed measured 80 inches long, which is small for a resident taller than six (6) feet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 5 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of facilities Policy and procedure (P/P) titled, Resident Rights- Accommodation of Needs, dated 1/1/2012, the P/P indicated resident's individual needs were accounted for in the facility's provision of a clean comfortable bed with adequate mattress, sheets, pillow, pillowcase and blankets, all of which are in good repair, and consistent with individual resident needs. The P/P indicated the residents' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, were evaluated upon admission and reviewed on an ongoing basis. Event ID: Facility ID: 555677 If continuation sheet Page 6 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, facility failed to change the bed sheets for one of 18 residents (Resident 57) after experiencing a vomiting episode. Resident 57, who vomit on top of her bed sheets, was observed lying down in bed with vomitus over the bed sheet Resident 57 was laying on. Residents Affected - Few This deficient practice had the potential to spread infection, reduce resident's dignity and selfsteem. Findings: During a concurrent observation and interview of Resident 57, on 6/15/2021 at 10:20 a.m., Resident 57 was observed lying down on a soiled dirty blanket. Resident 57 stated she threw-up and had requested for a towel, but the staff never came back to check on her. Resident 57 stated, I just think some nurses do not need to be nurses. It's a hard job. The nurses do not come to reposition residents and when asked to help for repositioning they get upset. Resident 57 stated the staff removed her bedside rails and now she is unable to assist herself up from the bed and reposition self. During a review of Resident 57's admission Record (Face sheet), the face sheet indicated Resident 57 was initially admitted to the facility on [DATE] and re-admitted [DATE]. Resident 57's diagnoses included reduced mobility, morbid (severe obesity due to excess calories), and history of COVID-19 (a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) disease. During a review of Resident 57's History and Physical (H/P), dated 5/12/2021, the H/P indicated Resident 57 had the capacity to understand and make decisions. During a review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/14/2021, the MDS indicated Resident 57 was intact of cognition (ability to make decisions, understand, learn) for daily decision making. The MDS indicated Resident 57 required extensive assistance of a one-person physical assist for activities of daily living ([ADL]) bed mobility, transfer, locomotion on unit and off unit, dressing, eating, toilet, and personal hygiene. During a review of Resident 57's care plan titled, Activities of Daily Living (ADL), dated 5/7/2021, the care plan indicated Resident 57 need assistance with bed mobility, walking, locomotion, dressing, transfer and personal hygiene. The staffs' intervention indicated to monitor for change in self-performance of ADLs and report significant changes to physician. During a review of Resident 57's nursing progress notes, dated 6/15/2021 and timed at 4:30 a.m., the notes indicated Resident 57 vomit light brown food particles. During an interview on 6/15/2021 at 3:40 p.m., Certified Nurse Assistant 9 (CNA9) stated Resident 57 had a vomit episode on 6/15/2021 early morning and was aware of it, but did not go back to check on the resident because she was not the nurse assign to Resident 57. During an interview on 6/17/2021 at 10:58 a.m., the Director of staff Development (DSD) stated the CNAs job responsibilities to assist the residents even if not assign to them, and if the CNA is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 7 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few busy, the CNA can come back no later than 10 minutes or ask another colleague to return to the resident especially if the resident was vomiting. The DSD stated it was not acceptable CNA 9 did not go back to help clean Resident 57. During an interview on 6/17/2021 at 11:53 a.m., CNA 16 stated on 6/14/2021 she took care of Resident 57 from 11 p.m. to 7 a.m. CNA 16 stated she did not noticed or was notified of Resident 57 vomiting on her sheets. During an interview on 6/17/2021 at 2:15 p.m., Registered Nurse 1 (RN 1) stated Resident 57 had complained of vomiting of 6/15/2021 at approximately 4:30 a.m., RN 1 stated after she competed Resident 57's assessment, she expected for CNA 16 to back and clean the resident while she called the physician to report Resident 57's change of condition. During a review of facility's Policy and Procedure (P/P), titled Activity of Daily living -Grooming, dated 1/1/2012, the P/P indicated the facility's staff would work with residents to improve their ability to groom self to promote independence, hygiene, comfort, self-esteem, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 8 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) During a review of Resident 12's Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 11's diagnoses included muscle weakness, hypertension (high blood pressure), and long term (current) use of insulin (hormone produced by the body that controls the amount of glucose[sugar] in the bloodstream). Residents Affected - Some During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 12 had no cognitive (thought) impairment. The MDS also indicated Resident 12 thought it was somewhat important to participate in favorite activities, have books, newspapers, and magazines to read, and to do things with groups of people. During a review of Resident 12's activity assessment dated [DATE], the assessment indicated Resident 12's activity interests were religious, socialization, one-on-one, and musical activities. During a review of Resident 12's care plan titled, Resident Care Plan Activities, dated 5/11/2021, the care plan indicated Resident 12 preferred in room independent activities and refuses to attend group activities. The care plan also indicated staff will offer Resident 12 the opportunity to listen to music, watch television and movies, and play crossword puzzles. During a review of Resident 12's Activity Attendance Record for 5/2021 and 6/2021, the record indicated Resident 12's activities only included room visits and independent activities. During an interview on 6/18/2021 at 9:59 a.m., Resident 12 stated he never refused activities or indicated he preferred one to one activity. Resident 12 stated I was not even aware the facility had an activities room until speaking to the surveyor. If I would have known, then I would have gone. I would like to go if possible. They just offered me crossword puzzles and I do not even like to do crossword puzzles. During an interview on 6/18/2021 at 10:06 a.m., CNA 4 acknowledged Resident 12 does not go to activities. During a review of the facility's policy and procedure (P/P) titled, Activities Program and revised on 11/1/2013, the P/P indicated the facility would provide an activity program designed to meet the needs interest and preferences of the residents and the residents would be given an opportunity to choose when where and how he or she will participate in activities and social events. The P/P indicated an individualized Care Plan would be developed and implemented for each resident .The resident's activity plan will be reviewed and up-dated at least quarterly and with any change of condition. In addition, the P/P indicated, the Activity Department would maintain accurate records of each resident's participation in group, independent and room visit involvement. Based on observation, interview, and record review, the facility failed to ensure activities were provided consistently on a daily basis, with consideration of the residents' preferences and activities assessment, for four of four (4) sampled residents (Residents 12, 19, 27, and 72). This deficient practice had the potential to negatively affect the psychosocial well-being of Residents 12, 27, and 72, and resulted in Resident 19 experiencing boredom. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 9 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a) During a review of Resident 19's admission Record (Face Sheet), dated 4/14/2021, the face sheet indicated the resident was admitted to the facility on [DATE]. Resident 19's diagnoses including anemia (low red blood cells), muscle weakness, difficulty in walking, and contracture (a fixed tightening of muscle, tendons, ligaments, or skin). During a review of Resident 19's Minimum Data Set (MDS), a comprehensive assessment and care-planning tool, dated 4/7/2021, the MDS indicated Resident 19 was intact of cognition (thought process) for skills of daily decision making. During a review of Resident 19's care plans, no activities care plan was found. During a review of Resident 19's Activity Assessment, dated 3/30/2021, the assessment indicated Resident 19's activity preferences needed to be reassessed because the resident refused to provide any information at the time of the assessment. During an interview, on 6/15/2021 at 10:53 a.m., Resident 19 stated he does not receive the activities he enjoys doing. Resident 19 stated he just sits in his room most of the time and his only activity is watching TV. During an interview, on 6/18/2021, at 12:50 p.m., Resident 19 stated the only activities he had was going to physical therapy and to the dining room to watch TV, which makes him feel bored most of the time. Resident 19 stated he would like to listen to music as an activity, but staff have not asked what activities he would like to do. b) During a review of Resident 27's Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 27's diagnoses including severe protein-calorie malnutrition (inadequate intake of food) and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was severely impaired of cognition for daily decision making. During a review of Resident 27's care plans indicated there was no care plan completed for activities. During a review of Resident 27's Activity Assessment, dated 3/30/2021, the assessment indicated Resident 27 would be provided picture of family, play the Indian bible, Bollywood music, movies and music. During a concurrent interview and review of Resident 27's care plan, on 6/18/2021, at 12:20 p.m., Registered Nurse 1 (RN 1) stated every resident should have a care plan for activities, and confirmed the resident did not have a care plan for activities. RN 1 stated licensed nurses were responsible for initiating care plans once a resident was admitted to the facility, but activities personnel created the activities care plan. RN 1 stated care plans should be initiated within seven days of the resident's admission to the facility. c) During a review of Resident 72's Face Sheet, indicated the resident was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing foods or liquids), contracture of the left and right knees and ankles, and dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 10 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 was severely impaired of cognition. During a review of Resident 72's care plan titled, Activities, dated 5/11/2021, the care plan indicated Resident 72 would be provided activities such as cards/table games, discussion and reminiscences, music, social events, watching TV/music, and family visits. During an interview, on June 18, 2021, at 2:10 p.m., the Activity Director (AD) stated she conducts activity assessments upon residents' admission and completes an activities progress note quarterly (every three months). During a concurrent interview and review of Residents 19, 27, and 72 Activity Attendance Record, on 6/21/2021, at 8:37 a.m., the AD stated and confirmed activities for the residents were not documented daily. The AD stated it was important to provide residents with activities and encourage them to participate to help keep the residents motivated and looking forward to the next day, and to prevent them from feeling depressed. The AD stated the staff supposed to documented if activities are offered to residents, but they are refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 11 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

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 observation, interview and record review, the facility failed to ensure one of one resident's (Resident 82) quality of care in accordance with professional standards of practice was met by: Residents Affected - Some a. Not notifying the physician regarding a refusal of laboratory blood draw (a procedure in which a needle is used to take blood for testing). b. Not notifying the physician of blood sugar over 250 mg/dl (milligrams per deciliter), as ordered by Resident 382's physician. Normal blood sugar level is between 60 mg/dl to 100 mg/dl. These deficient practices placed the resident at risk for delayed treatment of elevated laboratory values and potential for harm Findings: a. During a review of Resident 382's Facesheet, indicated the resident was admitted to the facility on [DATE] with a diagnoses including fracture of left femur (the bone of the thigh or upper hind limb), history of type 2 diabetes mellitus (abnormal blood sugar) and cerebrovascular accident (CVA), a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired. During a review of Resident 382's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/9/2021, the MDS indicated Resident 382's had no cognitive impairment (ability to think, understand and make decisions of daily living). During a review of Resident 382's Medication Administration Record (MAR), the resident was receiving insulin glargine (a medication used to control the amount of sugar in the blood) and metformin for diabetes mellitus and enoxaparin (a medication used to treat and prevent blood clots) and aspirin to prevent blood clots. During a review of Resident 382's laboratory records, Resident 382's chart did not indicate any laboratory blood results. During a review of Resident 382's laboratory requisition titled, Trident Care dated 6/4/2021, the laboratory requisition indicated patient refused labs on 6/4/2021. During a review of Resident 382's progress notes for the month of June 2021, there were no documentations that a licensed nurse notified Resident 382's primary physician, the registered nurse supervisor or Director of Nursing (DON) about Resident 382's refusal of laboratory blood draw. During an interview on 6/21/2021 at 11:19 a.m., Registered Nurse 1 (RN 1) stated Resident 382 has had no laboratory blood draw since admission. During a current interview and concurrent record review with Licensed Vocational Nurse 8 (LVN 8) on 6/21/2021 at 11:34 a.m., LVN 8 stated that the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/9/2021, indicated the resident was on insulin (a medication used to lower the amount of sugar in the blood) and on an anticoagulant (an agent that is used to prevent the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 12 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0684 formation of blood clots). Level of Harm - Minimal harm or potential for actual harm During an interview on 6/21/2921 at 11:44 a.m. with Resident 382, the resident stated the laboratory technician (skilled workers that perform highly technical, mechanical and diagnostic tests in medical or scientific laboratories) attempted to obtain laboratory blood on Resident 382's left hand. Resident 382 stated he refused to have his blood work drawn on his left hand. Resident 382 stated that the lab technician left Resident 382's room without drawing any blood. Residents Affected - Some During a review of Resident 382's care plan, there were no documentation of the resident's refusal of treatment. A review of facility's Policy and Procedure (P/P) titled, Refusal of Treatment dated 1/1/2021, the P/P indicated that, When a resident refuses treatment, the Charge Nurse or Director of Nursing Services (DNS) will attempt to address the resident's concerns and explain the consequences of the refusal. The facility's policy further indicated, The Attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. c. During a review of Resident 382's Medication Administration Record (MAR) dated June 2021, the MAR indicated resident's blood sugar was 280 mg/dl (milligrams per deciliter) on 6/9/2021. During a review of Resident 382's physician's orders, dated 6/2/2021 indicated, Finger stick blood sugar check using test strip and lancets twice daily before meals without insulin (a hormone that lowers the body sugar level) coverage. Call MD (medical doctor) if blood sugar (BS) is less than 60 mg/dl or greater than 250 mg/dl. During a review of Resident 382's progress notes for the month of June 2021, the progress notes had no indication a licensed nurse notified Resident 382's primary physician for out of range blood sugar as per the physician's orders. During an interview on 6/21/2021, at 11:33 a.m., Registered Nurse (RN 1) stated, Resident 382's progress notes did not indicate the primary physician was notified from 6/6/2021 to 6/14/2021 and further stated that if the blood sugar was out of the range per physician's orders, the blood sugar result should be documented in the progress notes. During a review of Resident 382's care plan for diabetes mellitus dated 6/2/2021, the care plan indicated to, Obtain labs as ordered and report results to MD as indicated. During a review of facility's policy and procedure (P/P) titled, Change of Notification dated 4/1/2015, the P/P indicated, A licensed nurse will notify the Attending Physician of routine laboratory .as soon as possible after received and document notification on the report and progress notes. During a review of facility's policy and procedure (P/P) titled, Blood Glucose Monitoring dated 1/1/2012, the P/P indicated, The Attending Physician will be notified of a BSL (blood sugar level) lower than 70 or higher than 350, unless otherwise indicated in the physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 13 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview, observation and record review, the facility staff failed to provide bilateral (having or relating to two sides) floor mats as a safety precaution for one of one (Resident 52) based on the resident's physician's (MD) orders, fall risk assessment and care plan. This deficient practice placed the resident at risk for injury Findings: During an observation on 6/15/21 at 2:23 p.m. Resident 52 was observed lying on the bed with no fall mats visible on both sides of the bed. A review of Resident 52's admission Record, indicated the resident was re-admitted on [DATE] with diagnoses including, a history of dementia (loss of memory, language, problem-solving and other thinking abilities), schizophrenia (mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and liver cirrhosis (injury of the liver). A review of Resident 52's Minimum Data Set (MDS), a specialized care screening and assessment tool, dated 5/11/2021 indicated the resident needed total assistance with feeding of meals and activities of daily living (ADLS) including bathing and turning/repositioning. A review of Resident 52's physician orders dated 12/28/20 indicated to maintain lowest bed position with bilateral floor mats to prevent injury from falling. During a record review of the facility's Morse Fall Risk Assessment dated 12/28/20 indicated that Resident 52 fall risk score was 30, indicating the resident was at high risk for falls. The assessment also indicated to Implement high risk fall prevention interventions. During a record review of the facility's Resident 52 Fall Risk Prevention and Management dated 12/30/20, Resident 52 was identified to be at risk for falls and bilateral (on each side) floor pads should be implemented. This care plan was re-evaluated on 3/30/21 and 5/21/21, the plan stated that bilateral fall pads were still needed for this resident. During a record review dated of the medication administration record (MAR) from 5/1/21- 5/30/21 and 6/1/21-6/21/21, indicated maintain at the lowest bed position with bilateral floor mats to prevent injury from falling. During a review of the Informed Consent (permission granted in the knowledge of the possible consequences, which is given by a patient/public guardian to a doctor for treatment with full knowledge of the possible risks and benefits ), was signed by resident's public guardian on 5/30/19 giving consent for bilateral floor mats to be placed by Resident 52 bedside for safety and to prevent injury from falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 14 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/16/21 at 8:14 a.m. with the public guardian via telephone, stated the resident should have fall pads. The public guardian stated a consent was signed on December 30, 2019. During an interview on 6/16/21 at 4:21 pm, Licensed Vocational Nurse 1 (LVN 1) stated residents who are at risk for falls must have their beds in the lowest position, and thick foamy fall mats on each side of the bed for protection. On 6/16/21 at 4:30 pm, during a concurrent observation and interview, LVN 1 was observed going into Resident 52's room and stated there were no fall mats present on either side of the resident's bed. During an interview on 6/17/21 at 9:19 a.m., Registered Nurse 1 (RN 1) stated all fall risk patient's beds are in the lowest position and they have floor mats on each side for safety. RN 1 said that it is important to have the pads at the bedside so if the resident falls, there wass padding on the floor to minimize or prevent injury. RN 1 stated a physician's order and consent was needed for floor mats. RN 1 stated if the resident was non-verbal or had a responsible party, the charge nurse will call the responsible party to get consent to place the fall pads. RN 1 identified Resident 52 as a fall risk. RN 1 stated that it was the responsibility of all staff to make sure the fall mats were in place for the resident. During an interview on 6/21/21 at 11:15 a.m., the Director of Staff Development (DSD) stated if the resident is a high risk for falls, the facility policy indicated licensed nurses need to get consent and contact the doctor for an order. The DSD stated the floor mats were for both sides of the bed to prevent injuries, providing cushioning in case of a fall. The DSD stated all staff including housekeepers are to ensure residents who are high fall risks have floor mats. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 15 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four of four (4) residents (Residents 18, and 19) as follows: a) Nursing staff were not aware of Resident 18's anticoagulants (blood thinner) medication therapy and what signs and symptoms to monitor. b) For Resident 19, Licensed Nursing staff did not clarify Resident 19's medication administration time with physician. These deficient practices had the potential to result in Residents 18 and 19 to not receive the care and response to their individualized needs. Findings: a) During a review of Resident 18's admission Record (Face Sheet), dated 3/15/2021, the face sheet indicated Resident 18 was admitted to the facility on [DATE]. Resident 18's diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), hypertension (high blood pressure), muscle weakness, and difficulty in walking. During review of Resident 18's Physician Order Summary, dated 6/2021, indicated the resident had physician orders, both dated 3/5/2021, for clopidogrel 75 milligrams ([mg] units of measurement) 1 tablet by mouth daily for thrombotic [blood clot] event prevention and aspirin 81 mg chewable 1 tablet by mouth daily for cerebrovascular accident ([CVA] medical term for stroke - damage to the brain from interruption of its blood supply). During a review of Resident 18's physician order, dated 3/5/2021, the order indicated to monitor for changes in bowel patterns or in stool color - dark black, red, or streaked with blood, and hematemesis (vomiting of blood) every shift. During a review of Resident 18's Care Plan titled, Anticoagulant Therapy - Risk for Bleeding, dated 3/5/2021, the care plan indicated Resident 18 was at risk for injury, bleeding, and bruises due to being on anticoagulant therapy. The staffs' interventions included to inform the physician of unusual bruising, blood in urine, blood in stool, bleeding from gums, bleeding from nose, excessive bleeding from wounds, or petechiae (tiny purple, red, or brown spot on the skin caused by bleeding). During an interview, on 6/16/2021, at 2:21 p.m., LVN 5 stated residents' plans of care were endorsed to CNAs during huddle at the beginning of shift so they can know what is going on with the residents. During an interview, on 6/16/2021, at 4:04 p.m., LVN 1 stated if resident were on an anticoagulant medication, licensed nurses were responsible to inform the CNAs on what signs and symptoms to monitor such as bright, red, or tarry blood in their stool because it can indicate a bleed and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 16 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0726 resident could have internal bleeding. Level of Harm - Minimal harm or potential for actual harm During an interview, on 6/17/2021, at 9:19 a.m., Registered Nurse 3 (RN 3) stated residents' diagnoses are explained to the CNAs by LVNs and RNs during huddle at the beginning of each shift. RN 3 stated special considerations in caring for residents on anticoagulant medications include monitoring for bloody stool and preventing falls. Residents Affected - Few b) During a review of Resident 19's Face Sheet, dated 4/14/2021, indicated the resident was admitted to the facility on [DATE]. Resident 19's diagnoses including anemia (low red blood cells), muscle weakness, difficulty in walking, contracture (a fixed tightening of muscle, tendons, ligaments, or skin), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). During a review of Resident 19's physician's telephone order, dated 6/6/2021, the order indicated to administer glipizide 5 mg one tablet PO (by mouth) with meals daily for Diabetes Mellitus ([DM] condition of chronic high blood sugar). During a review of Resident 19's Care Plan - Diabetes Mellitus, dated 3/25/2021, indicated the resident was at risk for actual or potential injury related to hypoglycemia (low blood sugar) to oral hypoglycemic agents or insulin therapy. During an interview, on 6/16/2021, at 1:35 p.m., CNA 8 stated she did not know Resident 19's diagnoses but also stated that the resident is not diabetic. During a concurrent interview and record review, on 6/21/2021, at 10:36 a.m., of Resident 19's electronic medical record (EMR), LVN 5 stated Resident 19 was diabetic and has a physician's order, dated 6/8/2021, for glipizide 5mg 1 tablet PO with meals daily for DM. LVN 5 stated Resident 19 is administered glipizide once daily after breakfast so his blood sugar does not go down. During a concurrent interview and record review, on 6/21/2021, at 11:07 a.m., of Resident 19's medication orders, upon reading the resident's glipizide order, LVN 2 stated the glipizide is supposed to be given at 7:15 a.m. with breakfast. LVN 2 stated medication orders usually will indicate the time it is to be administered. LVN 2 stated the order should have been clarified with the doctor to specify the time the medication is to be administered. LVN 2 stated licensed nurses should know that the medication should be given with breakfast. During a concurrent interview and record review, on 6/21/2021, at 11:15 a.m., of Resident 19's medication orders, with the Director of Staff Development (DSD), the DSD stated the resident's glipizide order should have a specified time for administration. The DSD further stated the glipizide medication order needed to be clarified with the physician. During an interview, on 6/21/2021, at 2:51 p.m., the DSD stated glipizide should be administered with meals but Resident 19's glipizide order did not specify the time the medication is to be administered. The DSD stated the medication order needs to be specified so whoever gives the medication knows when to give it or else someone would not know what meal the medication is to be administered with. The DSD stated the resident can become hypoglycemic (low blood sugar) if he receives too much of the medication. During review of the facility's policy and procedure (P&P), entitled 24 Hour Communication Log, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 17 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0726 revised 1/1/2012, indicated, The Licensed Nurses will communicate with CNAs any important aspects of care that they will need to implement or be aware of. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 18 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure accurate documentation of disposition of controlled medications (medications that have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) during medication destruction. The facility consultant pharmacist (Pharm D 1) and the Director of Nursing (DON) did not document the date of disposition (destruction) of controlled meds on the controlled medication forms from 1/2021 through 5/2021. This deficient practice had the potential to conceal loss or potential diversion of controlled medications. Findings: During a concurrent interview and record review on 6/28/2021 at 12:11 p.m. the DON retrieved controlled medication destruction forms and stated each month she and the facility's Pharm D1 counted the controlled medications for destruction, Pharm D 1 destroys the medications, and then both (DON and Pharm D1) signed the controlled medication forms to indicate the medications were destroyed. The DON stated and confirmed no dates of medication destruction were documented on the forms. The DON called Pharm D1 on speaker telephone and when asked if there was supposed to be a date of destruction, Pharm D 1 stated, Yes, we will do that, moving forward we will make sure to include the dates. During a review of the facility's policy and procedure (P/P), titled, Disposal of Medications and Medication-Related Supplies, dated 2/23/2015, the P/P indicated controlled medications remaining in the facility after a resident had been discharged or the order discontinued were disposed by the DON and consultant pharmacist, as directed by state laws and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 19 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure it was free of a medication error rate of five percent (5%) or greater as evidenced by the identification of three out of 25 medication opportunities (observations during medication administration) for error, to yield a cumulative error rate of 12% for two of four residents observed during the medication administration facility task (Residents 389 and 31). Residents Affected - Some a. For Resident 389, the facility failed to follow the physician's order to administer the correct dose of Docusate Sodium (stool softener for bowel management) as ordered and failed to administer a dose of multivitamin with minerals as ordered. b. For Resident 31, the facility failed to administer Metformin (for diabetes [disease in which blood glucose/blood sugar levels are too high]) within the correct timeframe as ordered. These deficient practices had the potential to result in harm to Residents 389 and 31 by not administering medication as prescribed by the physician to meet their individual medication needs and therapeutic doses. Findings: a. During a review of Resident 389's admission Record (Face Sheet), the face sheet indicated the resident was originally admitted to the facility on [DATE]. Resident 389's diagnoses included diabetes (disease in which blood glucose/blood sugar levels are too high), chronic kidney disease (kidneys not working properly) , moderate protein-calorie malnutrition (inadequate intake of protein and food) and arthritis (inflammation[swelling] of the joints and tissues). During a review of Resident 389's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/9/2021, the MDS indicated Resident 389's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was moderately impaired. The MDS indicated Resident 389 required supervision with transfers, dressing, toileting, and bathing. During a review of Resident 389's Physician's order, dated 6/2/2021, the order indicated to give Docusate Sodium 100 milligrams ([mg] units of measurement) tablet twice a day for stool softener. During a review of Resident 389's Medication Administration Record (MAR), dated 6/2021, the MAR indicated to give Docusate Sodium 100 mg one tablet twice a day for stool softener. During a medication pass observation on 6/17/2021 at 9:15 a.m., Registered Nurse (RN 2) administered one 250 mg tablet of stool softener to Resident 389. During the same observation, RN 2 did not administer a multivitamin to Resident 389. During a concurrent record review and interview on 6/18/2021 at 7:43 a.m., RN 1 reviewed Resident 389's medical record and stated the resident was supposed to receive one 100 mg tablet of stool softener and one multivitamin at 9 a.m. daily. During an interview on 6/18/2021 at 11:15 a.m. with Licensed Vocational Nurse (LVN 4), LVN 4 stated she had passed medications to Resident 389 today and was familiar with the resident. LVN 4 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 20 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Resident was supposed to receive 100 mg of stool softener at 9 a.m. LVN 4 opened the medication cart and pulled out three bottles of stool softeners and stated they stock three kinds:100 mg tablet, 100 mg soft gel, and 250 mg tablets. During a telephone interview on 6/18/2021 at 1:43 p.m., RN 2 stated he could not remember what medications he gave to Resident 389 on 6/17/2021. RN 2 stated he thought Resident 389 was supposed to have 100 mg stool softener. When asked if there was more than one kind of stool softeners inside the medication cart, RN 2 stated yes. When asked if he gave the 250 mg instead of 100mg, RN 2 paused and then stated, I don't know, I think it was 100 mg, gosh I hope so. RN 2 stated he would make sure to look at the dosage next time. When asked if a multivitamin was given to Resident 389, RN 2 stated, Oh, I forgot to give it during medication pass, so I went back and gave it later. During a review of the facility's policy and procedure (P/P), titled, Medication-Administration, revised 1/1/2021, the P/P indicated the purpose of the policy was to ensure the accurate administration of medication as prescribed and the medication should be given at the right time. b. During a review of Resident 31's admission Record, the record indicated the resident was originally admitted to the facility on [DATE]. Resident 31's diagnoses included diabetes (disease in which blood glucose/blood sugar levels are too high), high blood pressure, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and arthritis (inflammation[swelling] of the joints and tissues). During a review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31's cognition was moderately impaired. The MDS indicated Resident 31 required supervision with dressing and set-up assistance with toileting, bathing, and eating. During a review of Resident 31's physician's orders, dated 10/28/20, the order indicated to give Metformin HCL 500 mg one tablet twice daily with breakfast and dinner. During a review of Resident 31's MAR, dated 6/2021, the MAR indicated Resident 31 was supposed to receive Metformin HCL 500 mg one tablet twice a day and to give the medication with breakfast at 7:15 a.m. and with dinner at 5:15 p.m. During a medication pass observation on 6/16/2021 at 9:15 a.m., Licensed Vocational Nurse (LVN 5) administered Metformin to Resident 31. During an interview on 6/16/2021 at 9:29 a.m., with LVN 5, when asked if the Resident was supposed to receive Metformin at this time, LVN 5 stated, Resident 31 usually takes the medication after breakfast. When asked what time breakfast trays arrived, LVN 5 stated it was usually between 7:15 a.m. and 7:30 a.m. During a review of Resident 31's orders on 6/16/2021 at 1:30 p.m., RN 1 reviewed Resident 31's medical record and stated Metformin was supposed to be given at 7:15 a.m. During a concurrent interview and record review on 6/16/2021 at 1:50 p.m., LVN 5 looked at Resident 31's MAR and stated he usually gives Metformin at 7:30 a.m. LVN 5 stated he has one hour before and after the designated time to give the medications. When asked if Resident 31 was supposed to have received the medication at 9:15 a.m., LVN 5 stated, I should have given it within one hour of 7:15 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 21 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 6/16/2021 at 2:02 p.m. LVN 5 stated the facility nursing staff use Nursing 2022 Drug Handbook to review medications. LVN 5 opened the handbook and turned to the page for Metformin and stated according to the book, the medication was supposed to be given with meals. During an interview on 6/21/2021 at 1:09 p.m. the Director of Nursing (DON) stated there was no facility policy on diabetes or giving Metformin. DON stated Metformin should be given with meals. DON stated she had already provided in-services to her staff and reminded them to give metformin with meals. During a review of the facility's policy and procedure (P/P) titled, Medication-Administration, revised 1/1/2021, the P/P indicated the purpose of the policy was to ensure the accurate administration of medication as prescribed and the medication should be given at the right time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 22 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: a. Resident 16's medication was in a locked medication cart following medication pass. Licensed Vocational Nurse (LVN 5) administered Lidocaine cream (for temporary relief of pain and itching due to minor cuts, minor scrapes, minor skin irritations) to Resident 16, then placed the cream on top of the medication cart (which was located in the hallway) and walked away to wash his hands. The medication was left unattended and unsecured. b. One Tuberculin Purified Protein Derivative (PPD) solution (for intradermal administration as an aid in the diagnosis of tuberculosis, performed by a skin test) was labeled with the date first opened. c. The medication refrigerator did not have ice around freezer compartment (which was located inside the refrigerator). d. Nurses witnessing the destruction of non-controlled medications documented both signatures on the medication disposition form. These deficient practices had the potential to expose other residents and visitors to accidental ingestion of the medication, exposure to expired skin test solution, unsafe temperatures to compromise the efficacy of medication and potential for medication loss or theft. Findings: a. During a review of Resident 16's admission Record (Face Sheet), the face sheet indicated the resident was originally admitted to the facility on [DATE]. Resident 16's diagnoses included diabetes (disease in which blood glucose/blood sugar levels are too high), history of drug and alcohol abuse, diabetic wounds on foot, and peripheral vascular disease (blood vessels in arms or legs become narrowed and can block blood flow). During a review of Resident 16's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], the MDS indicated Resident 16's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The MDS indicated Resident 1 required extensive assistance with transfers, dressing, toileting, and bathing. During an observation and interview of a medication pass on [DATE] at 8:39 a.m., Licensed Vocational Nurse (LVN 5) applied Lidocaine cream to Resident 16's right shoulder, then LVN 5 left the resident's room and placed the Lidocaine cream on top of the medication cart (located in the hallway). LVN 5 left the medication cart unattended to wash his hands. LVN 5 did not lock the Lidocaine cream inside the medication cart. LVN 5 stated she usually locks the medication back in the cart. LVN 5 stated leaving the medication unattended can cause for another resident to get it. During a review of the facility's policy and procedure (P/P), titled, Medication Storage in the Facility, dated [DATE], the P/P indicated medications would be stored safely, securely, and properly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 23 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm b. During an inspection of the medication storage room refrigerator and interview on [DATE] at 10:48 a.m., there was one Tuberculin skin test vial that had been opened and not dated with the first date opened. Registered Nurse (RN 1) stated and confirmed the vial was not dated with the first date open and did not know how long the vial had been stored since opened. RN 1 stated, We are supposed to label it with the date it is opened, that way we know how long it has been open. Residents Affected - Few During a review of the facility's policy and procedure (P/P), titled, Preparation and General Guidelines: Vials and Ampules of Injectable Medications, dated [DATE], the P/P indicated the date opened and the initials of the first person to use the vial were recorded on multidose vials on the vial label or an accessory label affixed for that purpose. c. During an inspection of the medication storage room refrigerator and interview on [DATE] at 10:48 a.m., the refrigerator was a dormitory-style refrigerator with a combined open freezer compartment inside the refrigerator, observed with ice covering the rim of the freezer storage area. The medication refrigerator contained two emergency medication kits, one package of unopened Prevnar (pneumococcal vaccine) vaccines, one vial of unopened Influenza vaccine, and two vials of unopened insulin. RN 1 stated the refrigerator was not supposed to have ice build-up around it. During a concurrent observation and interview on [DATE] at 11:53 a.m. Director of Nursing (DON) stated and confirmed there should not be ice around the freezer. DON called the facility consultant pharmacist (Pharm 1) on speaker phone and pharm 1 stated they could use the dormitory-like small refrigerator but needed to be keep defrosted. Pharm 1 stated the vaccines should be fine if they were on the middle shelf and the temperatures were correct, it should be no problem. DON stated she understood the vaccines were fragile and if they got too cold, it could affect their efficacy. During a review of the Centers for Disease Control and Prevention (CDC) guidelines for Vaccine Storage and Handling, dated [DATE] and accessed at: cdc.gov/vaccines/pubs/pinkbook/vac-storage.html#storing, the guidelines indicated to never store any vaccine in a dormitory-style or bar-style combined unit and these units pose a significant risk of freezing vaccines, even when used for temporary storage. During a review of the facility's policy and procedure (P/P) titled, Medication Storage in the Facility: Storage of Medications, dated [DATE], the P/P indicated medications and biologicals were to be stored safely, securely, and properly. d. During an inspection of the medication storage room on [DATE] at 10:48 a.m., RN 1 stated it was the facility policy for two licensed staff to sign the destruction logs when non-controlled medications were destroyed. RN 1 opened the destruction logbook and 15 pages of destruction (disposition) sheets were missing a second licensed signature from [DATE] through [DATE]. During a review of the facility's policy and procedure (P/P) titled, Disposal of Medications and Medication-Related Supplies: Medication Destruction, dated [DATE], the P/P indicated non-controlled medication destruction occurs only in the presence of two individuals, including two licensed nurses. The P/P indicated the nurses witnessing the destruction would ensure the signatures of the witnesses were entered on the medication disposition form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 24 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) and Dietary Supervisor (DS) were competent to provide and report food preferences based on her likes and dislikes on daily meals for one of one resident (Resident 68). This deficient practice can cause the resident psychological discomfort which made her frustrated and was tearful, and placed the resident at risk for weight loss. Findings: During an observation on 6/15/21 at 10:15 a.m. Resident 68 was observed sitting in wheelchair at the bedside. Resident 68 stated she only liked bacon and no other meat with her meals. A review of Resident 68's admission Record indicated the resident was admitted on [DATE] with diagnoses including urinary tract infection (UTI-an infection I any part of the urinary system, the kidneys, bladder or urethra), unspecified dementia without behavioral disturbance and atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 68's MDS (Minimum Data Set), a resident assessment and care screening tool, indicated the resident was at risk of malnutrition (when the body does not get enough nutrients) and gastrointestinal esophageal reflux disease (GERD-when stomach acid frequently flows back into the tube connecting your mouth and stomach). A review of Resident 68's care plans titled, Nutrition and Hydration dated 5/24/21, indicated that resident was at risk for weight loss due to decreased feeding and poor appetite. During record review of physician orders dated 5/24/21, Resident 68 was ordered a Regular, no added salt, renal diet (diet that is low in sodium, phosphorus and protein). The resident preferences for likes or dislikes was left blank (not documented). Upon observation of Resident 68 preference card on 6/17/21 during meal service, the preference card did not indicate no meat in the photo submitted for verification. The policy also indicates in section 4 that The Dietary Department will provide residents with meals consistent with their preferences as indicated on the tray card. During an interview on 6/16/21 at 1:25 pm with Certified Nurse Assistant 8 (CNA 8) stated resident reported to her on 6/13/21, that she does not like red meat., sometimes turkey, and sometimes does not eat meat at all. Stated she like veggies (vegetables). CNA 8 said she did not inform anyone that resident does not like eating meat. CNA 8 stated if the resident does not eat food, alternatives can be offered. CNA 8 stated it was important for residents to choose what they eat so they are happy and feel like they are home. During record review of dietary communication slip dated 6/16/21 submitted by Licensed Vocational Nurse 2 (LVN 2) to the dietary supervisor, it was documented under comments no meat for Resident 68. During observation and concurrent interview with DS on 6/17/21 at 1:35 p.m. during the meal tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 25 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few line, Resident 68 was observed to have pork loin on the resident's lunch plate. When asked if pork was acceptable to be served to Resident 68, the DS stated it's fine and continued to proceed with the tray line. During an interview on 6/17/21 at 3:26 p.m., the DS stated Resident 68 informed her on 6/16/21 the resident liked vegetables and does not like meat. The DS said she did not write No Meat on the preference card because the dietary staff will not serve her meat and resident wanted bacon this morning for breakfast, which she was given. The DS stated Resident 68 liked bacon and informed the DS she does not eat meat all the time. The DS stated she puts meat on the resident's plate anyway, regardless of preference, to make the meal complete. During an interview on 6/17/21 4:00 p.mm with Resident 68, the resident stated she did not eat the pork loin or rice, stating she did not care for it. Resident 68 said she only liked bacon in the mornings. During an interview on 6/21/21at 11:15 a.m. with the Director of Staff Development (DSD), it was indicated that if there were food preferences, the CNA reports it to any nurse on duty. The nurse will report it to the dietary supervisor any food preferences of the resident. The DSD said the staff will report to the charge nurse if the resident does not eat and documents on the ADLS (activities of daily living) sheet. During a record review of the facilities policy titled Resident Preference Interview, section 3 indicated the resident preferences will be reflected on the tray card and updated in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 26 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0880 Provide and implement an infection prevention and control program. 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: Residents Affected - Some a. Ensure proper doffing (taking off) of Personal Protective Equipment (PPE) when exiting resident's rooms in the yellow zone [residents under observation for Covid-19 virus (a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] per facility's policy and procedure (P/P). b. Ensure foley catheter drainage bag was up and off the floor for one of one resident (Resident 385). c. Ensure infection control measures for medication storage and during medication pass. d. Ensure one laundry staff did not store their personal belongings in a clean laundry cart. These deficient practices had the potential of cross contamination and spread of the Covid -19 infection among residents and staff in the facility and potential for UTI (infection of the urinary system). Findings: a. During an observation and interview on 6/15/21 at 11:00 a.m., Certified Nurse Assistant 1 (CNA 1) was observed walking out of residents' rooms in the yellow zone of the facility while wearing a gown, gloves and face shield and was pulling a dirty utility cart into the resident's room in the yellow zone. CNA 1 stated, she was out in the hallway wearing her PPE gown, gloves and face shield, because they emptied my linen cart and left it too far away from the resident's door. CNA 1 stated she was giving a resident a bed bath. During a concurrent observation, resident's rooms in the yellow zone were observed not containing PPE closed lid doffing containers for staff to doff inside the rooms. A large closed container labeled dirty linen was observed in the center of the yellow zone hallway full of discarded PPE. Yellow zone staff were observed doffing inside the doorway of the resident's room and walking outside the rooms, then placing their PPE gowns into the closed lid cart. During an interview on 6/15/21 at 11:15 a.m., Resident 382, stated, he had not observed any of the staff taking their PPE gown or gloves off inside the room. During an interview on 6/15/21 at 12:28 p.m., the Infection Control Preventionist Nurse (IP) stated, job duties include help preventing and identifying the spread of infectious agents. The IP stated, regarding the process of donning and doffing per the facility P/P indicated, the process for doffing should occur in the rooms. The IP Nurse stated the staff are a bit confused by all these new guideline. During a concurrent observation with the IP in resident's rooms in the yellow zone, there were no PPE doffing carts available for staff to facilitate doffing. During an interview on 6/16/2021 at 2:21 p.m., Certified Nursing Assistant (CNA 1) stated, the facility's policy for donning and doffing instructions indicated was to be done inside the residents' room. CNA 1 stated, there should be a large white cart inside the room where PPE gowns are disposed of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 27 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when doffing. CNA 1 stated, each room in the yellow zone should contain a large white closed step touch lid cart for doffing inside each resident's room. CNA 1 stated, housekeeping staff came and took the linen cart out of the room on 6/15/21 while she was providing care to the resident. CNA 1 stated, I could have waited until I saw someone and asked them to bring me the linen cart instead of stepping outside the resident's door in a dirty PPE gown and dirty gloves. CNA 1 stated, removal of gloves and performing hand hygiene was required per facility policy before leaving a resident's room. CNA 1 stated infection control in-services were held on a regular basis in change of shift huddles by the IP nurse and the last infection control in-service she was on 6/15/2021. During an interview on 6/17/21 at 10:15 a.m., Certified Nurse Assistant 3 (CNA 3) stated, the facility's infection control policy and procedure for donning and doffing are always completed inside the resident's room. CNA 3 stated, removal of gloves and handwashing occurs inside resident's room before exiting the room. CNA 3 stated, if leaving the room is required during rendering care to a resident's facility staff are required to doff, remove gloves, wash hands, leave room obtain necessary equipment or linen and re-don per facilities policies and procedure. During an interview on 6/17/21 at 3:24 p.m., the Director of Staff Development (DSD) stated, the procedure and protocol for doffing PPE is inside the room. Since the Covid-19 pandemic started the facility has made a point to administer in-services to all staff on a regular basis regarding donning and doffing practice in the facility. The DSD stated, the last in-service on infection control which contained PPE donning and doffing was on 6/16/21 during all shift's huddles along with IP nurse. During a review of Facility's Mitigation Plan and AFL 20-53, dated 6/10/2021, recommended PPE should be donned and doffed appropriately for patients suspected or confirmed to have COVID-19. Infection preventionist (IP) or designee will oversee the training of all staff on the donning and doffing procedures required based on the color-coded cohorting groups. During a review of an undated facility policy and procedure, titled Personal Protective equipment (PPE), indicated When gowns are used, they are used only once and discarded into appropriate receptacles located in the room in which the procedure was performed. During a review of Centers for Disease Control and Prevention (CDC, a federal health agency) undated brochure titled How to Safely Remove PPE, indicated remove all Personal Protective Equipment (PPE) before exiting the patient's room except a respirator, if worn. b. During an observation on 6/15/21 at 12:54 p.m, Resident 385's indwelling catheter bag (Foley catheter), a sterile tube that is inserted into the bladder to drain urine, containing dark yellow urine was observed hanging off the left side of bed and touching the floor without a privacy bag covering the urinary drainage bag. A review of Resident 385's Facesheet (admission Record), indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and diabetes mellitus (abnormal blood sugar). A review of Resident 385's Minimum Data Set (MDS), a specialized resident care screening and assessment tool, dated 6/9/2021 indicated the use of an indwelling catheter. A review of Resident 385's care plan titled Foley Catheter dated 6/3/2021 indicated the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 28 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was at risk for urinary tract infection. The care plan goals included for the resident to not have an infection within 90 days. During a follow up interview on 6/16/2021 at 11:25 a.m., CNA 1 stated, Resident 385 Foley catheter bag should not be touching the floor. CNA 1 stated I was busy passing trays and did not want to touch the catheter bag and then touch the resident's trays. CNA 1 stated, now that she has had time to think about the situation, she could have washed her hands and picked up Resident 385 urinary catheter bag up off the floor and washed her hands again and finished passing out trays. CNA 1 stated, after she was finished passing the resident's trays. During an interview on 6/17/21 at 10:01 a.m. Certified Nurse Assistant 6 (CNA) CNA 6 stated, all residents' foley catheter bags and tubing should be up and off the floor to maintain infection prevention and control per the facility's policy and procedure. During interview on 6/17/21 at 12:15 p.m., Licensed Vocational Nurse Treatment Nurse 2 (LVNTX 2) stated her responsibilities included monitoring residents' catheter bags, ostomy bags, any type of drains that residents may have. LVNTX2 stated on 6/16/21 CNA 1 notified her via telephone that Resident 385 was found to have catheter bag touching the floor and without a privacy bag. LVNTX 2 stated the urinary bag not touching the floor will ensure the resident will not develop a a bladder infection. LVNTX2 also states, it is important for the resident to have a privacy bag to provide the resident dignity. During an interview on 6/17/ 21 at 3:24 p.m., Director of Staff Development (DSD) stated, the process of caring for residents with indwelling (Foley) catheter consisted of staff ensuring no leakage from tubing and urine free of visible blood in tubing. DSD stated, it is also the certified nursing assistant's (CNA) role to ensure the Foley catheter bag was up off the floor with privacy bag, record output and empty urinary catheter bag per facility policy. DSD states it was the responsibility of all staff to ensure infection control measures were always maintained. DSD stated, if a facility staff observed a Foley catheter bag touching the floor per the facility's policy and procedure, the priority was to stop, wash hands, pick foley catheter bag up and off the floor and notify the charge nurse immediately. A review of the undated facility policy and procedure titled Infection Control indicated the facility will maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the Centers for Disease Control and Prevention (CDC, a federal health agency) infection control guidelines on recommendations on prevention of catheter associated urinary tract infection (CAUTI) titled Proper Care of Urinary Catheter Maintenance indicated the resident's collection bag should be kept below the level of the bladder at all times and the catheter bag should not rest the bag on the floor.d. During a concurrent observation of the laundry room and interview with Laundry Personnel (LP) 1 on 6/17/21, at 11:50 a.m., a phone, bag, and clothing items were observed in the clean linen cart in contact with residents' linen. LP 1 stated the items belonged to her, which she sometimes stores in the laundry room because she does not want to leave her things upstairs in the staff lockers. LP 1 stated she was not aware she was not supposed to store her belongings or why she should not store them in the clean linen cart . During an interview on 6/21/2021, at 4:15 p.m., with the Maintenance Supervisor (MS), the MS stated staff are not allowed to store personal belongings in the laundry room. The MS stated there are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 29 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lockers employees can use to store their personal belongings, located by the outside patio. The MS stated personal belongings should not be stored in the laundry room to prevent contaminating clean laundry; if contaminated, infections can spread to the residents. During an interview, on 6/21/2021, at 4:29 p.m., with the MS, the MS stated he did not have any in-services related to storing personal belongings of infection control in the laundry room, and was still searching for the facility's policy related to the matter. A review of the facility's policy and procedure (P&P), titled Infection Control - Policies & Procedures, revised January 1, 2012, indicated the facility intends to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the Centers for Disease Control and Prevention (CDC, a federal health agency) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, indicated, The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and staff. c. During an observation of the medication storage room and interview, on 6/16/2021 at 10:48 a.m., two soiled feeding pumps (used to deliver nutrition solution to residents), with brown substance dripping from the sides of the machines were mixed in with four (4) clean feeding pumps, stored on the same shelf marked as clean; staff purses/personal belongings, ketchup packets, dishes and cooking utensils were stored inside the cabinets. Registered Nurse (RN 1) looked at the feeding pumps and stated, Yeah, they look dirty; they should not be mixed like that. RN 1 looked at the purses/personal belongings, dishes, ketchup packets and stated they should not be in the medication storage room. RN 1 stated staff should not store their purses or food items in the medication room because it could cause contamination. During a concurrent observation and interview on 6/16/2021 at 11: 50 a.m., the Director of Nursing (DON) looked at the staff's personal items in the medication room and stated there should not be anything else stored in the medication storage room except medications or medication supplies. The DON stated the staff had lockers to store their personal belongings and she did not know why they were not using the lockers. During a review of the facility's policy and procedure (P/P) titled, Medication Storage in the Facility: Storage of Medications, dated 2/23/2015, the P/P indicated medication storage areas would be kept clean and free of clutter. During a concurrent observation and interview on 6/16/2021 at 7:10 a.m., Licensed Vocational Nurse (LVN 5) opened medication cart 1 located in the green zone (area designated for residents how have tested negative for COVID-19, or been fully vaccinated against COVID-19 and are not exhibiting signs and symptoms of COVID-19) nurses' station and inside the top drawer were two yellow-colored rings sitting inside the same bin as eye drops. LVN 5 stated he was not sure if the rings belonged to a staff member or a resident. When asked if jewelry should be stored next to medications, LVN 5 stated, No, it could be an infection control problem. During a concurrent observation and interview on 6/16/2021 at 3:24 p.m., LVN 7 opened medication cart 1 located in the yellow zone (area designated to quarantine residents who may have been exposed to COVID-19 [a highly contagious infection, caused by a virus that can spread from person to person]) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 30 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurses' station and inside the narcotic drawer was a multicolored zipper wallet. LVN 7 stated she thought it belonged to a resident and the wallet was probably in there because this was a safe place to lock it up. When asked if personal items were supposed to be stored next to medications, LVN 7 stated, It's infection control; it really shouldn't be there. During the same observation and interview, there was a container of Sanicloth disinfectant wipes sitting next to routine medication bubble packs, inside the same drawer. When asked if disinfectants or cleaning products were supposed to be stored in the same drawer, next to medications, LVN 7 stated, No and moved the disinfectant wipes to the bottom drawer, next to other disinfectant products. During the same observation and interview, there was one box of tissues and one pulse oximeter device (placed on residents' finger to measure oxygen levels in the blood) sitting inside the same drawer as the over the counter (OTC) floor stock medications. LVN 7 stated the items should not be there because it could be an infection control problem and then LVN 7 proceeded to remove the items from the medication cart. During a review of the facility's policy and procedure (P/P) titled, Medication Storage in the Facility: Storage of Medications, dated 2/23/2015, the P/P indicated potentially harmful substances such as cleaning supplies and disinfectants should be stored in a locked areas separately from medications. During a review of the facility's policy and procedure (P/P) titled, Infection Control-Policies and Procedures, revised 1/1/2012, the P/P indicated infection control policies and procedures were required for a safe and sanitary environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 31 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, facility failed to evaluate antibiotics (medication used to treat a bacterial infection) prescribed to ensure appropriateness and follow-up with laboratory work for culture (test to find germs [such as bacteria or a fungus] that can cause an infection) and sensitivity (test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.) during antibiotic therapy for three of three residents (Residents 65,68, and 78). Residents Affected - Some These deficient practices had the potential to lead to Residents 65, 68 and 78 to receive unnecessary medication, create resistance to antibiotics and develop a super infection (infection occurring after or on top of an earlier infection). Findings: a) During a review of Resident 65's admission Record (Face sheet), the face sheet indicated Resident 65 was initially admitted to the facility on [DATE]. Resident 65's diagnoses included muscle weakness and colitis (inflammation of the lining of the colon). During a review of Resident 65's History and Physical (H/P), dated 5/24/2021, the H/P indicated Resident 65 had capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/29/2021, the MDS indicated Resident 65 had intact cognition (ability to make decisions, understand, learn) for daily decision making. The MDS indicated Resident 65 required extensive assistance for activities of daily living ([ADL]) bed mobility, transfer, locomotion on unit and off unit, dressing, eating, toilet, and personal hygiene. During a review of Resident 65's care plan, dated 5/29/2021, the care plan indicated Resident 65 required antibiotic therapy for the treatment of colitis. The staffs' interventions included to monitor resident for signs of ongoing infection, monitor for adverse reactions to antibiotic medication and notify physician of any changes. During a review of Resident 65's physician order, dated 5/28/2021, the order indicated to administer Resident 65 Levaquin (antibiotic) 500 milligrams ([mg] units of measurement) tablet by mouth for colitis for 5 days and flagyl (antibiotic) 500 mg by mouth one tablet three times a day for colitis. During a review of Resident 65's physician orders and laboratory work for 6/2021, the orders and laboratory did not indicate any culture and sensitive for antibiotic use was done. b) During Review of Resident 68's Face sheet, the face sheet indicated Resident 68 was initially admitted to the facility on [DATE]. Resident 68's diagnoses included muscle weakness and history of falling. During a review of Resident 68's physician order dated 5/24/2021, the order indicated to administer Resident 68 nitrofurantoin (antibiotic) 100 mg every 12 hours for 10 days for Urinary tract infection ([UTI] infection of the urine). However, there was no urine culture and sensitivity perform. During a review of the facility's antibiotic stewardship program ([ASP]a program to measure and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 32 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some improve how antibiotics are prescribed by clinicians and used by patients) and interview on 6/18/2021 at 9:41 a.m., the Infection preventionist ([IP] nurse in charge of infection prevention for the facility) stated he reviewed antibiotic orders for all residents in the facility receiving antibiotic and checked the labs, culture and sensitivity as ordered. The IP stated he was responsible for ensuring residents were receiving antibiotics for the right purpose and to ensure it was the correct antibiotic prescribed and check the culture and sensitivity for antibiotic eligibility. The IP stated the charge nurse conducted the McGeer's criteria (a criteria that defines infections were systematically reviewed) and he (IP) completes the entire surveillance. The IP nurse stated he forgot to complete the surveillance and rule out the reason Residents 65, 68 and 78 were receiving the antibiotics. The IP nurse stated it was very important to follow up with culture and sensitivity to ensure the wrong antibiotic is not given and prevent the development of antibiotics resistance. During an interview on 6/18/2021 at 11:14 a.m., the Director of Nursing (DON) stated the facility had the antibiotic stewardship program, but they were not conducting the monitoring and surveillance of the antibiotic's usage. The DON stated they should be a culture and sensitive conducted to ensure the residents receive the correct antibiotic treatment for the onset of infection. During a concurrent interview and review, on 6/21/2021 at 2:24 p.m., in the presence of the DON, the IP nurse stated there was no system of feedback reports on antibiotic use for all the residents who received antibiotic treatment in the facility. The IP nurse stated they forgot to conduct a surveillance and monitoring report for all the resident receiving antibiotics, It is an honest mistake. During a review of facility's Policy and Procedure (P/P) titled, Antibiotic Stewardship, dated 5/20/2021, the P/P indicated the facility would implement an antibiotic stewardship program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infections, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for residents. The IP would collect and analyze infection surveillance data, coordinate data collection and monitor adherence to infection control policies and procedures. The contracting laboratory services would provide culture reports, antibiotic resistant organism information and patterns, alerts and antibiograms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 33 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 provide education regarding the benefits and potential side effects of pneumococcal immunization (vaccines against the bacterium Streptococcus pneumoniae use for the prevention of pneumonia, meningitis, and sepsis) to three of five residents (Residents 385, 41, and 11) and/or their responsible party. Residents Affected - Few This deficient practice had the potential to cause Residents 385, 41, and 11 to make uninformed decisions regarding receiving pneumococcal immunization and could result in adverse health outcomes. Findings: a) During a review of Resident 385's admission Record (Face Sheet), Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 385's diagnoses included muscle weakness, reduced mobility, and pressure ulcer (localized damage to the skin and underlying tissue that usually occur over bony areas due to long term pressure). During a review of Resident 385's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/12/2021, the MDS indicated Resident 385 had moderate cognitive (thought) impairment. The MDS also indicated Resident 385 was offered the pneumococcal vaccine and declined. During a review of Resident 385's Admission/Standard orders form, dated 5/14/2021, the form indicated the pneumococcal vaccine was not part of Resident 385's applicable orders. The form did not indicate Resident 385 was offered or refused the pneumococcal vaccine. During an interview on 6/21/2021 at 2:27 p.m., Resident 385 stated she remember receiving a vaccination. Resident 385 stated the facility did not explain to her what vaccine was she receiving, and they did not give her any written information about the pneumonia vaccine. b) During a review of Resident 41's face sheet, the face sheet indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included osteoarthritis (joint disease that results from breakdown of joint cartilage and bone) and trans ischemic attack (TIA [temporary blockage of blood flow to the brain). During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41 had severe cognitive impairment. The MDS also indicated Resident 41 was offered the pneumococcal vaccine and declined. During a review of Resident 41's Admission/Standard orders form dated 7/14/2020, the form indicated the pneumococcal vaccine was part of Resident 41's applicable orders and to administer Pneumovax 23 0.5 millimeters([ml] units of measurement) at 9 p.m. when available. The form indicated to obtain consent and document in the resident's record. The form did not indicate Resident 41 was offered or refused the pneumococcal vaccine. c) During a review of Resident 11's face sheet, the face sheet indicated Resident 11 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 11's diagnoses included muscle weakness, hypertension (high blood pressure), difficulty walking, and dementia (a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 34 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had severe cognitive impairment. During a concurrent interview and record review on 6/21/2021 at 1:47 p.m., the Infection Prevention Registered Nurse ([IPN] nurse in charge of infection prevention for the facility) stated she was not able to find any consents or indications of Residents 385, 42, and 11 education regarding the pneumococcal vaccine in their medical record. The IPN stated the staff was to offer the pneumococcal vaccines and educate the Resident's on the benefits of the vaccine every quarter even if residents refuse the vaccine and document the refusal or administration of the vaccine. During an interview on 6/21/2021 at 2:12 p.m., the Director of Staff Development (DSD) stated new residents were offered a consent to take or refuse the pneumococcal vaccine. The DSD stated the resident education regarding the benefits and risks of taking the vaccine was on the consent form. The DSD also stated It's important for elderly residents to get pneumococcal vaccine because of their age and because they are prong to getting pneumonia if they do not get vaccinated. During an interview on 6/21/2021 at 2:35 p.m., the Director of Nursing (DON) stated the facility staff are to offer residents and/or their representatives with the education of the purpose, side effects, number, and type of vaccine. The [NAME] stated the residents or responsible party must sign a consent form to receive or refuse vaccine. During a review of the facility's policy and procedure (P/P) titled, Pneumococcal Disease Prevention, revised on 2/18/2021, the P/P indicated, before offering the pneumococcal vaccine, each Resident or Resident representative must be given education regarding the benefits and potential side effects of the immunization using the most recent Vaccine Information Statement. The P/P also indicated the Resident's medical record should include documentation that indicates at a minimum that the Resident or Resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal vaccine, the Resident's informed consent or refusal should be placed in the Resident's medical record, and whether the resident did or did not receive the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 35 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 ensure the call lights (button or pad pressed by a resident to alert staff of the need for assistance) was functioning properly for one of three residents (Resident 11). Upon testing the call light in Resident 11's room, the notification light outside and above Resident 11's room, the notification alarm at the nurse's station did not alarm or sound to alert the staff Resident 11 was calling. Residents Affected - Few This deficient practice had the potential to cause Resident 11 to experience a delayed response to a medical emergency, care, and for Resident 11 not to attain the highest practicable physical, functional, mental, and psychosocial well-being possible. Findings: During a review of Resident 11's admission record (Face Sheet), the face sheet indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 11's diagnoses included muscle weakness, hypertension (high blood pressure), difficulty walking, and dementia (a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life). During a review of Resident 11's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 3/12/2021, it indicated Resident 11 had severe cognitive (thought) impairment. The MDS indicated Resident 11 needed staff to provide guided maneuvering of limbs (assistance with moving limbs) and other non-weight bearing assistance with bed mobility, moving between surfaces, dressing, toilet use and personal hygiene. During a review of the facility's monthly maintenance log titled, Call Lights, dated 1/27/2021 through 5/12/2021, the log indicated call lights for rooms in station 1 and 2 and the annunciator panel (panel at nurse's station that alarms to indicate a resident is pressing the call light) were checked once per month. During an interview on 6/15/2021 at 10:40 a.m., Resident 11 stated, Sometimes it takes a long time for nurses to respond when I press the call light. It makes me feel lonely and this happens on all shifts. During a concurrent observation and interview on 6/15/2021 at 2:30 p.m., Resident 11 was observed pressing her call light. The reset light inside of Resident 11's room did not turn on, the light outside and above Resident 11's room did not come on, and the alarm at the annunciation panel at the nurses' station did not sound. Certified Nursing Assistant 8 (CNA 8) stated the light was supposed to come on outside the room, a buzzer sound should ring in front of the nursing station, and a light appear on the wall in the room also. During an interview on 6/16/2021 at 8:35 a.m. Maintenance Supervisor (MS) stated, We test call lights to see if they are functional once a month every room and every week two random rooms at time. Yesterday, Resident 11's call light and cord were not working, and I replaced the call light. During an interview on 6/16/2021 at 11:17 a.m., the director of Staff Development (DSD) stated We do rounds every day and the CNA's check the resident's call lights to see if they are functioning. If (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 36 of 37 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 555677 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave. Hawthorne, CA 90250 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)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a call light is not working, then we alert the maintenance supervisor and documented on a communication book at the nurses, During an interview on 6/18/2021 at 9:08 a.m. Registered Nurse Supervisor (RNS) stated the CNAs conducted rounds at the start of their shift, checking if residents are clean and if the bed are in the lowest position, make sure the call lights are in reach of the residents and ensure the call lights are functional. The DON stated if during rounds, the CNAs find call lights are not working, they are to report the problem to the charge nurse or to maintenance. The DON stated Maintenance Supervisor was also in charge of performing routine checks on call lights. The DON stated non-functional call lights places the residents at risk for falls and to be neglected due to not able to communicate to the nurses when needing help. During a review of the facility's policy and procedure (P/P) titled, Communication-Call System, revised 1/1/2012, the P/P indicated nursing staff would answer call bells promptly and in a courteous manner. The P/P also indicated if a call bell was defective, it will be reported immediately to maintenance and replaced immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 37 of 37

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Citations

17 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0881GeneralS&S Epotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0679GeneralS&S Epotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0726GeneralS&S Dpotential for harm
F726 - Nursing Services
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.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Dpotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0919GeneralS&S Dpotential for harm
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
0341GeneralS&S Dpotential for harm
Install a fire alarm system that can be heard throughout the facility.
0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.

FAQ · About this visit

Common questions about this visit

What happened during the June 21, 2021 survey of HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP?

This was a inspection survey of HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP on June 21, 2021. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP on June 21, 2021?

Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement a program that monitors antibiotic use."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·June 21, 2021