Health inspection·October 10, 2023

F 0656 one, because it beeps. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/6/2023 at 4:45 p.m., with Director of Nursing (DON), DON 1 stated, care plan for risk for elopement is documented since 4/23/2023. DON stated, Resident 1 refused to wear a wander guard bracelet. DON stated. The facility policy indicated that, when residents is at high risk of elopement, residents need to wear a wander guard bracelet. DON stated, if Resident 1 refused to wear a bracelet, a refusal care plan must be developed. DON stated, there is not a care plan for refusal. Residents Affected - Few During an interview on 10/10/2023 at 11:07 p.m., with Registered nurse (RN) RN 1 stated, care plan is done so everybody in the team knows resident plan of care. RN stated, nurses must develop a care plan when resident refused. RN 1 stated, when Resident 1 refused to wear a wander guard bracelet, all staff should be aware of the interventions and be more vigilant with resident. RN 1 stated the risk of not developing a care plan of refusal is that resident 1 will not have the necessary supervision for avoiding elopement. During a review of the facility ' s policies and procedures (P&P) dated 11/2018 titled Care Plans, Comprehensive Person-Centered, the P&P indicated The comprehensive care plan will be periodically review and revised by Interdisciplinary Team Meeting (IDT) after each assessment. I addition, the comprehensive care plan will also be reviewed and revised at the following times: Onset of new problem, to address changes in behaviors and care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 2 of 4 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 10/10/2023 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 observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as a high risk for elopement (to leave a secured institution without notice or permission) and had episode of leaving the facility without notifying staff as indicated in care plan. This failure has the potential for Resident 1 sustain an accidental injury while outside the facility's premises without supervision from staff. Findings: During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Parkinson disease (a brain disorder that causes unintended or uncontrollable movements), muscle weakness (commonly due to lack of exercise, ageing, muscle injury), reduce mobility (mobility to use transport is reduced due to physical disability). During a review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 9/11/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was capable to understand and be understood by others. The MDS indicated Resident 1 required supervision with activities of daily living such as dressing, toilet use, personal hygiene, supervision with bed mobility (how resident moves from lying to turning side to side). During a review of Resident 1 ' s Multidisciplinary Care Conference dated 7/27/2023, the multidisciplinary care conference indicated Resident 1 was monitor for behavior episodes continue to be wandering around the hallway, refused to wear wander guard for elopement purpose. During a review of Resident 1 ' s Resident 1 is an elopement risk/wanderer care plan dated 4/7/2023, the care plan indicated. Resident 1 will not leave facility unattended. Resident 1 safety will be maintained. Distract Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversations, television, book, Resident 1 prefers. Identified pattern of wandering. During an interview on 10/6/2023 at 4:20 p.m., with Resident 1, Resident 1 stated,I left the facility last Friday 9/29/2023. Resident 1 stated, I sneaked out from the back door. Resident stated, I tried before to leave, but I come back. Resident 1 stated, I have no injuries. I am okay. Resident 1 stated, I went to the hospital for couple of hours and the paramedics brought me back to the facility late that night. Resident 1 stated, when I left the alarm sound but then sound stop, the nurses saw me leaving and tried to stop me, but I wanted to go. Resident 1 stated, I did not tell anybody. The nurses know I want to go. During an interview on 10/6/2023 at 4:45 p.m., with Director of Nursing (DON), DON 1 stated,Resident 1 wanted to go out of pass (OOP) on 9/29/2023 around 9:00 a.m. DON stated, we did not have an order for Resident 1 to go OOP, but Resident 1 insisted on going, and my assistance accompanied him to take the bus. DON stated, there was no order for OOP on 9/29/23 before Resident 1 left the facility. DON stated, I do not have documentation regarding when Resident 1 come back to the facility, but the Licensed Vocational Nurse (LVN) 3 informed me that was before midnight. DON stated, nobody was aware where Resident 1 was until 9:00 p.m., when the charge nurse ' s supervisor received a call from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 3 of 4 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 10/10/2023 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 the Fire Department, informing, that Resident 1 will be transfer to the hospital. DON stated nurses are unaware, how Resident 1 was brought back to the facility before midnight. DON stated, the out pass is usually given for 4 hours and when past the 4 hours, nurses must try to locate the resident and call the doctor. DON stated, every attempted to locate the resident must be documented. DON stated, there is no documentations, that we tried to located Resident 1. DON stated, is not okay for resident to be out of pass until midnight. DON stated, Yes, is our responsibility to follow up and monitor what time Resident 1 is coming back. DON stated, it is dangerous not checking in resident is a safety issue, nurses must be alert and know if resident is safe and did not have an accident. During an interview on 10/10/2023 at 10:45 a.m., with LVN 1, LVN 1 stated, when resident goes OOP, need to be an order from the doctor. LVN 1 stated, the resident must wait until we received an order from the doctor. LVN 1 stated, usually OOP is for 4 hours, if resident is not back in 4 hours, nurses must contact the resident, family, and doctor. LVN 1 stated, we endorse to the next shift and enter a progress notes. LVN 1 stated, OOP can last from the morning to midnight, but after midnight, nurses must contact police department to report missing resident. LVN 1 stated, it is very important resident safety, nurses are here to protect the resident and check if resident 1 was safe. During an interview on 10/10/2023 at 11:07 p.m., with Registered Nurse (RN) 1, RN 1 stated, on 9/29/2023 around 9:00 a.m., staff told me Resident 1 was outside at the parking lot, I when and talked to Resident 1 and he stated, that he wants to go and take the bus. RN 1 stated, I told Resident 1 the facility transportation, can take him any place, but he refused. RN 1 stated, Yes, there is not order for resident going out of pass on 9/29/23. RN 1 stated, It was on my mind to enter an order but the order was place on 9/30/23. RN 1 stated, I walked Resident 1 to the bus station, and he did not come back until my shift was over. RN 1 stated, nurses must check on Resident 1 safety, nurses need to keep calling the residents or investigated where Resident 1 can be. RN 1 stated, it is our responsibility to check on them and make sure they are safe. During an interview on 10/10/2023 at 12:27 p.m., with LVN 3, LVN 3 stated, last Friday 9/29/2023 at 11:00 p.m., I was endorsing by the nurses that Resident 1 was OOP. LVN 3 stated, I do not know what time Resident 1 comeback. LVN 3 stated, Resident 1 come on a gurney with two paramedics, the paramedics told me that the hospital asked them to transfer Resident to the Facility. LVN 3 stated, I when to Resident 1 ' s and refused to tell me where he was and assessment. LVN3 stated, I did not note any injuries. LVN 3 stated, I forgot to documented when he come back, and that I notified the doctor. LVN 3 stated, nurses did not follow in Resident 1 to make sure Resident 1 was safe and okay. LVN 3 stated, our responsibility is Resident 1 safety. During a review of the facility ' s policies and procedures (P&P) titled Resident Safety, dated 4/15/2021 the P&P indicated Any facility staff member who identifies an unsafe situation, practice or environment risk factor should immediate notify to their supervisor. The P&P titled Wandering & Elopement, dated 7/2017 the P&P indicated Facility staff will reinforce proper procedures for leaving the Facility for residents assessed to be at risk of elopement. When an individual who departed without following proper procedures returns to the facility, notify the Physician, and responsible party. Upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 4 of 4