Health inspection·January 26, 2024

F 0656 revised the CP to set a new blueprint with new goals and interventions. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 1/26/2024 at 12:19 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's Care Plans (CP) were reviewed. LVN 2 stated there were no CP for the bedrails being up. LVN 2 stated it was important to have a CP for Resident 4's bedrails being up because it's a form of restraint. LVN 2 stated having the bedrails place Resident 4 at risk for entrapment and bruising of the skin. LVN 2 stated having a CP gives us a verbal understanding of what is going on with Resident 4 and what precautions to take. Residents Affected - Some b. During a review of Resident 33s admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included Fournier gangrene (an infection of the genital area), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 33's History and Physical (H&P), date 9/29/2023, the H&P indicated, Resident 33 has the capacity to understand and make decisions. During a review of Resident 33's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/29/2023, the MDS indicated, Resident 33's cognition (ability to learn reason, remember, understand, and make decisions) had the capacity to recall information after cueing and remember year, month, and day. The MDS indicated, Resident 33 was always incontinent and had indwelling urinary catheter (IDC). During a concurrent interview and record review on 1/26/2024 at 3:54 p.m. with Assistant Director of Nursing (ADON) 1, Resident 33's Oder Summary Report, dated 1/25/2024 was reviewed. The Oder Summary Report indicated, on 9/30/2023 Resident 33 had an IDC. ADON 1 stated there was no Care Plan (CP) regarding the IDC and there should have been a CP for Resident 33. ADON 1 stated it was important to have a CP for the IDC, so we know what interventions to do for Resident 33. ADON 1 stated the CP is the way we communicate with other departments of the continuity of care. ADON 1 stated the CP is the way we evaluate and check if the plan of care is working for Resident 33. During a concurrent interview and record review on 1/26/2024 at 4:01 p.m. with Director of Nursing (DON) 1, Resident 33's Oder Summary Report, dated 1/25/2024 was reviewed. The Oder Summary Report indicated, on 9/30/2023 Resident 33 had an IDC. DON 1 stated there was not a CP regarding the IDC for Resident 33. DON 1 stated the CP is the blueprint for providing care for Resident 33. DON 1 stated it is important to have a CP to know if the care for Resident 33 was effective or not. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, the P&P indicated, To ensure that a comprehensive person centered care plan is developed for each resident .It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 2 of 19 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 01/26/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure there was a revised care plan for using an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) for one out of six sampled Residents (Resident 3). This deficient practice had the potential to affect Resident 3's provision of care. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Parkinson (a motor system that manifest as rigidity and tremors of the body), epilepsy (a sudden alteration in behavior due to temporary change in the electrical functioning of the brain), and schizophrenia (a severe mental illness characterized by disruptions in thinking, perception, emotions, and social interactions). During a review of Resident 3's History and Physical (H&P), dated 2/13/2023, the H&P indicated, Resident 3 can make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023, the MDS indicated, Resident 3's cognition (ability to learn reason, remember, understand, and make decisions) could not remember year, month, and day. The MDS indicated, Resident 3 activities of daily living ([ADL] activities related to personal care) Resident 3 was dependent with toileting hygiene, showering, and putting on and off footwear. During a review of Resident 3's Order Summary Report, dated 1/23/2024 was reviewed. The Order Summary Report indicated, on 1/23/2024 Resident 3 were to use an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) ten breaths in the morning and in the evening while awake. During a review of Resident 3's Nursing Progress Notes, dated 1/23/2024, the Nursing Progress Notes indicated, Resident 3 was readmitted on [DATE] to the facility. The Nursing Progress Notes indicated to continue previous order and medications reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient had been taking) from hospital and continue plan of care. During a concurrent interview and record review on 1/25/2024 at 3:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 3's Care Plan (CP), dated 9/26/2023 was reviewed. The CP indicated, Resident 3 was at risk for ineffective airway clearance with interventions to 1. Monitor for signs and symptoms of dysphasia (trouble swallowing) 2. Monitor Resident's ability to expectorate secretions 3. Perform oral suctioning to maintain airway 4. Position Resident upright 5. Provide oxygen as indicated by Resident condition. LVN 2 stated when the physician orders were received the care plan should have been initiated or revised. LVN 2 stated it is important to start the revision of the care plan and add the IS to the care plan to see the progression of care. LVN 2 stated the care plan intervention will help us to assess the effectiveness of care. During a concurrent interview, and record review on 1/25/2024 at 3:20 p.m. with Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 3 of 19 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 01/26/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (DON) 1, Resident 3's Order Summary Report, dated 1/23/2024 was reviewed. The Order Summary Report indicated, on 1/23/2024 Resident 3 were to use an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) ten breaths in the morning and in the evening while awake. DON 1 stated the IS is for lung expansion to prevent pneumonia. DON 1 stated it is important to set up a care plan and revised a care plan with goals and interventions. DON 1 stated the care plan is the blueprint to identify the problem if the interventions are effective or not. DON 1 stated if the care plan is not followed or updated it will place Resident 3 at risk for respiratory infection. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person -Centered Care Planning, dated 11/2018, the P&P indicated, To ensure that a comprehensive person centered care plan is developed for each resident .The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission .It should address resident-specific health and safety concerns to prevent decline .Since baseline care plan is developed before the comprehensive assessment, goals and interventions may change .If the comprehensive assessment and the comprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning, which was not previously identified on the problem specific care plans used for the baseline care plan, those changes must be updated on each specific care plan used and incorporated, as applicable, into the initial and/or updated baseline care summary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 4 of 19 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 01/26/2024 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** b. During a review of Resident 69's admission record, dated 1/26/2024, the admission record indicated Resident 69 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included, encephalopathy (damage or disease that affects the brain), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Residents Affected - Some During a review of Resident 69's History and Physical (H&P) dated 10/1/2023, the H&P indicated that Resident 69 had the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/16/2023, the MDS indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a screening tool used to identify the cognitive condition of residents upon admission into a long-term care facility) of six (severe impairment, normal BIMS score is 13-15). The MDS indicated Resident 69 required minimal assistance or supervision with eating, oral and personal hygiene, and moderate assistance with toileting, showering and walking. During a review of Resident 69's Care Plan, regarding Communication Problem, initiated on 12/19/2022 and revised on 3/30/2023, the care plan indicated that a communication board was provided to the resident. The care plan indicated Resident 69's interventions were to communicate by lip reading, writing, using communication board, gestures, sign language and translator. The care plan also indicated interventions to monitor Resident 69 for effectiveness of communication strategies and assistive devices. During an observation on 1/24/2024 at 3:03 p.m., while in Resident 69's room, Resident 69 was observed speaking a language other than English. Resident 69 was asked if she could speak or understand English. Resident 69 continued to speak in her language. Observed Resident 69 did not have any forms of interpretive materials in her language nor a communication board to assist with communication. During a concurrent interview and observation on 01/24/2024 at 8:48 a.m., with CNA 3 in Resident 69's room, CNA 3 was asked how she communicated with Resident 69. CNA 3 stated that Resident 69 spoke Arabic and was unable to speak English. CNA 3 stated that she was able to say hello in Arabic. CNA 3 stated that she used the Arabic word for hello to communicate with Resident 69. CNA 3 was asked if Resident 69 had any type of communication board to assist with communicating. CNA 3 stated, No. CNA 3 stated that she was able to understand Resident 69's requests and that Resident 69 was able to get up and go to the restroom on her own. Observed CNA 3 speak to Resident 69 by saying hello in Arabic. This prompted Resident 69 to begin speaking full sentences in Arabic and making hand gestures to CNA 3. CNA 3 stated, Hello! in Arabic again. CNA 3 was asked if she understood what Resident 69 was attempting to communicate. CNA 3 stated that she did not understand what Resident 69 communicated in her language. CNA 3 then stated that she believes Resident 69 should have something above her bed with indicators in her language or a communication book at bedside so that the staff can communicate with her (Resident 69). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 5 of 19 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 01/26/2024 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 - Some During an interview on 1/26/2024 at 12:44 p.m., with the Director of Nursing (DON) 1, DON 1 stated that residents that do not speak English should have some type of communication board or device at the bedside. DON 1 stated that the Activities Director (AD) 1 is responsible for providing residents in the facility with the communication device. DON 1 stated that during huddle and chart review, the nursing staff will let the AD know which residents need communication boards. DON 1 stated that Resident 69 should have had some type of universal pictures in her room in order for staff to communicate with her. DON 1 stated that if a resident does not have a communication device, the staff won't be able to understand the needs of the resident. During an interview on 1/26/2024 at 3:16 p.m., AD 1, the AD 1 stated that the activities department provided cue cards for any residents that had a language barrier. The AD 1 stated that any staff member could inform the department that there is a resident in the facility with a language barrier. The AD 1 stated that once the activities department was notified of a resident with a language barrier, the resident would be assessed and a cue card (a board or cards with images used to assist residents who do not speak English) developed in the resident's preferred language. The AD 1 stated that Resident 69 used to have a cue card hanging on her wheelchair, but he cue card is no longer in her room. The AD 1 stated that Resident 69 should have a communication board because the resident can get frustrated without a way to communicate her needs and the staff can get frustrated because they cannot understand what the resident is trying to communicate. During an interview on 1/25/2024 at 4:29 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that Resident 69 should have a third-party interpreter for communication. LVN 2 stated that Resident 69 would not have her needs met if she could not communicate. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Residents' Communication Needs, dated March 2017, the P&P indicated, the facility staff will assist residents to express or communicate their requests, needs, opinions, urgent problems, and/or participate in social conversations, whether through speech in writing, using gestures, with adaptive devices, or the combination of these methods. The P&P also indicated that the staff would provide adaptive devices as needed to enable the resident to communicate as effectively as possible. During a review of the facility's policy and procedure (P&P) titled, Translation or Interpretive Services, dated December 2013, the P&P indicated, the facility will ensure that residents with limited English proficiency will have the same access to facility services as other residents. The P&P also indicated that the facility provides assistance to residents with limited English proficiency through translation and interpretation services. During a review of the facility's policy and procedure (P&P) titled, Resident Rights - Accommodation of Needs, dated January 2012, the P&P indicated, The Facility's environment is designed to assist the resident in achieving independent functioning and maintain the resident's dignity and well-being. The P&P also indicated that the facility staff will interact with residents in a way that accommodates the physical or sensory limitation of the residents, promotes communication, and maintains each resident's dignity. Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 69 and 11) were provided with a communication tool or resources to effectively communicate their needs. This deficient practice had the potential to result in the resident's care needs not effectively (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 6 of 19 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 01/26/2024 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 conveyed to staff which could lead to a decline in the resident's quality of life. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some a. During a review of Resident 11's admission Record (Face Sheet), dated 1/24/2024, the Face Sheet indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Psychotic Disorder with Delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary), Anxiety (intense, excessive, and persistent worry and fear about everyday situations), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 11's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/10/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required limited assistance. During a review of Resident 11's History and Physical (H&P), dated 10/23/23, the H&P indicated Resident 11 has fluctuating capacity to understand and make decisions. During a review of Resident 11's Care Plan for Resident 11 titled communication deficient dated 4/24/2023 Resident 11 has an impaired communication at risk for impaired communication related to language barrier, patient speaks an obscure Chinese dialect, cognitive deficit impact's ability to communicate needs effectively. Goal: include patient will improve capability to communicate time 90 days, Patient will be able to communicate basic needs times 90 days, Patient will be able to follow simple directions times 90 days. Intervention included speak while facing patient when explaining procedures, assess for other alternative means of communication to establish means of anticipating needs, use short and direct phrases to communicate, communication board if applicable, Interpreter as appropriate, Audio consults as needed to check for hearing difficulties. During a review of Resident 11's Nursing Assessment Record titled, Mental Status dated 5/24/2023, indicated communication board - Care Profile no communication board, alert & Oriented times 3, communicated verbally, speech is clear, is able to understand and be understood when speaking is (Not Met). Language Barrier indicated Yes. During a review of Resident 11's Social Service Notes titled, Language dated 10/26/2023, indicated Do you need or want an interpreter to communicate with a doctor or health care staff Unable to determine. During an observation on 1/23/2024 at 9:01 a.m. in the residents room, there was no communication board. During an interview and observation on 1/23/2023 at 9:02 a.m. with LVN 3. The LVN 3 agreed there is no communication board anywhere in the room. During an interview on 1/25/2024 at 3:37 p.m., with RN 2. The RN 2 stated Resident 11 speaks Mandarin/Chinese. RN stated Resident 11 should have had a communication board. RN 2 stated it is important so that resident can let staff know what his concerns are clinically. RN 2 stated Resident 11 may feel isolated if he cannot communicate, Resident 11 was sent to the hospital for aggressive verbal and physical behavior and was sent back to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 7 of 19 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 01/26/2024 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 During a review of the facility's policy and procedure (P&P) titled, Accommodation of Residents' Communication Needs Revised dated 3/2017, indicated [V1 B.] Communication Boards/Charts. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 8 of 19 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 01/26/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide oral hygiene for one out of six Resident (Resident 4). Residents Affected - Few The failure also resulted in the potential for dental problems and compromise resident's physical health and psychosocial well-being. Findings: During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). During a review of Resident 4's History and Physical (H&P, date unknown, the H&P indicated, Resident 4 does not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023, the MDS indicated, Resident 4's cognition (ability to learn reason, remember, understand, and make decisions) could not remember year, month, and day. The MDS indicated, Resident 4 activities of daily living ([ADL] activities related to personal care) required extensive assistance with toileting, dressing, and personal hygiene. During an observation and interview on 1/24/2024 at 8:17 a.m. with Resident 4. Resident 4 stated I get clean daily, but no one brushes my teeth. Resident 4 displayed her teeth and there was buildup of food particles and residue on Residents 4 teeth. During a concurrent observation and interview on 1/25/2024 at 3:03 p.m. with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 4 teeth do not look like they have been cleaned. LVN 1 stated Resident 4 should have had her teeth brushed. LVN 1 stated the risk of not brushing Resident 4 teeth can result in cavities or a tooth infection. LVN 2 stated Resident 4 is blind, and it is our duty to make sure Resident 4 had mouth care daily or as needed. During a concurrent observation and interview on 1/15/2024 at 3:14p.m. with Director of Nursing (DON) 1. DON 1 stated Resident 4 teeth look like they have not been cleaned. DON 1 stated Resident 4 should have had her teeth brushed daily. DON 1 stated if Resident 4 does not receive oral hygiene Resident 4 is at risk for gingivitis (inflammation of the gums). During a review of the facility's policy and procedure (P&P) titled, Oral Care, dated 1/2012, the P&P indicated, All residents receive appropriate oral care, including denture if applicable, daily .It is the responsibility of each staff member within the nursing department is to ensure good oral care for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 9 of 19 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 01/26/2024 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 out of six Residents (Resident 3) had an incentive spirometer ([IS] a device used to expand the lungs to prevent respiratory infection) at bedside. Residents Affected - Few This deficient practice of not having the IS device available for Resident 3 had the potential for a respiratory infection. Findings: During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Parkinson (a motor system that manifest as rigidity and tremors of the body), epilepsy (a sudden alteration in behavior due to temporary change in the electrical functioning of the brain), and schizophrenia (a severe mental illness characterized by disruptions in thinking, perception, emotions, and social interactions). During a review of Resident 3's History and Physical (H&P), dated 2/13/2023, the H&P indicated, Resident 3 can make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023, the MDS indicated, Resident 3's cognition (ability to learn reason, remember, understand, and make decisions) could not remember year, month, and day. The MDS indicated, Resident 3 activities of daily living ([ADL] activities related to personal care) Resident 3 was dependent with toileting hygiene, showering, and putting on and off footwear. During a review of Resident 3's Order Summary Report, dated 1/23/2024 was reviewed. The Order Summary Report indicated, on 1/23/2024 Resident 3 were to use an Incentive Spirometer ten breaths in the morning and in the evening while awake. During a review of Resident 3's Nursing Progress Notes, dated 1/23/2024, the Nursing Progress Notes indicated, Resident 3 was readmitted on [DATE] to the facility. The Nursing Progress Notes indicated to continue previous order and medications reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient had been taking) from hospital and continue plan of care. During a concurrent observation, interview, and record review on 1/25/2024 at 3:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 3's Order Summary Report, dated 1/23/2024 was reviewed. The Order Summary Report indicated, on 1/23/2024 Resident 3 were to use an Incentive Spirometer ([IS] a device that measures the volume of the air inhaled into the lungs during inspiration) ten breaths in the morning and in the evening while awake. LVN 1 stated there is no IS in the Resident 3's room. LVN 1 stated there should be an IS in the room and it should be resulted of Resident 3's usage of the IS in the eMAR ([electronic Medication Administration Record] used to document information). LVN 1 stated the IS is used to expand the lungs and to prevent respiratory infection. During a concurrent interview, and record review on 1/25/2024 at 3:20 p.m. with Director of Nursing (DON) 1, Resident 3's Order Summary Report, dated 1/23/2024 was reviewed. The Order Summary Report indicated, on 1/23/2024 Resident 3 were to use an Incentive Spirometer ([IS] a device that measures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 10 of 19 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 01/26/2024 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 Level of Harm - Minimal harm or potential for actual harm the volume of the air inhaled into the lungs during inspiration) ten breaths in the morning and in the evening while awake. DON 1 stated the physician orders were not being followed. DON 1 stated the Incentive Spirometer is used to help Resident 3 to expand her lungs and to prevent pneumonia (an infection in the lungs causing inflammation and fluid accumulation). DON 1 stated the IS device needed to be at Resident 3's bedside to provide the breath exercises to prevent pneumonia. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Residents Rights, dated 1/2012, the P&P indicated, To promote and protect the rights of all residents at the facility .Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interest, assessments and plans of care, including .Health care scheduling, such as times of day for therapies and certain treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 11 of 19 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 01/26/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a consent from resident representative for having bedrails up for one out of six Residents (Resident 4). This failure had the potential to put residents at risk of falls and entrapment due to the use of side rails. Findings. During a review of Resident 4's admission Record (Face Sheet), the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), respiratory failure (life-threatening condition of breathing failure that can occur in very ill people). During a review of Resident 4's History and Physical (H&P, date unknown, the H&P indicated, Resident 4 does not have the capacity to understand and make decisions During a review of Resident 4's Minimum Data set ([MDS] a standardized care screening and assessment tool), dated 9/23/2023, the MDS indicated, Resident 4's cognition (ability to learn reason, remember, understand, and make decisions) could not remember year, month, and day. The MDS indicated, Resident 4 activities of daily living ([ADL] activities related to personal care) required extensive assistance with toileting, dressing, and personal hygiene. During a concurrent observation and an interview on 1/26/2024 at 9:40 a.m. with Director of Nursing (DON) 1 in Resident 4 room, Resident 4's bedrails were up on both sides of the bed. DON 1 stated Resident 4's bedrails were up to prevent falls and to help Resident 4 with mobility (moving one's extremities, changing positions, sitting, standing, and walking). DON 1 stated Resident 4 did not have a consent from the family for the bedrails to be up. DON 1 stated the licensed nurse are the ones to get the consent from the family. DON 1 stated Resident 4 would be at risk for serious injury. DON 1 stated it was important to have the consent to educate the family of the risk for entrapment (a patient being, caught, trapped, or entangled in the spaces in or about the red rail and bedframe). During a concurrent observation and interview on 1/26/2024 at 12:19 p.m. with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the bedrails are up and it is considered a restraint (devices that limit a patient's movement). LVN 2 stated a consent is required when the bedrails are up. LVN 2 stated having the bedrails up can cause bruising of the skin and could cause entrapment. LVN 2 stated we needed to get a consent from the responsible party. LVN 2 stated it is important to have a consent so the responsible party can have a verbal and written understanding of the risk of having the bedrails up. During a review of the facility's policy and procedure (P&P) titled, Restraints, dated 12/2022, the P&P indicated, The facility will verify and document that the resident, or surrogate healthcare decision maker if the resident is unable to make healthcare decisions, has given informed consent before initiating restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 12 of 19 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 01/26/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to use the correct sized scoop for 11 of 11 residents receiving pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These failures had the potential for a highly susceptible population of residents to be at risk for receiving meals that did not meet their nutritional needs. Findings: During an observation on 1/25/2024 at 12:29 p.m., in the kitchen, while serving lunch trays, observed [NAME] 1 searching for a scoop to serve the pureed meat loaf. [NAME] 1 briefly searched for a blue scoop and asked the dishwasher to find one. When the dishwasher was unable to find a blue scoop, [NAME] 1 then used a red scoop to serve the pureed meatloaf instead. During an interview on 1/25/2024 at 1:03 p.m. with [NAME] 1, Cook1 stated that he should have used a blue scoop for the pureed meat loaf, but he could not find another blue scoop. [NAME] 1 stated that he substituted the blue scoop for a red scoop. [NAME] 1 stated that a blue scoop is equal to 2.5 ounces and the red scoop is equal to 2 ounces. [NAME] 1 stated that when appropriate scoop sizes are not available, he (Cook 1) will use another size scoop and eyeball the amount to make sure it is the correct portion size. During an interview on 1/25/2024 at 1:42 p.m. with the Dietary Service Supervisor (DSS) 1, DSS 1 stated that it is inappropriate to change scoops and portion sizes cannot be guessed or eyeballed. DSS 1 stated that it is important to give residents the exact serving size. DSS 1 also stated that changing the serving sizes might cause unintentional weight loss or weight gain. DSS 1 stated that he did not know that the kitchen was short of scoops. He says he will order more scoops today. DSS 1 stated that he will also give an in-service to his staff regarding serving sizes. and to notify him when supplies are running low. During an interview on 1/26/2024 at 9:11 a.m., with the Registered Dietician (RD) 1, RD 1 stated that the kitchen staff must follow the menu and recipes and cannot switch out scoops because it will change the nutritional value of the meal. During a review of the facility's menu, titled Cooks Spreadsheet - Winter Menus, dated 1/22/2024, the facility menu indicated that the pureed Old Fashioned Meatloaf served on 1/24/2024 #8 scoop for smaller size portions and a #16 scoop for larger size portion. According to this menu, a #8 scoop is equal to ½ cup and # 12 scoop was equal to 1/3 cup. During a review of the facility's policy and procedure (P&P) titled, Menus, dated April 2014, the P&P indicated, The Dietary Manager will develop menus in collaboration with the Dietitian to develop menus at least a week in advance. The P&P also indicated that food served should adhere to the written menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 13 of 19 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 01/26/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to use the correct sized scoop for 11 of 11 residents on pureed (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) diets. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference. Findings: During an observation on 1/25/2024 at 12:29 p.m., in the kitchen, while serving lunch trays, observed [NAME] 1 searching for a scoop to serve the pureed meat loaf. [NAME] 1 briefly searched for a blue scoop and asked the dishwasher to find one. When the dishwasher was unable to find a blue scoop, [NAME] 1 then used a red scoop to serve the pureed meatloaf instead. During an interview on 1/25/2024 at 1:03 p.m. with [NAME] 1, Cook1 stated that he should have used a blue scoop for the pureed meat loaf, but he could not find another blue scoop. [NAME] 1 stated that he substituted the blue scoop for a red scoop. [NAME] 1 stated that a blue scoop is equal to 2.5 ounces and the red scoop is equal to 2 ounces. [NAME] 1 stated that when appropriate scoop sizes are not available, he (Cook 1) will use another size scoop and eyeball the amount to make sure it is the correct portion size. During an interview on 1/25/2024 at 1:42 p.m. with the Dietary Service Supervisor (DSS) 1, DSS 1 stated that it is inappropriate to change scoops and portion sizes cannot be guessed or eyeballed. DSS 1 stated that it is important to give residents the exact serving size. DSS 1 also stated that changing the serving sizes might cause unintentional weight loss or weight gain. DSS 1 stated that he did not know that the kitchen was short of scoops. He says he will order more scoops today. DSS 1 stated that he will also give an in-service to his staff regarding serving sizes. and to notify him when supplies are running low. During an interview on 1/26/2024 at 9:11 a.m., with the Registered Dietician (RD) 1, RD 1 stated that the kitchen staff must follow the menu and recipes and cannot switch out scoops because it will change the nutritional value of the meal. During a review of the facility's menu, titled Cooks Spreadsheet - Winter Menus, dated 1/22/2024, the facility menu indicated that the pureed Old Fashioned Meatloaf served on 1/24/2024 #8 scoop for smaller size portions and a #16 scoop for larger size portion. According to this menu, a #8 scoop is equal to ½ cup and # 12 scoop was equal to 1/3 cup. During a review of the facility's policy and procedure (P&P) titled, Menus, dated April 2014, the P&P indicated, The Dietary Manager will develop menus in collaboration with the Dietitian to develop menus at least a week in advance. The P&P also indicated that food served should adhere to the written menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 14 of 19 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 01/26/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food at a safe temperature for 11 of 11 residents two of twenty sampled (Residents 23 and 243). This finding had the potential to cause food borne illness (illness from contaminated food). Residents Affected - Some This failure had the potential to call meal dissatisfaction, decreased food intake and place residents at risk for unplanned weight loss. Findings: During the kitchen lunch tray line observation on 1/23/2024 at 11:39 p.m., the facility thermometer was calibrated and used take food temperatures as follows: Meatloaf: 174 degrees Fahrenheit (F) Potato: scalloped 184 F Peas: 196 F During an observation and interview of lunch tray line on 12/24/2024 at 12:52 p.m., observed [NAME] 1 retrieve Styrofoam plates from the cabinet. [NAME] 1 then proceeded to use the Styrofoam plates to serve lunch to the remaining residents. Asked [NAME] 1why he switched from regular plates to Styrofoam plates. [NAME] 1 stated that the facility ran out of regular plates. During an observation and interview of the lunch tray line on 12/24/2024 at 1:03 p.m., with DSS 1 and Dietary Aide 1, observed Dietary Aide 1 placing a plate covered in plastic wrap onto the food cart. Asked Dietary Aide 1 why she is using plastic wrap to cover plates. Dietary Aide 1 stated that a resident has been throwing the domes (plate covers) away. Dietary Aide 1 stated that they don't have enough to cover the all the plates because they ran out. DSS 1 stated that the plates and plate covers are currently on back order because they are out of stock at the supply company. During a concurrent observation and interview on 1/24/2024 at 1:20 p.m. with Dietary Service Supervisor (DSS) 1, DSS 1 used the facility's calibrated digital thermometer to check the temperature of food items on the lunch test tray. The test tray was requested to be prepared and placed on the last food cart that would be delivered to the last resident's room served. The test tray arrived in a paper container and contained a serving of meatloaf, scalloped potatoes green beans and a wheat roll and a container of orange blossom parfait. The following items were tested for temperature from the lunch test tray: Meatloaf 116 F Peas 112 F During an interview on 1/26/24 at 3:50 p.m., DSS 1 stated that the food should be served to residents over 140 degrees F. DSS 1 stated that food served below 140 F will be cold and is not going to be good. DSS 1 stated that food served below 140 F can also cause food poisoning to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 15 of 19 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 01/26/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Review of the facility's 2012 policy Food Preparation, indicated the facility will follow proper techniques when testing temperatures. Food should be served at proper temperatures. . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 16 of 19 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions for residents by failing to: Residents Affected - Few 1. Discard an open package of marshmallows with an open date of 12/24/2024. 2. Remove soiled disposable gloves and perform hand hygiene before picking up dinner rolls. These deficient practices had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview on 1/23/2024 at 8:40 p.m., with the Dietary Service Supervisor (DSS 1), while in the dry goods storage area of the kitchen, observed an opened package of marshmallows with an open date of 12/24/2023. DSS 1 was asked how long opened food items can be stored in the dry storage. DSS 1 stated that opened food should be discarded after two weeks. DSS 1 stated that he would discard the marshmallows right away because the marshmallows had been opened for over 2 weeks. DSS 1 stated that serving a resident food that has been opened for over 2 weeks can make them sick from food poisoning. During an observation on 1/24/2024 at 12:05 p.m., in the kitchen, during the lunch service line, [NAME] 1, placed oven mitts over his disposable gloves to check food in the oven. [NAME] 1 removed the oven mitts and used his gloved hands to close the oven door. [NAME] 1 also used the gloved hands to open and close cabinet doors. [NAME] 1 then proceeded to use the same gloved hands to pick up dinner rolls and place them on residents' plates without changing his gloves or performing hand hygiene. [NAME] 1 used his hands while wearing soiled gloves instead of using the appropriate utensil to place the rolls on the residents' plates. During an interview on 1/25/2024 at 1:03 p.m., with [NAME] 1, [NAME] 1 stated that he was really nervous, but he is usually very good about washing his hands. [NAME] 1 stated that he should have changed gloves and washed his hands before touching the rolls. [NAME] 1 also stated, Using hands to serve rolls is not the proper way, I should have used tongs to serve the rolls. [NAME] 1 stated that it is important to wash hands because if you touch something that is dirty and then touch the food, you contaminate the food, and the residents can become ill with diarrhea or food poisoning. During an interview on 1/25/2024 at 1:57 p.m., with the Dietary Service Supervisor (DSS) 1, the DSS stated that [NAME] 1 should have used tongs to serve the bread. DSS 1 also stated that touching food with soiled gloves can lead to cross-contamination of food and residents could get food poisoning. During a review of the facility's policy and procedure (P&P) title, Food Storage, dated July 2019, the P&P indicated that any opened products in dry storage should be placed in storage containers with tight fitting lids. During a review of the facility's P&P titled, Infection Control, dated January 2012, the P&P indicated that the objective of facility's infection control P&P is to prevent, detect investigate and control infections in the facility and to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 17 of 19 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 01/26/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P, titled Hand Hygiene, dated September 2020, the P&P indicated, The Facility considers hand hygiene as the primary means to prevent the spread of infections. The P&P also indicated that wearing gloves does not replace the need for hand hygiene and appropriate hand hygiene is required before and after food preparation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 18 of 19 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 01/26/2024 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 Based on observation, interview and record review, the facility failed to ensure standard infection control practices were followed by failing to wear gloves when one of three laundry aid staff wear gloves while handing soiled linens. Residents Affected - Few This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents in the facility. Findings: a. During an observation on 1/25/2024 at 9:43 a.m. in the laundry area, LA 1 used non-deposal glove when handling soiled linen, then placing soiled non disposal gloves on top of an overhead shelf and reusing the same non-disposal gloves again to sort a different cart of soil linen. b. During an observation on 1/25/2024 at 9:53 a.m. in the Laundry Area, LA1 picked up linen off the floor in the laundry area and place it on top of clean linen in the laundry cart which contain clean linen. During an interview on 1/25/2024 at 11:12 a.m. with MS. stated LA 1 should not be wearing non-disposable gloves. MS stated LA 1 did not disinfect the gloves prior to using them. MS stated he observed LA 1 placing the linen that failed on the floor on top of the clean linen. MS stated LA 1 should not have been throwing soiled linen against the wall. MS stated we have a lot of laundry and LA 1 should have used another laundry basket to put soiled blanket in a separate cart. During a concurrent interview on 1/25/2024 at 11:48 a.m. with MS. MS read the facility policy and procedure (P&P) dated 1/1/2012 Section 1 [A] Wear rubber gloves to empty hampers containing soiled linen into containers used for sorting linens in laundry. The P&P indicated Facility staff wear gloves whenever there is touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. (Section ii) indicates facility staff will wear gloves that fit and are durability for the task. (Section iii) Gloves are used only once and are discarded into the appropriate receptacle located in the room in which the procedure is being performed. (Section iv) Hands are washed before and after the removing of gloves. (Section v) Hypoallergenic gloves, glove liners, powder-less gloves, or other similar alternatives are available to those employees who are allergic to the gloves normally proved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555677 If continuation sheet Page 19 of 19