Health inspection·April 8, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Grievances and Complaints which indicated the facility would promptly review, investigate and resolve grievances and complaints for one out of three sampled residents (Resident 1). This failure had the potential for unaddressed and unresolved grievances for Resident 1 and had the potential to negatively affect the resident's quality of life and safety. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1's History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a review of the facility's Grievance Log dated 03/2025-04/2025, the Log did not indicate there was any grievance or concern from Resident 1. During an interview on 4/8/2025 at 10:50 a.m. with Resident 1, Resident 1 stated her roommate kept touching the (privacy) curtain and it bothered her. Resident 1 stated she reported the issue to a staff member (unknown) the previous day and nothing was done about it. During an interview on 4/8/2025 at 1:02 p.m. with the Social Services Director (SSD), the SSD stated, Resident 1 notified her that she (Resident 1) was having an issue with her roommate closing the privacy curtain. SSD stated she offered Resident 1 a room change, and the resident declined. SSD stated, any grievances and potential issue of roommate incompatibility, should have been documented on the grievance log and followed up on. SSD stated there was no supporting documentation to indicate a room change was offered or any follow-up was completed to resolve the grievance by Resident 1. Page 1 of 6 555816 555816 04/08/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0585 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/9/2025 at 1:51 p.m. with the Director of Nursing (DON), the DON stated, if a resident has a grievance related to their room or roommate, the grievance should be written down to be discussed along with solutions that were offered. The DON stated that if it was not documented on the grievance log, the problem was not acknowledged. The DON stated a room change should have been offered to prevent any altercation between Resident 1 and her roommate. Residents Affected - Few During a review of the facility's P&P titled, Grievances and Complaints dated 12/2017, the P&P indicated, The disposition of all written grievances and/or complaints is recorded on the Resident Grievance/Complaint Log (i.e. resolved, dispute, etc.) The P&P indicated, upon receiving a grievance/complaint report, the Grievance Official or designee provides a copy of the report to the appropriate department manager to begin the investigation, and subsequent resolution. The P&P indicated, if follow-up is required, the Grievance Official is responsible for ensuring that the follow-up action is taken in a timely manner. 555816 Page 2 of 6 555816 04/08/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 ensure pain management was effective for one of three sampled residents (Resident 1) by failing to: Residents Affected - Few 1.Thoroughly assess and reassess Resident 1 when the resident complained of 4 out of 10 pain (pain rating reference: 1-4=mild pain, 5-7=moderate pain, 8-9= severe pain, 10=excruciating pain) 2.Administer pain medication and/or provide non-nonpharmacological interventions (techniques other than medications to alleviate pain) as ordered by the physician. This failure had the potential to leave Resident 1 with unresolved pain and had the potential to negatively affect Resident 1's physical, mental, and psychosocial wellbeing. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). During a review of Resident 1's History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a review of Resident 1's Physician Order Summary report dated 4/01/2025, the Order Summary indicated the following: -On 3/9/2025, the physician ordered to administer acetaminophen oral tablet 500 milligrams ([mg] a unit of measurement) tablet, two tablets by mouth every six hours as needed for mild pain. The order indicated non-pharmacological interventions including heat, repositioning, relaxation breathing, food/fluids, massage, exercise and immobilization. -On 1/4/2025, the physician ordered to assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. During a review of Resident 1's Medication Administration Record (MAR) dated 3/2025, the MAR indicated Resident 1 reported 4 out of 10 pain on 3/29/2025 and 3/30/2025. The MAR did not indicate acetaminophen and/or non-pharmacological interventions were provided to Resident 1 as ordered by the physician. During a review of Resident 1's Medication Administration Notes dated 3/2025, the Notes did not indicate Resident 1's was thoroughly assessed nor any interventions provided 3/29/2025 and 3/30/2025 555816 Page 3 of 6 555816 04/08/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0697 after the resident reported 4 out of 10 pain. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interviews on 4/8/2025 at 2:28 p.m. and 2:56 p.m. with the Director of Nursing (DON), the DON stated residents should be assessed for pain including location of the pain, the pain rating and whether any interventions were provided. The DON stated, there should also be a pain reassessment 30 minutes to one hour after to ensure the medication/interventions provided were effective in relieving the resident's pain. The DON stated, Resident 1 had 4 out 10 pain on 3/29/2025 and 3/30/2025 and there was no supporting documentation to indicate Resident 1 was thoroughly assessed and reassessed, nor given any interventions for pain. Residents Affected - Few During a record review of facility's policy and procedure (P&P) titled, Pain Management dated 5/25/2023, the P&P indicated, a pain assessment will be completed when there is a new onset of pain. P&P indicated, the Licensed Nurse will administer pain medication as ordered and document medication administered on the MAR. The P&P indicated, after medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour and the Licensed Nurse will assess the resident for pain and document results on the MAR each shift. 555816 Page 4 of 6 555816 04/08/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

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 provide a functional call device (a device used by residents to communicate their needs to staff) for two out of three sampled residents (Residents 1 and 2). Residents Affected - Few This failure had the potential to result in a delay in care for Resident 1 and Resident 2 and the resident ' s needs not being met. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1 ' s History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a concurrent observation and interview on 4/8/2025 at 9:03 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 ' s call light did not turn on when the resident pressed it. There was no call bell or other means to call staff observed at the resident ' s bedside. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2 ' s diagnosis included polyneuropathy (a condition where many nerves throughout the body are damaged or malfunctioning, affecting sensation and movement). A review of Resident 2 ' s H&P dated 3/25/2025, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 had no cognitive impairment. The MDS indicated Resident 2 required substantial/maximal assistance to perform ADLs such as lower body dressing, transfers and walking 10 feet. During a concurrent observation and interview on 4/8/2025 at 8:56 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 ' s call light did not turn on when the resident pressed it. There was no call bell or other means to call staff observed at the resident ' s bedside. Resident 2 stated she has not been able to use her call light to call the nurses. Resident 2 stated her call light had not been working for two weeks and had to go to the nurse ' s station whenever she needed medication. During a concurrent observation, record review and interview on 4/8/2025 at 9:23 a.m. with 555816 Page 5 of 6 555816 04/08/2025 Lawndale Healthcare & Wellness Centre LLC 15100 S Prairie Lawndale, CA 90260

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Restorative Nursing Assistant (RNA) 1, the facility ' s Maintenance Request Log dated 4/6/2025 was reviewed. RNA 1 stated the call lights for Resident 1 and Resident 2 ' s room did not work when pressing the call light button. RNA 1 stated this issue started on 4/6/2025. RNA 1 stated, Resident 1 and Resident 2 ' s call light had an issue with not turning off and there was no documentation to support that the call light issue was resolved on 4/6/2025. RNA 1 stated, this is not acceptable for residents not to have a functional call light because Resident 1 and Resident 2 could not be attended to right away. During an interview on 4/8/2025 at 2:28 p.m. with the Director of Nursing (DON), the DON stated residents whose call lights did not work and could not be repaired right away, should have call bells to alert the staff of their needs. The DON stated residents should not be left without a call light because it placed the resident at risk for fall or accidents. During a review of facility ' s policy and procedure (P&P) titled, Communication – Call System, dated 2022, the P&P indicated, the call alert device will be placed within the resident ' s reach and If the call alert system cannot be repaired immediately, an alternative call alert process will be put in place (i.e. tap bells, auxiliary aids, etc.). Enter comment here 555816 Page 6 of 6