Other·April 26, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of an entity reported incident (ERI). ERI number CA00503934 Representing the Department of Public Health: Surveyor ID: 36385, RN, HFEN The inspection was limited to specific ERI investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of ERI number: CA00503934. Amended 4/4/19

F223 SS=D FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.13(b), 483.13(c)(1)(i)

F223 04/28/2018 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EC5U11 Facility ID: CA910000004 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056143 (X3) DATE SURVEY COMPLETED 03/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OSAGE HEALTHCARE & WELLNESS CENTRE 1001 S Osage Ave Inglewood, CA 90301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to ensure residents were free of verbal abuse for one of one sampled residents (Resident 1). A Certified Nursing Assistant 1 (CNA 1) was overheard by Housekeeper 1 being verbally and physically abusive to Resident 1. This deficient practice resulted in Resident 1 being verbally and physically abused. Findings: On September 28, 2016, at 4:05 p.m., Resident 1 was observed sitting in a chair, in the activity room. Resident 1 was unable to answer questions when asked. A review of Resident 1's Admission Records indicated the resident was admitted to the facility on March 14, 2016, and last re-admitted on July 5, 2016. Resident 1's diagnoses included sepsis (life-threatening response of the body to fight infection), urinary tract infection ([UTI] an infection of the bladder and urinary tract), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated August 1, 2016, indicated Resident 1 had severe cognitive impairment (never/rarely made decisions). The MDS indicated Resident 1 was unable to say the correct year, month, and day. A review of Resident 1's Social Work Progress Note, dated September 19, 2016, and timed at 10:52 a.m., indicated Housekeeper 1 reported to Social Service Staff (SSS 1) that she witnessed a female nurse, Certified Nursing Assistant 1 (CNA 1), speaking inappropriately to Resident 1. The note indicated CNA 1 grabbed the resident by the elbow in an aggressive manner to redirect him to his room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EC5U11 Facility ID: CA910000004 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056143 (X3) DATE SURVEY COMPLETED 03/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OSAGE HEALTHCARE & WELLNESS CENTRE 1001 S Osage Ave Inglewood, CA 90301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE According to the note, this incident happened at 6:20 a.m., on September 19, 2016 when CNA 1 observed Resident 1 wandering the hall naked. The note indicated CNA 1 was upset, frustrated, and stated to Resident 1, "I don't have time for you, get your naked a-- in the room. This is not my job to be chasing you." During an interview, on October 18, 2016 at 11:15 a.m., Housekeeper 1 stated on September 19, 2016, at 6:20 a.m., she witnessed CNA 1 telling Resident 1 to " ...get your a-- in the room and lay down." On October 18, 2016 at 11:30 a.m., a telephone interview with CNA 1 was attempted unsuccessfully without a return call. A review of CNA 1's employee file indicated the cna was hired on September 14, 2016, and terminated on September 20, 2016. There was no indication for CNA 1's termination documented. A review of the facility's policy titled, "Resident Rights," revised January 1, 2012, indicated the facility staff were to speak respectfully to residents at all times. The policy indicated demeaning practices and standards of care that compromise dignity are prohibited. A review of the facility's policy titled, "Abuse Prevention," dated November 6, 2015, indicated "the facility does not condone any form of resident abuse," and verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents regardless of their disability to comprehend. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EC5U11 Facility ID: CA910000004 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056143 (X3) DATE SURVEY COMPLETED 03/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OSAGE HEALTHCARE & WELLNESS CENTRE 1001 S Osage Ave Inglewood, CA 90301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: EC5U11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA910000004 (X5) COMPLETE DATE If continuation sheet 4 of 4