Other·January 25, 2019

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 Department of Public Health during the investigation of a facility reported incident (FRI) during an abbreviated standard survey. FRI Number: CA00486545 Representing the Department of Public Health: Surveyor ID: 36385, RN, HFEN The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for facility reported incident number CA00486545.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d), 483.20(k)(1)

F279 01/05/2019 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 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: W9YL11 Facility ID: CA910000004 If continuation sheet 1 of 12 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 12/27/2018 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 The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy regarding fall incidents and a resident's plan of care to provide the necessary assistance and supervision to prevent the falls for one of two sampled residents (Resident 1). Resident 1 had a diagnosis of Parkinson's disease (a disorder that affects the nerve cells and causes changes in muscle rigidity [muscles stays contracted or partly contracted for an extended period], tremors [repetitive shaking] and movement) and required staff supervision/assistance for mobility around the facility. This deficient practice resulted in Resident 1 having two falls on the same day and sustaining an acute (sudden) fracture (broken bone) of the left femoral head (head of the leg bone that fits in the hipbone), which required a transfer to a general acute care hospital (GACH) and undergoing a bipolar arthroplasty of the left hip (a surgical procedure that replaced the head of a damaged leg bone with an implant designed to stabilized the leg bone and restore hip function). Resident 1 was admitted into the GACH for four days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 2 of 12 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 12/27/2018 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 Findings: A review of Resident 1's "Admission Record" indicated the resident was admitted to the facility on 11/25/14 with diagnosis that included Parkinson's disease with a movement disorder. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and carescreening tool, dated 8/31/16, indicated the resident's cognition (ability to reason and think) was intact. According to the MDS, Resident 1 was not steady, used a wheelchair for mobility and required staff supervision for getting around in the facility. A review of Resident 1's care plan, initiated 12/4/15, indicated the resident was at risk for fall related to the diagnosis of Parkinson's disease. The staff's intervention included to monitor the resident closely for risk of falls. A review of another care plan, initiated 3/4/16, indicated Resident 1 had self-care deficits for activities of daily living ([ADL], basic self-care tasks on daily basis such as eating and walking) and the resident required assistance with locomotion on and off the unit. The staff's intervention indicated that the staff would provide assistance and cues for the resident with moving around the facility. A review of Resident 1's Physician Progress Note, dated 10/2/16 and timed at 8 p.m., indicated the resident had muscle weakness and tremors (involuntary muscle contraction leading to shaking movements of the body). A review of Resident 1's Nurses Progress Note, dated 10/10/16 and timed at 7:30 p.m., indicated the resident had a fall incident. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 3 of 12 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 12/27/2018 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 note indicated Resident 1 was behind his wheelchair and was ambulating in the hallway and he told Certified Nurse Assistant 1 (CNA 1) that he fell in the dining room. The note indicated Licensed Vocational Nurse 1 (LVN 1) heard a "bang" and she found the resident in a sitting position behind a nightstand in his room. The resident complained of slight pain on bluish discolored left knee and was unable to bend the knee. According to the nurse's note, a PA (physician assistant) was notified with an order for x-ray of the left knee. A review of another nurse's note, dated 10/10/16 and timed at 23:05 (11:05 p.m.) indicated the results of Resident 1's left knee xrays were negative with no fracture or dislocations. A review of a Nurses Progress Note, with a topic of "Fall Incident," dated 10/11/16 and timed at 15:15 (3:15 p.m.) indicated Resident 1 complained of pain to the left knee and was medicated with extra strength (ES) Tylenol (for mild pain). A review of a Nurse's Progress Note, dated 10/12/16 and timed at 19:20 (7:20 p.m.), indicated Resident 1 complained of left hip pain. According to the nurse's note, the PA was notified with new orders noted and carried out. A review of Resident 1's x-ray results of the left hip, dated 10/13/16, indicated the resident had an acute fracture of the left femoral head (left hip area). A review of a Physician's Order, dated 10/14/16 and timed at 4:50 p.m., indicated to transfer Resident 1 to the emergency room for evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 4 of 12 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 12/27/2018 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 A review of a Nurse's note, dated 10/14/16 and timed at 4:50 p.m., indicated Resident 1 was transferred to the GACH's emergency room for a left femoral head fracture. A review of the GACH's hospital "Admission Record" indicated Resident 1 was admitted to the hospital on 10/14/16 and discharged on 10/18/16, four days later, from the hospital with a diagnosis of a left femoral neck fracture. A review of the GACH's record, dated 10/14/16 and titled, "History and Physical (H/P)" indicated Resident 1 was brought in by ambulance with complaints of left femur (leg bone) fracture. The H/P indicated the facility's staff reported that three days prior Resident 1 yelled from the cafeteria [sic] and the resident was found down on the floor. The H/P indicated Resident 1 recalled that he fell and he was weak already on baseline. A record review of a report of an x-ray of the left femur and pelvis (hip), dated 10/14/16, indicated Resident 1 had an intertrochanteric fracture of the left femur. A record review of an operative report, dated 10/16/16, indicated Resident 1 had a bipolar arthroplasty of the left hip (a surgical procedure that replaced the head of a damaged leg bone with an implant designed to stabilized the leg bone and restore hip function). On 6/6/17 at 8:25 a.m., during an interview, Resident 1 was asked about the incident on 10/10/16, the resident stated on that evening, after dinner he had slipped and fell and his left hip hit the floor. Resident 1 stated when he fell; he had left hip pain of 7 on a pain scale 10 being the worse (0 being no pain and 10 being the worst pain possible). Resident 1 stated he had another fall the same evening in his room, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 5 of 12 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 12/27/2018 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 which he landed in a sitting position next to his roommate's nightstand. At 11:40 a.m., on 6/6/17, during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she was assigned to take care of Resident 1 on the night of the unwitnessed fall incident on 10/10/16. LVN 1 stated after dinner between the hour from 8 p.m. to 9 p.m., Certified Nurse Assistant 1 (CNA 1) reported to her that Resident 1 had a fall in the dining room. LVN 1 stated there was not a staff assigned to supervise the residents in the dining room at that time because the dining room was closed by then. LVN 1 stated after the fall, Resident 1 walked behind his wheelchair by himself from the dining room back to his room. LVN 1 stated Resident 1 had another unwitnessed fall in his room the same evening. LVN 1 stated when she heard a noise, she saw Resident 1 in a sitting position on the floor in the resident's room. LVN 1 stated she did not investigate how Resident 1 fell in the dining room, as per policy. On 6/7/17 at 11:10 a.m., during an interview, Director of Nursing 2 (DON 2) stated after dinner there were no staff assigned to monitor the dining room on 10/10/16. DON 2 stated when Resident 1 had an unwitnessed fall in the dining room; the staff should have assisted all the residents back to their rooms after dinner, including Resident 1 to prevent another fall. DON 2 stated the staff should have investigated circumstances of the fall in the dining room by finding out how the fall occurred and what part of the resident's body hit the floor and provided that information to the physician so the physician could determine the appropriate orders. According to the facility's policy and procedure titled, "Safety and Supervision of Residents," revised December 2007, indicated the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 6 of 12 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 12/27/2018 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 strives to make the environment as free from accident hazards as possible. The resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. According to the facility's policy and procedure titled, "Accidents and Incidents- Investigating and Reporting," revised April 2012, the facility was responsible for including in the investigation, the circumstances surrounding the accident or incident and the injured person's account of the accident or incident.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 01/05/2019 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow a resident's plan of care and provide adequate supervision to ensure a resident who was confused and dependent on the staff and had a high risk for elopement (to leave the facility without supervision/permission) did not leave the facility unsupervised for one of three sampled residents (Resident 1). Resident 1, who had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 7 of 12 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 12/27/2018 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 diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), left the facility unsupervised. This deficient practice resulted in Resident 1 being missing for 11 days and later being found in a general acute care hospital (GACH) sustaining a laceration (deep cut) on the back of the head which required surgical sutures (staples). Findings: A review of Resident 1's Admission Records indicated the resident was admitted to the facility on April 7, 2016. Resident 1's diagnoses included hypertension (high blood pressure), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures [uncontrolled activity in the brain, which causes sudden irregular movement of the body]). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and screening tool, dated April 14, 2016 indicated the resident had severe cognitive (thought process) impairment. A review of Resident 1's Elopement Risk Assessment, dated April 8, 2016, indicated a score of 8, due to intermittent confusion and being ambulatory (walk) independently. The Risk Assessment form indicated a total score of 8 or greater, the resident should be considered at risk for potential elopement from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 8 of 12 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 12/27/2018 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 A review of Resident 1's care plan titled, "Elopement Precautions," dated April 8, 2016, with a goal for the resident to have no episode of leaving the facility unsupervised daily. The staff's approach plan included: constant monitoring of the resident's whereabouts and to maintain a safe and hazard free environment. A review of Resident 1's "Interdisciplinary Team (IDT) Conference Record" ([IDT] a group of health care professionals from diverse fields who collaborate toward a common goal for the resident), dated May 2, 2016, indicated that on May 1, 2016, at approximately 6 p.m., Resident 1 went missing from the facility. On May 2, 2016, the facility reported to the Department of Public Health (DPH) that Resident 1 eloped from the facility. On May 12, 2016 (11 days after going missing), DPH received a fax from the facility indicating Resident 1 was found at a general acute care hospital (GACH). A review of the GACH's "Emergency Documentation," dated May 3, 2016, and timed at 3:44 p.m., indicated Resident 1 was brought to the GACH by a law enforcement, after a ground level fall ([GLF] fall to the floor). It was unclear of how Resident 1 sustained the fall. The ER note indicated Resident 1 had a onecentimeter (cm) laceration to the occipital area (back) of the head with a hematoma (swelling of clotted blood). The ER note indicated Resident 1 was confused, spoke incoherently (without logical or meaningful connection), and did not answer questions appropriately. A review of the ER Nursing Progress notes from the GACH, dated May 3, 2016, and timed at 4:17 p.m. (16:07), indicated Resident 1 was having an episode of tonic-clonic (jerking movements, followed by stiffness) seizure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 9 of 12 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 12/27/2018 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 activity. The Nursing Progress Note further indicated on the same day, at 5:51 p.m. (17:51), the resident had the occipital laceration repair with staples ([for wound closure] did not indicate how many staples) and was placed on cervical spine ([the first 7 bones of the spine {vertebrae}] are efforts to prevent movement of the spine in those with a risk of a spine injury) and seizure precautions (interventions used to minimize injuries during seizure activity). During an interview on May 12, 2016 at 3:50 p.m., the GACH's Social Worker (SW) stated that Resident 1 was altered (confused) when he first arrived at the hospital and was identified as a John Doe (name given to patients whose identities could not be verified at time of admission). The SW stated when Resident 1's condition became stable he was able to let the hospital's staff know who he was and the hospital's staff called the family, who verified that Resident 1 was missing from the skilled nursing facility. During a tour of the facility on May 4, 2016 at 8:25 a.m. with Licensed Vocational Nurse 1 (LVN 1), the East middle building side doors were observed to be unlocked. The main East middle building doors opened out to the smoking patio. There were ambulatory (able to walk independently with or without an assistive device) and wheelchair-bound residents observed going in and out of the doors. The doors also had no wander guard alarm (a door alarm that operates by monitoring motion through a doorway or hallway, by sending an audible alert, to prevent wandering) installed. At 9 a.m., on May 4, 2016, during a tour of the facility grounds with the Administrator, there was an opened area observed between the skilled nursing facility (for residents who required higher level of medical care) east FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 10 of 12 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 12/27/2018 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 building and the adjacent Assisted Living (for residents who are more independent, but required some assistance with daily activities) area which was shared by both facilities. From the opened area, there was a walkway from the Assisted Living that led to a gate that opened onto a main street. The gate was observed to be unlocked from the inside of the facility. During a concurrent interview, the Administrator stated the Assisted Living residents had keys to come into the facility, but did not need keys to go out. During an interview on May 4, 2016 at 9:15 a.m., the Administrator stated the East middle building entrance never had a wander guard alarm on the door since she started working at the facility in 2011. On May 4, 2016 at 9:30 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 1 was "a little confused" but knew where he was. CNA 1 stated that Resident 1 would sit in a chair on the outside patio. CNA 1 stated that on May 1, 2016, she observed the resident sleeping in his Geri-chair (type of medical chair that reclines) in the East middle building lobby when she left to go home at approximately 3 p.m. During an interview on July 19, 2016 at 1:15 p.m., the facility's Activity Assistant (AA) stated that she was working as the smoking monitor (a person who monitors residents during smoking breaks) the day Resident 1 eloped from the facility. The AA stated that the last time she saw Resident 1 was on May 1, 2016 at approximately 4 p.m., sitting in the patio corner "where he sat all the time." A review of a "Missing Person Report" from the local law enforcement, dated May 1, 2016, indicated that the facility reviewed the video FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 11 of 12 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 12/27/2018 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 surveillance system and saw Resident 1 walking out of the facility at 5:45 p.m., northbound onto the main street and then out of sight. The report indicated a redacted (blocked out) name that indicated the resident (Resident 1) had made several statements about wanting to leave the facility and go home. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W9YL11 Facility ID: CA910000004 If continuation sheet 12 of 12