Other·May 15, 2019

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 an investigation of a Complaint. Complaint Number: CA00624506 Representing the Department of Public Health: HFEN, 34180, RN The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility.

F684 SS=G Quality of Care CFR(s): 483.25

F684 05/02/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its policy, resident's plan of care, and the physician's orders to ensure medication was administered as prescribed by the physician for one of three sampled residents (Resident 1). Resident 1, who had a diagnosis of epilepsy ([seizure] a brief episode of uncontrolled body jerking and loss of mental awareness]), was prescribed Dilantin ([anticonvulsant medication] used to prevent and control seizures), but received more than 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: AYEK11 Facility ID: CA910000004 If continuation sheet 1 of 8 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 04/15/2019 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 prescribed amount by the physician. This deficient practice resulted in Resident 1 receiving 800 milligram [mg] of Dilantin a day, 300 mg more a day than prescribed by the physician resulting in the resident having Dilantin toxicity with a level of 47.4 micrograms (mcg)/dl (deciliters) (Normal Reference Range [NRR] is 10 to 20 mcg/dl ). Resident 1 required an emergency transfer to a general acute care hospital (GACH) and was diagnosed with Dilantin toxicity, admitted on a telemetry unit (a unit in the hospital where residents are under continuous electronic monitoring) and requiring monitoring and treatment for eight (8) days. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on 5/27/14. Resident 1's diagnoses included a history of hydrocephalus (an accumulation of cerebrospinal fluid (CSF) occurs within the brain [typically causes increased pressure inside the skull) with a shunt (a hole or a small passage which moves, or allows movement of fluid from one part of the body to another), dysphagia (difficulty swallowing), gastronomy ([G-tube] a tube surgically placed into the stomach to provide nutrition and medication), dementia (a chronic or persistent disorder of memory loss) and epilepsy ([seizure] a brief episode of uncontrolled body jerking and loss of mental awareness). A review of Resident 1's Minimum Data Set (MDS), an assessment and care- screening tool, dated 12/24/18, indicated the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 2 of 8 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 04/15/2019 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 cognitive skills for daily decision-making was moderately impaired. According to the MDS, Resident 1 was non-ambulatory and required total assistance with all activities of daily living ([ADLS] grooming, mobility etc.). A review of Resident 1's history and physical (H/P), dated 12/27/18, indicated the resident did not have the capacity to understand and make decisions. A review the GACH's laboratory record, dated 12/24/18, indicated Resident 1 had a low Phenytoin (Dilantin) level of 1.0 mcg/dl [NRR-10 to 20 mcg/dl). A review of the Admission orders, dated 12/27/18, indicated to give Resident 1 Dilantin 100 milligrams (mg) twice daily (BID [9 a.m. and 5 p.m.]) via the G-tube and check monthly Dilantin laboratory levels. A review of Resident 1's Care Plan, dated 12/27/18 and titled, "Seizure Disorder" indicated for the staff to administer the antiseizure medications as ordered and monitor for signs of adverse effects. A review of a physician's order, dated 1/15/19 and timed at 1 p.m., indicated to discontinue Resident 1's previous order of Dilantin 100 mg and change to Dilantin 150 mg via G-tube twice a day and a repeat the Dilantin level in one week. A review of Dilantin laboratory level results, dated 1/22/19, indicated Resident 1's Dilantin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 3 of 8 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 04/15/2019 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 level was low at 5.2 mcg/dl. A review of a Resident 1's physician's order, dated 1/24/19 and timed at 1 p.m., indicated to discontinue the previous Dilantin 100 mg order and change to Dilantin 250 mg twice daily (for a total of 500 mg daily) and recheck the Dilantin level. A review of Resident 1's laboratory result, dated 1/31/19 indicated the Dilantin level was pending. However, after further review of Resident 1's clinical records, there was no documented evidence of a Dilantin level result for 1/31/19. A review of a nurses' note, dated 2/1/19 and timed at 6 p.m., indicated Resident 1's Dilantin laboratory level remained in pending status. According to the note, Resident 1 was observed to be in a somnolent (sleepiness or drowsiness) state. A review of MedlinePlus, an online pharmacy site, indicated under Poisonous Ingredient that Dilantin could be harmful in large amounts. The article indicated the symptoms of Dilantin overdose varied, but included confusion, coma, lethargy (a pathological [disease] state of sleepiness or deep unresponsiveness and inactivity), low blood pressure and sleepiness @ https:/medlineplus.gov/ency/article/002632.htm A review of an untimed nurses' note, dated 2/2/19, indicated an inquiry was made to the laboratory regarding Resident 1's pending Dilantin level. According to the note, the laboratory's staff indicated that the Dilantin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 4 of 8 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 04/15/2019 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 level results were completed within two-three days. A review of an untimed nurses' note, dated 2/3/19, indicated Resident 1's family member expressed concern about the Dilantin level results because of the resident's behavior. A review of a nurses' note, dated 2/4/19 and timed at 11:08 a.m., indicated the staff called the laboratory again regarding Resident 1's Dilantin level that was collected on 1/31/19. According to the note, the laboratory indicated that the resident's Dilantin level was "rejected" and since the family was concerned about the resident's behavior a STAT (immediate) Dilantin level was repeated. A review of a Dilantin laboratory result, dated 2/4/19 and timed at 1:19 p.m., and verified on the same day at 3:08 p.m., indicated Resident 1 had a critically high Dilantin level of 40 mcg/dl. A review of a nurses' note, dated 2/4/19 and timed at 1:30 p.m., indicated Resident 1's physician was notified of the abnormal Dilantin level results. A review of the Medication Administration Record (MAR), for the month of 1/2019, indicated Dilantin 150 mg/6 ml was administered to Resident 1 twice daily from 1/15/19 to 1/31/19. Another MAR, for the same month, indicated Dilantin 150 mg/6 ml was administered to Resident 1 twice daily from 1/15/19 to 1/24/19 and then discontinued on 1/24/19. According to the two MARs, Resident 1 received 800 mg of Dilantin a day, 300 mg more than prescribed, from 1/25/19 to 1/31/19 (7 days). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 5 of 8 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 04/15/2019 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 the MAR for the month of 2/2019 indicated Dilantin 250 mg was administered to Resident 1 twice daily from 2/1/19 to 2/4/19, for a total of 500 mg a day. A review of a physician's order, dated 2/4/19 and timed at 3:30 p.m., indicated to transfer Resident 1 to the GACH for further evaluation of a critical Dilantin level of 40 mcg/dl. A review of the GACH's Emergency Department note, dated 2/4/19 and timed at 6:20 p.m., indicated Resident 1's Dilantin level was critically high at 47.4 mcg/dl and Poison Control (provides expert treatment advice and assistance in case of exposure to poisonous, hazardous, and/or toxic substances) was notified. On 2/22/19 at 7:51 a.m., during a telephone interview, Resident 1's family member (FM 1) stated the resident had Dilantin toxicity due to the facility over medicating the resident. FM 1 stated she informed the Registered Nurse Supervisor (RNS) that Resident 1 had received too much Dilantin, but the RNS indicated Dilantin had not been administered to Resident 1. On 4/9/19 at 8:10 a.m., during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated she administered Dilantin 150 mg/6 ml to Resident 1 at 9 a.m., on 1/16/19, 1/21/19, 1/22/19, 1/25/19, 1/26/19, 1/27/19, 1/28/19, 1/30/19 and 1/31/19 and denied administering 250 mg of Dilantin to Resident 1. However, during the interview and record review of the Resident 1's MAR, LVN 1 confirmed her initials indicating she administered Dilantin 250 mg at 9 a.m. on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 6 of 8 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 04/15/2019 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 1/25/19, 1/26/19, 1/27/19, 1/28/19, 1/30/19 and 1/31/19. On 4/9/19 at 9:06 a.m., during an interview, the Director of Nursing (DON) stated Resident 1's Dilantin order for 1/24/19 to receive 250 mg BID was not located until later. The DON stated that they made an effort to cover themselves and documented on the MAR. On 4/11/19 at 1:20 p.m., during a telephone interview, LVN 2 stated he administered 150 mg of Dilantin to Resident 1 on 1/17/19 and 1/21/19 and denied administering the resident 150 mg of Dilantin on 1/30/19 and 1/31/19. LVN 1 stated he administered 250 mg of Dilantin on 1/30/19, 1/31/19. LVN 1 was asked about his initials on the MAR for 1/30/19 and 1/31/19, indicating he administered 150 mg and 250 mg of Dilantin to Resident 1, LVN 1 stated he possibly made a mistake initialing. A review of the facility's revised policy, dated 1/1/12 and titled, "Medication," indicated medication and treatments will be administered as prescribed to ensure compliance with dose guidelines. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR). Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. A review of another facility policy, dated 8/1/10 and titled, "Specific Medication Administration Procedures [Dilantin Administration via Feeding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 7 of 8 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 04/15/2019 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 Tube]," indicated the nurse would observe for signs and symptoms of sub-therapeutic levels, which may include breakthrough seizures as well as signs of toxic levels which may include drowsiness and dizziness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AYEK11 Facility ID: CA910000004 If continuation sheet 8 of 8