Other·January 22, 2020

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 (DPH) during the investigation of a complaint. Complaint number: CA00660611 Representing the DPH: RN, HFEN 11912 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint number CA00660611 Amended 12/24/19

F690 SS=G Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 01/22/2020 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless 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: MKWT11 Facility ID: CA910000004 If continuation sheet 1 of 7 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 12/23/2019 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 resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide the necessary urinary catheterization (insertion of a catheter [soft tubing] into the urethra [hollow tube that leads from the bladder and transports and discharges urine outside the body] to release the urine) care and treatment for one of two sampled residents (Resident 1). Resident 1 required urinary catheterization to drain urine and Licensed Vocational Nurse 2 (LVN 2), after noticing resistance upon insertion, forced the catheter into the urethra. As a result, Resident 1 had gross hematuria (blood in the urine that can be seen with the naked eye). Resident 1 required transfer to General Acute Care Hospital 1 (GACH 1), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 2 of 7 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 12/23/2019 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 underwent a cystoscopy (a procedure that lets the urologist view the inside of the bladder and urethra in detail with the use of a hollow tube [cystoscope] equipped with a lens) and required blood transfusion of five units of blood due to blood loss. Resident 1 was hospitalized for nine days. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on 6/10/19, with diagnoses including paraplegia (inability to move or feel from the waist down). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and carescreening tool) dated 6/17/19, indicated Resident 1 was able to make decisions and did not have memory problems. Resident 1 required intermittent urinary catheterization. A review of Resident 1's Physician's Orders on admission, 6/10/19, indicated Resident 1 to self-catheterize using an in-and-out straight catheter. A review of Resident 1's History and Physical (H/&) exam completed by the attending physician on 6/11/19, indicated Resident 1 had the capacity to understand and make decisions and could self-catheterize as needed. A review of Resident 1's Nurses' Progress Note from 6/11 to 6/27/19, indicated Resident 1 did not have signs and symptoms of adverse reaction (any unexpected or dangerous reaction to a drug) from the antibiotic (medication to treat infections) treating a urinary tract infection (UTI - an infection in any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 3 of 7 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 12/23/2019 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 part of the urinary system: kidneys, ureters, bladder and urethra) and Resident 1 did not have complaints. A review of Resident 1's Nurses' Progress Note dated 6/27/19, for the 3 p.m. to 11 p.m. shift, indicated Resident 1 performed an in-and-out catheterization obtaining clean yellow urine drainage without any sediment (matter that settles to the bottom, causing the urine to be dark/cloudy) and Resident 1 did not have discomfort. A review of Resident 1's Nurses' Progress Note completed by LVN 1 on 6/28/19 and timed at 4 p.m., indicated LVN 1 inserted a urinary indwelling catheter (this catheter remains in the bladder and drains urine to a drainage bag continuously) with clear urine return (drainage). The amount of urine was not included. A review of Resident 1's Nurses' Progress Note completed by LVN 2 on 6/30/19 and timed 9:30 a.m., indicated Resident 1 had a change of condition because the indwelling urinary catheter was leaking. LVN 2 documented that a new indwelling catheter was inserted without resistance, obtaining yellow urine return. There was no bleeding and Resident 1 did not have complaints. There was no documentation of Resident 1's amount of urine output after the procedure and by 3 p.m., the end of the LVN 2's shift (7-3 p.m.). A review of Resident 1's Nurses' Progress Note completed by LVN 3 on 6/30/19 at 4:50 p.m., indicated Resident 1 had a change in condition because of hematuria. The amount of urine drained was no documented. The physician was notified and ordered transferring Resident 1 to GACH 1 for evaluation. A review of Resident 1's GACH 1 Physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 4 of 7 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 12/23/2019 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 Emergency Room (ER) note dated 6/30/19, indicated "a Foley (indwelling catheter brand name) was inserted at the nursing home at 9:30 a.m. today with significant resistance. The patient has had hematuria since that time." Resident 1's laboratory test results, performed at the ER, indicated: - Low hematocrit (the proportion of the blood that consists of packed red blood cells) at 33.2 percent [%] with a reference range of 42-52%. - Low hemoglobin (a protein in red blood cells that transports oxygen and carbon dioxide, and gives blood its red color) at 10.3 grams per deciliters (g/dl - unit of measurement) with a reference range of 14-18.0 g/dl. A review of Resident 1's GACH 1 ER note dated 7/1/19 indicated Resident 1 went to Telemetry Unit (close monitoring unit) for admission and observation. A review of Resident 1's GACH 1 Urology (a doctor specialized on the function and disorders of the urinary system) consultation dated 7/1/19 indicated, "the nursing facility's staff inserted a Foley catheter, but had significant resistance in passing the Foley catheter tube. The patient had hematuria (blood in the urine) since that time. Upon physical exam, a Foley catheter was in place with bloody urine output." The urologist documented Resident 1 usually managed selfcatheterization four times a day himself until recently due to UTI and then, an indwelling urinary catheter was placed. A review of Resident 1's GACH 1 PostOperative report dated 7/2/19, indicated Resident 1 had urinary retention and hematuria with urethral injury from a catheter placement. A review of Resident 1's GACH Discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 5 of 7 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 12/23/2019 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 Summary dated 7/9/19 (nine days after admission), indicated Resident 1 experienced significant urethral trauma from an attempt to place an indwelling catheter. Resident 1 required a cystoscopy with a catheter placement done properly. Resident 1 had a precipitous (dangerous, sudden reduction) drop in hemoglobin requiring the transfusion of five units of packed red blood cells. On 11/21/19 at 11:45 a. m., during a telephone interview, LVN 2 stated there was no problem during the insertion of the indwelling urinary catheter on 6/30/19. LVN 2 stated there was no bleeding and the urine was clear yellow. LVN 2 stated she could not remember the amount of urine returned upon insertion and/or the amount at the end of the shift. During a telephone interview on 12/18/19 at 2 p.m., LVN 3 stated on 6/30/19, during her shift starting at 3 p.m., Resident 1 did not have urine output but Resident 1's bed sheets were bloody. A review of an online article titled, "Current Trends in the Management of Difficult Urinary Catheterizations" by the National Library of Medicine Institution of Health, indicated proper placement technique is critical, as failed attempts at catheterization may lead to injury. Forcing a catheter past the point of resistance can cause injuries ranging from a mucosal tear to more serious false passages (perforations [a hole made by boring or piercing; passing through or into something]), which are associated with infection, urethral stricture, and subsequent surgical management. A review of the facility's policy and procedure, dated 9/1/14 and titled, "Indwelling Catheter" indicated to record intake and output in accordance with intake and output recording. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 6 of 7 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 12/23/2019 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 facility's policy and procedure, dated 10/27/16 and titled, "Intake and Output Recording," indicated to record intake and output when the following conditions exist as a nursing measure: all residents who have an indwelling catheter will have intake and output recorded for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MKWT11 Facility ID: CA910000004 If continuation sheet 7 of 7