Other·October 16, 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 the Department of Public Health during the investigation of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00632595 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 19152 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Three deficiencies were issued for Complaint number CA00632595

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 06/18/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: 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: 23R511 Facility ID: CA910000047 If continuation sheet 1 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 Based on interview and record review, the facility's staff failed to ensure they readmitted one of one sampled residents (Resident A) following a therapeutic transfer to a general acute hospital (GACH). Resident A was transferred to a GACH for evaluation related to aggressive behavior. Resident A was cleared to come back to the facility, however, on arrival she was locked outside for 20-30 minutes and not permitted to enter the facility until the police arrived and authorization was given by the Director of Nursing (DON). This deficient practice resulted in Resident A being locked out of the facility (her home) for up to 30 minutes and feeling that no one at the facility liked her and they were trying to get rid of her and had the potential to cause the resident harm. Findings: A review of Resident A's Admission Records indicated the resident was initially admitted to the facility on 1/29/15, and last readmitted to the facility on 2/22/19. Resident A's diagnoses included major depressive disorder and bipolar disorder (a mental illness characterized by periods of elevated mood and periods of depression). A review of Resident A's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/5/19, indicated Resident A scored 15 out of 15 on the Brief Interview for Mental Status ([BIMS]) indicating her cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 2 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 Continued review of the MDS indicated Resident A had no behavioral episodes. The MDS indicated Resident A required a limited one-person physical assist for bed mobility, transfers, walking in the room, corridors and on/off the unit as well as completion of her ADLs ([activities of daily living] the things we normally do such as eating, bathing, dressing, grooming and toileting) and she was able to eat with supervision and set-up help. Resident A's active diagnoses included anxiety disorder (a group of mental illnesses that cause intense, excessive and persistent worry and fear about everyday situations), systemic lupus erythematosus (the immune system of the body mistakenly attacks healthy tissue; affecting the skin, joints, kidneys, brain, and other organs) and chronic pain syndrome. A review of Resident A's SBAR ([Situation, Background, Assessment, Recommendation] a form of communication between members of a health care team), dated 4/4/19, indicted Resident A was to be discharged to a a general acute care hospital (GACH) for medical clearance due to increased aggressiveness of slapping another resident, threatening to hit other residents, increased confabulatory behavior, cursing others and danger to others. A review of a Physician's Order, dated 4/4/19, indicated to discharge Resident A to a GACH emergency room for medical clearance due to increased aggressiveness of slapping another resident with a bed-hold for seven days. A review of a GACHs emergency room (ER) note, dated 4/4/19, indicated Resident A was brought to the ER for medical clearance with aggressive behavior, and a danger to self and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 3 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 others. A review of systems (an assessment) indicated Resident A indicated no confusion, no anxiety, no depression, no hallucinations, no mood problems or aggressive behavior. Continued review of the note indicated Resident A refused to go to a psychiatric facility and would be sent back to skilled nursing facility (SNF). A review of the GACH's ER Nursing Narrative Note, dated 4/4/19, at 11:31 p.m., indicated Resident A was calm and cooperative, only refusing x-rays and transfer to another GACH for psychiatric evaluation and wanted to be discharged back to the SNF. The note indicated the SNF was called and made aware that Resident A would be going back to the facility. On 4/9/19 at 3:50 p.m., during an interview, Resident A stated on 4/4/19, she got into a physical altercation with another resident. Resident A stated that staff called the EMTs (emergency medical technicians) to send her to the GACH to be evaluated. Resident A stated they told her if she was cleared mentally she could come back. Resident A stated initially she refused to leave but later consented to be transferred. Resident A stated she was cleared by the GACH and sent her back to the facility before 1 a.m., however, the doors were locked and two nurses refused to let her in. Resident A stated the driver who brought her to the facility told them he was from the GACH and returning her to the SNF. The two nurses told the driver they could not let Resident A in because she was dangerous. The driver told them that Resident A had been cleared by the GACH and was bringing her back, but they still refused to let her in and the driver had to call the police. Resident A stated the police came FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 4 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 and told them they had to let her in and finally they did. On 4/12/19 at 11:24 a.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated Registered Nurse Supervisor 1 (RN 1), who worked on the 3 p.m. - 11 p.m., shift, reported to her that Resident A had been transferred to a GACH because of her behavior and was to be seen by a psychiatrist. RN 1 instructed her not to let Resident A in if she came back. LVN 2 stated they received a call from the GACH telling them Resident A was on her way back and LVN 1 showed her a text message with instructions from the Assistant Director Of Nursing (ADON) not to let Resident A in the facility. LVN 2 stated she called the Director of Nursing (DON) for clarification, and the DON instructed her to call the ADON. LVN 2 stated she called the ADON who told her not to let Resident A in. LVN 2 stated Resident A arrived at the facility and came to the door with the driver, and LVN 2 told the driver and the resident that she had been instructed not to let her in. The driver called the police and they arrived and come inside to talk to her. LVN 2 stated she called the DON again who this time instructed her to let Resident A in. LVN 2 stated this all happened at approximately 1 a.m., it was cold outside and Resident A was outside for approximately 20-30 minutes before they let her in. LVN 2 stated Resident A was understandably angry and she (LVN 2) felt bad because it was wrong not to let her in but she was caught between the resident and instructions from RN 1 and the ADON not to let her in. On 4/12/19 at 11:58 a.m., during a telephone interview, the ADON initially stated that he did not instruct LVN 1 and LVN 2 not to accept FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 5 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 Resident A. The ADON stated the resident needed to be cleared by a psychiatric doctor but if Resident A was on a bed-hold and if she showed up they have to let her in. When the ADON was asked about a text message he sent to LVN 1 with instructions not to let Resident A in, the ADON acknowledged that yes it did exist. The ADON stated there were several text messages going back and forth between him and LVN 1 but interpreted (it was written in Tagalong) a portion of what was text to say to LVN 1 that Resident A arrived by private transportation, do not admit her until she is cleared by the other GACH (a psychiatric facility). On 4/12/19 at 12:28 p.m., during a telephone interview, the DON stated she was not aware of police being called and when she was called she instructed the LVN's 1 and 2 to let Resident A in. The DON stated they thought Resident A would be evaluated by a psychiatrist but was not. The DON stated she was aware of the bed-hold policy and that Resident A had a right to come back after being cleared by the GACH. On 4/12/19 at 3:15 p.m., during an interview, RN 1 stated Resident A was still at the facility when she started her shift (4/4/19) and believes she was transferred between 5 p.m., and 6 p.m. RN 1 stated she received a report from the ADON that other residents were scared of Resident A and not to admit her back to the facility. RN 1 stated at the end of her shift she reported to LVN 1 not to admit Resident A. She stated she knew they would get in trouble if they did not readmit the resident and instructed the nurses if the hospital pressed they had to admit the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 6 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 Nurse's Note, dated 4/5/19, at 1 a.m., indicated Resident A returned back to the facility via hospital car. Continued review of the nursing note indicated no written documentation of the events that occurred when Resident A arrived for readmittance from the GACH. A review of the facility's policy and procedure titled, "Resident Rights," with a revision date of 1/1/12, indicated employees were to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 06/18/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 7 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's nursing staff failed to ensure that a pharmacist recommendation for one of one sampled residents (Resident A) was responded to by the physician/prescriber. This deficient practice placed Resident A at risk for receipt of unnecessary medication. Findings: A review of Resident A's Admission Records indicated the resident was initially admitted to the facility on 1/29/15, and last readmitted to the facility on 2/22/19. Resident A's diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 8 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 included chronic pain disorder. A review of Resident A's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/5/19, indicated Resident A scored 15 out of 15 on the Brief Interview for Mental Status ([BIMS]) indicating her cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of a Physician's Order, dated 2/27/19, indicated to administer Resident A Topamax (a medication used to treat epilepsy and prevent migraines) 25 milligrams (mg) two times daily for nerve pain. A review of a Note To Attending Physician/Prescriber, by the facility's pharmacist consultant, dated 3/12/19, indicated Resident A was receiving Topamax 25 mg for nerve pain, which was a non FDA-labeled use of the medication for this particular indication. The note indicated According to the Centers for Medicare and Medicaid Services (CMS) guidelines, this can be considered duplicate, unnecessary therapy and to evaluate the risk/benefits of this medication for this resident to keep the facility in compliance with regulations. Continued review of this recommendation indicated the physician/prescriber should either agree, disagree or other, nothing was checked by the physician/prescriber. A review of Resident A's clinical records indicated that as of 5/2019, Topamax was still prescribed and being administered to the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 9 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 On 5/30/19 at 2:50 p.m., during a telephone interview, the Director of Nursing (DON) stated when a pharmacist recommendation was made, she obtains a copy and a copy goes in the progress note section for the physician of the resident's clinical record and he/she should respond to it. The DON stated if there is no response the nurses should follow up. On 5/30/19 at 3:45 p.m., during a telephone interview, the Assistant Director of Nursing (ADON) stated he was present when Resident A's physician attempted to explain the risk and benefits for Topamax. The ADON stated Resident A refused to have her medication discontinued and he does not know why the physician did not respond to the pharmacist recommendation. A review of facility policy titled, "Consultant Pharmacist Reports," and dated 8/1/10, indicated recommendations are acted upon and documented by the facility staff and/or the prescriber. The policy indicated if the prescriber does not respond to the recommendation directed to him/her within a reasonable time frame, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 06/18/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 10 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained forFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 11 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's staff failed to ensure the readmission records for one of one sampled residents (Resident A) was complete to include the resident's status, care and events that occurred. Resident A was transferred to a general acute care hosptial (GACH) for evaluation related to aggressive behavior. Resident A was cleared to come back to the facility, however, on arrival she was locked outside for 20-30 minutes and not permitted to enter the facility until the police arrived and authorization was given by the director of nursing (DON). Resident A's clinical records do not reflect these events. This deficient practice resulted in a gap of events in Resident A's care and treatment and had the potential to affect her quality and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 12 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 continuity of care. Findings: A review of Resident A's Admission Records indicated the resident was initally admitted to the facility on 1/29/15, and last readmitted on 2/26/19. Resident A's diagnoses included major depressive disorder and bipolar disorder (a mental illness characterized by periods of elevated mood and periods of depression). A review of Resident A's Minimum Data Set (MDS), an assessment and care-screening tool, dated 3/5/19, indicated Resident A scored 15 out of 15 on the Brief Interview for Mental Status ([BIMS]) indicating her cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. Continued review of the MDS indicated Resident A had no behavioral episodes. The MDS indicated Resident A required a limited one-person physical assist for bed mobility, transfers, walking in the room, corridors and on/off the unit as well as completion of her ADLs ([activities of daily living] the things we normally do such as eating, bathing, dressing, grooming and toileting) and she was able to eat with supervision and set-up help. Resident A's active diagnoses included anxiety disorder (A group of mental illnesses that cause intense, excessive and persistent worry and fear about everyday situations), systemic lupus erythematosus ( the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs) and chronic pain syndrome. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 13 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 An SBAR ([Situation, Background, Assessment, Recommendation] a form of communication between members of a health care team), dated 4/4/19, indicated Resident A was to be discharged to a a general acute care hospital (GACH) for medical clearance due to increased aggressiveness of slapping another resident, threatening to hit other residents, increased confabulatory behavior, curing others and danger to others. A review of a Physician's Order, dated 4/4/19, indicated to discharge Resident A to a GACH emergency room for medical clearance due to increased aggressiveness of slapping another resident with a bed-hold for seven days. A review of a GACHs emergency room (ER) note, dated 4/4/19, indicated Resident A was brought to the ER for medical clearance with aggressive behavior, and a danger to self and others. A review of systems (an assessment) indicated Resident A indicated no confusion, no anxiety, no depression, no hallucinations, no mood problems or aggressive behavior. Continued review of the note indicated Resident A refused to go to a psychiatric facility and would be sent back to skilled nursing facility (SNF). A review of the GACH's ER Nursing Narrative Note, dated 4/4/19, at 11:31 p.m., indicated Resident A was calm and cooperative, only refusing x-rays and transfer to another GACH for psychiatric evaluation and want to be discharged back to the SNF. The SNF was called and made aware that Resident A would be going back to the facility. On 4/9/19 at 3:50 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 14 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 Resident A stated on 4/4/19, she got into a physical altercation with another resident. Resident A stated that staff called the EMTs (emergency medical technicians) to send her to the GACH to be evaluated. Resident A stated they told her if she was cleared mentally she could come back. Resident A stated initially she refused to leave but later consented to be transferred. Resident A stated she was cleared by the GACH and sent her back to the facility before 1 a.m., however, the doors were locked and two nurses refused to let her in. Resident A stated the driver who brought her to the facility told them he was from the GACH and returning her to the SNF. The two nurses told the driver they could not let Resident A in because she was dangerous. The driver told them that Resident A had been cleared by the GACH and was bringing her back, but they still refused to let her in and the driver had to call the police. Resident A stated the police came and told them they had to let her in and finally they did. On 4/12/19 at 11:24 a.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated Registered Nurse Supervisor 1 (RN 1), who worked on the 3 p.m. - 11 p.m., shift, reported to her that Resident A had been transferred to a GACH because of her behavior and was to be seen by a psychiatrist. RN 1 instructed her not to let Resident A in if she came back. LVN 2 stated they received a call from the GACH telling them Resident A was on her way back and LVN 1 showed her a text message with instructions from the Assistant Director Of Nursing (ADON) not to let Resident A in the facility. LVN 2 stated she called the Director of Nursing (DON) for clarification, and the DON instructed her to call the ADON. LVN 2 stated she called the ADON who told her not to let Resident A in. LVN 2 stated Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 15 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 arrived at the facility and came to the door with the driver, and LVN 2 told the driver and the resident that she had been instructed not to let her in. The driver called the police and they arrived and come inside to talk to her. LVN 2 stated she called the DON again who this time instructed her to let Resident A in. LVN 2 stated this all happened at approximately 1 a.m., it was cold outside and Resident A was outside for approximately 20-30 minutes before they let her in. LVN 2 stated Resident A was understandably angry and she (LVN 2) felt bad because it was wrong not to let her in but she was caught between the resident and instructions from RN 1 and the ADON not to let her in. On 4/12/19 at 11:58 a.m., during a telephone interview, the ADON initially stated that he did not instruct LVN 1 and LVN 2 not to accept Resident A. The ADON stated the resident needed to be cleared by a psychiatric doctor but if Resident A was on a bed-hold and if she showed up they have to let her in. When the ADON was asked about a text message he sent to LVN 1 with instructions not to let Resident A in, the ADON acknowledged that yes it did exist. The ADON stated there were several text messages going back and forth between him and LVN 1 but interpreted (it was written in Tagalong) a portion of what was text to say to LVN 1 that Resident A arrived by private transportation, do not admit her until she is cleared by the other GACH (a psychiatric facility). On 4/12/19 at 3:15 p.m., during an interview, RN 1 stated Resident A was still at the facility when she started her shift (4/4/19) and believes she was transferred between 5 p.m., and 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 16 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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 p.m. RN 1 stated she received a report from the ADON that other residents were scared of Resident A and not to admit her back to the facility. RN 1 stated at the end of her shift she reported to LVN 1 not to admit Resident A. She stated she knew they would get in trouble if they did not readmit the resident and instructed the nurses if the hospital pressed they had to admit the resident. A review of the Nurse's Note, dated 4/5/19, at 1 a.m., indicated Resident A returned back to the facility via hospital car. Continued review of the nursing note indicated no written documentation of the events that occurred when Resident A arrived for readmittance from the GACH. Continued review of Resident A's clinical records indicated no written time of the altercation between Resident A and Resident B and no written documentation related to Resident A's behavior or physical status when she was transferred from the facility on 4/4/19. On 5/30/19 at 11:22 a.m., during a telephone interview, the DON stated the standard of practice and expectations from the nursing staff was to document times that events occur, document any events that occur and to document the condition of the resident when they are transferred. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 23R511 Facility ID: CA910000047 If continuation sheet 17 of 18 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 06/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (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: 23R511 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA910000047 (X5) COMPLETE DATE If continuation sheet 18 of 18