Other·March 14, 2020

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended 4/27/2022 The following reflects the findings of the Department of Public Health during the investigation of a Complaint. Complaint Number; CA00668061. Representing the Department: 36504 RN, HFEN Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency issued for Complaint Number CA00668061.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 03/23/2020 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. 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: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an air temperature range of 71 to 81-degree Fahrenheit ([°F] a unit of measure) for 11 of the 88 resident rooms and ensure the heater, which provided warmth to 28 of 28 residents who occupied these 11 rooms, was functioning. Four of the 28 residents complained their rooms were cold and required extra blankets at night (Residents 1, 2, 3, and 4). This deficient practice resulted in Residents 1, 2, 3, and 4 complaining of being cold and this had the potential for all the residents in the facility to have adverse consequences due to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 the environment being too cold. Findings: A review of the air temperatures from a weather website (weather.com) for the city in which the facility was located indicated from 12/13/19 through 12/19/19, the air temperature ranged from 64 °F to 70 °F during the day and 44 °F to 55 °F during the night. The highest air temperature during the day on 12/19/19 for the city in which the facility was located was 66 °F. According to an online article by the Mayo Clinic titled, "Asthma-Diagnosis and Treatment," an asthma attack is defined as the airways become swollen and inflamed, which results in extra mucus production causing the breathing tubes to narrow. The article indicated wintertime was an especially hard with people with asthma, as studies have indicated asthma hospital admission increases during the winter months. The article indicated cold air increases mucus production, which triggers asthma attacks and allergy attack. Cold dry air was listed as an asthma trigger. On 12/19/19 at 7:56 a.m., during an interview with Resident 1's family member (FM 1), FM 1 stated that the facility was always cold every time she visited the resident (no date specified). FM 1 stated she complained to the management (no name or title specified) about the resident's room being cold but nothing was done about it. FM 1 stated that on one of her visits (on 12/16/19), she noticed that Resident 1 was shaking (in the resident's room), the staff could not get the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function), and the resident had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 to be sent to the hospital by 911. On 12/19/19 at 9 a.m., during an observation while conducting a tour of the facility and a concurrent interview with the Maintenance Supervisor (MS), the MS measured the air temperatures of the resident rooms, Rooms 2 to 11, and stated the room temperatures were as follows: Rooms 3 and 4 were 67°F Rooms 2, 5, 7, 8, and 10 were 68°F Rooms 6, 9 and 11 were 69°F The MS adjusted the thermostats (a device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) in the residents' rooms but the air temperatures did not change. The MS stated he needed to go to the roof to check the heater. On 12/19/19 at 10:55 a.m., during an interview, the MS stated he checked the residents' room air temperatures daily and he maintained a temperature log. The MS stated his routine inspection entailed checking the air temperatures in the hallways and one or two resident rooms. The surveyor asked the MS to review with him the temperature log for the facility's hallway and resident rooms. The MS provided air temperature logs with readings for March, April, July, August, September, and October but without a year indicated. The MS stated he had not checked the temperatures in the resident rooms recently (time period not specified) so he could not tell how long the air temperatures in the resident rooms had been low (cold). On 12/19/19 at 12:15 p.m., during the interview, the Administrator stated she had not received any complaints from any residents or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 visitors regarding the air temperature in the facility. The Administrator stated the facility's goal was to provide residents with a comfortable and home-like environment. The Administrator stated residents' room air temperature should be maintained within an acceptable range of 71 to 81°F. On 12/19/19 at 1 p.m., during an interview with the Administrator and the MS, the MS stated the heater was not functioning due to loosened and old wires. 1. A review of Resident 1's Admission Face Sheet indicated the facility admitted Resident 1 on 5/15/18 with a diagnosis that included asthma. A review of Resident 1's Minimum Data Set (MDS), Resident Assessment and Care Screening, dated 12/23/19, indicated the resident cognitive (thought process) skills for decision-making were severely impaired. A review of the History and Physical record, dated 12/20/19, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's nurse's note, dated 12/16/19 and timed at 10:48 a.m., indicated a licensed nurse documented Resident 1 was transferred to GACH's Emergency Department (ED) due to a pronounced cough, twitching episode, shaking, congestion and body pains. A review of GACH's ED note, dated 12/16/19 and timed at 9:21 p.m., indicated the facility sent Resident 1 to ED due to a productive cough with thick yellow sputum (mixture of saliva [watery liquid secreted into the mouth by glands] and mucus) coughed up from the respiratory tract [the passage formed by the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 mouth, nose, throat, and lungs, through which air passes during breathing]), and an apparent difficulty in breathing. The ED note indicated Resident 1 was admitted to the telemetry unit for further observation and work up. A review of Resident 1's Medication Administration Record (MAR) in the GACH's telemetry unit indicated Resident 1 received breathing treatments of an Albuterol (an inhaler that relaxes muscles in the airways and increases air flow to the lungs) via hand held nebulizer (a device that delivers medicines and moisture to your air passages) every four hours with the last dose received on 12/18/19 at 8:28 a.m. 2. On 12/19/19 at 11:10 a.m., during an interview, Resident 2 stated it was cold the night before (12/18/19) and it was still cold in the building that morning. A review of Resident 2's MDS, dated 12/23/19, indicated the resident's cognitive skills for decision-making were moderately impaired and the resident was able to make self-understood and understand others. 3. On 12/19/19 at 11:20 a.m., during an interview, Resident 3 stated the facility was always cold especially in her room. Resident 3 stated she had to use two blankets at night. A review of Resident 3's MDS, dated 11/5/19, indicated the resident's cognitive skills for decision-making were intact and the resident was able to make self-understood and understand others. 4. On 12/19/19 at 11:40 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 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: _______________ 555677 (X3) DATE SURVEY COMPLETED 02/14/2020 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 interview, Resident 4 stated he was cold all the time in the facility, but especially at night. Resident 4 stated he would ask the staff for extra blankets (at night). A review of Resident 4's MDS, dated 1/13/20, indicated the resident's cognitive skills for decision-making were moderately impaired and the resident was able to make self-understood and understand others. A review of the facility's policy and procedure (P/P) titled, "Resident Rooms and Environment," with a revised dated of 1/1/2012, the P/P indicated the facility would provide residents with a safe, clean, comfortable and homelike environment with close attention to comfortable temperature. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QFCV11 Facility ID: CA910000047 If continuation sheet 7 of 7