Hawthorne Healthcare & Wellness Centre, Lp

During a review of the facility's policy and procedures (P&P), titled RAI Process, dated 10/4/2016, the P&P indicated the purpose of the RAI process was To provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

orders), dated 3/26/2026, the Order Summary Report indicated, the physician placed a telephone

dosage and/or amount) by mouth two times a day (9 a.m., and 5 p.m.) for schizophrenia manifested by

2:22 p.m., with the Director of Nursing (DON), Resident 12's PASARR Level 1 screening completed by the facility on 3/18/2021, was reviewed.

The DON stated the PASARR Level 1 screening indicated Resident 12 had no serious mental illness diagnoses and was not on prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).

The DON stated the PASARR Level 1 screening also indicated Resident 12's case was closed, and a PASARR level II mental health evaluation was not required.

The DON stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because Resident 12 had a mental illness diagnoses of paranoid schizophrenia, MDD, and psychosis and Resident 12 was prescribed Haloperidol.

The DON stated the facility did not follow the PASARR procedure for resubmitting a PASARR Level 1 screening under Resident Review.During a review of the facility's policy and procedure (P&P), titled Pre-admission Screening Resident Review, dated 6/12/2024, the P&P indicated The facility MDS coordinator will be responsible for accessing and ensure updates to the PASRR are completed per MDS guidelines.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

During a review of Resident 77's history and physical form (H&P), dated 2/26/2026, the H&P indicated

During a review of Resident 77's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/4/2026, the MDS indicated Resident 77's cognitive (thinking) skills were severely impaired.

The MDS indicated Resident 77 was dependent on staff members with Activities of Daily Living (ADLs).

During a review of Resident 77s' care plan, on 03/26/2026, there was no schizophrenia care plan noted.

During a concurrent interview and record review, on 03/26/2026 at 10:14 a.m., with the MDSN 2, the MDSN 2 stated care plans were initiated to indicate what type of treatment staff would provide for the resident during their stay at the facility according to a resident's diagnosis and needs.

The MDSN 2 stated psychiatric diagnosis were required to have a care plan.

The MDSN 2 stated she did not see a schizophrenia care plan for Resident 77.

The MDSN 2 stated Resident 77 required a care plan for schizophrenia.

The MDSN 2 stated the risk of not initiating a care plan for a resident with a psychiatric diagnosis could result in a resident not obtaining the care and services needed according to their diagnosis.

During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

During an observation, on 3/25/2026 at 3:23 p.m., in Resident 58's room, there was no communication board at the bedside. Resident 58 was nonverbal but attempted to use gestures to communicate.During a concurrent interview and record review, on 3/26/2026 at 10:14 a.m., with MDSN 2, MDSN 2 stated non-verbal residents are provided a communication board with pictures to indicate their needs or a marker to write what they would like to express. MDSN 2 stated Resident 58 was not provided a communication board. MDSN 2 stated Resident 58 used gestures to indicate her needs. MDSN 2 stated Resident 58's care plan indicated Resident 58 should have had a communication board instead of having staff translate her needs. MDSN 2 stated the risk of not providing a communication board could result in not understanding a resident or translating their needs correctly.

During a review of the facility's policy and procedures (P&P), titled Accommodation of Residents' Communication Needs dated 2/24/2026, the P&P indicated The following are examples of adaptive devices or accommodations the staff may provide the Resident: A.

Writing pad and pen; and B.

Communication boards/charts.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

During a review of the facility's Social Service Coordinator Job Description, the Social Service Coordinator Job Description indicated one of the principal responsibilities of the Social Service Coordinator is to ensure the resident's psychosocial and care needs are identified and met in accordance with federal, state and company requirements.During a review of the facility's policy and procedure (P&P), titled Social Service Program, dated 5/22/2025, the P&P indicated, Responsibilities of the Social Service Department may include making referrals and obtaining services from outside referrals.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

following irregularity reporting guidelines in developed policies and procedures.

interview and record review, the facility failed to ensure a recommendation from the Consultant

identify and report changes) was acted upon for one of eight sampled residents (Resident 9).This failure had the potential to result in Resident 9 experiencing a delay in treatment.

Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrolled fear or worry that interferes with daily life), epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 9's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/29/2026, the MDS indicated, Resident 9's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions).

The MDS indicated Resident 9 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 9's History and Physical (H&P), dated 2/23/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a concurrent interview and record review on 3/26/2026 at 9:46 a.m., with the Assistant Director of Nursing (ADON), Resident 9's Consultant Pharmacist Medication Regimen Review ([MRR] - a structured, comprehensive evaluation of a resident's entire medication list, conducted by a pharmacist to ensure safety and effectiveness), dated 12/11/2025, was reviewed.

The MRR indicated to please ensure to obtain a Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 key substances in the blood, assessing electrolyte balance, kidney, liver function, and blood sugar), Complete Blood Count ([CBC] - a blood test that checks the overall health of the blood by measuring the number and types of cells), Carbamazepine level (a drug level blood test that measures the amount of seizure-control medication), lipid (a blood test that measures the amount of cholesterol [type of fat] in your blood), Folate level (a blood test that measures the amount of folate [vitamin B9] in your blood to check for deficiency), and vitamin B12 level (a blood test that measures the amount of cobalamin [Vitamin B12] in your bloodstream).

The ADON stated the facility failed to take any action on the consultant pharmacist recommendation by not informing Resident 9's physician.

The ADON stated there was no documentation by facility staff that the Consultant's Pharmacist MRR recommendation for Resident 9 was completed.

During an interview on 3/26/2026 at 10:05 a.m., with the Director of Nursing (DON), the DON stated the MRR by the pharmacy consultant should be completed by the licensed nursing staff at the end of the month.

The DON stated the facility's Consultant Pharmacist comes once a month to review residents drug regimen for any medication irregularities and drug interactions (a reaction between two or more drugs).

The DON stated it is very important to address the Consultant Pharmacist recommendation in a timely manner for the welfare of the residents.During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated 5/2022, the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

10) behaviors while prescribed psychotropic medications (any drug that affects brain activities

the use of unnecessary psychotropic medication that could cause harm to Resident 10.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included paranoid schizophrenia (a chronic mental health disorder where a person experiences intense, irrational suspicion that is characterized by disturbances in thought), major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).During a review of Resident 10's History and Physical (H&P), dated 10/5/2025, the H&P indicated, Resident 10 could make needs known but could not make medical decisions.During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions).

The MDS indicated Resident 10 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, lower body dressing, and personal hygiene.During a review of Resident 10's Order Summary Report (a document containing active orders), dated 3/25/2026, the Order Summary Report indicated the physician placed a telephone order on 3/3/2026 for Resident 10 to start on Quetiapine Fumarate (a psychotropic medication, used to treat certain mental/mood disorder) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime (9 p.m.) for other psychotic disorder manifested by increased agitation and verbal aggression and mirtazapine (a drug used to treat depression) 7.5 mg by mouth at bedtime (9 p.m.) for major depressive disorder.During a concurrent interview and record review on 3/25/2026 at 2:50 p.m., with the Assistant Director of Nursing (ADON), Resident 10's Medication Administration Record ([MAR] - a daily documentation record used by licensed nurse to document medications and treatments given to a resident) from 3/3/2026 to 3/25/2026, were reviewed.

The ADON stated there was no documented evidence of behavior monitoring of Resident 10's episode of increased agitation, verbal aggression, and depression.

The ADON stated if a resident was prescribed with psychotropic medications, there should be an indication, dose, frequency and behavior manifestation.

The ADON stated the behavior monitoring should be documented in the MAR by checking Yes or No.

The ADON stated, monitoring of behaviors was important in order to keep track and determine if the psychotropic medications were effective and if the facility could attempt a gradual dose reduction ([GDR] - a structured, stepwise, and monitored decrease in medication dosage to determine if a resident can manage with a lower dose or discontinue the drug entirely).

The ADON stated a lack of behavior monitoring of Resident 10's psychotropic medications would be considered as an unnecessary medications.During a review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management, dated 3/24/2024, the P&P indicated, The facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting the health, safety, psychosocial, behavioral, and environment needs of residents.During a review of the facility's P&P titled, Behavior/Psychoactive Medication Management, dated 1/30/2026, the P&P indicated, Any order for psychoactive medications must include a specific behavior manifestation.

The P&P did not disclose the frequency and the importance of monitoring resident's behavior.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases

had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 12.Findings:During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypothyroidism (a condition when the thyroid gland [a butterfly-shaped or H-shaped gland located in the neck below the Adam's apple] does not make enough thyroid hormones to meet your body's needs), urinary tract infection ([UTI] - an infection in the bladder/urinary tract), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 12's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/25/2025, the MDS indicated, Resident 12 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making.

The MDS indicated Resident 12 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 12's History and Physical (H&P), dated 3/24/2026, the H&P indicated, Resident 12 had fluctuating capacity to understand and make decisions.During a review of Resident 12's Order Summary Report (a document containing active orders), dated 3/26/2026, the Order Summary Report indicated, the physician placed a telephone order on 3/12/2026 for Resident 12 to have triiodothyronine 3 level ([T3] - a blood test that measures the level of active T3 hormone in the blood to evaluate thyroid function), Free Thyroxine ([FT4] - a blood test measuring the unbound, active form of T4 hormone produced by the thyroid gland to manage metabolism), and thyroid-stimulating hormone level ([TSH] - a test that measures the amount of TSH in your blood).During a concurrent interview and record review on 3/25/2026 at 2:36 p.m., with the Assistant Director of Nursing (ADON), Resident 12's laboratory results, were reviewed.

The ADON stated Resident 12's order for T3, FT4, and TSH level were not completed, and results were not available.

The ADON stated there was no documentation that the facility staff made a follow-up call to the laboratory provider to find out what happened with the laboratory results.

The ADON stated for whatever reasons, if laboratory orders were not completed, the licensed nursing staff must document and notify the resident's physician.

The ADON stated it is important to check Resident 12's T3, FT4, and TSH level for medication dose adjustment since Resident 12 was taking levothyroxine (a drug used to treat hypothyroidism).

During an interview on 3/25/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated it is important to check Resident 12's T3, FT4, and TSH level to evaluate the effectiveness of his levothyroxine medication and for the physician to provide new interventions if needed.During a review of the facility's policy and procedure (P&P) titled, Laboratory Services, dated 1/1/2012, the P&P indicated, The facility should provide laboratory services in an accurate and timely manner to meet the needs of residents per attending physician orders.

The P&P also indicated the nurse documents the time when laboratory results were reported along with the attending physician's response in the resident's medical records.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

of one sampled resident (Resident 30).This deficient practice had the potential to result in inability to

Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included dysphagia (difficulty swallowing), cerebral ischemia (a condition where blood flow to the brain is reduced or blocked), and epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures).During a review of Resident 30's Dental Progress Note, dated 9/3/2025, the Dental Progress Note indicated the dentist recommended a denture for Resident 30.During a review of Resident 30's History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions.During a review of Resident 30's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 30's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions).

The MDS indicated Resident 30 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper and lower body dressing.During a review of Resident 30's Dental Progress Note, dated 2/5/2026, the Dental Progress Note indicated the dentist recommended a denture for Resident 30.

During an interview on 3/24/2026 at 9:50 a.m., with Resident 30, Resident 30 stated she broke her dentures about 3 to 4 months ago. Resident 30 stated she had a hard time eating without her dentures.

During an interview on 3/25/2026 at 10:56 a.m., with the Social Service Director (SSD), the SSD stated he was aware that Resident 30 was seen by the dentist on 9/3/2025 and 2/5/2026 but was not aware of the dentist treatment recommendation for Resident 30 to receive a denture.

The SSD stated he did not follow-up with the dentist regarding the update of Resident 30's denture.

The SSD stated it is important for Resident 30 to receive dentures for her to chew the food properly.

The SSD stated the risk of not providing dentures to Resident 30 would result in gum discomfort and pain that would affect her quality of life.

During an interview on 3/25/2026 at 11:31 a.m., with the Director of Nursing (DON), the DON stated he was not aware of the dentist treatment recommendations for Resident 30 to receive a denture.

The DON stated it is important to follow up with the dentist regarding the status of Resident 30's denture for resident's comfort when eating.During a review of the facility's Social Service Coordinator Job Description, the Social Service Coordinator Job Description indicated to communicate needs and plan of care to resident, families, responsible parties and appropriate staff and to arrange ancillary services that have been determined necessary to maintain the resident's concrete needs.During a review of the facility's policy and procedure (P&P) titled, Oral Healthcare and Dental Services, dated 7/14/2017, the P&P indicated The facility will provide oral healthcare and dental services for preventive care and treatment.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

During a review of the facility's policy and procedures (P&P), titled Food Storage, dated 11/1/2014, the P&P indicated to Label and date all food items.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

Based on interview and record review, the facility failed to revise and maintain an updated average

and identifying the resources needed to provide care and services).This deficient failure had the potential to place residents at risk for not receiving care and services necessary to maintain their highest practicable physical, mental and psychosocial well-being.Findings:During a review of the facility census for 3/23/2026, the facility census indicated, 83 residents resided in the facility.During a review of the facility census for 3/24/2026, the facility census indicated, 83 residents resided in the facility.During a concurrent interview and record review on 3/25/2026 at 11:45 a.m., with the Administrator (ADM), the Facility Assessment Tool, updated 3/23/2026, was reviewed.

The ADM stated she was responsible for updating the Facility Assessment Tool.

The ADM stated the Facility Assessment Tool should be updated yearly or as needed if there is a change in the facility census or if there are special treatments or services provided to the residents.

The ADM stated the assessment provided was the average daily census of 80 residents.

The ADM stated the Facility Assessment Tool was not accurate because of the average daily census which was below the actual census of residents residing in the facility.

The ADM stated there were three residents who were not accounted for on the Facility Assessment Tool.

The ADM stated it is important to indicate the correct average daily census in the Facility Assessment Tool so the facility staff could adequately provide care and support to the residents.During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, dated 4/15/2021, the P&P indicated The Administrator should review and update the Facility Assessment annually and as necessary whenever there is, or the facility plans, for any change that would require a substantial modification to any part of the assessment.

During an interview, on 3/26/2026 at 3:02 p.m., with the Administrator (Admin), the Admin stated the facility's consulting group was responsible for submitting the PBJ fiscal year information timely.

The Admin stated the PBJ was required to be submitted quarterly.

During a concurrent interview and record review, on 3/27/2026 at 8;09 a.m., with the Admin, the Admin stated the CMS submission report for the PBJ validation report, dated 2/13/2026, indicated fiscal year 2 was submitted instead of fiscal year 1 which covers October 2025 through December 2025.

The Admin stated the risk of not submitting the facility's PBJ in a timely manner could result in not being able to prove care services are being provided to the residents in the facility.During a record review of the State Operations Manual (SOM), dated 7/23/2025, the SOM indicates the facility is responsible for submitting staffing data through the CMS Payroll-Based Journal (PBJ) system.

The facility's failure to submit PBJ data, as required, will be reflected on their CASPER report and result in a deficiency citation.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

result in cross contamination (a transfer of harmful bacteria from one place to another or one object

observation and interview on 3/24/2026 at 9:25 a.m. with the Infection Preventionist Nurse (IPN) in the resident's hallway, one gray sweater was observed inside the clean linen cart.

The IPN stated the soiled gray sweater belonged to a resident, but she did not know which resident it belonged to.

The IPN stated residents' personal clothing whether it's clean or dirty should be bagged in a plastic bag and should not be mixed with the facility's clean linen cart.

The IPN stated soiled items could contaminate and transfer bacteria to a clean linen.

The IPN stated the facility must follow strict guidelines in infection control for residents' safety.During a review of the facility's policy and procedure (P&P) titled, Infection Control Policies and Procedures, dated 1/2012, the P&P indicated The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250

communications for direct care staff members.

Certified Nurse Assistant's (CNA] 1 and CNA 2) received mandatory effective communications

which may negatively impact residents' quality of care.Findings:During a concurrent interview and record review on 3/26/2026 at 3:35 p.m. with the Director of Staff Development (DSD), CNA 1 and 2's personnel records were reviewed.

The DSD stated CNA 1 was hired on 7/7/2025 and did not have evidence of effective communication training on file.

The DSD stated CNA 2 was hired on 3/5/2026 and did not have evidence of effective communication training on file.

The DSD stated she was responsible for providing effective communication training for all direct care staff.

The DSD stated it was important to provide effective communication training for all direct care staff so staff could adequately interact with residents and other staff to ensure a good working environment and residents' safety.During a review of the Facility Assessment Tool, updated on 3/23/2026, the Facility Assessment Tool indicated the facility's current CNA training program sufficiently addresses their resident population as identified by the Facility Assessment.During a review of facility's Director of Staff Development, Job Description, the DSD Job Description indicated the Director of Staff Development was responsible for planning, implementation, direction and evaluation of the facility's educational programs for all employees.

The DSD Job Description indicated the DSD was to coordinate and conduct an effective on-going in-service plan for all employees.

555677 03/27/2026

Hawthorne Healthcare & Wellness Centre, LP 11630 South Grevillea Ave.

Hawthorne, CA 90250