Norwalk Skilled Nursing & Wellness Centre, Llc

F-F756)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to monitor valproic acid levels (a laboratory test used Residents Affected - Few to ensure medications used to treat seizures are present at a safe and effect level in the blood) related to the use of divalproex sodium (a medication used to treat seizures) in one of five residents sampled for unnecessary medications (Resident 5.)

The deficient practices of failing to monitor valproic acid levels related to the use of divalproex increased the risk that Resident 5 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) or seizures related to valproic acid levels being too high or too low leading to medical complications possibly resulting in hospitalization .

Findings:

During a review of Resident 5's Admission Record (a document containing diagnostic and demographic information), dated 6/6/24, indicated she was admitted to the facility on [DATE REDACTED] and most recently readmitted

on [DATE REDACTED] with diagnoses including psychosis (a mental condition characterized by the inability to determine reality from non-reality.)

During a review of Resident 5's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/4/24, indicated she had fluctuating capacity to understand and make decisions.

During a review of Resident 5's Order Summary Report (a summary of all currently active physician orders), dated 7/25/24, indicated on 3/31/24, Resident 5 was prescribed divalproex sodium 500 milligrams (mg - a unit of measure for mass) by mouth two times a day for poor impulse control manifested by getting agitated easily leading to verbal and physical aggression.

During a review of the consultant pharmacist's recommendation, dated 6/4/24, indicated the consultant pharmacist asked the physician to consider monitoring Resident 5's valproic acid levels related to the use of divalproex sodium.

During a review of Resident 5's clinical record indicated there was no physician response to the pharmacist's recommendation to monitor Resident 5's valproic acid level related to the use of divalproex sodium and no laboratory monitoring of valproic acid levels had been ordered or conducted.

During an interview on 7/25/24 at 11:01 AM with the Director of Nursing (DON), the DON stated the facility failed to respond to the pharmacist's request to monitor the valproic acid level for Resident 5's divalproex sodium use. The DON stated the facility failed to monitor the valproic acid level at any other time to ensure

the medication was effective and not toxic. The DON stated failure to monitor the valproic acid level for a resident with divalproex sodium therapy could cause the medication to be ineffective at controlling behaviors if the level is too low or could be toxic if the level is too high possibly leading to medical complications requiring hospitalization .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 During a review of the facility's policy Medication Regimen Review (monthly report), dated June 2021, indicated The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least Level of Harm - Minimal harm or monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the potential for actual harm resident maintains the highest practicable level of functions and prevents or minimizes adverse consequences related to medication therapy . Recommendations are acted upon and documented by the Residents Affected - Few facility staff and/or the prescriber . Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit .

During a review of the facility's policy Laboratory Monitoring Guidelines, revised November 2017, indicated serum drug levels of divalproex sodium should be monitored 7-10 days after initiation or dosage change then every 6 months .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 40994 Residents Affected - Few Based on observation, interview, and record review, the facility failed to discard and replace one expired fluticasone/salmeterol inhaler (a medication used to treat breathing problems) affecting Resident 22 in one of two inspected medication carts (East Medication Cart.)

The deficient practice of failing to remove expired medications from the medication carts increased the risk that Resident 22 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Findings:

During a concurrent observation and interview on 7/24/24 at 12:56 AM of East Medication Cart with the licensed vocational nurse (LVN 6), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:

1. One opened fluticasone/salmeterol inhaler for Resident 22 was found labeled with an open date of 5/4/24.

According to the manufacturer's product labeling, fluticasone/salmeterol inhalers should be used or discarded within 30 days after removal from the protective foil pouch.

LVN 6 stated Resident 22's fluticasone/salmeterol inhaler was opened on 5/4/24 and expired around 6/4/24 based on the manufacturer's instructions. LVN 6 stated the facility failed to remove this inhaler from the medication cart once it expired. LVN 6 stated it should have been removed 30 days after opening and replaced for the resident whether it still had doses of medication or not. LVN 6 stated this medication is used to treat breathing problems which may get worse if the medication is less effective possibly causing the resident to be hospitalized .

During a review of the facility's policy Storage of Medications, dated April 2008, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of those of

the supplier . Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46537

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure foods were dated, properly sealed, refrigerated after opening per manufacturer's recommendation, and discarded before the used by date (expiration dates) for 91 out 93 total residents.

This failure placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage from contaminated food with germs) which can cause symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization .

Findings:

During a concurrent observation and interview on [DATE REDACTED], at 8:22 a.m., with Dietary Manager (DM), in dry storage room [ROOM NUMBER], there were food items that were not dated, properly sealed, refrigerated

after opening per manufacturer's recommendation, and discarded before the used by date as follows:

a. Opened and used lemon juice in a plastic bottle with Receiving Date (RD- the day of delivery) of [DATE REDACTED], no Open Date (OD), and no Used By (UB). It should be refrigerated after opening per manufacturer's recommendation.

b. Opened and used sesame oil in a bottle with RD of [DATE REDACTED], OD [DATE REDACTED], and no UB.

c. Opened and used Italian dressing in a plastic bottle with RD of [DATE REDACTED], OD [DATE REDACTED], and no UB. It should be refrigerated after opening per manufacturer's recommendation.

d. Opened and used penne pasta with no RD, OD of [DATE REDACTED], UB of [DATE REDACTED]. It was expired according to its label.

e. Opened and used orzo pasta in an unsealed zip lock bag with no RD, OD of [DATE REDACTED], UB [DATE REDACTED]. It was expired according to its label.

f. Opened and used marshmallows in an unsealed bag with RD [DATE REDACTED], no OD, and no UB.

g. Opened and used soy source in a bottle with no RD, OD of [DATE REDACTED], UB [DATE REDACTED]. It was expired according to its label, and it should be refrigerated after opening per manufacturer's recommendation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 DM stated, all food items should have been labeled with receiving date when the facility got delivery from vendors. DM stated, all food items should have open date and used by date (expiration date). DM stated, it Level of Harm - Minimal harm or was all dietary staff (including herself) responsibility to check all food items for labels, dates, properly stored potential for actual harm and sealed. DM stated, all expired items should have been discarded. DM stated these practices were important to make sure all food items were in good condition because the residents consumed these food Residents Affected - Many items. DM stated, she would provide in-service for dry food storage guidelines, because once the food items were opened, there should be different shelf life (a time limit on how long a product can be stored before it becomes unsuitable for consumption or use). DM stated, all staff should refer Dry Goods Storage Guidelines for shelf life after opening and labeled UB date on food items.

During a concurrent observation and interview on [DATE REDACTED], at 8:44 a.m., with DM, in the kitchen, there was opened and used liquid coffee creamer in a plastic bottle with no RD, no OD, and UB of [DATE REDACTED] in the refrigerator #1. DM stated, all food items should be dated, and dietary staff should follow Refrigerated Storage Guide to ensure safety of perishable items that required refrigeration.

During a concurrent observation and interview on [DATE REDACTED], at 8:52 a.m., with DM, in the kitchen, there was opened and used hash browns in a bag with RD of [DATE REDACTED], no OD, and UB of [DATE REDACTED] in the freezer #1. DM stated, dietary staff should follow Freezer Storage Guideline to ensure safety of perishable (spoil quickly and therefore have a short shelf life) items in freezer. DM stated, all items should be dated per policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised [DATE REDACTED], the P&P indicated, Policy: Food items will be stored, thawed, and prepared in accordance with standard sanitary practices. All items will be correctly labeled and dated .13. Dry Storage Area .g. Place opened products in storage containers with tight fitting lids. h. Label and date all storage products.

During a review of the facility's policy and procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated, lemon juice should be refrigerated after opening. The P&P indicated, shelf life (the period during which a material may be stored and remain suitable for use) for sesame oil was three months

after opening. The P&P indicated, bottled salad dressing should be refrigerated after opening. The P&P indicated, shelf life for dry pasta was one year after opening. The P&P stated shelf life for marshmallows were one month after opening. The P&P indicated that soy source should be refrigerated after opening.

During a review of the facility's policy and procedure (P&P) titled, Refrigerated Storage Guide, dated 2023,

the P&P indicated, liquid coffee creamer should be used by three weeks after delivery.

During a review of the facility's policy and procedure (P&P) titled, Freezer Storage Guidelines, dated 2023,

the P&P indicated, length of time in freezer for hashbrowns was one year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46415 potential for actual harm Based on interview and record review, the facility failed to assess mental capacity (ability to make decisions) Residents Affected - Few and provide information to one of three sampled residents (Resident 85) and their responsible parties before signing arbitration agreement (a way of resolving a dispute without filing a lawsuit and going to court).

This failure had the potential to result in Resident 85 not fully understanding their right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions.

Findings:

During a review of Resident 85's Admission Record, the Admission Record indicated, Resident 85 was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnosis including gastrostomy (surgical opening made into the stomach to introduce food), dementia (progressive loss of memory), bilateral age-related cataract (cloudy area in the lens (the clear part of the eye that helps to focus light) of your eye, and altered mental status.

During a review of Resident 85's History and Physical (H&P), dated 7/21/2024, the H&P indicated, Resident 85 does not have the capacity to understand and make decisions due to cerebral vascular disease (group of condition affection blood flow to brain).

During a review of Resident 85's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 6/8/2024, the MDS indicated Resident 85's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 85 had impairment on both of her upper (arms and shoulders) extremities and is dependent on all aspects of activities of daily living (ADL: bathing, toileting, transfer, hygiene).

During a review of Resident 85's Arbitration Agreement (AA), dated 5/17/2024, the AA indicated, Resident 85's family member (FM)1 signed the arbitration agreement on 5/17/2024.

During an interview on 7/26/2024 at 3:37p.m. with Resident 85's FM 1 via phone with the assistance of Registered Nurse Supervisor 2 (RNS 2)FM 1 stated she did not remember signing the Arbitration and did not understand the Arbitration that was written in English. FM 1 stated she thought she signed the admission packet, and no one explained to her what the arbitration was. FM 1 stated no one told her that she could rescind the Arbitration within 30 days of the signed date.

During an interview on 7/26/2024 at 4:10p.m. with Admission Coordinator (AC), AC stated she is responsible for the Arbitration and indicated the Arbitration is an agreement between the family and facility. AC stated the Arbitration is provided with the admission packed and indicated since she speaks fluent Spanish, she did not need a witness. AC stated she realized the family and resident may not understand and it is important to ensure the representative and/or resident understand the Arbitration Agreement content. it with admission packet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 During a review of the facility's policy and procedure (P&P) titled, Arbitration Agreements, revised date 5/25/2023, the P&P indicated if the facility presents an arbitration agreement to a resident, the person Level of Harm - Minimal harm or presenting the arbitration agreement will explain the agreement to the resident in a form and manner that potential for actual harm they understand, including in a language the resident understand and confirm that the resident understands

the agreement. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 555668 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555668 B. Wing 07/26/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Norwalk Skilled Nursing & Wellness Centre, LLC 11510 Imperial Highway Norwalk, CA 90650

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 49889

Residents Affected - Many Based on observation, interview and record review, the facility failed to ensure all facility staff were provided with five hours of dementia (diseases that affect memory and thinking) training annually.

This failure had the potential to result in residents with dementia being neglected and not provided with resident centered, comprehensive care.

Findings:

During a concurrent interview and record review on 7/26/2024 at 11:54 a.m. with the Director of Staff Development (DSD), the DSD stated, all facility staff are to be in-serviced on dementia training two hours upon hire and six hours annually to prevent residents with dementia from being neglected or abused.

During an interview on 7/26/2024 at 3:24 p.m. with the Director of Nursing (DON), the DON stated it was important to provide dementia training to all facility staff to prevent nurse burnout and to educate staff on how to care for residents who are at a higher risk of being started on unnecessary medications.

During a review of the facility's policy and procedure (P&P) titled Dementia Care revised on October 2017, indicated, all staff will complete the two-hour dementia specific training within the first (40) hours of employment. All staff will complete a minimum of 5 hours of Dementia specific in-service training per year, as part of the facility's ongoing staff education program.

a. Attendance at the in-service will be documented and maintained in each employee's personal file.

b. The 2 hours of dementia specific training that is completed as part of orientation is not included in the five (5) hours off annual dementia- specific training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 555668