The Springs Post-acute

F-F580

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 055297

F-F684

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44443 jeopardy to resident health or safety Based on interview and record review, the facility failed to ensure residents, with a change in condition (COC- a sudden, clinically important deviation from a patient's baseline [a minimum or starting point used for Residents Affected - Few comparisons] in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by temperature of 103.8 degrees Fahrenheit ( F-unit of measurement [normal body temperature can range from 97 F to 99 F ]), heart rate of 130 beats per minute ( bpm normal resting heart rate is between 60 and 100 beats per minute), hematuria ( blood in the urine) was transferred to a general acute care hospital (GACH) without a delay for one of three sampled residents (Resident 1).

The facility failed to:

1. Ensure Licensed Vocational Nurse (LVN 1) assessed and monitored Resident 1's condition, including vital signs, when the resident had a change in condition as follows:

a. On [DATE REDACTED] at 10:12 p.m. Resident 1 had body temperature of 99.8 F

b. On [DATE REDACTED] 10:57 a.m., Resident 1 had hematuria (blood in urine).

c. On [DATE REDACTED] at 11:43 p.m. Resident 1 had an elevated body temperature of 103.8 F and heart rate of 130 bpm.

2. Develop a care plan for Resident 1's diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder-impaired bladder control and difficulty emptying the bladder) with interventions to prevent the resident from developing a urinary tract infection (UTI- an infection in the bladder/ urinary tract) and sepsis (a life-threatening condition in which the body's reaction to an infection).

3. Ensure licensed nurses, transferred Resident 1 to GACH on [DATE REDACTED] at 11:53 p.m., without a delay of up to 6 hours, when Resident 1 had an elevated temperature of 103.8 F and heart rate of 130 bpm.

These failures resulted in a six-hour delay transferring Resident 1 to the GACH from the time Resident 1 had

a change in condition, where he was diagnosed with septic shock (life threatening condition when an infection spreads throughout the body and causes a dangerously low blood pressure) and he expired on [DATE REDACTED], (13 hours after he was admitted to the GACH.

On [DATE REDACTED], at 2:34 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to transfer Resident 1 to GACH) timely, when he had a COC on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 On [DATE REDACTED], at 2:30 p.m., the facility submitted an acceptable IJ removal plan ([IJRP]- an intervention to immediately correct the deficient practices). After verification the IJRP was implemented through Level of Harm - Immediate observation, interview, and record review, the IJ was removed while onsite on [DATE REDACTED] at 2:30 p.m., in the jeopardy to resident health or presence of the ADM, DON, and the Regional Director of Operations (RDO). safety

The IJRP included the following: Residents Affected - Few 1.License Nurse 1 was educated by the DON regarding Change of Condition policy and procedure focusing

on immediate notification of the physician as it relates to quality of care.

2. In-service education was commenced by the DON and Quality Staff Registered Nurse (QS RN) to all licensed nurses on [DATE REDACTED] regarding physician notification of the change of condition (COC) including but not limited to vital signs that are out of range for the sepsis prevention (that is [i.e.] temperature< 96.8 F or >99 F or, HR <60 bpm or >90 bpm, respiratory rate <12 or > 20, systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries) < 100 mmHg. If base line SBP is < 100 mmHg, + 5 mmHg than the baseline, Oxygen saturation (O2 Sat a measure of how much oxygen the blood is carrying as a percentage) of < 90% and any change of condition.

3. In-service education was commenced by the DON and/or designee on [DATE REDACTED] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.

4.Competency Skills Check for licensed nurses was commenced on [DATE REDACTED] by DON and QS RN regarding (1) assessing residents' change in conditions (2) identifying symptoms of infection/sepsis and of change of condition, (3) assess, monitor and implement needed interventions based on residents' change in condition (4) recognizing symptoms of urinary tract infection and including elevated temperature, hematuria, abdominal pain, and low back pain, and (5) compliance with recognizing, evaluating and monitoring.

5.The facility checked Situation, Background, Assessment, Recommendation (SBAR a technique that can be used to facilitate prompt and appropriate communication) /COC from [DATE REDACTED] to [DATE REDACTED]. All 161 SBAR/COC showed that medical doctor (MD) was notified on a timely manner.

6.In-service education was commenced by the DON and/or designee on [DATE REDACTED] regarding initiation, review, and revision of resident-centered care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing UTI/sepsis and other areas that accurately reflects resident's conditions and care.

7.In-service education was commenced on [DATE REDACTED] regarding Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention. As of [DATE REDACTED] at 10 a.m., 50 out of 50 Registered Nurses (RNs)/Licensed Vocational Nurses (LVN) staff (100%) received the in-service on Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention.

8.Competency Skills Check regarding COC was commenced on [DATE REDACTED] by DON and QS RN. As of [DATE REDACTED] at 10 a.m., Competency Skills Check regarding COC was conducted to 50 out of 50 RNs/LVNs staff (100%).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 What measures will be put into place or what systemic changes will make to ensure that the deficient practice does not recur? Level of Harm - Immediate jeopardy to resident health or 1.The facility nursing staff will notify the DON or designee at the time of a change of condition. The DON or safety designee (i.e. Assistant Director of Nursing (ADON) and RN Supervisor) will ensure that MD/Nurse Practitioner (NP- a nurse who has advanced clinical education and training) and Physician Assistant (PA-a Residents Affected - Few licensed medical professional who works with physicians to provide patient care) notification has been completed ( i.e. MD notified of the COC, MD responded, and carry out physician order, if with physician order) or the DON or designee will call the MD/NP/PA on call personally. In the event the resident's MD/NP/PA on record may not be reached at the time of the residents COC, the RN Supervisor will obtain orders from a doctor on the medical panel (i.e. other medical doctors) obtain the order to send the resident to

the acute care hospital if needed in real time as to prevent any delay in resident care.

2.COC of the previous day will be reviewed by the clinical team (such as but not limited to DON, ADON, Director of Staff Development (DSD), Infection Preventionist (IP) on the following day in the Clinical Meeting to ensure that all change of conditions have been checked for compliance such as but not limited to (1) assessing any residents' change in condition (1) symptoms of infection/sepsis and of change of condition were identified, (2) appropriate assessment, monitoring and needed interventions were implemented (3) symptoms of UTI including elevated temperature, hematuria, abdominal pain, and low back pain were identified and (4) compliance with recognizing, evaluating, monitoring.

3.The License Nurse will follow the process of MD notification:

a. The attending physician will be notified promptly (i.e. within 30 minutes) for any change of conditions including but not limited to out-of-range vital signs, cardiovascular (heart) changes, neurological changes (brain/mental), genitourinary (bladder), etc.

b. If no response from the attending physician within 30 minutes, the Medical Director will be notified of any change of conditions including but not limited to out-of-range vital signs, cardiovascular changes, neurological changes, genitourinary, etc.

c. If no response from the Medical Director and the resident is manifesting a significant change of condition (such as decrease level of consciousness, unresponsiveness, critical labs level, out of range vital sign, etc. [used at the end of a list to indicate that further, similar items are included.]) registered nurse will refer Physician Orders for Life-Sustaining Treatment (POLST form is a written medical order that specifies a patient's end-of-life care preferences) if to be sent out to emergency room (ER) for further evaluation. Then, attending physician will be notified thereafter.

4. In-service education was commenced to Licensed Nurses by the DON and/or designee on [DATE REDACTED] regarding timely Physician Notification of the COC including but not limited to vital signs that are out of range for the sepsis prevention and any change of change of condition.

5.In-service education was commenced by the DSD to CNAs on [DATE REDACTED] regarding identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any change of condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 6.The DSD or designee (i.e. QS RN, RN Supervisor) will do random verbal quiz to CNAs on different shifts re identification and reporting to License Nurse in-charge and/or the RN Supervisor in a timely manner of any Level of Harm - Immediate change of condition. CNAs will be immediately re-in serviced by the DSD for those CNAs needing further jeopardy to resident health or education. DSD will present the findings and progress status to the Monthly Quality Assessment Assurance safety (QAA- responsible for identifying and responding to quality deficiencies that are identified in the facility) meeting for recommendations/suggestions. Residents Affected - Few a. Four CNAs weekly for four weeks then;

b.Three CNAs weekly for two weeks then;

c.Two CNAs a month for two months.

7.In-service education was commenced by the DON and/or designee on [DATE REDACTED] regarding initiation, review, and revision of care plan of residents with a diagnosis of neuromuscular dysfunction of the bladder with interventions to prevent the resident from developing urinary tract infection (UTI) and sepsis and other care plan that accurately reflects the residents' conditions and care.

8.Competency Skills Check for Licensed Nurses (Registered Nurses and Licensed Nurses [LN]) on COC by DON, QS RN and was commenced on [DATE REDACTED].

9.The DON, or designee will do random verbal quiz to licensed nurses (LN) on different shifts re regarding (1) Verbalize/name change of condition such as symptoms of infections/sepsis, (2) name the process of timely Physician Notification of the Change of Condition (COC) including but not limited to out-of-range vital signs which is an early sign of infection and change of condition, (3) name symptoms of UTI and including elevated temperature, hematuria, abdominal pain, and low back pain, and (4) able to name/recognize, evaluate, monitor, and assess any residents' change of condition:

a. Four LNs weekly for four weeks then;

b. Three LNs weekly for two weeks then;

c. Two LNs a month for two months.

10.The DON or designee (i.e. ADON, QS RN) will conduct random chart audits on SBAR/Change of Conditions. The DON or designee (i.e. ADON, QS RN) will further investigate for findings (such as but not limited to MD was not notified on a timely manner, or other missing information in the SBAR). An in-service education will immediately be provided to the RN/LN involved. Findings and progress status will be presented in the Monthly QAA Meeting for suggestions/recommendations.

d.Three residents weekly for four weeks then;

e.Two residents weekly for two weeks then;

f.Two residents a month for two months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 11.Licensed Nurse staff who are not present during the In-service education (such as those who are on leave, per-diem, or part-time status), in-service education will be provided on day-1 return to work prior to Level of Harm - Immediate start of shift. jeopardy to resident health or safety 12.New hires (licensed nurses) and Registries (provides nursing personnel to facility in need of temporary staff) will be educated on change of condition and physician notification regulations, as well as facility policy Residents Affected - Few and procedure, accordingly in orientation by the DON and/or DSD

13.The DON implemented a Quality Assurance Performance Improvement (QAPI data-driven approach to improving the quality of care and services in nursing homes) Performance Improvement Project (PIP) with a focus on physician notification of significant changes.

14.The PIP resulted in implementation of daily ADON/designee audits of the Clinical Alerts Listing audit to monitor timely notification of MD for residents with vital signs that are out-of-range and other change of conditions.

15.The QS RN/consultant nurse will visit the facility at least once a week to provide general oversight and monitoring of the PIP.

How the facility plans to monitor performance to make sure that solutions are sustained.

1.Under the supervision of the Administrator, DON or Designee will be responsible and accountable to submit audit findings utilized the Quality Assurance (QA) monitoring/audit tool to QAA committee member monthly for 3 months until 100% compliance.

2.The Administrator and DON shall be responsible for the implementation, monitoring, and evaluation of this Plan of Correction.

Findings:

During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses including acute respiratory failure (a serious condition that occurs when your lungs can't get enough oxygen into your blood or remove carbon dioxide), bronchopneumonia (an inflammation of the lungs that affects the small airways and the surrounding lung tissue, seizures (a sudden uncontrolled change in behavior or body movement caused by abnormal electrical activity in the brain, hemiplegia (paralysis on the same side of the body) and hemiparesis (total paralysis of

the arm, leg, and trunk on the same side of the body), encounter for tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe, and neuromuscular dysfunction of the bladder.

During a review of Resident 1's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated Resident 1 did not have the capacity to understand and make decisions.

During a review of Resident 1's Physician Order Summary report dated [DATE REDACTED], the Physician Order Summary indicated to notify Medical Doctor (MD) if Resident 1 had any of the following symptoms:

1. Temperature less than (<) 96.8 F or greater than 99 F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 2. Heart rate greater than (>) 90 beats per minute

Level of Harm - Immediate 3. Respiratory (breathing) rate greater than 20 jeopardy to resident health or safety 4. Acute change in mental status

Residents Affected - Few 5. Oxygen saturation (O2 sat- a measure of how much oxygen the blood is carrying as a percentage) less than 90 percent (%)

6. Systolic blood pressure (SBP- pressure exerted when the heart beats and blood is ejected into the arteries [blood vessels that distribute oxygen-rich blood to your entire body]), if baseline less than 100 millimeters of mercury (mmHg a unit of measurement for pressure), more than 5 mmHg lower than the baseline, every shift for sepsis prevention.

During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE REDACTED], the MDS indicated, Resident 1 had severe impairment in cognitive (ability to think, understand, learn, and remember), skills for daily decision making. The MDS indicated Resident 1 was dependent on staff with bed mobility, chair/ bed to chair transfer, and tub/ shower transfer.

During a record review of Resident 1's COC dated [DATE REDACTED] timed at 6:19 a.m., the COC indicated Resident 1 had a moderate amount of hematuria in his incontinent pad (diaper). The COC indicated on [DATE REDACTED] at 6:30 a. m. Resident 1's Primary Care Physician (PCP) 1 was notified., but there was no documentation of recommendations or physician orders.

During a record review of Resident 1's COC dated [DATE REDACTED] timed at 7:10 a.m., the COC indicated Resident 1 was unresponsive to verbal, tactile (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and deep stimuli (when a person does not respond to pain, touch, and voice). The COC indicated PCP 1 was notified and facility staff called 911.

During a review of Resident 1's Paramedics Run Sheet (a detailed written record that paramedics fill out

during each emergency medical call) dated [DATE REDACTED] timed at 6:33 a.m., the Paramedics Run Sheet indicated Resident 1 was observed with eyes open and unresponsive. The Paramedics Run Sheet indicated Resident 1 had fever for three days and became hypotensive (low blood pressure) with an altered mental status. The Paramedics Run Sheet indicated on [DATE REDACTED] at 6:46 a.m., Resident 1's blood pressure was ,d+[DATE REDACTED] mmHg, HR 110 bpm, and respiratory rate of 20.

During a review of Resident 1's GACH emergency room (ER) Notes dated [DATE REDACTED], the GACH ER Notes indicated, Resident 1 was admitted on [DATE REDACTED] at 7:31 a.m., with diagnoses of UTI, acute kidney injury (a sudden loss of kidney function, that can range from minor to complete kidney failure) and septic shock (a life-threatening condition that occurs when the body's response to an infection causes dangerously low blood pressure). The GACH ER notes indicated on [DATE REDACTED] was 8:11 a.m., Resident 1 was noted to have severe sepsis. GACH ER notes indicated Resident 1's temperature was 98.7 F, HR 111 bpm, and blood pressure , d+[DATE REDACTED] mmHg. The GACH ER notes indicated on [DATE REDACTED] at 6:12 p.m., the first code blue (a hospital emergency code that indicates a patient needs immediate medical attention, usually due to cardiac (heart) or respiratory arrest) was called, and at 7:50 p.m., the second code blue was called. The GACH ER notes indicated on [DATE REDACTED], at 8:11 p.m., Resident 1 expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 During an interview on [DATE REDACTED] at 3:14 p.m. with LVN 2, LVN 2 stated she did not assess or monitor Resident 1's vital signs when the resident had a change of condition (temperature of 103.8 F and HR 130 bpm) on Level of Harm - Immediate [DATE REDACTED] at 11:43 p.m. LVN 2 stated there was no documentation of Resident 1's temperature and HR after it jeopardy to resident health or was last taken on [DATE REDACTED] at 11:43 p.m. safety

During a concurrent interview and record review on [DATE REDACTED], at 4:24 p.m., with Registered Nurse Supervisor Residents Affected - Few (RNS 1), Resident 1's Weight and Vital Sign Summary and Situation, Background, Assessment, Recommendation (SBAR a communication tool used by healthcare workers when there is change of condition among the residents) / Change of Condition (COC) were reviewed. The Weight and Vital Sign Summary indicated, Resident 1 had the following temperatures and heart rates:

a. On [DATE REDACTED] 10:12 pm for Resident 1's temperature 99.8 F

b. On [DATE REDACTED] 11:25 am for Resident 1's HR 96 bpm

c. On [DATE REDACTED] 11:31 pm for Resident 1's HR 91 bpm

d. On [DATE REDACTED] 2:31 pm Resident 1's temperature 99.1 F

e. On [DATE REDACTED] 10:32 pm Resident 1's temperature 99.8 F

f. On [DATE REDACTED] 11:43 pm Resident 1's temperature 103.8 F

g. On [DATE REDACTED] 2:31 p.m., for Resident 1's HR 98 bpm

h. On [DATE REDACTED] 11:43 p.m., for Resident 1's HR 130 bpm

RNS 1 stated Resident 1's physician order dated [DATE REDACTED] indicated to notify MD if Resident 1 had any of the following symptoms:

Temperature less than 96.8 F or greater than 99 F,

Heart rate greater than 99 bpm

Respiratory rate greater than 20,

Acute change in mental status, O2 saturation less than 90 %, systolic blood pressure, if baseline less than 100 mmHg, more than 5 mmHg lower than the baseline, every shift for sepsis prevention. RNS 1 stated the orders should have been followed for Resident 1's physician to address COC. RNS 1 stated there was no care plan for neuromuscular dysfunction of the bladder to ensure licensed nurses will have specific intervention related to the diagnosis. RNS 1 further stated that there was no re-assessment done by licensed nurses after Resident 1 was noticed to have change of condition (temperature of 103.8 F and HR 130 bpm)

on [DATE REDACTED] at 11:43 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 During an interview on [DATE REDACTED], at 4:40 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 physician was not notified of Resident 1's temperature of 103.8 F and HR 130 bpm on [DATE REDACTED] at 11:43 p. Level of Harm - Immediate m. LVN 1 stated nonpharmacological (healthcare strategies that do not involve the use of medications) jeopardy to resident health or interventions including cooling measures such as removing blankets, put a fan on, and placing cold towels safety on Resident 1's forehead and under the arms were initiated. LVN 1 stated Resident 1's physician was not called because Resident 1 had a COC on [DATE REDACTED] when Resident 1 had temperature of 99.8 F and Residents Affected - Few hematuria. LVN 1 stated she failed to inform Resident 1's physician when he spiked a temperature of 103.8 F. LVN 1 stated she did not think it was an infection as Resident 1's temperature went down to 99 F. LVN 1 stated she does not recall the exact time Resident 1's temperature was taken and was not documented. LVN 1 stated she did not notify the doctor of Resident 1's HR of 130 bpm, as Resident 1's heart rate came down but failed to document. LVN 1 stated Resident 1's physician should be notified as interventions (cooling measures) were not working. LVN 1 stated no other temperatures or heart rates were documented after it was taken on [DATE REDACTED] at 11:43 p.m. LVN 1 stated the next vital signs was taken on [DATE REDACTED] at 6 a.m., (6 hours after). LVN 1 stated Resident 1 was sent to the GACH on [DATE REDACTED] at 6 a.m.

During an interview on [DATE REDACTED], at 5:10 p.m., with RNS 3, RNS 3 stated Resident 1's physician was not notified of the resident's temperature of 103.8 F, as Resident 1 was already on monitoring for elevated temperatures and hematuria. RNS 3 stated primary care physicians get upset when called so nonpharmacological interventions were initiated for Resident 1. RNS 3 stated looking back Resident 1's physician should have been notified of Resident 1's temperature of 103.8 F as Resident 1 had previous elevated temperature of 99.8 F on [DATE REDACTED]. RNS 3 stated Resident 1 could have had a UTI, pneumonia (an infection/ inflammation in the lungs), or sepsis (a life-threatening blood infection). RNS 3 stated on [DATE REDACTED] when Resident 1 had altered level of consciousness (a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) and low blood pressure of , d+[DATE REDACTED] mmHg, it could have been sepsis. RNS 3 stated Resident 1 was transferred to GACH via 911 on [DATE REDACTED] at 6 a.m.

During an interview on [DATE REDACTED], at 9:35 a.m., with Resident 1's Primary Care Physician (PCP)1, PCP 1 stated

on [DATE REDACTED] he was not informed of Resident 1's temperature of 103.8 F and HR of 130 bpm. PCP 1 stated he could have ordered for Resident 1 to be transferred to a GACH especially when Resident 1 was exhibiting signs of infection. PCP 1 stated on [DATE REDACTED] at 11:43 p.m., Resident 1 could have had a septic shock (a life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure) when his temperature increased to 103.8 F and HR 130 bpm. PCP 1 stated Resident 1 should have been transferred to the GACH.

During an interview on [DATE REDACTED], at 1:57 p.m., with RN 3, RN 3 stated, on [DATE REDACTED] Resident 1 had altered level of consciousness ( ALOC-a change in a person's state of awareness and alertness, where they are not fully conscious or responsive to their surroundings) as Resident 1's eyes were closed, the resident was not responding to tactile stimuli (any form of touch or physical contact perceived by the skin such as a sternal rub [a painful stimulus to the chest that is used to assess a patient's responsiveness ]), and when called by his name. RN 3 stated Resident 1's temperature was checked every 30 minutes to one hour but was not documented. RN 3 stated if it was not documented it was not done. RNS 3 stated he should have called Resident 1's PCP 1 or called 911 when Resident 1 had a COC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 055297 Department of Health & Human Services Printed: 09/09/2025 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 055297 B. Wing 02/06/2025

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

The Springs Post-Acute 10625 Leffingwell Road 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 0684 During a concurrent interview and record review on [DATE REDACTED] at 11:13 a.m., with the Director of Nursing (DON), Resident 1's COC, Physician's Orders, Nurse Notes, Medication Administration Record (MAR) for the Level of Harm - Immediate month of ,d+[DATE REDACTED] were reviewed. The DON stated the Physician Order dated [DATE REDACTED] for sepsis prevention jeopardy to resident health or indicated to notify MD if any vital signs were abnormal such as temperature less than 96.8 F or greater than safety 99 F and HR greater than 90 bpm. The DON stated there was no documentation indicating on [DATE REDACTED] Resident 1's physician was notified when Resident 1 had a temperature of 99.8 F. The DON stated, on Residents Affected - Few [DATE REDACTED] at 11:43 p.m., when Resident 1 had a temperature of 103.8 F and HR of 130 bpm, licensed staff should have transfer Resident 1 to a GACH for evaluation and treatment and not wait until the next day [DATE REDACTED] at 6 a.m., (6 hours later). The DON stated there was no care plan to address Resident 1's diagnosis of neuromuscular dysfunction of the bladder. The DON stated it was important to have a plan of care with interventions needed for Resident 1's diagnosis. The DON stated when there was a change of condition for any resident licensed nurses were expected to complete an assessment, notify the physician and resident representative. The DON stated sepsis was a complication of an infection that could be fatal.

During a review of Job Description LVN, ([undated]), the Job Description LVN indicated, the LVN is responsible for demonstrating the ability to assign meaning to a resident symptoms and initiating appropriate action and consistently monitoring resident condition, initiating appropriate nursing action, consistently documenting resident care and reports pertinent clinical observations and reactions to the appropriate individual, and documenting nursing interventions and resident responses including physical and psychological response.

During a review of the Job description Registered Nurse (RN), ([undated]), the Job Description RN indicated,

The RN is responsible for making supervisory decisions, demonstrating the ability to assign meaning to resident symptoms and initiating appropriate action, consistently monitoring resident condition and initiates appropriate nursing intervention, consistently documenting resident care and reports pertinent clinical

observations and reactions to the appropriate individual, and documenting nursing interventions, consistently and accurately performs reassessments during each shift and when the resident condition changes, and documenting nursing interventions and resident responses including physical and psychological response.

During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated ,d+[DATE REDACTED], the P&P indicated, These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated ,d+[DATE REDACTED], the P&P indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) specific instruction to notify the Physician of changes in the resident's condition.

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