Health inspection·February 21, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident 1 required two-person assistance with turning and repositioning, due to impaired mobility, and total dependence with bed mobility (the ability to move around in bed, including rolling, sitting up, and scooting). During a review of Resident 1's Alert Charting (Succeeding Documents for Change of Condition [COC] and Skilled Documentation about an event that has occurred with a resident ) dated 2/8/2025, the Alert Charting document indicated a restorative nursing assistant ([RNA] a certified nursing assistants that have additional training in specific therapeutic techniques) 1 alerted licensed vocational nurse (LVN) 1 of a potential incident with Resident 1 and certified nursing assistant 1 (CNA 1). The Alert Charting document indicated CNA 1 informed LVN 1 he was working with Resident 1 to change her bed sheets and in the process of turning the resident to her left side, he heard a discomforting, unnatural sound (indicating something was wrong) from what sounded like the left wrist or arm, so he asked RNA 1 to get LVN 1. The Alert Charting document indicated Resident 1's physician (MD 1) was notified and ordered a STAT (urgent) Xray (a photographic or digital image of the internal composition of something, especially a part of the body) of the left hand and left forearm. Resident 1 left the facility with emergency services (911) on 2/8/2025 at 3:54 p.m. to the GACH. During a review of Resident 1's Order Summary Report (the physician's orders), the Order Summary Report indicated a physician's order dated 2/8/2025 for a STAT Xray of the resident's left hand and left forearm and transfer the resident to GACH via 911 for further evaluation and treatment due to acute fracture of the distal forearm. During a review of Resident 1's Radiology (the medical specialty that uses medical imaging to diagnose diseases and guide treatment within the body) Results Report dated 2/8/2025, the Radiology Results Report indicated an Xray taken on 2/8/2025 of the left forearm indicated the resident had an acute fracture of the distal shaft of the left forearm, normal bony mineralization (the degree of bone density), and no osteoblastic (the cells that form new bones and grow and heal existing bones) or osteolytic lesion (a softened bone area) were noted. During a review of Resident 1's GACH's Emergency Department (ED) Note dated 2/8/2025, the ED Note indicated Resident 1 was brought to the ED via 911 for evaluation of a left forearm fracture. The ED Note indicated Resident 1 sustained a left forearm fracture while the resident was being moved in bed at the facility. The ED Note indicated Resident 1 had contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) on all four limbs, left arm deformity and was positive for trauma on the left forearm. The ED Note indicated a left arm splint was applied, and Resident 1 was admitted to the GACH for observation. The ED Note indicated Resident 1 had a flat mood and affect (absence of an appropriate emotional response) and was bedridden with limbs contractures. During a review of Resident 1's untitled Care Plan initiated 2/14/2025, the Care Plan indicated Resident 1 had a fracture of the left forearm with a soft splint. The Care Plan indicated Resident 1 was at risk for pain and skin breakdown. The Care Plan goals for Resident 1 included monitoring (frequency not defined) Resident 1 for pain and ensure the resident would not have any adverse effects (an undesired effect) from the left forearm fracture. The Care Plan Interventions for Resident 1 included two-person assistance for all activities of daily living ([ADL] the everyday tasks that people perform to care for themselves) care, cradling (to support protectively) Resident 1's left arm while providing ADL care and repositioning to keep the left arm in alignment (how the head, shoulders, spine, hips, knees and ankles relate and line up with each other) with the left side of the body, turning Resident 1 to the right side and back only, and gentle handling of Resident 1 during ADL care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055297 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 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 0689 Level of Harm - Actual harm During a review of the Order Summary Report dated 2/17/2025, the Order Summary Report indicated an order dated 2/17/2025 for Norco (pain management) tablet 5-325 (strength) milligrams (mg, a unit of measurement), give one tablet via gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) every eight hours for pain management for 14 days. Residents Affected - Few During an interview on 2/21/2025 at 12:13 p.m., CNA 1 stated on 2/8/2025 he (CNA 1) was going to change Resident 1's soiled adult incontinence (no voluntary control of urination and bowel movements) briefs (disposable, absorbent underwear that helps with urinary or bowel incontinence). CNA 1 stated it was around 9 a.m. and all the other CNAs were busy with other residents' morning care. CNA 1 stated RNA 1 was putting splints on other residents (unknown), and LVN 1 was busy passing medication. CNA 1 stated there was no one available to help him to turn Resident 1. CNA 1 stated Resident 1 required a two-person assistance, but he could not get anyone to help him to turn Resident 1, so he felt confident he could turn the resident alone, and he did it. CNA 1 stated Resident 1 resided in the subacute unit (a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) and needed two-person assistance when turning due to the resident being stiff, Resident 1's inability to help with turning, presence of medical devices including gastrostomy tube ([GT] and tracheostomy [surgically created opening in the trachea [windpipe]), and having contractures. CNA 1 stated that the subacute unit was very busy with residents' care due to the complexity of the residents, and he was instructed to call a licensed nurse for help if a CNA could not assist him, but the LVNs were busy as well. CNA 1 stated this was not the first time he was unable to obtain help to turn Resident 1. CNA 1 stated on /2/28/2025 when he was changing Resident 1, he was standing on the right side of Resident 1's bed and he put one of his hands behind resident 1's right shoulder and one hand behind Resident 1's right knee and began to turn her to the left side when he heard a loud cracking sound. CNA 1 stated he did not know where the cracking sound came from, so he pulled her onto her back carefully. CNA 1 stated Resident 1 had a deformity (contracture) in her left wrist that caused her left land to point outward away from her body and after the loud cracking noise. CNA 1 stated he noticed the resident's left hand and wrist appeared more open and looser than normal, meaning the arm was able to move a little more towards the body when it usually could not. CNA 1 stated RNA 1 just happened to enter the room at that time and he asked her to call LVN 1 for help. CNA 1 stated when repositioning Resident 1 with a two-person assistance you were able to see where the resident's limbs were including the contracted left hand and wrist from both sides of the bed to ensure you knew where the arm was always. CNA 1 stated they were able to turn and reposition Resident 1 more carefully using a two-person assistance. During an interview on 2/21/2025 at 1:07 p.m., RNA 1 stated on 2/8/2025 CNA 1 asked her to call LVN 1 for help, so she did, CNA 1 told her (RNA 1) he heard a pop. RNA 1 stated Resident 1 was very stiff, and staff had to take extra precautions when working with the resident because the stiffness made it hard to move and reposition Resident 1. RNA 1 stated it was kind of scary to move the resident's limbs around due to the severity of stiffness Resident 1 had and staff had to be extra gentle and take precautions when moving her around. RNA 1 stated Resident 1 was supposed to be a two-person assistance because she was very fragile, so they needed two-people to turn her safely. RNA 1 stated CNA 1 was a big guy, and he may have assumed he could turn the resident by himself without an assistance because the resident was a small lady. RNA 1 stated it gets kind of hard because there was usually three CNAs on the subacute unit during the day shift (7 a.m. to 3 p.m.) and if two were helping each other, she does not know who was helping the third CNA. During an interview on 2/21/2025 at 1:45 p.m., MD 1 stated facility staff had to take (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055297 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 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 0689 Level of Harm - Actual harm precautions with this resident population and be careful with the residents because they do not respond appropriately to pain due to anoxic brain damage so staff could not tell if the resident was in pain. MD 1 stated there was an increased risk for fracture in residents with brittle (break or shatter easily) bones, so facility staff had to handle these residents gently, turn the residents carefully, and not rush care. Residents Affected - Few During an observation and concurrent interview in Resident 1's room on 2/21/2025 at 2:16 p.m., with LVN 2, LVN 2 was observed to uncover Resident 1's left arm while Resident 1 was in bed. Resident 1 was observed to have a splint on her left forearm. LVN 2 stated the facility staff could not tell if Resident 1 was in pain, so they were giving her around the clock (regularly scheduled) Norco at this time for pain from the fracture. LVN 2 stated Resident 1's left hand and wrist were contracted causing the left hand to point outwards. During an interview on 2/21/2025 at 2:18 p.m., CNA 2 stated they usually need two-person assistance for the residents on the subacute unit due to their health status but sometimes everyone was busy, so you must keep going to get your work done and do the work alone. During an interview on 2/21/2025 at 2:26 p.m., the director of rehabilitation ([DOR] a medical specialty that helps people regain abilities lost due to injury, disease, or surgery) stated she reviewed Resident 1's rehabilitative services Discharge (DC) Summary from June 2023 and the DC Summary indicated Resident 1 was totally dependent on staff for bed mobility. The DOR stated a total dependence meant the resident could not help with the activity at all and often the resident would be two-person assist. The DOR stated due to Resident 1's stiffness and posturing (involuntary and abnormal positioning of the body due to preserved motor reflexes) it can be harder to turn her. The DOR stated Resident 1 had a left wrist contracture which abnormally pointed away from her body and when you turned Resident 1, you had to ensure all her limbs were out of the way. The DOR stated Resident 1's left arm at the shoulder was internally rotated (causes the associated limb to rotate internally or toward the body) which caused the left hand and wrist to point out away from the body, so you had to adjust the arm and help it become midline prior to turning. During an interview on 2/21/2025 at 2:52 p.m., the director of staff development (DSD) stated if the resident was assessed as a two-person assistance on the care plan, they should be a two-person assistance for resident safety. The DSD stated most subacute residents should be a two-person assistance they do not want medical devices getting dislodged, or they have contractures, so they do not want any injuries. During an interview on 2/21/2025 at 3:26 p.m., the director of nursing (DON) stated Resident 1 had a flat affect but after she was readmitted back from the hospital with the fracture, they noticed some facial grimacing (a facial expression of pain) and an order from MD 1 for Norco 5-325 mg for 14 days was received. The DON stated the plan was to reevaluate her in two weeks to see if she still required the Norco. The DON stated residents with osteoporosis needed to be handled gently. The DON reviewed Resident 1's care plans and stated Resident 1 had a Care Plan to prevent skin issues that indicated Resident 1 was a two-person assist. The DON stated if the care plan indicated Resident 1 was a two-person assistance for turning and repositioning, she should have had two people assisting her to turn and reposition. During a review of the facility's policy and procedure (P/P) titled Turning a Resident on His/ Her Side Away from You, dated 10/2020, the P/P indicated the purpose of this procedure was to provide comfort to the resident and to promote good body alignment. The P/P indicated to review the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055297 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 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 0689 care plan to assess for any special needs of the resident. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055297 If continuation sheet Page 5 of 5