Health inspection·November 19, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify the physician of a significant change in condition (COC sudden, clinical deviation from a resident's baseline in physical, cognitive, behavioral, or functional status) for one of three sampled residents (Resident 1) when the facility did not notify the physician when Resident 1 developed swelling and discoloration of the left fourth and fifth fingers.This failure had the potential to delay necessary medical evaluation and treatment, placing the resident at risk for worsening of the condition or other complications.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 11/27/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a rereview of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired and was dependent (helper does all the effort) with dressing, personal hygiene, and toileting. During a review of Resident 1's COC dated 9/21/2025, timed at 1:13 p.m., the COC indicated Resident 1 had swelling and discoloration of her left hand. During a review of Resident 1's Nurses Notes dated 9/21/2025, timed at 1:44 p.m., the Nurses Note indicated Resident 1's physician was called, a message was left, with no response. During a review of Resident 1's Nurses Notes dated 9/21/2025, timed at 8:07 p.m., the Nurses Note indicated a follow-up call was placed to Resident 1's doctor regarding Resident 1's left hand swelling and discoloration. During a review of Resident 1's Nurses Notes dated 9/22/2025, timed at 2:52 a.m., the Nurses Note indicated a new order was received from Resident 1's doctor for an x-ray (pictures of the inside of your body) of left hand due to swelling and discoloration. During an interview on 9/25/2025 at 10:49 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Registered Nurse Supervisor (RNS) 2 called Resident 1's physician two to three times regarding Resident 1's left hand swelling and discoloration but was unable to reach him. During an interview on 9/25/2025 at 11:26 a.m., with RNS 2, RNS 2 stated she called and texted Page 1 of 4 055297 055297 11/19/2025 The Springs Post-Acute 10625 Leffingwell Road Norwalk, CA 90650

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's doctor regarding Resident 1's left hand swelling and discoloration but was unable to reach him and reported it to RNS 3 in report at the end of her shift (3-11 shift). During a concurrent interview and record review on 9/25/2025 at 12:17 p.m., with RNS 1, RNS 1 validated Resident 1's physician did not call back regarding Resident 1's left hand swelling and discoloration until 9/22/2025 at 2:52 a.m.( 13 hours after Resident 1 was observed with a swelling and discoloration of the left hand). RNS 1 stated it was the policy of the facility to call the medical director if they were unable to reach the residents primary physician. RNS 1 stated not getting a hold of Resident 1's primary physician could cause Resident 1 to become frustrated and delayed in care. During an interview on 9/25/2025 at 2:31 p.m., with LVN 4, LVN 4 stated if unable to reach a resident's primary physician, she would notify her supervisor and reach out to the medical director. LVN 4 stated the facility policy was if the primary physician does not call back within 30 minutes, we are supposed to call the medical director. LVN 4 stated it was important to get a hold of a physician to get orders because we cannot do anything without a physician orders. During an interview on 9/25/2025 at 3:21 p.m., with the Director of Nursing (DON), the DON stated Resident 1's primary physician responded late to his calls and texts regarding Resident 1's left hand swelling and discoloration but the staff should have reached out to the medical director. The DON stated this caused a delay in treatment which could potentially cause the residents to feel frustrated. During a review of the facility's LVN Job Description, the LVN Job Description indicated, Essential Responsibilities and Job Functions: Reports all abnormal test results to physician in a timely manner; triage activities based on borderline and/or abnormal and/or unusual findings. During a review of the facility's policy and procedure (P&P) titled, Physician Services, dated 2/2021, the P&P indicated, Each resident remains under the care of a physician. An alternate physician supervises the care of residents when his or her attending physician is not available. The attending physician may designate another physician to act on his or her behalf when unavailable. If the attending physician does not delegate another physician, the facility will have a physician available to supervise the care of the residents. 055297 Page 2 of 4 055297 11/19/2025 The Springs Post-Acute 10625 Leffingwell Road Norwalk, CA 90650

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report a fracture (broken bone) of unknown origin for one of two sampled residents (Resident 1 ) to the California Department of Public Health (CDPH), law enforcement, or the Ombudsman. This deficient practice resulted in a delay in initiating an investigation and potentially increased the risk of abuse, neglect or mistreatment of other residents. of an investigation and potentially increased the risk of abuse, neglect, and mistreatment of other residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility 11/27/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a rereview of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired and was dependent (helper does all the effort) with dressing, personal hygiene, and toileting. During a review of Resident 1's Change of Condition (COC- a sudden, clinically deviation from a patient's baseline in physical, cognitive {ability to think, understand, learn, and remember} behavioral, or functional status) dated 9/21/2025, timed at 1:13 p.m., the COC indicated Resident 1 had swelling and discoloration of her left hand. During a review of Resident 1's COC dated 9/23/2025 timed at 12:45 a.m., the COC indicated Resident 1's x-ray (pictures of the inside of your body) were received indicating Resident 1 had a non-displaced fracture (broken bone) of Resident 1's fifth finger. During a review of Resident 1's Radiology Results Report dated 9/22/2025, the Radiology Results Report indicated Resident 1 had an acute, transverse, non-displaced fracture (a bone that has a broken cleanly in half, straight across its length, but the broken ends remain perfectly aligned and don't move out of position) at proximal (nearer to the center) third of fifth proximal phalanx (one of the bones in the finger) of the left hand. During a concurrent interview and record review on 9/25/2025 at 12:17 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that Licensed Vocational Nurse (LVN) 5 received Resident 1's X-ray results on 9/23/2025 at 12:45 a.m. but failed to report the results to California Department of Public Health (CDPH), local law enforcement, and the Ombudsman within two hours. RNS 1 further stated that, due to the absence of documentation explaining how Resident 1 sustained the fracture, it was critical to notify the appropriate agencies to ensure a proper investigation could be conducted. During an interview conducted on 9/25/2025 at 2:31 p.m. with LVN 4, LVN 4 stated that a fracture of unknown origin should be reported immediately, as the cause is unclear and could potentially be the result of abuse. During an interview on 9/25/2025 at 3:21 p.m. with the Director of Nursing (DON), the DON stated that LVN 5 should have reported Resident 1's fracture immediately upon receiving the information on 055297 Page 3 of 4 055297 11/19/2025 The Springs Post-Acute 10625 Leffingwell Road Norwalk, CA 90650

F 0609 Level of Harm - Minimal harm or potential for actual harm 9/23/2025 at 12:45 a.m. The DON stated that the fracture should have been reported within two hours, but it was not, as he only became aware of the incident from RNS 1 at approximately 8:00 a.m. on 9/23/2025. The DON emphasized the importance of notifying the three required agencies—California Department of Public Health (CDPH), law enforcement, and Ombudsman because timely reporting is mandated by regulation to ensure appropriate investigation. Residents Affected - Few During a review of the facility's LVN Job Description, the LVN Job Description indicated, Essential Responsibilities and Job Functions: Follow guidelines regarding contacting administrator and DON regarding real or potential abuse situations. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 9/2022, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. 055297 Page 4 of 4