Health inspection·September 23, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of five sampled resident's (Resident 1) debit and credit cards were documented on their Personal Effects Inventory form, Resident 1 was made aware of the risk involved in keeping her debit and credit cards at her bedside and Resident 1 was offered a place to safely keep her debit and credit cards. This deficient practice resulted in Resident 1 being unaware of her rights as it pertained to her personal valuables and it had the potential for Resident 1's personal belongings to be lost, stolen and for her funds to be inappropriately used by unauthorized persons. Findings: During a review of Resident 1's admission Record (Face sheet), the Face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/9/2024, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent. During a review of Resident 1's Resident Inventory form dated 9/2/2024, the Resident Inventory form indicated the following items were listed: 1. A debit card (no description or quantity identified) 2. A credit card (no description or quantity identified) During a review of Resident 1's Personal Effects Inventory form dated 9/3/2024 and timed at 2:14 p.m., the Personal Effects Inventory form indicated there was no documentation that Resident 1's debit and credit cards were listed. During a review of Resident 1's clinical records there was no written documentation that Resident 1 was offered a safe place to store her debit and credit cards or that Resident 1's debit and credit cards were put in a safe place. Resident 1's clinical record indicated no documented evidence that Resident 1 was educated on the risks of keeping her debit and credit cards at her bedside. During an interview on 9/18/2024 at 8 a.m., Resident 1 stated there were two nurses who did the inventory of her belongings on the night of her readmission to the facility (9/2/2024). Resident 1 (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555668 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 555668 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 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)