Health inspection·October 23, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan indicating two- person assist with using a mechanical lift (a device that helps safely transfer people with limited mobility from one place to another) was followed for one of three sampled residents (Resident 1), This deficient practice resulted in Resident 1 sliding out of the mechanical lift's sling and sustaining a bump on the right parietal (located near the back and top of the head) area of the head. Findings: During a record review of the admission Record for Resident 1, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of morbid obesity (having too much body fat), dementia (a progressive state of decline in mental abilities) and chronic kidney disease (a long-term condition that occurs when the kidney are damaged and can't filter blood properly). During a record review of Resident 1's History and Physical (H/P) dated 10/19/2024, the H/P indicated that Resident 1 does not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Sheet ([MDS], a federally mandated resident assessment tool), dated 8/30/2024, the MDS indicated Resident 1 was moderately impaired in cognitive skills (thought process) for daily decision making and was dependent (helper does all of the effort to complete activities, the assistance of 2 or more helpers is required) for self-care activities such as oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility such as rolling left and right, sitting to lying, lying to sitting and bed to chair transfers. During a concurrent observation and interview on 10/22/2024 at 2:45 p.m., with Resident 1, Resident 1 stated she does not remember the fall; she knew that she fell but does not remember how she fell. During a telephone interview on 10/23/2024 at 9:47 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was transferring Resident 1 from her bed to her shower chair by herself, using the mechanical lift. CNA 1 stated that halfway to the shower chair, the right upper side of the sling hook latch ripped, and Resident 1 fell to the floor. During an interview on 10/23/2024 at 11:03 a.m., with the Registered Nurse Supervisor (RNS), the RNS stated she went into the room and saw Resident 1 on the floor. The RNS stated Resident 1 was considered a two person assist with transfers. (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 10/23/2024 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)