Health inspection·April 4, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), whose cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired, and who was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), was monitored to prevent him eloping from the facility. This deficient practice resulted in Resident 1 eloping from the facility, on 4/1/2025 at approximately 7 p.m. Resident 1 was found by a good Samaritan on 4/2/2025, approximately 14 miles from the facility, he was transferred to a General Acute Care hospital (GACH) for evaluation before being readmitted to the facility on [DATE]. This deficient practice had the potential for Resident 1 to continue to be missing, injury and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/11/2025, the MDS indicated Resident 1's cognition was severely impaired, and he required supervision or touch assistance (when a helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) to walk. During a review of Resident 1's Elopement Evaluation dated 3/11/2025, the Elopement Evaluation indicated a score of two which indicated a risk of elopement. During a review of Resident 1's Care Plan dated 6/6/2024, the Care Plan indicated Resident 1 was at risk for wandering/elopement. Under this Care Plan a goal for Resident 1 was for him not to leave the facility unattended. The Care Plan's interventions included identifying Resident 1's triggers for wandering/eloping. The Care Plan's documentation did not indicate what triggers to look for. During a review of Resident 1's Change in Condition (COC) dated 4/1/2025, the COC indicated Resident 1 was missing at 7 p.m. During an observation on 4/3/2025 at 9:50 a.m., the facility's receptionist desk was observed in a (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 04/04/2025 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)