Inspection·July 14, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few 7/7/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making and required set up assistance (helper sets up while resident completes the activity) with self-care abilities such as eating, and supervision (helper provides verbal cues as resident completes the activity) with oral hygiene, upper body dressing and personal hygiene, moderate assistance (helper does less than half the effort) with lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1's mood severity score (a measure used to gauge the overall severity of depressive symptoms [a cluster of emotional, cognitive, and behavioral changes that characterize depression]) was 10, which indicated moderate depression (a level of depression that is in the middle of mild and severe which persist for at least two weeks such as persistent low mood or sadness, sleep disturbances, feeling of guilt of worthlessness).During a review of Resident 1's untitled Care Plan dated 7/8/2025, the Care Plan indicated Resident 1 was having ideations of self-harm. The Care Plan indicated Resident 1 felt frustrated with being physically impaired because of morbid obesity. The Care Plan goal was for Resident 1 to remain safe, evaluate the risk of depression and manage undesirable behaviors (such as thoughts of self-harm). The Care Plan interventions included calmly listening to the resident's storytelling without judgement, asking directly if any chance to hurt himself, frequent visual checks, provide one-on-one sitter, engaging Resident 1 in conversation to distract him from thoughts of self-harm and ensure the safety of Resident 1 and others.During a review of Resident 1's medical records including Nursing Progress Notes for July 2025, admission Notes dated 7/7/2025, and Social Services assessment dated [DATE], the medical records did not indicate the facility staff assessed Resident 1 regarding thoughts of self-harm or harm to others when he was admitted back to the facility on 7/7/2025.During a review of Resident 1's Change of Condition form dated 7/8/2025, the Change of Condition form indicated Resident 1 told Registered Nurse Supervisor (RNS) 1 that he wanted to go to a psychiatric (things related to mental illness and its treatment) hospital for further evaluation. The Change of Condition form indicated Resident 1 stated he sprayed oven cleaner on his forearms (to cause pain). The Change of Condition form indicated Resident 1 showed RNS 1 both of his forearms that had scattered pinpoint redness. The Change of Condition form indicated the back of Resident 1's right hand had a brown patch measuring 8.0 by 9.0 centimeters ([cm], a unit of measurement) and the back of his left hand had scattered brown patches. The Change of Condition form indicated Resident 1 stated he needed to go to a psychiatric hospital that has therapy to stabilize him and to help him stop hurting himself. The Change of Condition form indicated 911 was called and Resident 1 was brought to GACH 2 for further evaluation and management due to the appearance of his forearms.During a review of Resident 1's Physician's Orders Summary Report, the Physician's Orders Summary Report indicated an order dated 7/8/2025to transfer the resident to GACH 2 due to threatening to hurt self, for evaluation and treatment.During a review of Resident 1's Skilled Nursing Facility (SNF) to GACH Transfer Form dated 7/8/2025, the SNF to GACH 2 Transfer Form indicated Resident 1 was transferred out to GACH at 7:12 p.m., with flat tan to brownish discoloration on the back of his right hand and left arm noted with flat tan-brownish scattered discoloration. The SNF to GACH 2 Transfer Form indicated Resident 1 had symptoms of agitation with risk to harm self or others.During a review of Resident 1's GACH 2 Records dated 7/8/2025 at 7:22 p.m., the GACH 2 Records indicated Resident 1 was admitted to GACH 2 with diagnoses including second-degree chemical burns to both forearms. The GACH 2 records indicated poison control (a specialized unit that advises on and assists in the prevention, diagnosis and management of poisoning) was called and Resident 1 received a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555668 If continuation sheet Page 2 of 4 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 07/14/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few surgical consultation for the burns on both forearms. The GACH 2 records indicated Resident 2 was in distress (emotional or psychological difficulty that is noticeable and impactful).During a review of Resident 1's GACH 2 records dated 7/9/2025 at 8:55 a.m., the GACH 2 records indicated Resident 1 had a pain level of 9 out of 10 on a pain rating scale (a tool used to help people describe and quantify their pain, allowing healthcare professionals to better understand and manage it, ranging from 0 [no pain] to 10 [worst pain imaginable]) due to the chemical burns on both of his arms.During a review of Resident 1's GACH 2 records dated 7/9/2025 at 11:17 a.m., the GACH 2 records indicated a physician's order for:-Hydrocodone-Acetaminophen (medication used for moderate to severe pain), with not specified dosage, one tablet every six hours for pain (severity of pain not specified).-Morphine Sulfate intravenous ([IV] into a vein]) medication used for severe pain) 2.0 milligram (mg-unit of measurement)/1.0 milliliter (mL-unit of measurement) intravenously (IV [into or within a vein]) every six hours.During a review of Resident 1's GACH 2 records dated 7/9/2025 at 9:05 p.m., the GACH 2 Records indicated Resident 1 had a surgical consultation.During a review of Surgical Consultation note, the Surgical Consultation note indicated both of Resident 1 arms were necrotic (tissue that is dead or dying) and the resident would need debridement and possible skin grafting to an area on the back of the left hand. The Surgical Consultation Note indicated Resident 1 would need a transfer to a higher level of care/burn center for treatment.During a review of Resident 1's GACH 3 Records, the GACH 3 Records indicated Resident 1 did have a history of a prior self-harm and was admitted to GACH 2 and then transferred to GACH 3 for management of both upper extremity (arm) burns. The GACH 3 records indicated Resident 1 was on one-on-one sitter for self-harm precautions and psychiatric evaluation.During a telephone interview on 7/11/2025 at 10:15 a.m., with RNS 1, RNS 1 stated Resident 1 was admitted back to the facility on 7/7/2025 around 12:40 p.m., with a diagnosis of ideations of harm to self or others. RNS 1 stated Resident 1 did not have a one-on-one sitter to keep him safe. RNS 1 stated Resident 1 should have had a one-on-one sitter to keep him safe from self-harm and should have had a psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) consultation regarding his ideations of self-harm when admitted back to the facility on 7/7/2025.During an interview on 7/11/2025 at 1:37 p.m., with the Administrator (ADM), the ADM stated the facility does not have a screening and assessment process for residents that are admitted to their facility with diagnoses of thoughts of self-harm. The ADM stated the facility did not screen Resident 1 for thoughts of self-harm, but the facility should have implemented a screening assessment for residents who had diagnoses of ideation of harm to self or others.During an interview on 7/11/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated there was no screening assessment done for Resident 1 who was admitted to their facility after discharge from GACH 1 on 7/7/2025, with diagnoses of ideations of harm to self or others. The DON stated there was no specific screening assessment implemented for residents (general) with diagnoses of harm to self or others but there should have been a screening done for Resident 1 to screen for thoughts of harm to self or others.During a concurrent interview and record review on 7/11/2025 at 3:26 p.m., with the Director of Nursing (DON), the untitled Care Plan initiated on 7/8/2025 and Nurse Progress Note dated 7/7/2025 were reviewed. The DON stated Resident 1's care plan interventions such as one-on-one sitter were not implemented when Resident 1 was readmitted back to the facility on 7/7/2025. The DON stated Resident 1 was not with a one-to-one sitter because Resident 1 did not express he had any thoughts or feelings of harming self or others. The DON stated there was no documentation of any assessment or screening done upon admission. The DON stated Resident 1 was on visual and verbal hourly monitoring/rounding where staff would check on the resident every hour. The DON stated t Resident 1 would have benefitted from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555668 If continuation sheet Page 3 of 4 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 07/14/2025 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the one-on-one sitter because there would be continuous monitoring with eyes on the resident.During a telephone interview on 7/11/2025 at 4:01 p.m. with Resident 1, Resident 1 stated he had thoughts of self-harm when he was admitted back to the facility on 7/7/2025. Resident 1 stated the facility staff did not ask him if he had any thoughts of hurting himself when he was admitted back to the facility on 7/7/2025. Resident 1 stated he ordered the oven-cleaner online and had it delivered to him on 7/8/2025 at the facility. Resident 1 stated he did not tell anyone he wanted to hurt himself but wished the staff had asked him if he had thoughts of self-harm. Resident 1 stated he wished he received help from the facility staff about his thoughts of self-harm. During a telephone interview on 7/14/2025 at 10:27 a.m., with the RN that took care of Resident 1 at the GACH 3 burn center (RNGACH 3), RNGACH 3 stated Resident 1 was transferred to their facility on 7/10/2025. RNGACH 3 stated Resident 1 had a one-to-one sitter for self-harm precautions because Resident 1 had wounds from the self-harm he inflicted on himself from the facility he was at. RNGACH 3 stated Resident 1 needed treatment for second degree chemical burn injuries and surgery was planned for 7/15/2025. RNGACH 3 stated Resident 1 was scheduled for surgery for debridement on his bilateral (both) arms for the second-degree burns. During a concurrent interview and record review on 7/14/2025 at 1:25 p.m. with RNS 1, RNS 1 stated Resident 1 had a one-on-one sitter before he was transferred out on 6/24/2025 but he did not have a one-on-one sitter when he was readmitted back on 7/7/2025. Resident 1 was on hourly rounding where a CNA kept an eye on him every hour, to have visuals on him every hour but Resident 1 would have benefitted from one-on-one sitter to prevent him from harming himself. RNS 1 stated a one-on-one sitter would always keep eyes on the residents. During a review of the facility's policy and procedures (P&P), titled, Resident Safety, dated 4/14/2021, indicated, the purpose was to provide a safe and hazard free environment .residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident during the comprehensive assessment period, the interdisciplinary team ([IDT], a collaborative meeting where professionals from various healthcare disciplines come together to discuss and coordinate patient care) members will assess the resident's safety risk as well as any other resident specific safety risks .the IDT will establish a person centered observation or monitoring systems for residents to address the identified risk factors identified .the person centered care plan may require more frequent checks.During a review of the facility's P&P titled, Resident Initial admission Assessment, dated 3/23/2023, indicated upon admission to the facility, licensed nursing staff will complete an initial admission assessment to identify the resident's needs and develop plans of care . the assessment will be documented in the medical records.During a review of the facility's P&P titled Person-Centered Care Planning, dated 5/22/2025, indicated the facility must develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing .comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Event ID: Facility ID: 555668 If continuation sheet Page 4 of 4