Health inspection·April 4, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended 3/8/2024 The following reflects the findings of the California Department of Public Health during the investigation of one facility-reported incident. Facility-reported incident number: CA00884604. Representing the Department: HFEN 45773. The inspection was limited to the specific facility-reported incident investigated and does not represent the findings of a full inspection of the facility. Three deficiencies were written for facilityreported incident number CA00884604. See Tag F580, F656, F689 On 2/14/2024 at 1:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility ' s Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent his elopement from the facility on 2/9/2024. On 2/16/2024 at 12:05 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 1 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE IJ was removed on 2/16/2024 at 2:21 p.m., in the presence of the facility ' s ADM, the DON and Vice President of Clinical Services.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 03/19/2024 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 2 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the responsible party (RP) for one of three sampled residents (Resident 1), after Resident 1 eloped from the facility. This deficient practice resulted in Resident 1's RP not knowing that Resident 1 was no longer at the facility. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on 12/28/2023 with diagnoses including hypertension (HTN), major depressive disorder (a state of confusion), anxiety (feeling nervous, restless or tense, having a sense of impending danger, or panic), psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse and paranoid (a pattern of behavior where a person feels distrustful of and suspicious of other people) schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 3 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recognize what is real). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/8/2024 the MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and had a behavior that placed him at significant risk of getting into a potentially dangerous place (e.g., the stairs, outside of the facility) occurring one to three days. During a review of Resident 1's Nurses Notes dated 2/9/2024 and timed at 8:23 a.m., the Nurses Notes indicated Resident 1's breakfast was not touched, nor did Resident 1 attend the smoke break at 8 a.m. The Nurses Notes indicated a search for Resident 1 was initiated inside and outside of the facility and Resident 1 was not found. During a telephone interview with Resident 1's RP on 2/13/2024 at 12:39 p.m., the RP stated he was unaware of Resident 1's elopement from the facility. The RP stated there was no communication from the facility regarding Resident 1's elopement. During an interview with the Director of Nursing (DON) on 2/13/2024 at 2:13 p.m., the DON stated if there was a change of condition (COC), it was important to notify the Medical Doctor (MD) and the Resident's RP, so everyone is aware. The DON stated there was no documentation that Resident 1's physician or Resident 1's RP were notified of Resident 1's elopement from the facility and if it was not documented there was no proof that it was done. During a review of the facility's policy and procedure (P/P), titled "Change of Condition Notification," dated 10/1/2023, the P/P FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 4 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated that residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely matter. During a review of the facility's "Job Description: for Licensed Vocational Nurse (LVN)," updated 2017, the facility's Job Description indicated LVN responsibility includes proficiently and accurately monitors and reports resident condition changes to the Registered Nurse, attending physician, family, and interdisciplinary team members.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1)(3) 03/19/2024 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), 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 (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 5 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(iii) Be culturally-competent and traumainformed. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and/or implement a care plan for one of three sampled residents (Resident 1) who had a previous history of elopement (leaving an institution without notice or permission) upon admission. This deficient practice resulted in Resident 1 eloping from the facility with the potential of being exposed to severe environmental conditions including excessive cold, possible motor vehicle accident, medical complications including malnutrition (health problems that may arise due to lack of nutrients [substances found in food necessary for the body to function normally]), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [abnormally high blood pressure] ) due to missing routine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 6 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications including high blood pressure medication, and mood stabilizer medication. Resident 1 remains missing. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on 12/28/2023 with diagnoses including hypertension (HTN), major depressive disorder (a state of confusion), anxiety (feeling nervous, restless or tense, having a sense of impending danger, or panic), psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse and paranoid (a pattern of behavior where a person feels distrustful of and suspicious of other people) schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/8/2024 the MDS indicated Resident 1 had moderately impaired cognitive skills (process of thinking) for daily decision-making and had a behavior that placed him at significant risk of getting into a potentially dangerous place (e.g., the stairs, outside of the facility) occurring one to three days. During a review of Resident 1's Admission Assessment dated 1/6/2024, the admission assessment titled "Wandering and Elopement Assessment", the answers are blank. During a review of Resident 1's clinical record, the care plan section indicate there was no care plan developed upon admission regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 7 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's risk for elopement and wandering. During a review of Resident 1's Nurses Notes dated 2/9/2024 and timed at 8:23 a.m., the Nurses Notes indicated Resident 1's breakfast was not touched, nor did Resident 1 attend the smoke break at 8 a.m. The Nurses Notes indicated a search for Resident 1 was initiated inside and outside of the facility and Resident 1 was not found. During a concurrent interview and record review with the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) on 2/14/2024 at 12:13 p.m., Resident 1's MDS section E and care plans were reviewed. The MDS Nurse stated after review of Resident 1's MDS, that Resident 1 had wandering behavior and based on that information a care plan should have been created to address Resident 1's wandering behavior. During a review of the facility's Policy and Procedure (P/P) titled "Care Planning/Baseline Care Plan," dated 10/1/2023, the P/P indicated the care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and Interdisciplinary Team (IDT) work to help the resident move toward resident specific goals that address the resident's medical, nursing, mental and psychosocial needs. During a review of the facility's "Job Description: for Registered Nurse (RN) - SNF" updated 2017, the facility's Job Description indicated RN responsibilities includes working collaboratively with the resident/family and interdisciplinary team members to develop an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 8 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE individualized plan of care for each resident.

F689 SS=J Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/19/2024 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a resident, who was at a moderate risk for elopement, did not elope from the facility for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility (12/28/2023). 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. Ensure licensed nurses monitored the placement of Resident 1's wander guard bracelet (a system that helps monitor the movement of patients and prevent them from leaving a facility), following his attempt to leave the facility on 1/12/2024 and after a physician's order for a wander guard bracelet and to monitor its placement each shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 9 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. Develop a care plan for Resident 1's use of the wander guard bracelet with intervention including monitoring the wander guard bracelet for its presence every shift, and to address Resident 1's refusal to wear the wander guard bracelet and taking it off. 5. Have a system in place to alert staff when the facility's entrance and exit doors without alarms were opened, to prevent residents from leaving the facility without staff knowledge. As a result of these deficient practices, Resident 1's risk for wandering and elopement was not realized by facility staff when Resident 1 was admitted to the facility on 12/28/2024. Resident 1 attempted to leave the facility on 1/12/2024 and subsequently eloped from the facility on 2/9/2024. These deficient practices placed Resident 1 at risk to be exposed to severe weather related conditions (rain and/or cold), hypothermia, medical complications including malnutrition (health problems that may arise due to lack of nutrients), dehydration (abnormally low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [HTN] high blood pressure) due to missing routine medications and self-inflicted injuries related to Resident 1's documented suicidal ideations of throwing himself into oncoming traffic, and possible death. On 2/14/2024 at 1:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent his elopement from the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 10 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/9/2024. On 2/16/2024 at 12:05 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 2/16/2024 at 2:21 p.m., in the presence of the facility's ADM, the DON and Vice President of Clinical Services. The facility's IJPR included the following immediate actions: A. Inservice the facility staff starting on 2/14/2024 to include: 1. All licensed staff on the facility policy "Wandering and Elopement" how to perform an Elopement Risk Assessment upon admission, quarterly and when an elopement incident occurs. 2. Residents with a history of wandering or who IDT have assessed to be a serious risk for wandering or elopement will have a photograph maintained in the medical record, have specific welcome activities to make residents more comfortable and feel they are a part of the community and provide adequate physical and social environment that is monitored and safe. 3. Residents with serious risk for wandering and elopement and actual wandering and/or elopement behaviors will be monitored every hour by nursing staff and their whereabouts documented on the MAR. 4. All licensed staff will receive instruction on developing a person-centered care plan with interventions for residents who are high risk for elopement to keep residents safe inside the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 11 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. All licensed staff will be instructed on developing a person-centered care plan for residents who refuse to wear and/or takeoff their wander guard. 6. All staff will be instructed to (1) Provide visual supervision to residents with serious risk for wandering and/or elopement and an actual behavior of wandering and/or elopement. Nursing staff will monitor at risk residents every hour and document at risk resident's whereabouts on the MAR to ensure that facility staff are aware of resident's whereabouts. (2) to keep the alarm on all four exit doors and to immediately check all four exit doors when alarms sound to ensure residents have not gone out of the facility unsupervised. 7. All staff will be instructed to check resident's wander guard every shift to ensure proper placement and function. The wander guard's placement on the resident's body will be indicated on the Physician's order, MAR, and the resident's care plan. B. The Maintenance Supervisor will conduct weekly checks on Residents with wander guards to ensure their function and log the results accordingly using a device to confirm that the wander guard being used by the resident works properly. C. The Licensed Nurses will conduct a check every shift, of all 4 exit doors to ensure the alarms are in place, functioning properly and document the results in the log. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 12 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/28/2023 with diagnoses including hypertension (HTN), major depressive disorder (a state of confusion), anxiety (feeling nervous, restless or tense, having a sense of impending danger, or panic), psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse and paranoid (a pattern of behavior where a person feels distrustful of and suspicious of other people) schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/8/2024 the resident had moderately impaired cognitive skills (process of thinking) for daily decisionmaking and had a behavior that placed him at significant risk of getting into a potentially dangerous place (e.g., the stairs, outside of the facility) occurring one to three days. During a review of Resident 1's of Psychiatric Evaluation from a General Acute Care Hospital (GACH), dated 12/10/2023, prior to Resident 1's transfer to the facility on 12/28/2023, the Psychiatric Evaluation indicated Resident 1 expressed feelings of helplessness, hopelessness, worthlessness and had thoughts of walking into traffic or overdosing (taking more than the recommended amount of something, often a medicine or drug). During a review of Resident 1's Physician's Order dated 12/28/2023, the Physician's Order indicated for Resident 1 to receive the following medications: 1. Lisinopril 40 milligrams ([mg] a unit of measurement), one time daily for hypertension. 2. Escitalopram Oxalate (a mood stabilizer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 13 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication) 10 mg, one time a day for depression manifested by verbalization of hopelessness and worthlessness. 3. Aripiprazole 10 mg, one time a day for schizophrenia manifested by hallucination (a sight, sound, smell, taste, or touch that a person believes to be real but is not real) of hearing voices. During a review of Resident 1's Admission Wandering and Elopement Assessment dated 1/6/2024, the Wandering Elopement Assessment was left blank. During a review Resident 1's clinical record, the care plan section, indicated there were no care plans in place addressing Resident 1's wander and elopement risk or addressing Resident 1's behavior of taking his wander guard off. During a review of Resident 1's Nurses Notes dated 1/12/2024 and timed at 10:21 p.m., the Nurses Notes indicated Resident 1 had a schizophrenic crisis, got upset and ran out of the unit (an area within the facility) toward the exit door but was stopped by staff. During a review of Resident 1's Elopement Risk Assessment dated 1/17/2024, the Elopement Risk Assessment indicated Resident 1 scored 2 (a score of 2 indicated Resident 1 was at moderate risk for elopement). During a review of Resident 1's Physician's Order dated 1/17/2024, the Physician's Order indicated to place a wander guard bracelet on Resident 1 and to check placement of the wander guard bracelet every shift. During a review of Resident 1's Nurses Notes dated 2/9/2024 and timed at 8:23 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 14 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nurses Notes indicated Resident 1's breakfast was not touched, nor did Resident 1 attend the smoke break at 8 a.m. The Nurses Notes indicated a search for Resident 1 was initiated inside and outside of the facility and Resident 1 was not found. During a tour of the facility on 2/12/2024 at 2:12 p.m., a total of four exit doors were observed. All four exit doors had a wander guard alarm installed, however only two of the four doors, in the front and back of the facility, had regular alarms installed. During an interview on 2/12/2024 at 3:11 p.m., Resident 2 stated he saw Resident 1 gathering his belongings from his closet. Resident 2 stated, Resident 1 told him (Resident 2), "I will see you, when I see you," waved goodbye and left. Resident 2 stated this happened before breakfast trays were handed out. During an interview on 2/12/2024 at 3:42 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated she was Resident 1's nurse the morning of his elopement (2/9/2024). LVN 1 stated Resident 1 did not have a wander guard bracelet on the morning he left, and she did not recall hearing an alarm sound that day. LVN 1 stated Resident 1 had a routine of walking around the facility, eating breakfast and then waiting in line for the smoke break. LVN 1 stated when she noticed Resident 1's breakfast had not been touched she went to see if Resident 1 was on the smoking patio, but he was not there. LVN 1 stated she reported to Registered Nurse (RN 2) that Resident 1 was missing. LVN 1 stated a search was conducted inside and outside the facility and the local sheriff's department was notified when Resident 1 was not located. As of 3/5/2024 Resident 1 had not been located. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 15 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 2/13/2024 at 10:56 a.m., the Receptionist stationed at the facility's front desk stated someone was assigned at the front desk from 7 a.m., to 8 p.m., daily. The Receptionist stated the front door did not have a regular alarm; it only had a wander guard alarm. During a concurrent tour of the facility and interview with the Maintenance Supervisor (MS) on 2/13/2024 at 12:08 p.m., staff were observed going in and out of the facility's back door, there was no alarm that sounded. The MS stated, "You see the problem, people go in and out of that door, if someone was to leave, no one would know." During an interview on 2/13/2024 at 12:23 p.m., a Certified Nurse Assistant (CNA 1) stated on 2/8/2024 (the day before Resident 1 eloped) Resident 1 refused to wear his wander guard and gave the wander guard to the DON. CNA 1 stated on the day Resident 1 eloped (2/9/2024), she noticed Resident 1's breakfast had not been touched. CNA 1 stated Resident 1 liked to walk around the facility, so she did not think much about it at the time. CNA 1 stated when Resident 1 was not at the morning smoke break, staff began to search for him. During a concurrent interview and record review with the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) on 2/13/2024 at 1:23 p.m., and a subsequent interview on 2/14/2024 at 12:13 p.m., Section E of Resident 1's MDS dated 1/8/2024 and Resident 1's Admission Wandering Assessment dated 1/6/2024 were reviewed. Resident 1's MDS indicated the resident had wandering behavior. The MDS Nurse stated based on that information, a care plan related to Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 16 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wandering behavior should have been created. The MDS Nurse reviewed Resident 1's Admission Wandering Assessment and confirming it was left blank and stated the Wandering Assessment should have been completed by the nurse who admitted Resident 1. The MDS Nurse stated if Resident 1 refused to wear a wander guard, a change of condition (COC) and care plan should have been created. During a concurrent interview and record review with RN 1 on 2/13/2024 at 1:44 p.m., and a subsequent interview on 2/14/2024 at 1:39 p.m., Resident 1's Medication Administration Record (MAR) dated 1/2024 and 2/2024 was reviewed. The MAR indicated an "X" was documented under the section indicated to check Resident 1's wander guard placement. RN 1 stated Resident 1 had an order to check the placement of his wander guard bracelet every shift and an "X" indicated the order was not carried out and no one checked to see if Resident 1 was wearing his wander guard. During an interview on 2/13/2024 at 2:13 p.m., the DON stated on 2/8/2024, after Resident 1 took off his wander guard bracelet and gave it to her, she (the DON) placed the wander guard bracelet back on Resident 1 (2/8/2024). The DON stated she was not sure if Resident 1 took the wander guard bracelet off again but stated if Resident 1 had the wander guard bracelet on, staff would have heard the alarm sound when Resident 1 was going out through any of the facility's doors. The DON stated all staff are responsible for the safety of the residents, and anything could happen to a resident when they elope from the facility. During a telephone interview on 2/26/2024 at 9:40 a.m., LVN 2 stated on 1/12/2024 Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 17 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1 ran toward the exit door located in the lobby of the facility but staff were able to stop him before he got out of the building and redirect him back to his room. During a review of the facility's policy and procedure (P/P) titled "Wandering and Elopement" dated 10/1/2023, the P/P indicated the facility will identify residents at risk for elopement and minimize any possible injury because of elopement. The P/P indicated the licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the Resident Assessment Instrument ([RAI ] an assessment that helps nursing home staff to gather information on a resident's strengths and needs, which must be addressed in an individualized care plan) guidelines to determine their risk of wandering/elopement. During a review of the facility's P/P titled "Wandering Bracelet Policy" dated December 2016, the P/P indicated that once wandering potential is established using a wandering and elopement assessment, a wander guard bracelet maybe applied as part of the intervention to keep a resident from wandering away from a safe environment. The P/P also indicated that a daily check of the wander guard bracelet needs to be completed and documented in the resident's medical records. During a review of the facility's P/P titled "Missing Resident Policy" dated December 2016, the P/P indicated that upon admission to the facility, the licensed nurse will complete a wandering and elopement risk assessment. Once the risk has been identified, developed a plan of care for resident at risk for exit seeking behavior, elopement, and post elopement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZUNH11 Facility ID: CA940000071 If continuation sheet 18 of 19 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056425 (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE STUDEBAKER HEALTHCARE CENTER 13226 Studebaker Rd Norwalk, CA 90650 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: ZUNH11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA940000071 (X5) COMPLETE DATE If continuation sheet 19 of 19