Inspection·June 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours to the State Survey Agency (SSA) and to the Long-Term care (LTC) Ombudsman for one of three sampled residents (Resident 1). The facility was made aware of Resident 1 ' s right arm fracture on May 23, 2025. This failure had the potential for state agencies and the LTC Ombudsman not to be able to advocate for the residents in protecting their rights to be free from abuse and neglect. Findings: On June 9, 2025, at 10:35 a.m., during a concurrent observation and interview, Resident 1 was observed with right arm in a blue sling with right hand contracted. Resident 1 was attempted to be interviewed but only responded with a mumble. A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit and muscle weakness. Further review of the record indicated the resident was transferred to the hospital on May 23, 2025, for a fracture on the right arm. A review of Resident 1 ' s nursing notes dated May 23, 2025, indicated, .Relayed x-ray result to Right forearm w/ (with) conclusion: Osteopenia w/ flexion contracture, displaced fracture of Olecranon w/ margins appearing chronic .ordered to Transfer to (name of hospital) for further evaluation and treatment . A review of Resident 1 ' s progress notes, did not indicate documentation of how the patient sustained the right arm fracture. On June 9, 2025, at 12:34 p.m., during a concurrent interview and record review with the Assistant Director of Nursing (ADON), the ADON verified Resident 1 was transferred to the hospital for a higher level of care on May 23, 2025, and the Ombudsman was notified only of the transfer via fax transmittal on May 23, 2025. The ADON verified there was no documented evidence the facility notified the Ombudsman and SSA of Resident 1 ' s fracture of unknown origin. The ADON further stated there was no documented evidence the facility performed an investigation of Resident 1 ' s fracture of unknown origin. The ADON stated the Ombudsman and SSA should have been notified of Resident 1 ' s fracture of unknown origin and the facility should have investigated of Resident 1 ' s fracture of unknown origin. (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 4 Event ID: 056186 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 056186 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centinela Grand Inc 2225 North Perris Boulevard Perris, CA 92571 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)