Health 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. Page 1 of 4 056186 056186 06/09/2025 Centinela Grand Inc 2225 North Perris Boulevard Perris, CA 92571

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On June 9, 2025, at 1:34 p.m., during a concurrent interview and record review with the Social Worker (SW), the SW verified that the transfer notice for a higher level of care for Resident 1 was dated May 23, 2025, and only a copy of the transfer notice was sent to the Ombudsman on May 23, 2025. The SW verified there was no documented evidence the facility reported Resident 1 ' s fracture of unknown origin to the Ombudsman and CDPH. The SW further stated the Ombudsman and CDPH should have been notified of Resident 1 ' s fracture of unknow origin. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, not dated, indicated .Identification of Abuse, Neglect .The facility will consider factors indicating possible abuse, neglect of residents .the following possible indicators .physical injury of resident unknown source .an investigation is immediately warranted .once the resident is cared for and initial reporting has occurred an investigation should be conducted .anyone in the facility can report suspected abuse .When abuse, neglect is suspected the licensed should respond to resident .notify Director of Nursing .initiate an investigation immediately .notify physician .contact the State Agency and the local Ombudsman office to report the alleged abuse . 056186 Page 2 of 4 056186 06/09/2025 Centinela Grand Inc 2225 North Perris Boulevard Perris, CA 92571

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate what could have caused one of three sampled residents ' (Resident 1) right arm fracture. The facility did not witness the source of the fracture, and the resident could not explain the source of the right arm fracture. Residents Affected - Few This failure had the potential to delay provision of corrective action to ensure Resident 1 is free from potential abuse, neglect, and mistreatment. 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 general acute care hospital (GACH) on May 23, 2025, for a fracture of 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. A review of Resident 1 ' s medical record indicated no documented evidence the facility investigated Resident 1 ' s injury of unknown origin on the right arm. 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 GACH for a higher level of care on May 23, 2025. The ADON verified there was no documented evidence the facility performed an investigation of Resident 1 ' s fracture of the right arm, which was of unknown origin. The ADON stated the facility should have investigated Resident 1 ' s fracture of the right arm. On June 9, 2025, at 1:34 p.m., during a concurrent interview and record review with the Social Worker (SW), the SW verified that the transfer notice for a higher level of care for Resident 1 was dated May 23, 2025. The SW verified there was no documented evidence the facility investigated Resident 1 ' s fracture of unknown origin. The SW further stated the facility should have been investigated Resident 1 ' s fracture of unknown origin. A review of the facility policy and procedure titled, Abuse, Neglect and Exploitation, undated, indicated .Identification of Abuse, Neglect .The facility will consider factors indicating possible abuse, neglect of residents .the following possible indicators .physical injury of resident unknown source .an investigation is immediately warranted .once the resident is cared for and initial reporting has occurred an investigation should be conducted .anyone in the facility can report suspected 056186 Page 3 of 4 056186 06/09/2025 Centinela Grand Inc 2225 North Perris Boulevard Perris, CA 92571

F 0610 Level of Harm - Minimal harm or potential for actual harm abuse .When abuse, neglect is suspected the licensed should respond to resident .notify Director of Nursing .initiate an investigation immediately .notify physician .contact the State Agency and the local Ombudsman office to report the alleged abuse . Residents Affected - Few 056186 Page 4 of 4