Health inspection·February 20, 2024

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 interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:Ensure Licensed Vocational Nurse (LVN) 1 reported the alleged abuse to the Administrator (ADM), State Survey Agency, Law Enforcement, and Ombudsman when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (Registered Nurse [RN] 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. This deficient practice violated the Federal mandated reporting timeframe. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. Cross Reference- F610Findings:During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 9/16/2022 with diagnoses that included Down Syndrome (genetic condition caused by having an extra chromosome [structures that carry genetic information] which was presented by growth, developmental, and learning delays that vary from mild to severe), contracture (fixed tightening of muscles, tendons, ligaments, or skin) of muscles, and pressure-induced deep tissue damage of the sacral (triangular shaped bone at end of the spine) region. During a review of Resident 1's History and Physical (H&P) dated 9/20/2023, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1 had moderately impaired cognitive skills (ability to think, learn, and process information). The MDS indicated, Resident 1 depended on the staff for chair/bed-to-chair transfers.During a review of Resident 1's Nursing Notes (NN) dated 1/20/2024, timed at 2:00 PM, the NN indicated, (on 1/20/2024) at around 1:30 PM, FM 2 reported to LVN 1 that Resident 1 stated a male nurse slapped Resident 1 on Resident 1's face during transfer from bed to wheelchair on 1/20/2024 (untimed). The NN indicated, Resident 1 had a female Certified Nursing Assistant (CNA, unidentified) on 1/20/2024 and no male CNAs touched Resident 1 during the 7:00 AM to 3:00 PM shift. The NN indicated, Resident 1 had no signs and symptoms of acute distress and was smiling at LVN 1 and the CNA (unidentified).During a review of the facility's Monthly (Staffing) Schedule (MS) from 1/20/2024 to 2/17/2024, the MS indicated, RN 1 continued to work at the facility on 1/20/2024, 1/22/2024, 1/23/2024, 1/27/2024, 1/29/2024, 1/30/2024, 2/3/2024, 2/5/2024, 2/6/2024, 2/10/2024, 2/12/2024, 2/13/2024, and 2/17/2024 (total of 13 days).During an interview on 2/17/2024 at 10:30 AM with Resident 1 in Resident 1's room, Resident 1 stated a tall, male staff member (RN 1) slapped Resident 1 in the face during transfer from bed to wheelchair (unable to recall date and time). Resident 1 further stated Resident 1 was worried that RN 1 might hit Resident 1 again. During an interview on 2/17/2024 at 1:50 PM with another Family Member of Resident 1 (FM 1) in Resident 1's room, FM 1 stated Resident 1 told FM 2 that a male staff member slapped Resident 1 on the face on 1/20/2024 (during the 7:00 AM to 3:00 PM shift). FM 1 stated, FM 2 Page 1 of 7 056477 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported the alleged incident to LVN 1 on 1/20/2024 (untimed), and LVN 1 stated to FM 2 that Resident 1 probably had a bad nightmare.During a concurrent interview and record review on 2/17/2024 at 2:59 PM with LVN 1, Resident 1's Nursing Note (NN) dated 1/20/2024, timed at 2:00 PM, was reviewed. LVN 1 stated Resident 1 stated RN 1 slapped Resident 1 on the face (on 1/20/2024 at around 1:30 PM). LVN 1 stated LVN 1 informed RN 1 of Resident 1's alleged physical abuse. LVN 1 stated LVN 1 and RN 1 assessed Resident 1 with no physical injuries. LVN 1 stated facility staff were required to protect Resident 1 by thoroughly investigating and reporting allegations of abuse to the ADM immediately. LVN 1 stated LVN 1 did not thoroughly investigate and report the allegation of abuse to the ADM nor sent RN 1 home. LVN 1 stated LVN 1 did not follow the facility's Abuse P&P. LVN 1 stated not reporting the alleged physical abuse and not removing the alleged abuse perpetrator (RN 1) from Resident 1 put Resident 1 at risk for the abuse to happen again. During an interview on 2/17/2024 at 4:48 PM with RN 1, RN 1 stated LVN 1 notified RN 1 of Resident 1's allegation of physical abuse. RN 1 stated RN 1 did not think Resident 1's allegation of physical abuse was legitimate (legal/lawful/allowable). RN 1 stated he did not slap Resident 1. RN 1 stated RN 1 did not report the alleged physical abuse to the ADM and did not follow the facility's Abuse P&P to protect Resident 1.During an interview on 2/17/2024 at 4:36 PM with the DON, the DON stated LVN 1, and RN 1 did not inform the DON of Resident 1's physical abuse allegation. The DON stated LVN 1 informed the ADON of the alleged physical abuse on 2/17/2024 (untimed, unable to recall the time), after the survey team identified the IJ situation. The DON stated the DON followed up with RN 1 on 2/17/2024 (untimed) and confirmed that RN 1 was aware of Resident 1's alleged physical abuse and did not report the alleged physical abuse to the DON or the ADM. The DON stated there were no other male CNAs who worked on 1/20/2024 and RN 1 was the only male nurse who worked on 1/20/2024. The DON stated the DON notified the local police department on 2/17/2024 (untimed) of the alleged physical abuse that occurred on 1/20/2024. The DON stated RN 1 did not report the incident of alleged physical abuse to the ADM and did not follow the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating. During an interview on 2/17/2024 at 5:53 PM with the ADON, the ADON stated Resident 1 had Down Syndrome, but could make some of Resident 1's needs known. The ADON stated Resident 1 was alert, awake, engaged, and knew what was going on Resident 1's environment. During a review of the facility's Nursing Staffing Assignment and Sign-In Sheet, (NSA Sign-In Sheet) dated 1/20/2024, for 7:00 AM to 3:00 PM shift, the NSA Sign-In Sheet indicated, RN 1 was the only male nurse who worked on 1/20/2024 from 7:00 AM to 3:00 PM. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation of Misappropriation-Reporting and Investigation, revised in 9/2022, the P&P indicated, all reports of resident abuse were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated, if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, immediately was defined as within two hours of an allegation involving abuse. The P&P indicated, any employee who had been accused of resident abuse was placed on leave with no resident contact until the investigation was complete. 056477 Page 2 of 7 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

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 interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:1. Ensure Registered Nurse (RN) 1, who was the alleged perpetrator (the person identified in the initial report or during the investigation as the person suspected of committing an act of abuse), was placed on leave of absence (authorized absence from work for a certain period of time) and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024.2. Ensure Licensed Vocational Nurse (LVN) 1 thoroughly investigated the alleged abuse when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (RN 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. These deficient practices resulted in Resident 1 feeling worried that RN 1 might slap Resident 1 again. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. Cross Reference - F609Findings:During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 9/16/2022 with diagnoses that included Down Syndrome (genetic condition caused by having an extra chromosome [structures that carry genetic information] which was presented by growth, developmental, and learning delays that vary from mild to severe), contracture (fixed tightening of muscles, tendons, ligaments, or skin) of muscles, and pressure-induced deep tissue damage of the sacral (triangular shaped bone at end of the spine) region. During a review of Resident 1's History and Physical (H&P) dated 9/20/2023, the H&P indicated, Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's MDS dated [DATE], the MDS indicated, Resident 1 had moderately impaired cognitive skills (ability to think, learn, and process information). The MDS indicated, Resident 1 depended on the staff for chair/bed-to-chair transfers.During a review of Resident 1's Nursing Notes (NN) dated 1/20/2024, timed at 2:00 PM, the NN indicated, (on 1/20/2024) at around 1:30 PM, FM 2 reported to LVN 1 that Resident 1 stated a male nurse slapped Resident 1 on Resident 1's face during transfer from bed to wheelchair on 1/20/2024 (untimed). The NN indicated, Resident 1 had a female Certified Nursing Assistant (CNA, unidentified) on 1/20/2024 and no male CNAs touched Resident 1 during the 7:00 AM to 3:00 PM shift. The NN indicated, Resident 1 had no signs and symptoms of acute distress and was smiling at LVN 1 and the CNA (unidentified).During a review of the facility's Monthly (Staffing) Schedule (MS) from 1/20/2024 to 2/17/2024, the MS indicated, RN 1 continued to work at the facility on 1/20/2024, 1/22/2024, 1/23/2024, 1/27/2024, 1/29/2024, 1/30/2024, 2/3/2024, 2/5/2024, 2/6/2024, 2/10/2024, 2/12/2024, 2/13/2024, and 2/17/2024 (total of 13 days).During an interview on 2/17/2024 at 10:30 AM with Resident 1 in Resident 1's room, Resident 1 stated a tall, male staff member (RN 1) slapped Resident 1 in the face during transfer from bed to wheelchair (unable to recall date and time). Resident 1 further stated Resident 1 was worried that RN 1 might hit Resident 1 again. During an interview on 2/17/2024 at 1:50 PM with another Family Member of Resident 1 (FM 1) in Resident 1's room, FM 1 stated Resident 1 told FM 2 that a male staff member slapped Resident 1 on the face on 1/20/2024 (during the 7:00 AM to 3:00 PM shift). FM 1 stated, FM 2 reported the alleged incident to LVN 1 on 1/20/2024 (untimed), and LVN 1 stated to FM 2 that Resident 1 probably had a bad nightmare.During a concurrent interview and record review on 2/17/2024 at 2:59 PM with LVN 1, Resident 1's Nursing Note (NN) dated 1/20/2024, timed at 2:00 PM, was reviewed. LVN 1 stated Resident 1 stated RN 1 slapped Resident 1 on the face (on 1/20/2024 at around 1:30 PM). LVN 1 stated LVN 1 informed RN 1 of Resident 1's alleged physical abuse. LVN 1 stated LVN 1 and RN 1 assessed Resident 1 with no Residents Affected - Few 056477 Page 3 of 7 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical injuries. LVN 1 stated facility staff were required to protect Resident 1 by thoroughly investigating and reporting allegations of abuse to the ADM immediately. LVN 1 stated LVN 1 did not thoroughly investigate and report the allegation of abuse to the ADM nor sent RN 1 home. LVN 1 stated LVN 1 did not follow the facility's Abuse P&P. LVN 1 stated not reporting the alleged physical abuse and not removing the alleged abuse perpetrator (RN 1) from Resident 1 put Resident 1 at risk for the abuse to happen again. During an interview on 2/17/2024 at 4:48 PM with RN 1, RN 1 stated LVN 1 notified RN 1 of Resident 1's allegation of physical abuse. RN 1 stated RN 1 did not think Resident 1's allegation of physical abuse was legitimate (legal/lawful/allowable). RN 1 stated he did not slap Resident 1. RN 1 stated RN 1 did not report the alleged physical abuse to the ADM and did not follow the facility's Abuse P&P to protect Resident 1.During an interview on 2/17/2024 at 4:36 PM with the DON, the DON stated LVN 1, and RN 1 did not inform the DON of Resident 1's physical abuse allegation. The DON stated LVN 1 informed the ADON of the alleged physical abuse on 2/17/2024 (untimed, unable to recall the time), after the survey team identified the IJ situation. The DON stated the DON followed up with RN 1 on 2/17/2024 (untimed) and confirmed that RN 1 was aware of Resident 1's alleged physical abuse and did not report the alleged physical abuse to the DON or the ADM. The DON stated there were no other male CNAs who worked on 1/20/2024 and RN 1 was the only male nurse who worked on 1/20/2024. The DON stated the DON notified the local police department on 2/17/2024 (untimed) of the alleged physical abuse that occurred on 1/20/2024. The DON stated RN 1 did not report the incident of alleged physical abuse to the ADM and did not follow the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating. During an interview on 2/17/2024 at 5:53 PM with the ADON, the ADON stated Resident 1 had Down Syndrome, but could make some of Resident 1's needs known. The ADON stated Resident 1 was alert, awake, engaged, and knew what was going on Resident 1's environment. During a review of the facility's Nursing Staffing Assignment and Sign-In Sheet, (NSA Sign-In Sheet) dated 1/20/2024, for 7:00 AM to 3:00 PM shift, the NSA Sign-In Sheet indicated, RN 1 was the only male nurse who worked on 1/20/2024 from 7:00 AM to 3:00 PM. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation of Misappropriation-Reporting and Investigation, revised in 9/2022, the P&P indicated, all reports of resident abuse were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The P&P indicated, if resident abuse was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated, immediately was defined as within two hours of an allegation involving abuse. The P&P indicated, any employee who had been accused of resident abuse was placed on leave with no resident contact until the investigation was complete. 056477 Page 4 of 7 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record, review, the facility failed to provide care and services for one of three sampled residents (Resident 1), to prevent the development of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and promote healing by failing to: Residents Affected - Few 1. Ensure facility staff applied bilateral heel protectors (padding to protect the back of heels and feet from pressure injuries) on Resident 1's heels as ordered by the physician. 2. Ensure the Wound Care Nurse (WCN, treatment nurse) accurately set Resident 1's low air loss mattress (LAL, mattress designed to distribute resident's body weight and help prevent skin breakdown) according to Resident 1's current weight. These deficient practices resulted in Resident 1 developing Stage 1 pressure ulcer (intact skin with localized area of non-blanchable [skin discoloration that did not turn white when pressed] redness) on Resident 1's right medial (towards the middle/center) foot and right buttocks. This had the potential to result in worsening or delayed healing of Resident 1's Stage 4 pressure ulcer (full-thickness skin loss, muscles, tendons, and/or bones may be visible) on the sacrococcyx (both the sacrum [triangle-shaped bone in the lower spine] and coccyx [tailbone]). Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility admitted Resident 1 to the facility on 9/16/2022 with diagnoses that included Down Syndrome (genetic condition caused by having an extra chromosome [structures that carry genetic information] which was presented by growth, developmental, and learning delays that vary from mild to severe), contracture (fixed tightening of muscles, tendons, ligaments, or skin) of muscles, and pressure-induced deep tissue damage of the sacral (triangular shaped bone at end of the spine) region. During a review of Resident 1's Skin Progress Report, dated 11/03/2023, Resident 1 developed a Stage 4 pressure ulcer on the sacrococcyx on 11/03/2023. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 12/24/2023, the MDS indicated, Resident 1 required cues/supervision in making daily decisions. The MDS indicated, Resident 1 depended on the staff for chair/bed-to-chair transfers, rolling left and right, and transferring from tub/shower. The MDS indicated, Resident 1 was at risk for developing pressure ulcers/injuries and had one Stage 4 pressure ulcer present upon admission/entry or reentry. During a review of Resident 1's Care Plan (CP), untitled, revised on 1/3/2024, the CP indicated, Resident 1 with reopened Stage 4 pressure ulcer on the coccyx. The CP indicated, to provide LAL mattress as ordered. During a review of Resident 1's CP, untitled, revised on 2/12/2024, the CP indicated, Resident 1 had unavoidable/further skin breakdown. The CP indicated, to provide pressure relieving devices as appropriate and/or as ordered. During a review of Resident 1's CP, untitled, revised on 2/17/2024, the CP indicated, Resident 1 056477 Page 5 of 7 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

F 0686 Level of Harm - Minimal harm or potential for actual harm was at risk for developing pressure ulcers and other types of skin breakdown. The CP indicated, Resident 1 may have heel protectors. During a review of Resident 1's Order Summary Report (OSR) dated 2/17/2024, the OSR indicated, a physician order dated 9/16/2022 for heel protectors every shift. Residents Affected - Few During a review of Resident 1's OSR dated 2/17/2024, the OSR indicated, a physician order dated 12/16/2022 for a LAL mattress for wound care and management every shift for pressure ulcer and for staff to reposition Resident 1 every two hours. During a review of Resident 1's Weight and Vitals Summary (WVS) dated 2/17/2024, the WVS indicated, Resident 1 weighed 76 pounds (lbs.) on 2/5/2024. During an interview on 2/17/2024 at 8:45 AM with the Wound Care Nurse, WCN stated WCN provided all wound care treatments for residents with pressure ulcers or wounds. WCN stated Resident 1's LAL mattress was based off Resident 1's weight and the WCN was responsible for checking the settings and function of the LAL mattress. During a concurrent observation and interview on 2/17/2024 at 10:49 AM with the WCN, Resident 1 did not have the bilateral heel protectors in place. Resident 1 was observed with redness on Resident 1's right medial foot. WCN stated the heel protectors were not on Resident 1, and that the heel protectors needed to be applied on Resident 1. WCN nurse stated Resident 1 had a Stage 1 pressure ulcer on Resident 1's right medial foot. WCN stated Resident 1's Stage 1 pressure ulcer on the right medial foot was avoidable as the bilateral heel protectors were not in place and the resident was contracted with both feet laying on top of each other. WCN stated not having the bilateral heel protectors put the resident at risk of developing a pressure ulcer. WCN stated there was no excuse to not have the bilateral heel protectors on Resident 1. During a concurrent observation and interview on 2/18/2024 at 9:28 AM with WCN, in Resident 1's room, Resident 1's LAL mattress was observed to be programmed at 120 lbs. WCN stated the LAL was not on the right setting as Resident 1 currently weighed 76 lbs. WCN stated having the LAL mattress on the wrong setting could worsen Resident 1's current Stage 4 pressure ulcer as the mattress may be too firm. During a concurrent observation and interview on 2/18/2024 at 11:10 AM with WCN, in Resident 1's room, Resident 1 had redness on Resident 1's right buttocks. WCN stated the redness was non-blanchable and stated it was a Stage 1 pressure ulcer. WCN stated the Stage 1 pressure ulcer could be caused from laying on one side for too long and/or the LAL mattress being too firm. During an interview on 2/18/2024 at 1:45 PM with the Director of Nurses (DON), the DON stated if the LAL mattress was not on the correct setting, the resident would be at risk for skin breakdown, developing new pressures ulcers, or delay or impaired healing of a current pressure ulcer. The DON stated if heel protectors were ordered and not implemented, it would put the resident at risk for skin breakdown and development of new pressure ulcers. During a review of the facility's Proactive Medical Products Operation Manual (PMP OM), undated, the PMP OM indicated, users could adjust the LAL mattress to a desired firmness according to the resident's weight or the suggestion from a health care professional. 056477 Page 6 of 7 056477 02/20/2024 Eastland Subacute and Rehabilitation Center 3825 Durfee Ave El Monte, CA 91732

F 0686 During a review of the facility's policy and procedure (P&P) titled, Alteration in Skin Integrity, undated, the P&P indicated, implementation of treatment protocol to be based on the physician's orders. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056477 Page 7 of 7