Health inspection·June 27, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide interventions to prevent accidents for one of three sampled residents (Resident 1), by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA1) placed Resident 1's bed at the lowest position as indicated in Resident 1' care plan for At Risk for Injury from Falls (unintentionally coming to rest on the ground). 2. Ensure CNA1 did not walk away from Resident 1's bed while Resident 1's bed was not in the lowest position, while performing resident care. These deficient practices resulted in Resident 1's fall on 6/10/2023 at 10:15 AM and Resident 1 sustained three centimeters (cm- unit of measurement) laceration (cut or skin tear) to the scalp (skin on a person's head) on the right side of Resident 1's head. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 6/10/2023 and Resident 1's laceration was closed with Dermabond (sterile, liquid tissue adhesive). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), generalized muscle weakness and difficulty in walking. During a review of Resident 1's Fall Risk Assessment (evaluation to test a resident's risk level for falling), dated 5/1/2023, the Fall Risk Assessment indicated Resident 1 was assessed as high risk for fall. During a review of Resident 1 Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 5/17/2023, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason) and the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. During an interview on 6/23/2023 at 2:33 PM, CNA 1 stated the morning Resident 1 fell on 6/10/2023 at 10:15 AM, CNA 1 was getting the resident ready for the day by changing Resident 1's clothes and adult brief. CNA 1 stated Resident 1 was lying flat in the bed, with two side rails (bedrails) up, Page 1 of 5 555395 555395 06/27/2023 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and had the bed raised from the lowest position to middle height. CNA 1 stated she forgot Resident 1's socks and walked away from Resident 1's bed while the bed was still at middle height. CNA 1 walked towards Resident 1's dresser which was in between Resident 1's bed and Resident 1's roommate's bed, across from the foot of Resident 1's bed. CNA 1 stated while she was at the dresser, CNA 1 stated she observed Resident 1 slid down the right side of the bed into a seated position on the floor with Resident 1's legs out. CNA 1 stated she noticed Resident 1's head was leaning to the right but Resident 1's head did not touch the floor. CNA 1 stated she noticed blood on Resident 1's blouse. CNA 1 stated she called for help. CNA 1 stated she thought Resident 1 hit her head on the side rail. CNA 1 stated she should not leave Resident 1's bedside without lowering Resident 1's bed to the lowest position first. CNA 1 stated, when Resident 1 fell, the bed was not in the lowest position, but at the middle height (from how high the bed can be raised). During a review of Resident 1's GACH 1 Emergency Department (ED) note dated 6/10/2023, the ED note indicated the resident's chief complaints included head trauma (damage to the scalp, skull, or brain caused by injury) and neck pain. The ED note indicated Resident 1 sustained head trauma, cervical (neck) sprain (stretching or tearing of ligaments) and three centimeters (cm- unit of measurement) laceration to the scalp (skin on a person's head). The ED note indicated Resident 1's head was cleaned and closed with Dermabond. During a concurrent interview and record review on 6/27/2023 at 3:44 PM with MDS Nurse (MDSN), Resident 1's care plan for At Risk for Injury from Falls initiated on 2/20/2020 was reviewed. The care plan indicated Resident 1 was at risk for falls as evidence by impaired cognition, muscle weakness, difficulty in walking, and unsteady gait (manner of walking) and balance. The care plan interventions included to keep Resident 1's bed in the lowest position. During a concurrent observation and interview on 6/27/2023 at 4:39 PM with Registered Nurse Manager (RNM), RNM measured the height of Resident 1's bed from the lowest, middle, and highest positions, as follows: a. RNM stated at the lowest position, the distance from the floor to the bed frame was 11.5 inches and the distance from the floor to the top of the mattress was 19 inches. b. RNM stated at middle position, the distance from the floor to the bed frame was 17.75 inches and the distance from the floor to the top of the mattress was 23.5 inches. c. RNM stated at the highest position, the distance from the floor to bed frame was 24 inches and the distance from the floor to the top of the mattress was 32 inches. During an interview on 6/27/203 at 5:26 PM with Registered Nurse Charge (RNC), RNC stated the care plan intervention to keep the bed in the lowest position is to protect the resident (in general) from injury, if the resident falls. RNC stated if a resident falls from a higher bed position, the resident could sustain greater injury. RNC stated if staff (in general) needed to step away from the resident while performing patient care, staff needed to put the bed at the lowest position before stepping away, and then raise the height of the bed back to the desired height, once the staff is back at the resident's bedside. During an interview on 6/27/2023 at 6:25 PM with the facility's Director of Nursing (DON) and RNM, DON and RNM stated the staff (in general) were not practicing resident's safety if staff leave the resident's bedside and not put the bed in lowest position, as indicated. 555395 Page 2 of 5 555395 06/27/2023 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON and RNM stated Resident's 1 fall with injury could have been avoided if CNA 1 had lowered Resident 1's bed to the lowest position before stepping away from the resident's bed. During a review of the facility's Policy and Procedure (P&P) titled, Fall-Prevention and Risk Reduction, revised 2/2023, the P&P indicated the MDS Coordinator will complete a comprehensive care plan for all residents who are identified at risk for falls. The P&P indicated the nursing assistant must educate residents in safety awareness, keep bed wheels in locked position, and remind residents to call when needing assistance. During a review of the facility's undated P&P titled Person Centered Care Planning, the P&P indicated the facility will identify resident's individual needs and provide a data base for the resident's health assessment that begins on the day the resident is admitted in the facility and completed within seven days after completion of the comprehensive assessment. The P&P indicated the care plans are person centered and are used to assist the resident to reach his/her highest practicable level of physical, mental, and psychosocial wellbeing. 555395 Page 3 of 5 555395 06/27/2023 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate documentation for one of three sampled residents (Resident 1). The Social Services Director (SSD) documented on Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool) Resident 1 had moderately impaired cognition (ability to think, reason, and remember) when Resident 1 had severely impaired cognition. This deficient practice had the potential for Resident 1 not to receive the care and services needed for a resident with severely impaired cognition. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities), generalized muscle weakness and difficulty in walking. During a review of Resident 1's History and Physical (H&P) dated 1/19/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 5/17/2023, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason) and the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's care plan for impaired cognition initiated on 5/25/2023, the care plan indicated Resident 1 had short-term memory problems, long-term memory problems, impaired decision making, poor safety judgement, and episodes of confusion related to dementia and aging process. The care plan interventions included to address Resident 1 by name when initiating interaction, allow Resident 1 adequate time to absorb messages and respond to it and explain to Resident 1 in simple terms prior to doing routine and procedures. During a concurrent interview and record review on 6/27/2023 at 3:30 PM with the SSD, Resident 1's MDS was reviewed. SSD stated she completed the Cognitive Pattern section of Resident 1's MDS (Section C). SSD stated she used a Spanish interpreter to communicate with Resident 1 when she assessed the resident's cognitive ability. SSD stated Resident 1 was unable to complete the Brief Interview for Mental Status (BIMS). SSD stated she completed the section for Cognitive Skills for Daily Decision Making in Resident 1's MDS. SSD indicated in Resident 1's MDS that Resident 1's cognition was moderately impaired (decisions poor, cues/supervision required). SSD stated it was a mistake or her part to mark Resident 1 as moderately impaired because Resident 1 was severely impaired (never/rarely made decisions). SSD stated staff would not know how to accurately provide care to Resident 1 because the SSD's documentation was incorrect. SSD stated staff would not be able to provide the necessary care to Resident 1 as a severely impaired resident in terms of cognition because the SSD documented Resident 1 had moderately impaired cognition. SSD stated Resident 1 may not be getting the services needed to treat a resident with severe cognitive impairment, and that the error in documentation could affect how the staff (in general) will supervise Resident 1. 555395 Page 4 of 5 555395 06/27/2023 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/27/2023 at 3:44 PM with the MDS Nurse (MDSN), Resident 1's MDS was reviewed. The MDSN stated he was the MDS Coordinator for the facility. MDSN stated it was not his job to ensure the accuracy of Resident 1's MDS, but to ensure the completion of the MDS. The MDSN stated Resident 1 was not getting as much care the resident needed because the documentation was not accurate. MDSN stated this error in documentation in Resident 1's MDS could affect the delivery of care and services to Resident 1. During an interview on 6/27/2023 at 5:26 PM with the facility's Director of Nursing (DON), the DON stated the MDSN had to assess and evaluate the residents. The DON stated the MDSN needed to work with other disciplines to ensure the sections of the MDS were filled out accurately and completely before the MDSN finalized the MDS. The DON stated the inaccurate documentation on Resident 1's MDS had the potential for Resident 1 not to have a plan of care in place that accurately reflected Resident 1's current condition. During an interview on 6/27/2023 at 6:25 PM, the DON and Registered Nurse Manager (RNM) stated staff were not providing accurate care to Resident 1 because the MDS Section C was not accurate, putting Resident 1's safety at risk. A review the facility's Policy and Procedure (P&P) titled Charting and Documentation revised 2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P also indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 555395 Page 5 of 5