Health inspection·January 12, 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 observation, interview, and record review, the facility failed to report an injury of unknown origin for one of two sampled residents (Resident 1) to the Ombudsman and local law enforcement. This deficient practice had the potential for delayed investigation of abuse for Resident 1. Findings: During a review of Resident 1's admission Record, the admission record indicated the facility admitted the resident on 8/22/2016, with diagnoses that included dementia (a loss of cognitive functioning such as thinking, remembering, and reasoning that interferes with a person's daily life and activities) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks. During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/23/2023, the MDS indicated Resident 1's cognitive (ability to understand) skills for daily decision making was severely impaired. The MDS indicated Resident 1 had no impairment to bilateral (both) upper extremities and impairment to bilateral lower extremities. The MDS indicated Resident 1 was dependent with all activities of daily living except toilet transfer and walking that was not attempted. During a review of Resident 1's document titled SBAR Communication Form dated 1/2/2024, the SBAR indicated Resident 1 had large dark purplish discoloration to left upper inner arm; the left arm was warm and swollen. During a review of Resident 1's Nurse's Notes dated 1/2/2024, the notes indicated Registered Nurse (RN) from hospice agency came and ordered antibiotics (medication to treat infection) for the resident. That same day, Resident 1's physician came and ordered to hold antibiotics until an x-ray (imaging test to see images of structures inside the body) was completed. During a review of Resident 1's x-ray result dated 1/3/2024 at 12:11 pm, the result indicated proximal ulna (the long bone in the forearm) fracture (broken bone) with distracted fragments and mild soft tissue swelling. During an interview on 1/12/2024 at 10:57 am, Certified Nursing Assistant 1 (CNA 1) stated on 1/2/2024, she was not the assigned CNA to Resident 1. CNA 1 stated she helped CNA 2 who was the assigned CNA for Resident 1.CNA 1 stated she helped CNA 2 because Resident 1 was spitting but was not hitting Page 1 of 2 555395 555395 01/12/2024 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff at that time. CNA 1 stated she did not see Resident 1's arms because Resident 1 was wearing long sleeve shirt. CNA 1 stated Resident 1 was able to move her arms when CNAs 1 and 2 were about to change her diaper. CNA 1 stated she remembered Resident 1 was able to move her arm because when CNA 1 showed Resident 1 the adult brief, Resident 1 gave a thumbs up to CNA 1. During an interview on 1/12/2024 at 11:16 am, the Assistant Director of Nursing (ADON) stated they were not able to find the cause of injury for Resident 1's left upper arm. During an interview on 1/12/2024 at 11:23 am, the Director of Nursing (DON) stated they did not report Resident 1's injury to the left arm to the Ombudsman and Law Enforcement because there was no suspicion of abuse. During a phone interview on 1/12/2024 at 1:17 pm, Certified Nursing Assistant 2 (CNA 2) stated she was the assigned CNA to Resident 1 on 1/2/2024. CNA 2 stated she checked Resident 1 at 10:00 am and the resident was dry. CNA 2 stated she went back to check on Resident 1 with CNA 1 and attempted to give Resident 1 a bed bath, but Resident 1 was kicking, swinging her arms, and spitting. CNA 2 stated Resident 1 did not look like she was in pain when CNAs 1 and 2 turned Resident 1 to be cleaned. CNA 2 stated she did not know how Resident 1 could have hurt her left arm. During an interview on 1/12/2024 at 2:41 pm, Restorative Nursing Assistant (RNA 1) stated Resident 1's AAROM (Active Assist Range of Motion- the person will activate the muscles to perform movements with the assistance of a helper to support during the movement) exercises were done on Mondays, Wednesdays, and Fridays. RNA1 stated the day before the injury on 1/2/2024, he did not notice anything different on Resident 1. RNA 1 stated, Resident 1 had clothes on, so he did not see the resident ' s arms. RNA stated he asked Resident 1 to perform five [NAME] and the resident was able to follow. During an interview on 1/12/2024 at 3:00 pm, Certified Nursing Assistant 3 (CNA 3) stated on 1/2/2024 around dinner time, she noticed Resident 1 did not eat much. CNA 3 stated Resident 1 ate a lot during dinner the night before and she was able to move her arms. During an interview on 1/12/2024 at 4:00 pm, the Administrator stated the facility did not report Resident 1's injury to the Ombudsman and to the Law Enforcement because they did not think it was an abuse. The Administrator stated they did not know what had caused the fracture and it could be the resident's behavior of hitting staff during care. During a review of the facility's Policy and Procedure (P&P) titled Abuse Reporting Guidelines revised 7/14/2023, the P&P did not address reporting guidelines for injuries of unknown origin. 555395 Page 2 of 2