Health inspection·March 26, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure staff did not give medications to one of three sampled residents (Resident 1) without a current physician's order as indicated in the facility's policy and procedure (P&P) titled, Medication Administration. This deficient practice had the potential to result in the unnecessary use of medication, medication errors, and adverse side effects for Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 10/19/2020, with diagnoses that included non-displaced intertrochanteric fracture of right femur (a type of fracture that occurs in the upper part of the thigh bone), dementia (a group of symptoms affecting memory, thinking and social abilities), and difficulty in walking. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2025, the MDS indicated Resident 1 was usually understood by others and had the ability to usually understand others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's Order Summary Report (OSR), dated 2/22/2025, the OSR indicated there was no current physician's order for any medication as needed for nausea and vomiting. During a review of Resident 1's Licensed Nurses Progress Notes (PN), dated 3/10/2025 and timed at 11:30 pm, the PN indicated Licensed Vocational Nurse (LVN) 1 documented that Resident 1 had small amount of emesis (vomit), brown in color, liquid, similar to nighttime medications with chocolate pudding. The PN indicated Resident 1 had no further nausea or vomiting. The PN indicated Resident 1's vital signs were stable, and call light was within reach. During an interview on 3/26/2025 at 3:22 pm with LVN 1, LVN 1 stated Resident 1 had some Zofran (a medication that prevents nausea and vomiting) 4 milligrams (mg) tablets available in the medication cart, labeled with Resident 1's name on it. LVN 1 stated LVN 1 gave Zofran 4 mg (one tablet) to Resident 1 at 11:30 pm or 11:45 pm. LVN 1 stated LVN 1 did not review Resident 1's Medication Administration Record (MAR) and verify if there was a physician's order for Zofran before giving the Zofran to Resident 1. LVN 1 stated LVN 1 administered the Zofran to Resident 1 first then tried to document the medication administration in Resident 1's MAR but did not see an active order for the Zofran. LVN 1 stated before giving any resident a medication, LVN 1 needed to look at the MAR before (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: 555395 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 555395 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745 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)