Health inspection·February 5, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility (Skilled Nursing Facility [SNF] 1) failed to ensure one of three sampled residents (Resident 1) was permitted for readmission to the first available bed in a semi-private room on [DATE] after Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on [DATE] and transferred to Long-Term Acute Care Hospital (LTACH) 1 on [DATE], in accordance with SNF 1's policy and procedure (P&P) titled, Bed-Holds and Returns, dated 10/2022.This deficient practice resulted in Resident 1 remaining in LTACH 1 on [DATE] following an inquiry from LTACH 1 for Resident 1 to be transferred back to SNF 1 and had the potential to cause Resident 1 distress from not being able to return to Resident 1's previous living arrangement.(cross reference F628)Findings:During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on [DATE], and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions) and required partial/moderate assistance (helper does less than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Telephone Orders (PTO), dated [DATE] at 6:30 PM, the PTO indicated to transfer Resident 1 to a hospital via 911 (emergency number to request the services of the police, fire department, paramedics, ambulance).During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated [DATE], the SBAR indicated Registered Nurse (RN) 2 received an order from Resident 1's physician to transfer Resident 1 to a GACH via 911 due to altered mental status (AMS-a change in a person's thinking, awareness, or consciousness, causing confusion, reduced alertness, or unusual behavior), and desaturation (a drop in blood oxygen saturation levels below normal, usually falling under 90%) on [DATE] at 6:30 PM.During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated Resident 1 was transferred to GACH 1 by 911 on [DATE] at 7:15 PM due to AMS, increased respiration (rapid and shallow breathing, often resulting from conditions like lung infection, asthma, or anxiety), and desaturation.During a review of Resident 1's H&P from LTACH1, dated [DATE], the H&P indicated Resident 1 was transferred and admitted to LTACH 1 from GACH 1 for further evaluation and therapy on [DATE].During a review of Page 1 of 4 555395 555395 02/05/2026 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's Supportive Care and Palliative Visit Note (SCPVN) from LTACH 1, dated [DATE], the SCPVN indicated Resident 1's discharge goal/plan included transferring Resident 1 back to a skilled nursing facility (SNF).During a review of Resident 1's Psychiatric Consultation (PC- a thorough evaluation, when a psychiatrist assess mental, emotional, and physical health and address the emotional and behavioral issues [persistent and disruptive behaviors that negatively impact an individual's ability to function effectively in daily life and social interactions] to determine a diagnosis and personalized treatment plan ) report from LTACH 1, dated [DATE], the PC indicated Resident 1 was calm, quiet, and manageable with current treatment plan on [DATE].During an interview on [DATE] at 12:51 PM with SNF 1's admission Coordinator Director (ACD), the ACD stated the ACD received the inquiry from LTACH 1 regarding Resident 1's readmission on [DATE]. The ACD stated the facility refused to readmit Resident 1 on [DATE] because Resident 1's behavioral issues were not addressed and evaluated. The ACD stated Resident 1 was calm and had no behavior issues when the ACD assessed Resident 1 in LTACH 1 on [DATE].During an interview on [DATE] at 3:38 PM with SNF 1's Director of Nursing (DON), the DON stated the facility refused to readmit Resident 1 because Resident 1's behavioral issue was not addressed in Resident 1's medical record information from LTACH 1 on [DATE].During a telephone interview on [DATE] at 3:14 PM with LTACH 1's Case Manager (CM 1), CM 1 stated a PC was completed on [DATE] to evaluate Resident 1's behavior issues. CM 1 stated Resident 1's PC report was sent to SNF 1 on [DATE] and SNF 1 declined to readmit Resident 1 because Resident 1 was on hospice (care focused on comfort, pain management, quality of life and dignity as patients near the end of their life) and SNF 1 did not have any available bed for a hospice care resident.During a concurrent interview and record review on [DATE] at 9:02 AM with the Assistant DON (ADON), the facility's Census and Resident Roster, dated [DATE] and [DATE] were reviewed. The ADON stated the facility had 14 available female beds in a semi-private room (317A, 318A, 318B, 319A, 319B, 321A, 329C, 330A, 332B, 333C, 334A, 334B, 335A, and 335B) on [DATE] and on [DATE].During a concurrent interview and record review with the DON on [DATE] at 11:13 AM, Resident 1's PC report from LTACH 1, dated [DATE], was reviewed. The DON stated the facility received the PC report from LTACH 1 on [DATE] and refused to readmit Resident 1. The DON stated Resident 1 should be accepted for readmission to SNF 1 if Resident 1 did not have any behaviors which would endanger the health or safety of Resident 1 or other individuals in SNF 1. The DON stated SNF 1 should have readmitted Resident 1 on [DATE] because SNF 1 could provide the care and meet the needs of Resident 1.During a review of SNF 1's P&P titled, Bed-Holds and Returns, revised 10/2022, the P&P indicated, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source.Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. 555395 Page 2 of 4 555395 02/05/2026 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a complete transfer or discharge process for one of three sampled residents (Resident 1) when:1. A Notice of Transfer or Discharge (NTD) was not provided to Resident 1 and/or to Resident 1's representative (RP) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026.2. A copy of an NTD was not sent to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 1/3/2026.These deficiencies had the potential to violate Resident 1's right to not be inappropriately transferred or discharged and had the potential for the Ombudsman to not be able to advocate for Resident 1 from being inappropriately transferred or discharged .(cross reference F627)Findings:During a review of Resident 1's admission Record (AR), the admission Record indicated SNF 1 originally admitted Resident 1 on 12/10/2024, and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness or partial paralysis affecting one side of the body) following cerebral infarction (damage to brain tissue caused by loss of blood flow to a part of the brain), and dementia (a progressive state of decline in mental abilities).During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/3/2026, the MDS indicated Resident 1 was severely impaired in cognitive skills (ability to make daily decisions) and required partial/moderate assistance (helper does less than half the effort to complete the activity) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Physician's Telephone Orders (PTO), dated 1/3/2026 at 6:30 PM, the PTO indicated to transfer Resident 1 to a hospital via 911 (emergency number to request the services of the police, fire department, paramedics, ambulance).During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 1/3/2026, the SBAR indicated Registered Nurse (RN) 2 received an order from Resident 1's physician to transfer Resident 1 to a GACH via 911 due to altered mental status (AMS-a change in a person's thinking, awareness, or consciousness, causing confusion, reduced alertness, or unusual behavior), and desaturation (a drop in blood oxygen saturation levels below normal, usually falling under 90%) on 1/3/2026 at 6:30 PM.During a review of Resident 1's Progress Notes (PN), dated 1/3/2026, the PN indicated Resident 1 was transferred to GACH 1 by 911 on 1/3/2026 at 7:15 PM due to AMS, increased respiration (rapid and shallow breathing, often resulting from conditions like lung infection, asthma, or anxiety), and desaturation.During a review of Resident 1's medical record, there was no NTD found in the medical record regarding Resident 1's transfer to GACH 1 on 1/3/2026.During a telephone interview on 2/3/2026 at 11:40 AM with Registered Nurse (RN) 2, RN 2 stated RN 2 should have completed the NTD form and faxed the NTD form to the ombudsman after Resident 1 was transferred to GACH 1 on 1/3/2026.During a telephone interview on 2/3/2026 at 11:13 PM with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's medical record and stated the ADON was unable to find an NTD form in Resident 1's medical record. The ADON stated it was important to complete the NTD form, to inform the resident and the resident's family of the resident's transfer or discharge, and to fax the NTD to the ombudsman prior to the resident's transfer or discharge.During a review of the facility's policy and procedure (P&P) titled, Transfer or 555395 Page 3 of 4 555395 02/05/2026 El Encanto Healthcare Center 555 South El Encanto Road City of Industry, CA 91745

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Discharge, Facility-Initiated, dated 10/2022, the P&P indicated, The Notice of Transfer or Discharge (Emergent or Therapeutic Leave) should be given as soon as it is practicable but before the transfer or discharge if an immediate transfer or discharge is required by the resident's urgent medical needs. The P&P indicated, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (L TC) ombudsman when practicable. The P&P also indicated, Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. 555395 Page 4 of 4