Inspection·June 6, 2025

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster was found overflowing with trash. In addition, the lid of the dumpster was not completely closed. Residents Affected - Some This failure had the potential to attract pests. Findings: On May 12, 2025, at 12:33 p.m., during a garbage disposal inspection with the Dietary Manager (DM), a trash dumpster located outside the building by the parking lot area was observed overflowing with trash. In addition, the lid of the dumpster was not completely closed. In a concurrent interview with the DM, he stated the dumpster should not be overflowing with trash. He also stated, the dumpster lid should be completely closed to prevent attracting pests. On May 12, 2025, at 12:25 p,m, during an interview with the facility owner, he stated the dumpster should not be overflowing and the lid should be completely closed. A review of the facility policy and procedure, titled, Food-Related Garbage and Refuse Disposal, revised October 2017, indicated, .Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 2 of 4 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 055401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Post Acute 461 E. Johnston Avenue Hemet, CA 92543 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practice was followed for two of three residents reviewed (Residents 1 and 2) when: Residents Affected - Few 1. For Resident 1, the oxygen (O2) cannula (a flexible tube with two prongs that fit into the nostrils and delivers supplemental O2) was not dated and an undated nebulizer mask (a medical device that fits over the nose and mouth and allows an individual to inhale a mist of medication directly into their lungs) was found on top of Resident 1 ' s nightstand. In addition, the undated nebulizer mask was not stored in a plastic bag and was exposed to the environment; and 2. For Resident 2, the nebulizer mask was not changed since admission. These failures had the potential for Residents 1 and 2 to be exposed to bacterial cross contamination and the development of infection. Findings: 1. On May 12, 2025, at 11:18 a.m., Resident 1 was observed sitting in bed, awake and alert. Resident 1 was receiving O2 at 2 (two) LPM (Liters Per Minute – a unit of measurement). The O2 tubing was not dated. In addition, a nebulizer mask was found on top of the nightstand, not stored in a plastic bag and was exposed to the environment. The nebulizer mask was not dated. Resident 1 ' s record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included pneumonia (lung infection). The physician order dated January 20, 2025, indicated, .Change nasal cannula/mask every night shift every Sun (Sunday) .Change O2 tubing every night shift every Sun . On May 12, 2025, at 11:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed changing O2 plastic bag in resident ' s rooms. In a concurrent interview with LVN 1, he stated the O2 cannula, O2 plastic bag, and the nebulizer mask should be changed once a week. LVN 1 stated the night shift nurses were assigned to change them on Sunday night. He also stated the O2 cannula and the nebulizer mask should be stored in a clear plastic bag, labeled, and dated when not in use. LVN 1 stated the O2 cannula, and the nebulizer mask should not be left exposed for infection control. On May 12, 2025, at 11:48 a.m., the Respiratory Therapist (RT) was interviewed. He stated respiratory equipment such as nasal cannula and nebulizer mask should be changed once a week. He stated the respiratory equipment should be labeled, dated, and stored in a clean plastic bag when not in use for infection control purposes. On May 12, 2025, at 12:43 p.m., the Director of Staff Development (DSD) stated he was the acting Infection Preventionist (IP). He stated the RT would change the respiratory equipment every Monday for those residents assigned to them and the night shift Charge Nurse should change the respiratory equipment on Sunday night. He also stated, the nasal cannula, and the nebulizer mask should be stored in a clear plastic bag for infection control and should be changed once a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 3 of 4 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 055401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Post Acute 461 E. Johnston Avenue Hemet, CA 92543 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, .Steps in the Procedure .store in a plastic bag with the resident ' s name and the date on it .Change equipment and tubing every seven days, or according to the facility protocol . 2. On May 12, 2025, at 11:08 a.m., a resident belongings bag was observed hanging, attached to the drawer knob of Resident 2 ' s nightstand. The belongings bag indicated, .(Name of Resident 2) .Neb (nebulizer) mask .4/9/25 . Resident 2 was not in his room. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included pneumonia. A review of Resident 2's physician order dated April 9, 2025, indicated, .Change nasal cannula/mask every nigh shift every Sun .Change O2 tubing every night shift every Sun for hygiene . On May 12, 2025, at 11:40 a.m., Licensed Vocational Nurse (LVN) 1 was observed changing O2 plastic bag in resident ' s rooms. In a concurrent interview with LVN 1, he stated the O2 cannula, O2 plastic bag, and the nebulizer mask should be changed once a week. LVN 1 stated the night shift nurses were assigned to change them on Sunday night. He also stated the O2 cannula and the nebulizer mask should be stored in a clear plastic bag, labeled, and dated when not in use. LVN 1 stated the O2 cannula, and the nebulizer mask should not be left exposed for infection control. On May 12, 2025, at 11:48 a.m., the Respiratory Therapist (RT) was interviewed. He stated respiratory equipment such as nasal cannula and nebulizer mask should be changed once a week. He stated the respiratory equipment should be labeled, dated, and stored in a clean plastic bag when not in use for infection control purposes. On May 12, 2025, at 12:43 p.m., the Director of Staff Development (DSD) stated he was the acting Infection Preventionist (IP). He stated the RT would change the respiratory equipment every Monday for those residents assigned to them and the night shift Charge Nurse should change the respiratory equipment on Sunday night. He also stated, the nasal cannula, and the nebulizer mask should be stored in a clear plastic bag for infection control and should be changed once a week. On May 12, 2025, at 2:18 p.m., Resident 2 was observed in the Activities Room, sitting in the wheelchair. He stated his nebulizer mask had not been changed since he was admitted in the facility. On May 12, 2025, at 2:40 p.m., LVN 2 was interviewed. LVN 2 stated she gave Resident 2 ' s breathing treatment in the morning and did not change the nebulizer mask. LVN 2 stated the respiratory equipment should have been changed Sunday, by the night shift. She also stated respiratory equipment should be stored in a plastic bag when not in use. A review of the facility policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, .Steps in the Procedure .store in a plastic bag with the resident ' s name and the date on it .Change equipment and tubing every seven days, or according to the facility protocol . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 4 of 4