Inspection·June 25, 2025

F 0628 notified the ombudsman of Resident 1 transfer. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated .Notice of Transfer or Discharge .when residents are sent emergently to an acute care setting .the notice is given as soon as it is practicable but before the transfer or discharge .Notice of Transfer is provided to the resident .resident representative .as soon as practicable before the transfer .(LTC) ombudsman when practicable .monthly list of residents .includes all notice content requirements . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 2 of 5 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 06/25/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure wound care treatments were provided to meet the needs of residents when four sampled residents ' (Residents 1, 2, 3, and 4) were not provided wound care treatment in accordance with the physician ' s orders. Residents Affected - Some This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 ' s wounds to worsen and could lead to serious complications. Findings: On June 25, 2025, at 9:37 a.m., Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). A review of Resident 1 ' s Order Summary Report from April 1, 2025, to June 25, 2025, indicated the following: a. Clean right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/16/2025. Start date: 05/09/2025. b. Cleanse right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/23/2025. c. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/30/2025. d. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day every other day for wound care for 14 days. Start date 05/31/2025 End date 06/14/2025. A review of Resident 1 ' s Treatment Administration Record (TAR) for the month of May 2025, indicated treatment for the right foot stump was not signed as provided on May 14, 16, and 17, 2025, at 9 a.m. On June 25, 2025, at 10:58 a.m., Resident 2 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included low back pain, congestive heart failure (heart can ' t pump blood well enough leading to fluid (congestion) build up in body), and hypertension (high blood pressure). A review of Resident 2 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/09/2025, Start date:05/03/2025. The TAR has no documentation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 3 of 5 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 06/25/2025 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 0684 indicating treatment for the left heel was provided on May 4,2025. Level of Harm - Minimal harm or potential for actual harm b. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/23/2025, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided for the left heel on May 17, 2025. Residents Affected - Some c. Cleanse left heel blister with normal saline and pat dry and apply betadine and leave open to air. One time a day for a wound care to left heel blister until June 6, 2025. The TAR has no documentation indicating treatment was provided to the left heel blister on May 31, 2025. On June 25, 2025, at 11:38 a.m., Resident 3 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), chronic obstructive pulmonary disease (lung disease that makes it hard to breath), and dysphagia (difficulty swallowing). A review of Resident 3 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left great toe with normal saline and pat dry and apply triple Antibiotic and leave open to air. One time a day for treatment to left great toe for 14 days, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided on May 16 and 17, 2025. On June 25, 2025, at 9:37 a.m., Resident 4 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included subdural hemorrhage (blood collects in brain), gangrene (death of body tissue), palliative care (specialized medical care). A review of Resident 4 ' s TAR for the month of May 2025 indicated the following: a. Left foot 4th gangrene toe. Cleanse with NS wound cleanser, pat dry, then apply betadine. Cover with clean dry dressing daily and prn for dislodgement and soiled dressing. Every 48 hours for wound care to left foot until 05/30/2025, Start date: 05/15/2025. The TAR has no documentation indicating treatment was provided to the left foot 4th great toe on May 17, 2025. On June 25, 2025, at 1:03 p.m., an interview and concurrent record review was conducted with the Treatment Nurse. The Treatment Nurse stated there was no documented evidence that the wound treatment was administered on Resident 1's right foot stump on May 14, 15, nd 17, 2025. The TN verified as well that no treatment was provided for Resident 2's left heel wound on May 4, 17, and 31, 2025. For Resident 3's left great toe, the treatment nurse verified no treatment was documented on May 16 and 17, 2025; and For Resident 4's left foot 4th gangrene toe, no treatment was provided on May 17, 2025. The Treatment Nurse stated that wound treatments should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. On June 25, 2025, at 2:04 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON verified there was no documented evidence that the wound treatment was administered on Resident 1, Resident 2, Resident 3, and Resident 4. The DON stated the facility process is for nursing to follow all physician orders and document that the order has been performed in the resident ' s chart. The DON stated that wound treatment should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. A review of the facility policy and procedure titled Charting and Documentation, revised July 2017, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 4 of 5 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 06/25/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm indicated .The following information is to be documented in the resident medical record .treatments or services performed . documentation of procedures and treatments will include care-specific details .date .time .procedure/treatment . assessment .unusual findings .resident tolerance of the treatment .refusal . signature .title of individual documenting . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055401 If continuation sheet Page 5 of 5