Inspection·July 15, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few marked with 10, indicating other - specify. Review of Resident 1's eMAR - Medication Administration Notes for July 2025 showed the following:- dated 7/5/25, for the nystatin medication, there was no documentation why the medication was not administered; and- dated 7/5/25, for the ciclopirox medication, there was no documentation why the medication was not administered. Further review of Resident 1's progress notes for July 2025 failed to show documentation why the ciclopirox and nystatin medications were not administered on the above dates. Additionally, there was no documented evidence the physician was notified of the missed administrations of the medications. On 7/14/25 at 1433 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated after she provided a wound treatment, she would sign the TAR and a check mark on the TAR would appear, indicating the wound treatment was administered. LVN 1 stated she was Resident 1's main treatment nurse for March 2025. LVN 1 reviewed Resident 1's March 2025 blank treatment administrations for Resident 1's left lower thigh surgical incision. LVN 1 verified the findings and stated the charge nurse should administer the wound treatments for the evening and night shifts. LVN 1 stated the blank administrations meant the wound treatment was either not administered or not marked as administered. LVN 1 stated when 10 was marked on the TAR, it meant other, and the licensed nurse would need to write a progress note to specify the reason why the wound treatment or medication was not administered. LVN 1 was unable to state why the nystatin and ciclopirox medications were not given and marked with 10 on 7/5/25. On 7/14/25 at 1600 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated if the TAR was left blank, it meant that the licensed nurse forgot to mark it as given or it was not given. Additionally, the DON stated if the wound treatment/medication was marked 10, it meant other, and the licensed nurse should write a progress note to specify the reason why the treatment/medication was not given. The DON was unable to provide documented evidence to show why Resident 1's wound treatments and medications were not provided for the above dates. c. Review of Resident 1's Order Summary Report dated from 3/7 to 3/26/25, showed the following physician's orders:- dated 3/7/25, with a start date of 3/8/25, to administer meloxicam (nonsteroidal anti-inflammatory drug used for treating chronic musculoskeletal conditions) 15 mg 0.5 tablet by mouth one time a day for pain management;- dated 3/8/25, with a start date of 3/8/25, to administer fluticasone-salmeterol (medication used to improve breathing) 250-50 one puff inhalation orally every 12 hours for asthma (chronic respiratory disease that inflames and narrows the airways); and- dated 3/7/25, with a start date of 3/7/25, to administer gabapentin (a medication used to treat neuropathic pain) 100 mg one capsule by mouth two times a day for neuropathic pain (nerve pain). Review of Resident 1's MAR dated March 2025 showed the following:- on 3/8, 3/9, 3/10, and 3/11/25 at 0900 hours, for the meloxicam medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify;- on 3/8 and 3/9/25 at 0900 hours, for the fluticasone-salmeterol medication, the administrations were left blank and were not signed by a licensed nurse;- on 3/8, 3/24, and 3/25/25 at 0900 hours, for the gabapentin medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify; and- on 3/7 and 3/22/25 at 1700 hours, for the gabapentin medication, the administrations were signed by a licensed nurse and marked with 10, indicating other specify. Review of Resident 1's eMAR - Medication Administration Notes for March 2025 showed the following documentation:- dated 3/7/25, the documentation showed New admit arrived after start times. However, the documentation did not indicate which medication the note was written for;- dated 3/8/25, for the gabapentin and meloxicam medications, the documentation showed Medication unavailable, will follow up with the pharmacy;- dated 3/9/25, for the meloxicam medication, the documentation showed On order;dated 3/10/25, for the meloxicam medication, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 Residents Affected - Few documentation showed On order;- dated 3/11/25, the documentation showed Pending pharmacy delivery, physician made aware, give when delivered. However, the documentation did not indicate which medication the note was written for;- dated 3/22/25, for the gabapentin medication, the documentation showed Wait delivery;- dated 3/24/25, for the gabapentin medication, the documentation showed Med on order; anddated 3/25/25, for the gabapentin medication, there was no note written to indicate why the medication was not given. Further review of Resident 1's eMAR - Medication Administration Notes and progress notes for March 2025 failed to show documentation regarding the blank administration record for the fluticasone-salmeterol medication. Additionally, there was no documented evidence the physician was notified of the missed administrations of the medications. d. Review of Resident 1's Order Summary Report dated 7/14/25, showed the following physician's orders:- dated 7/3/25, with a start date of 7/3/25, to administer carboxymethylcellulose sodium (lubricant eye drop used for dry eyes) ophthalmic solution one drop in both eyes four times a day for dry eyes; and- dated 7/5/25, with a start date of 7/6/25, to administer carboxymethylcellulose sodium ophthalmic solution 0.5 % one drop in both eyes four times a day for dry eyes. Review of Resident 1's MAR dated July 2025 showed the following:- on 7/4 and 7/5/25, at 0900 and 1300 hours, for the carboxymethylcellulose sodium medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify;- on 7/4, 7/5, and 7/6/25 at 1700 hours, for the carboxymethylcellulose sodium medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify;- on 7/3, 7/4, 7/5 and 7/6/25 at 2100 hours, for the carboxymethylcellulose sodium medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify;- on 7/6/25 at 0900 and1300 hours, for the carboxymethylcellulose sodium 0.5 % medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify; and- on 7/6 and 7/7/25 at 1700 and 2100 hours, for the carboxymethylcellulose sodium 0.5 % medication, the administrations were signed by a licensed nurse and marked with 10, indicating other - specify. Review of Resident 1's eMAR - Medication Administration Notes for July 2025 showed the following documentation:- dated 7/3/25, for the carboxymethylcellulose sodium medication, the documentation showed Medication unavailable, will follow up with pharmacy due to resident being a new admit;- dated 7/4/25 at 0919 hours, for the carboxymethylcellulose sodium medication, the documentation showed Med unavailable, will follow up with pharmacy due to resident being a new admit;dated 7/4/25 at 1205 hours, for the carboxymethylcellulose sodium medication, there was no note written to indicate why the medication was not given;- dated 7/4/25 at 2151 hours, for the carboxymethylcellulose sodium medication, the documentation showed In transit from pharmacy;- dated 7/5/25 at 1110 hours, for the carboxymethylcellulose sodium medication, the documentation showed In transit from pharmacy;dated 7/5/25 at 1422 hours, for the carboxymethylcellulose sodium medication, there was no note written to indicate why the medication was not given;- dated 7/5/25 at 2309 hours, for the carboxymethylcellulose sodium medication, the documentation showed In transit from pharmacy;- dated 7/5/25 at 2310 hours, for the carboxymethylcellulose sodium medication, the documentation showed In transit from pharmacy;dated 7/6/25 at 1007 hours, for the carboxymethylcellulose sodium medication 0.5 %, the documentation showed Duplicate;- dated 7/6/25 at 1421 hours, for the carboxymethylcellulose sodium medication 0.5 %, the documentation showed Duplicate;- dated 7/6/25 at 1700 hours, for the carboxymethylcellulose sodium medication 0.5 %, the documentation showed Pending pharmacy delivery;- dated 7/6/25 at 1700 hours, for the carboxymethylcellulose sodium medication 0.5%, the documentation showed Pending pharmacy delivery;- dated 7/6/25 at 2101 hours, for the carboxymethylcellulose sodium medication, there was no note written to indicate why the medication was not given;- dated 7/6/25 at 2102 hours, for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete carboxymethylcellulose sodium medication 0.5 %, the documentation showed Pending pharmacy delivery;dated 7/7/25 at 1904 hours, for the carboxymethylcellulose sodium medication 0.5 %, there was no note written to indicate why the medication was not given;- dated 7/7/25 at 2102 hours, for the carboxymethylcellulose sodium medication, there was no note written to indicate why the medication was not given; and- dated 7/7/25 at 2221hours, for the carboxymethylcellulose sodium medication 0.5 %, there was no note written to indicate why the medication was not given. Further review of Resident 1's progress notes for July 2025 failed to show documented evidence the physician was notified of the missed administrations of the medications. On 7/14/25 at 1535 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 2. LVN 2 stated the licensed nurses signed the eMAR to show the medication was given to the resident and if the licensed nurse mark 10, it meant other, and the licensed nurse would have to write a progress note. On 7/14/25 at 1600 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated the medications should be given as ordered by the physician and the MAR must have a check mark (signed by the licensed nurse). The DON stated if the MAR was left blank, it meant the licensed nurse forgot to mark it as given or it was not given. However, the DON stated she would not know for sure. Additionally, the DON stated if the medication was marked 10 it meant other, and the licensed nurse should write a progress note for why the medication was not given. Resident 1's MAR for March 2025 and July 2025 was reviewed. The DON verified the above findings. The DON stated the licensed nurses should have contacted the physician immediately when it was known the medications were not available and should write a progress note if the medication administration was marked as 10. The DON stated for the blank administrations for the fluticasone-salmeterol medication, the licensed nurse either forgot to sign the MAR or the medication was not given. For the gabapentin medication, the DON stated they should not be running out of the medication and did not know why the medication was not available on 3/22, 3/24, and 3/25/25. However, the DON stated the medication should have been followed up with before it ran out. Event ID: Facility ID: 056110 If continuation sheet Page 4 of 4