Health inspection·February 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within two hours to the California Department of Public Health (CDPH), for one of four residents, (Resident 1). This failure had the potential to place Resident 1 at risk for further abuse or harm. Findings: A review of Resident 1's medical records indicated he was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (irregular heartbeat), diabetes mellitus (abnormal blood sugar levels), with diabetic neuropathy (a type of nerve damage that can occur in people with diabetes), and anxiety disorder (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1's History and Physical dated February 10, 2025, indicated he had the capacity to make decisions. A review of Resident 1's Progress Notes dated February 8, 2025, at 3:39 a.m., indicated .Resident (Resident 1) aggressive towards staff. When writer came to respond to call light resident verbalized request for immediate needs for side rails in very rude and loud: '(explicit word)' .tried to hit writer with fist. Writer immediately left pt. (patient) room and assigned resident to other SN. Pt (Resident 1) reported to local Police about being abused . A review of Resident 1's eINTERACT Change in Condition Evaluation dated February 8, 2025, at 4:02 p.m., indicated .The change in condition, symptoms or signs I am calling about is/are . allegation of physical abuse .This started on: morning . allegation of physical abuse by staff . 1.Were the change in condition and notifications reported to primary care clinician .yes .2/8/25 13:00 .Recommendation of primary clinician(s) . monitor anticipate needs . On February 21, 2025, at 12:58 p.m., a telephone interview was conducted with Registered Nurse (RN 1). RN 1 stated on February 8, 2025, at approximately 12 a.m., he responded to Resident 1's call light. RN 1 stated that Resident 1 was aggressive and using inappropriate language toward staff. RN 1 stated that Resident 1's call light had fallen to the floor, and after picking it up and placing it back on Resident 1's bed, Resident 1 attempted to punch him. RN 1 further stated, during his lunch break at 3 a.m., the police were called by Resident 1, who claimed he was being abused by the staff. RN 1 stated that allegations of abuse should be reported to the administrator within 24 hours. (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 2 Event ID: 056185 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 056185 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Menifee Lakes Post Acute 27600 Encanto Drive Sun City, CA 92586 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)