Health inspection·March 13, 2025

F 0578 and a follow up regarding formulating an AD were provided to the resident or RP. Level of Harm - Minimal harm or potential for actual harm A review of the facility Policy and Procedure titled, Residents' Rights Regarding Treatment and Advance Directives, dated December 2022, indicated, .the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive .the facility will provide information and education .the facility will provide the resident or resident representative information, in a manner that is easy to understand, about the rights to refuse medical or surgical treatment and formulate an advance directive .should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . Residents Affected - Some 3. On March 12, 2025, at 2:15 p.m., during an interview with Resident 29, Resident 29 stated she does not have an advance directive and would like to have one so they would know her wishes. A review of Resident 29's 'admission RECORD, indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis (narrowing of the spine). A review of Resident 29's HISTORY AND PHYSICAL EXAMINATION, dated June 16, 2024, indicated, Resident 29 was alert and oriented to person, place, time and event. A review of Resident 29's Social History Assessment, dated December 26, 2023, did not indicate Resident 29 had an AD. A further review of Resident 29's medical records indicated there was no documented evidence Resident 29 and or RP were provided information and education regarding AD. On March 13, 2025, at 12:55 p.m., during a concurrent interview and review of Resident 29's medical record with SSA 1, she stated Resident 29 had no AD and was not provided with resources and education. SSA 1 further stated Resident 29 should have been provided with resource and education and documented in the medical records. 4. A review of Resident 46's 'admission RECORD, indicated Resident 46 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of prostate (prostate cancer). A review of Resident 46's POLST dated February 29, 2024, did not include information regarding Advance Directive. A review of Resident 46's Advance Directive Acknowledgment, dated March 4, 2024, indicated, .I HAVE NOT executed an 'Advance Directive' . A review of Resident 46's Social History Assessment, dated March 11, 2024, did not indicate Resident 46 had AD. A review of Resident 46's, HISTORY AND PHYSICAL EXAMINATION, dated March 24, 2024, indicated Resident 46 was awake, alert, oriented to person, place and time. A further review of Resident 46's medical record indicated no documented evidence Resident 46 and or RP had been provided information and education regarding AD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 2 of 27 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 03/13/2025 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On March 13, 2025, at 12:55 p.m., during a concurrent interview and review of Resident 46's medical record with SSA 1, she stated Resident 46 did not have an AD and was not provided with resources and education. SSA 1 further stated Resident 46 should have been provided resources and education and this should have been documented in the medical records. Based on interview and record review, the facility failed to ensure, six of nine residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 9, 29, 46, 50, 51, 58) had the following: 1. A copy of the AD available in the resident's record for Resident 9; and 2. The resident or their resident representative had been provided information regarding the formulation of an AD for Residents 29, 46, 50, 51, and 58. These failures had the potential to result in the ADs for Residents 9, 29, 46, 50, 51, and 58 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. Resident 50's record was reviewed. Resident 50 was admitted to the facility on [DATE]. A review of Resident 50's Physician Orders for Life-Sustaining Treatment (POLST), dated May 4, 2023, indicated, Resident 50 did not have an AD. A review of Resident 50's Minimum Data Set (MDS - an assessment tool), dated January 6, 2025, indicated Resident 50 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 13 (intact cognitive response). A review of the Social Service assessment dated [DATE] indicated, .Advance Directives .DPOA (Durable Power of Attorney) for healthcare .agent .(name of representative). There was no documented evidence a copy of the DPOA was placed in Resident 50's medical record or was there evidence the resident or resident representative (RP) was provided information about the right to formulate an AD. On March 13, 2025, at 12:50 p.m. a concurrent interview and record review were conducted with Social Services Assistant (SSA) 1. SSA 1 stated the social service assessment indicated Resident 50 had a DPOA and that an AD had been reviewed. SSA 1 stated if a resident had an AD and DPOA, copies should be obtained and placed in the resident's medical record. SSA 1 stated no follow up had been conducted to indicate whether Resident 50 had an AD or DPOA. SSA 1 further stated Resident 50's AD and DPOA should have been available and accessible to the staff and physician. 2. Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE]. A review of the Social Service assessment dated [DATE], indicated, an AD and POLST were marked as available. A review of Resident 9's Physician Orders for Life Sustaining Treatment (POLST), dated June 29, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 3 of 27 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 03/13/2025 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm 2024, indicated, .Advance Directive .available and reviewed .health care agent if named in advance directive .name .(name of representative) . There was no documented evidence in Resident 9's medical record that a copy of the AD was obtained and made accessible to staff and the physician. Residents Affected - Some On March 13, 2025, at 12:50 p.m. a concurrent interview and record review were conducted with Social Services Assistant (SSA) 1. SSA 1 stated a social service assessment was conducted for all residents upon admission and that the assessment should include notations indicating whether an AD was discussed. SSA 1 stated if a resident had an AD, a copy of the AD should be obtained and placed in the resident's medical record. SSA 1 stated Resident 9 was indicated to have had an AD but it was not available in the resident's record. SSA 1 further stated Resident 9's AD should have been available and accessible to both staff and the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 4 of 27 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 03/13/2025 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)

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 observation, interview, and record review, the facility failed to ensure an assessment was conducted for one of two residents reviewed for respiratory issue (Resident 30) when resident developed shortness of breath. Residents Affected - Few This failure had the potential to negatively impact Resident 30's physical, mental, psychosocial wellbeing. Findings: On March 10, 2025, at 3:17 p.m., during a concurrent observation and interview with Resident 30, Resident 30 stated, he could not breath adequately, while pointing to his nose. Resident 30's nasal bridge appeared to be deviated toward the left side and his speech had noticeable nasal twang. Resident 30 stated that he had been bothered by this issue for about a month and nothing had been done to address it. A review of Resident 30 's admission Record indicated Resident 30 was admitted [DATE], with the diagnoses which included chronic subdural hemorrhage (a collection of blood that accumulates between the brain and the dura mater [the outermost layer of the brain's protective covering] over an extended period) and nasal septal deviation (occurs when your nasal septum [the thin wall of cartilage and bone that separates the two nasal passages], is significantly displaced to one side, making one nasal air passage smaller than the other). Further review of Resident 30's progress notes indicated no documentation Resident 30 had been assessed for shortness of breath. On March 13, 2025, at 3:11p.m., a concurrent interview and record review were conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated when a change in condition is identified such as shortness of breath due to septal deviation, a care plan should have been initiated for nursing interventions. The MDSN stated, the licensed nurse did not initiate the care plan for Resident 30. On March 13, 2025, at 9:44 p.m., an interview was conducted with LVN 2. LVN 2 stated he was not aware that the resident had a nasal septal deviation or shortness of breath. LVN 2 stated the licensed nurse should have assessed the resident, updated the care plan, and documented Resident 30's change in condition. A review of the facility policy and procedure titled, Care Plan Revisions Upon Status Change, dated December 19, 2022, indicated .Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable; The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options; The team meeting discussion will be documented in the nursing progress notes; The care plan will be updated with the new or modified interventions; Staff involved in the care of the resident will report resident response to new or modified interventions; Care plans will be modified as needed by the MDS Coordinator or other designated staff member and The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 5 of 27 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 03/13/2025 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 post- (after) hemodialysis (removal of toxins and fluids from the blood through the use of a machine) assessment was completed on January 10, 2025, and January 27, 2025, for one of two residents reviewed for hemodialysis (Resident 20). Residents Affected - Few This failure had the potential for delayed detection and/or management of complications arising from hemodialysis treatments for Resident 20. Findings: A review of Resident 20's admission Record, indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD-inability of the kidney to make urine and remove waste from the blood). A review of Resident 20's Dialysis Communication Form, indicated the licensed nurse did not assessed Resident 20's weight post dialysis on the following dates: - January 10, 2025; and - January 27, 2025. On March 12, 2025, at 11:35 a.m., a concurrent interview and record review of Resident 20's Communication Log were conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the licensed nurse failed to weigh Resident 20 after dialysis on January 10, 2025, and on January 27, 2025. LVN 1 stated, Resident 20 could have experienced complications such as overload, and the licensed nurse was not aware due to missing assessments. On March 12, 2025, at 11:50 a.m., a concurrent interview and record review of Resident 20's Communication Log were conducted with Registered Nurse Supervisor (RNS) 1. RNS 1 stated when a resident's weight was not assessed, there was a potential risk for fluid overload. A review of the facility policy and procedure titled, Hemodialysis, dated June 5, 2023, indicated .This facility will assure that each resident receives care and services for the provision of hemodialysis .consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment .Ongoing assessment and oversight of the resident before during and after dialysis treatment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 6 of 27 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 03/13/2025 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)

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 medically-related social service referrals were obtained for two of 21 sampled residents (Residents 26 and 30) when: Residents Affected - Few 1. A referral for CT scan (computerized tomography - procedure that uses a combinations of X-rays and computer technology to create detailed cross-sectional images of the body) of the abdomen for gross hematuria (bloody urination) was not obtained for Resident 26. This failure had the potential to delay the identification of underlying causes of gross hematuria for Resident 26; and 2. A referral for ENT (Ear, Nose, and Throat) evaluation for shortness of breath secondary to deviated nasal septum (occurs when your nasal septum [the thin wall of cartilage and bone that separates the two nasal passages], is significantly displaced to one side, making one nasal air passage smaller than the other) was not obtained for Resident 30 . This failure had the potential to result in unresolved symptoms of shortness of breath for Resident 30. Findings: 1. On March 10, 2025, at 9:48 a.m., an interview was conducted with Resident 26. Resident 26 stated she had a stroke in August and was on blood thinner due to DVT (deep vein thrombosis - a condition that occurs when a blood clot forms in a vein deep inside a part of the body). She further stated her urine was bloody two weeks ago. A review of Resident 26 's admission Record indicated Resident 26 was admitted [DATE], with the diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis ( weakness of one side of the body) following cerebral infarction (blockage of blood vessels in the brain by a clot (thrombus). A review of Resident 26's physician order dated February 17, 2025, indicated, .needs to schedule ct scan of abdomen, pelvis with contrast . A review of Resident 26's Social Service Progress Note, dated March 6, 2025, indicated a follow-up call was made to the imaging center. The notes also stated that the authorization received included an incorrect location address. A further review of Resident 26's progress notes indicated there was no documentation that a follow-up was made regarding the CT scan referral. On March 12, 2025, at 12:29 p.m., a concurrent interview and record review of Resident 26's Social Service Progress Note, were conducted with Social Service Assistant (SSA) 1. SSA1 stated there was no documented evidence that the incorrect address issue had been addressed prior to that time. SSA 1 stated there should have been a follow up call to the source of the authorization in order to correct the imaging center's address. SSA 1 further stated, Resident 26's referral for a CT scan of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 7 of 27 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 03/13/2025 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)

F 0745 abdomen had not been completed. Level of Harm - Minimal harm or potential for actual harm 2. On March 10, 2025, at 3:17 p.m., during a concurrent observation and interview with Resident 30, Resident 30 stated, he could not breath adequately, while pointing to his nose. Resident 30's nasal bridge appeared to be deviated toward the left side and his speech had noticeable nasal twang. Resident 30 stated that he had been bothered by this issue for about a month and nothing had been done to address it. Residents Affected - Few A review of Resident 30 's admission Record indicated Resident 30 was admitted [DATE], with the diagnoses which included chronic subdural hemorrhage (a collection of blood that accumulates between the brain and the dura mater [the outermost layer of the brain's protective covering] over an extended period) and nasal septal deviation (occurs when your nasal septum [the thin wall of cartilage and bone that separates the two nasal passages], is significantly displaced to one side, making one nasal air passage smaller than the other). A review of Resident 30's physician order dated February 26, 2025, indicated, ENT evaluation for SOB (shortness of breath) secondary to deviated nasal septum. A further review of Resident 30's medical record indicated there was no documentation that a referral to an ENT specialist had been made. On March 12, 2025, at 12:12 p.m., a concurrent interview and record review were conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she was not aware of any physician's order for a referral to an ENT specialist for Resident 30. LVN 1 stated if there was an order, it should have been followed up. On March 12, 2025, at 12:29 p.m., a concurrent interview and record review was conducted with Social Service Assistant (SSA) 1. SSA 1 stated, the primary role of the Social Service (SS) department was to assist in maintaining the highest practicable level of wellbeing for every resident. SSA 1 stated, this included identifying the need for medically related social services and ensuring that such services were provided in a timely manner. SSA 1 stated that the SS would be notified of physician referral through the facility's communication portal and via printed copies of referral requests placed in a designated social services basket outside her office. SSA 1 stated that they did not receive the ENT referral order for Resident 30 until March 12, 2025. SSA 1 further stated, if the order had been dated February 26, 2025, Social Service department should have been notified immediately, and Resident 30 should have been referred to ENT as soon as the referral was received. A review of the facility policy and procedure titled, Social Services Director, Job Description, dated 2023, indicated .The Social Service Director is responsible for overseeing the development, implementation of the ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintaining their highest practicable well-being. This includes identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 8 of 27 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 03/13/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when Residents 54 and 182 were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medications were signed out of the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 54. These failures resulted in inaccurate accountability of CS medications, which had the potential for misuse or diversion. Findings: During an interview on March 11, 2025 at 10:05 a.m. with the Director of Nursing (DON), the DON stated the facility's process for CS medication administration and wasting was as follows: - Nursing staff should have assessed the resident's pain to verify the quality and location; - Offered non-pharmacologic intervention (NPI) and if NPI ineffective nurse should have given the CS pain medication; - During administration, nurse should have removed the CS pain medication from the cart and signed the count sheet and documented on the administration on the resident's MAR; - If CS pain medication was not given, nursing staff should have wasted with another nurse; and - If wasted, nursing staff should have documented in a progress note as not given and documented on the count sheet as wasted with another nurse that witnessed the waste. Resident 54 had a physician's order, dated December 29, 2024, for Ativan (lorazepam, a potent controlled medication for anxiety) 1 mg (milligram, unit of measurement), 1 tablet by mouth every 6 hours as needed for anxiety m/b (manifested by) fidgety in bed. During a concurrent interview and record review on March 11, 2025 at 11:57 a.m. with LVN 3, a review of Resident 54's Count Sheet for Ativan 1 mg tablet and MAR dated February 2025 indicated the nursing staff signed out one tablet on February 26, 2025 at 6 a.m. but did not document the administration on the MAR. LVN 3 stated facility's process for CS medication administration required nursing staff to have documented the administration on Resident 54's MAR and the Count Sheet. LVN 3 acknowledged one Ativan 1 mg tablet for Resident 54 was unaccounted in February 2025. Additionally, Resident 54's Count Sheet for Ativan 1 mg indicated one tablet was wasted on March 6, 2025 and did not have a second nurse witness documented on the Count Sheet. LVN 3 stated the nurse should have had another nurse sign on the Count Sheet as a witness for Resident 54's wasted Ativan 1mg tablet on March 6, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 9 of 27 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 03/13/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 182 had a physician's order, dated March 1, 2025, for hydrocodone-acetaminophen (a potent controlled medication for pain) 5/325 mg, 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. A review of Resident 182's Count Sheet for hydrocodone-acetaminophen 5/325 mg tablet and MAR dated March 2025 indicated the nursing staff signed out one tablet on March 6, 2025 at 15:28 (3:28 p.m.) but did not document the administration on the MAR. During a concurrent interview and record review on March 13, 2025 at 1:28 p.m. with the DON, Resident 54's Count Sheet for Ativan 1 mg tablet and MAR dated February 2025; and Resident 182's Count Sheet for hydrocodone-acetaminophen 5/325 mg tablet and MAR dated March 2025 were reviewed. The DON acknowledged Resident 54 had one Ativan 1 mg tablet unaccounted in February 2025 and one Ativan 1 mg tablet wasted on March 6, 2025 without two nurse signatures on the Count sheet. Additionally, the DON acknowledged Resident 182 had one hydrocodone-acetaminophen 5/325 mg tablet unaccounted in March 2025. The DON stated it was important to have accurate CS accountability and documentation because these were controlled medications, and it could have led to diversion. A review of the facility's policy and procedures (P&P) titled, Medication Administration, dated December 19, 2022, indicated, Sign MAR after administered .If medication is a controlled substance, sign narcotic book. A review of the facility's P&P titled, Controlled Substance Administration & Accountability, dated June 5, 2023, indicated, In call cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified from and placed in the patient's medical record .The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration .The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy .Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 10 of 27 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 03/13/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of five sampled residents (Resident 1). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident. Findings: During a review of Resident 1's admission Record, dated March 13, 2025, the admission Record indicated, Resident 1 was elderly, initially admitted to the facility on [DATE], and was admitted again on December 23, 2024. Resident 1's diagnoses included metabolic encephalopathy (brain function changes that can cause confusion, memory loss and loss of consciousness), fracture (break) of left femur (long bone extending from hip to knee), difficulty walking, schizoaffective disorder (mental health condition with symptoms such as hallucinations and mood changes), anxiety, depression, right eye blindness, and left eye low vision (difficulty seeing). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated June 27, 2023, and December 28, 2024, indicated the resident had no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had no fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's current MDS dated [DATE], indicated the resident had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 12 - (moderate cognitive impairment), no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had a fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's Order Summary Report, dated March 12, 2025, indicated the following provider orders: - Oxycodone-acetaminophen (a potent controlled medication for pain, which has sedating effects) 10/325 milligram (mg, unit of measurement) every 6 hours as needed for moderate pain (4-6) to severe pain (7-10), started on December 23, 2024; - Quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia, which has sedating effects) 50 mg one time a day for schizo effective d/o (disorder) m/b (manifested by) auditory/visual hallucinations, started on December 23, 2024; - Trazodone (used to treat depression and anxiety, which has sedating effects) 100mg at bedtime for depression m/b inability to sleep, started on December 27, 2024; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 11 of 27 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 03/13/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Gabapentin (used to treat seizures and pain, which has sedating effects) 300 mg two times a day for neuropathy (nerve damage causing numbness), started on January 12, 2025. A review of Resident 1's clinical record indicated, on January 30, 2025, the provider ordered a new medication, Remeron (a hypnotic medication used to treat insomnia, which has sedating effects) 15 mg at bedtime for depression m/b poor PO (oral) intake less than 50 percent (%, unit of measurement). On January 31, 2025, Resident 1 sustained a fall during an Orthopedic (the medical specialty that focuses on injuries to bone, joints, muscles) office visit outside of the facility. A review of the Orthopedic provider's progress notes dated January 31, 2025 at 9 a.m., indicated, .patient took a backward slow tumble while attempting to ambulate (walk) . A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Remeron tablets, dated December 2011, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration) indicated, Because of the potentially significant effects of Remeron on impairment of performance, patients should be cautioned about engaging in activities requiring alertness .Sedating drugs may cause confusion and over-sedation in the elderly .Caution is indicated in administering Remeron to elderly patients . A review of Resident 1's change of condition progress notes, dated January 31, 2025 at 2 p.m., indicated, Ortho (orthopedic) doc (doctor) told patient to walk .Patient to have proper assistive device and assist for any mobility .continue to monitor. A review of Resident 1's clinical record indicated, on February 7, 2025, the provider ordered a new medication, Ativan (a type of benzodiazepine used to treat anxiety, which has sedating effects) 0.5 mg three times a day for anxiety, m/b verbalization of feeling anxious. A review of Resident 1's Progress Notes - Psychiatry, dated February 18, 2025, indicated, .discontinuing Seroquel (quetiapine) 50 mg daily due to ineffectiveness .Initiating Depakote (used to treat seizures and psychiatric conditions, which has sedating effects) 125 mg BID (twice a day) for mood stabilization .continue Trazodone 100 mg bedtime for sleep maintenance .continue Remeron 15mg qhs (bedtime) for depressive symptoms and poor appetite . A review of Resident 1's clinical record indicated, on February 19, 2025, the provider ordered a new medication, Depakote Delayed Release (Divalproex Sodium) 125 mg tablet, one (1) tablet two times a day for Mood affective disorder m/b poor impulse control yelling. Two weeks later, on March 5, 2025, the provider increased the dose of Depakote Delayed Release (Divalproex Sodium) 125 mg tablet to two (2) tablets two times a day for Mood affective disorder m/b poor impulse control yelling. A review of Resident 1's Interdisciplinary Care Conference -Behavior and Psychotropic Medication Management, dated March 7, 2025 at 2:42 p.m., indicated, continue all current medications, no changes, continue plan of care . On March 8, 2025, Resident 1 sustained a second fall. A review of A review of Resident 1's change of condition progress notes, dated March 8, 2025 at 4:58 p.m., indicated, s/p (status post, after an event) Fall hit his head c/o (complained of) severe pain .patient observed lying on the floor reassessed patient, stated, He got out from his bed from sleep, went to get his wheel chair, lost his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 12 of 27 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 03/13/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few balance and fell on the ground, able to move all his extremities, however he complained of severe pain, Patient was medicated with Oxycodone 10 mg as ordered. [Doctor] was notified with orders; Transfer to [hospital] for further evaluation and treatment . Further review of the PI for Remeron tablets, dated December 2011, retrieved from DailyMed, indicated, .impairment of motor skills produced by Remeron has been shown to be additive with those caused by diazepam (a type of benzodiazepine like Ativan, used to treat anxiety, which has sedating effects). Accordingly, patients should be advised to avoid diazepam and other similar drugs while taking Remeron . A review of PI for Ativan (lorazepam) tablets, dated May 2023, retrieved from DailyMed, indicated, Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam .Drug Interactions: The benzodiazepines, including lorazepam, produce increased CNS (Central Nervous System)-depressant effects when administered with other CNS depressants such as .antipsychotics, sedative/hypnotics, anxiolytics, antidepressants, narcotic analgesics (pain medications), anticonvulsants (medications to treat seizures) .Concurrent administration of lorazepam with valproate (Depakote) results in increased plasma concentrations (drug levels) and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50% when co-administered with valproate .Geriatric Use .the incidence of sedation and unsteadiness was observed to increase with age . A review of PI for Depakote delayed-release (divalproex sodium) tablets, dated January 2025, retrieved from DailyMed, indicated, Divalproex sodium is .comprised of sodium valproate and valproic acid .Somnolence (drowsiness) in the elderly can occur .Depakote dosage should be increased slowly and with regular monitoring for fluid and nutritional intake .Co-administration of valproate can affect the pharmacokinetics (how the body interacts with administered medications) of other drugs (e.g. [example] diazepam .) by inhibiting their metabolism (when your body processes/breaks-down medications) . During an interview on March 12, 2025 at 11:53 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she cared the for Resident 1 for approximately two (2) months. LVN 5 stated Resident 1 was at risk for falls, needed assistance to walk, and needed to be monitored to ensure he would not get up unassisted. During an interview on March 12, 2025 at 11:59 a.m. with the Certified Nursing Assistant (CNA), the CNA stated she had witnessed Resident 1 get out of bed and crawl on his knees one time. The CNA stated she had not witnessed Resident 1 fall. The CNA stated she was aware the resident fell before and had seen his bruises. During an interview on March 12, 2025 at 12:08 p.m. with LVN 3, LVN 3 stated Resident 1 was able to stand on his own and if he was told not to stand due to the fall risk he would stand up and walk outside the door. LVN 3 stated Resident 1 was not combative and mildly confused. During an interview March 12, 2025 at 12:38 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she was not aware of Resident 1's falls on January 31, 2025 or March 8, 2025. The ADON acknowledged the resident was at risk for falls and stated he needed assistance to walk. The ADON stated the pharmacist medication regiment review (MRR) process involved a monthly review of all the medications and additional MRRs could have been requested after a fall (or other event). The ADON stated the nursing staff would have needed to fax a form to the pharmacy to request another medication review to see if medications could have caused the fall (or other event). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 13 of 27 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 03/13/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on March 12, 2025 at 1:20 p.m. with the Director of Nursing (DON), regarding Resident 1's fall on January 31, 2025, the DON stated the fall occurred outside of the facility during an office visit that was witnessed by the Orthopedic doctor. The DON acknowledged the resident was taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. When asked whether the facility asked the pharmacist to review Resident 1's medication regimen to see if the fall could have been attributed to the medications, the DON stated a medication review was not requested. The DON said, We don't think the medications affected the fall. The DON stated Resident 1 fell because he was asked to stand and walk. Regarding Resident 1's second fall on December 8, 2025, the DON stated the resident was taken to the hospital. The DON acknowledged the resident's medications had potential side effects and drug interactions. During an interview on March 12, 2025 at 1:45 p.m. with the DON, regarding the facility's process for requesting additional MRR besides the monthly review, DON stated an additional MRR could have been requested to review medications after a fall or event if it was suspected during an assessment that the resident had experienced lethargy or side effects. During a telephone interview on March 12, 2025 at 2:03 p.m. with the Medical Director (MD), the MD stated he was directly involved in Resident 1's care. The MD stated all psychotropic medications were managed by the Psychiatrist and the Psychiatry Nurse Practitioner (NP); and they updated him when changes were made to Resident 1's psychotropic medications. Regarding Resident 1's recent falls, the MD stated he was aware Resident 1 was currently hospitalized due to a fall on March 8, 2025 and he was aware of the previous fall on January 31, 2025. The MD reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The MD acknowledged the combination of medications could have had the potential for additive sedation. When asked if a pharmacist should have reviewed Resident 1's medications after the fall on January 31, 2025, the MD stated the pharmacist should have reviewed the medications. MD stated there was no documentation in Resident 1's medical record that a pharmacist was contacted for a medication review after Resident 1 fell on January 31, 2025 and stated the facility should have requested a medication review. During a telephone interview on March 13, 2025 at 9:03 a.m. with the Consultant Pharmacist (CP), the CP stated during the monthly Medication Regimen Review (MRR), all medications for all residents were reviewed for appropriateness (timing, with or without food, parameters, monitoring), potential adverse effects, and potential drug-drug interactions. The CP stated he was not informed by the facility when Resident 1 fell on January 31, 2025. The CP stated he was unaware Resident 1 had another fall on March 8, 2025. The CP reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. Regarding the facility's process for requesting additional MRR besides the monthly review, the CP stated the facility could have requested an Intermediate Medication Regimen Review (IMRR) when changes in conditions (COC) such as falls occurred. The CP stated the facility would have faxed the IMRR Form to the pharmacy to request the medication review. The CP stated the facility did not request an IMRR after Resident 1 fell on January 31, 2025. When asked whether he identified in the monthly MRR in December 2024, January 2025, or February 2025, regarding the potential for Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin to contribute to the resident's fall and made recommendation for changes, the CP stated he did not make any recommendations. The CP stated if he was informed that Resident 1 fell on January 31, 2025, he would have recommended additional monitoring for increased risk of falls, dizziness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 14 of 27 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 03/13/2025 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)

F 0756 and sedation when the medications were taken together. Level of Harm - Minimal harm or potential for actual harm A review of the CP's monthly MRRs for Resident 1, in December 2024, January 2025, and February 2025, indicated there were no recommendations from the CP for consideration of changes to Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and/or gabapentin, as they could have contributed to the resident's falls. Residents Affected - Few During a telephone interview on March 13, 2025 at 9:41 a.m. with the Psychiatry Nurse Practitioner (NP), the NP stated he was Resident 1's mental health primary provider and worked with the Psychiatrist to manage Resident 1's psychotropic medications. The NP stated he recently saw Resident 1 on February 18, 2025 and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The NP stated he was informed that Resident 1 had a fall on January 31, 2025 but had not been informed Resident 1 sustained another fall on March 8, 2025. During a follow-up interview on March 13, 2025 at 1:41 p.m. with the DON, the DON acknowledged the CP was not notified after Resident 1 had a fall on January 31, 2025 and the facility did not request an IMRR. The DON acknowledged the pharmacist's MRRs in December 2024, January 2025, and February 2025 did not identify the combination of medications having the potential to increase the risk of sedations/falls or recommend dose adjustments or further evaluation of the above medications. A review of the facility's policy and procedures (P&P) titled, Use of Psychotropic Medications, dated December 19, 2022, indicated, The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to .during the pharmacist's monthly medication regimen review .during significant change .The resident's response to the medication (s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . A review of the facility's P&P titled, Medication Regimen Review, dated December 19, 2022, indicated, .The MRR includes .Review of the medical record in order to prevent, identify, report, and resolve medication-related problems .or other irregularities .For residents experiencing a change in condition and the nurse deems a MRR is necessary outside the routine visit, the facility will notify the pharmacy provider . A review of the facility's document titled, IMRR offsite medication review, (undated) indicated a form to be filled out by the facility to request via fax, .MRR requested for Change of condition .Falls, dizziness, or evidence of impaired coordination . A review of PI for Trazodone tablets, dated February 2024, retrieved from DailyMed, indicated, Warnings and precautions .Potential for Cognitive and Motor Impairment .adverse reactions .blurred vision, syncope (dizziness), drowsiness, fatigue .drug interactions .CNS Depressants: Trazodone .may enhance effects of .other CNS depressants . A review of PI for quetiapine (Seroquel) tablets, dated January 2025, retrieved from DailyMed, indicated, Most common adverse reactions .somnolence, dizziness . A review of PI for Gabapentin tablets, dated August 2023, retrieved from DailyMed, indicated, Warnings .Somnolence/Sedation and Dizziness .adverse reactions .Somnolence, dizziness, fatigue .drug interactions .Respiratory depression and sedation, sometimes resulting in death, have been reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 15 of 27 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 03/13/2025 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)

F 0756 following coadministration of gabapentin with opioids (e.g. [example] .oxycodone .) Level of Harm - Minimal harm or potential for actual harm A review of PI for Oxycodone/acetaminophen tablets, dated January 2024, retrieved from DailyMed, indicated, Risks from concomitant use with Benzodiazepines or other CNS depressants profound sedation, respiratory depression, coma, and death may result from the concomitant use of oxycodone and acetaminophen tablets with benzodiazepines and/or other CNS depressants, including .non-benzodiazepine sedatives/hypnotics, anxiolytics .antipsychotics .Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 16 of 27 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 03/13/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered a combination of psychotropic medications with sedating effects, sustained a fall, continued to receive additional sedating psychotropic medications without consideration of the potential additive sedative effects, and sustained a second fall. This failure resulted in unnecessary medications for Resident 1 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to falls, sedation, cognitive (the mental processes involved in thinking, learning, understanding, and remembering) impairment, blurred vision, and respiratory depression. Finding: During a review of Resident 1's admission Record, dated March 13, 2025, the admission Record indicated, Resident 1 was elderly, initially admitted to the facility on [DATE], and was admitted again on December 23, 2024. Resident 1's diagnoses included metabolic encephalopathy (brain function changes that can cause confusion, memory loss and loss of consciousness), fracture (break) of left femur (long bone extending from hip to knee), difficulty walking, schizoaffective disorder (mental health condition with symptoms such as hallucinations and mood changes), anxiety, depression, right eye blindness, and left eye low vision (difficulty seeing). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated June 27, 2023, and December 28, 2024, indicated the resident had no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had no fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's current MDS dated [DATE], indicated the resident had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 12 - (moderate cognitive impairment), no exhibition of hallucinations/delusions and no physical/verbal behavioral symptoms, had a fall history, had active psychiatric/mood disorder diagnoses, and had received antipsychotic/antidepressant medications. A review of Resident 1's Order Summary Report, dated March 12, 2025, indicated the following provider orders: - Oxycodone-acetaminophen (a potent controlled medication for pain, which has sedating effects) 10/325 milligram (mg, unit of measurement) every 6 hours as needed for moderate pain (4-6) to severe pain (7-10), started on December 23, 2024; - Quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia, which has sedating effects) 50 mg one time a day for schizo effective d/o (disorder) m/b (manifested by) auditory/visual hallucinations, started on December 23, 2024; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 17 of 27 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 03/13/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm - Trazodone (used to treat depression and anxiety, which has sedating effects) 100mg at bedtime for depression m/b inability to sleep, started on December 27, 2024; and - Gabapentin (used to treat seizures and pain, which has sedating effects) 300 mg two times a day for neuropathy (nerve damage causing numbness), started on January 12, 2025. Residents Affected - Some A review of Resident 1's clinical record indicated, on January 30, 2025, the provider ordered a new medication, Remeron (a hypnotic medication used to treat insomnia, which has sedating effects) 15 mg at bedtime for depression m/b poor PO (oral) intake less than 50 percent (%, unit of measurement). On January 31, 2025, Resident 1 sustained a fall during an Orthopedic (the medical specialty that focuses on injuries to bone, joints, muscles) office visit outside of the facility. A review of the Orthopedic provider's progress notes dated January 31, 2025 at 9 a.m., indicated, .patient took a backward slow tumble while attempting to ambulate (walk) . A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Remeron tablets, dated December 2011, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration) indicated, Because of the potentially significant effects of Remeron on impairment of performance, patients should be cautioned about engaging in activities requiring alertness .Sedating drugs may cause confusion and over-sedation in the elderly .Caution is indicated in administering Remeron to elderly patients . A review of Resident 1's change of condition progress notes, dated January 31, 2025 at 2 p.m., indicated, Ortho (orthopedic) doc (doctor) told patient to walk .Patient to have proper assistive device and assist for any mobility .continue to monitor. A review of Resident 1's clinical record indicated, on February 7, 2025, the provider ordered a new medication, Ativan (a type of benzodiazepine used to treat anxiety, which has sedating effects) 0.5 mg three times a day for anxiety, m/b verbalization of feeling anxious. A review of Resident 1's Progress Notes - Psychiatry, dated February 18, 2025, indicated, .discontinuing Seroquel (quetiapine) 50 mg daily due to ineffectiveness .Initiating Depakote (used to treat seizures and psychiatric conditions, which has sedating effects) 125 mg BID (twice a day) for mood stabilization .continue Trazodone 100 mg bedtime for sleep maintenance .continue Remeron 15mg qhs (bedtime) for depressive symptoms and poor appetite . A review of Resident 1's clinical record indicated, on February 19, 2025, the provider ordered a new medication, Depakote Delayed Release (Divalproex Sodium) 125 mg tablet, one (1) tablet two times a day for Mood affective disorder m/b poor impulse control yelling. Two weeks later, on March 5, 2025, the provider increased the dose of Depakote Delayed Release (Divalproex Sodium) 125 mg tablet to two (2) tablets two times a day for Mood affective disorder m/b poor impulse control yelling. A review of Resident 1's Interdisciplinary Care Conference -Behavior and Psychotropic Medication Management, dated March 7, 2025 at 2:42 p.m., indicated, continue all current medications, no changes, continue plan of care . On March 8, 2025, Resident 1 sustained a second fall. A review of A review of Resident 1's change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 18 of 27 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 03/13/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of condition progress notes, dated March 8, 2025 at 4:58 p.m., indicated, s/p (status post, after an event) Fall - hit his head c/o (complained of) severe pain .patient observed lying on the floor reassessed patient, stated, He got out from his bed from sleep, went to get his wheel chair, lost his balance and fell on the ground, able to move all his extremities, however he complained of severe pain, Patient was medicated with Oxycodone 10 mg as ordered. [Doctor] was notified with orders; Transfer to [hospital] for further evaluation and treatment . Further review of the PI for Remeron tablets, dated December 2011, retrieved from DailyMed, indicated, .impairment of motor skills produced by Remeron has been shown to be additive with those caused by diazepam (a type of benzodiazepine like Ativan, used to treat anxiety, which has sedating effects). Accordingly, patients should be advised to avoid diazepam and other similar drugs while taking Remeron . A review of PI for Ativan (lorazepam) tablets, dated May 2023, retrieved from DailyMed, indicated, Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam .Drug Interactions: The benzodiazepines, including lorazepam, produce increased CNS (Central Nervous System)-depressant effects when administered with other CNS depressants such as .antipsychotics, sedative/hypnotics, anxiolytics, antidepressants, narcotic analgesics (pain medications), anticonvulsants (medications to treat seizures) .Concurrent administration of lorazepam with valproate (Depakote) results in increased plasma concentrations (drug levels) and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50% when co-administered with valproate .Geriatric Use .the incidence of sedation and unsteadiness was observed to increase with age . A review of PI for Depakote delayed-release (divalproex sodium) tablets, dated January 2025, retrieved from DailyMed, indicated, Divalproex sodium is .comprised of sodium valproate and valproic acid .Somnolence (drowsiness) in the elderly can occur .Depakote dosage should be increased slowly and with regular monitoring for fluid and nutritional intake .Co-administration of valproate can affect the pharmacokinetics (how the body interacts with administered medications) of other drugs (e.g. [example] diazepam .) by inhibiting their metabolism (when your body processes/breaks-down medications) . During an interview on March 12, 2025 at 11:53 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she cared the for Resident 1 for approximately two (2) months. LVN 5 stated Resident 1 was at risk for falls, needed assistance to walk, and needed to be monitored to ensure he would not get up unassisted. During an interview on March 12, 2025 at 11:59 a.m. with the Certified Nursing Assistant (CNA), the CNA stated she had witnessed Resident 1 get out of bed and crawl on his knees one time. The CNA stated she had not witnessed Resident 1 fall. The CNA stated she was aware the resident fell before and had seen his bruises. During an interview on March 12, 2025 at 12:08 p.m. with LVN 3, LVN 3 stated Resident 1 was able to stand on his own and if he was told not to stand due to the fall risk he would stand up and walk outside the door. LVN 3 stated Resident 1 was not combative and mildly confused. During an interview March 12, 2025 at 12:38 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she was not aware of Resident 1's falls on January 31, 2025 or March 8, 2025. The ADON acknowledged the resident was at risk for falls and stated he needed assistance to walk. During an interview on March 12, 2025 at 1:20 p.m. with the Director of Nursing (DON), regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 19 of 27 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 03/13/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1's fall on January 31, 2025, the DON stated the fall occurred outside of the facility during an office visit that was witnessed by the Orthopedic doctor. The DON acknowledged the resident was taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. When asked whether the facility asked the pharmacist to review Resident 1's medication regimen to see if the fall could have been attributed to the medications, the DON stated a medication review was not requested. The DON said, We don't think the medications affected the fall. The DON stated Resident 1 fell because he was asked to stand and walk. Regarding Resident 1's second fall on December 8, 2025, the DON stated the resident was taken to the hospital. The DON acknowledged the resident's medications had potential side effects and drug interactions. During a telephone interview on March 12, 2025 at 2:03 p.m. with the Medical Director (MD), the MD stated he was directly involved in Resident 1's care. The MD stated all psychotropic medications were managed by the Psychiatrist and the Psychiatry Nurse Practitioner (NP); and they updated him when changes were made to Resident 1's psychotropic medications. Regarding Resident 1's recent falls, the MD stated he was aware Resident 1 was currently hospitalized due to a fall on March 8, 2025 and he was aware of the previous fall on January 31, 2025. The MD reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The MD acknowledged the combination of medications could have had the potential for additive sedation. When asked if a pharmacist should have reviewed Resident 1's medications after the fall on January 31, 2025, the MD stated the pharmacist should have reviewed the medications. During a telephone interview on March 13, 2025 at 9:03 a.m. with the Consultant Pharmacist (CP), the CP stated during the monthly Medication Regimen Review (MRR), all medications for all residents were reviewed for appropriateness (timing, with or without food, parameters, monitoring), potential adverse effects, and potential drug-drug interactions. The CP stated he was not informed by the facility when Resident 1 fell on January 31, 2025. The CP stated he was unaware Resident 1 had another fall on March 8, 2025. The CP reviewed Resident 1's current medications and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The CP stated if he was informed that Resident 1 fell on January 31, 2025, he would have recommended additional monitoring for increased risk of falls, dizziness and sedation when the medications were taken together. During a telephone interview on March 13, 2025 at 9:41 a.m. with the Psychiatry Nurse Practitioner (NP), the NP stated he was Resident 1's mental health primary provider and worked with the Psychiatrist to manage Resident 1's psychotropic medications. The NP stated he recently saw Resident 1 on February 18, 2025 and acknowledged the resident was currently taking a combination of potentially sedating medications including Remeron, Ativan, Depakote, oxycodone-acetaminophen, trazodone, and gabapentin. The NP stated he was informed that Resident 1 had a fall on January 31, 2025 but had not been informed Resident 1 sustained another fall on March 8, 2025. A review of the facility's policy and procedures (P&P) titled, Use of Psychotropic Medications, dated December 19, 2022, indicated, The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to .during the pharmacist's monthly medication regimen review .during significant change .The resident's response to the medication (s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 20 of 27 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 03/13/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of PI for Trazodone tablets, dated February 2024, retrieved from DailyMed, indicated, Warnings and precautions .Potential for Cognitive and Motor Impairment .adverse reactions .blurred vision, syncope (dizziness), drowsiness, fatigue .drug interactions .CNS Depressants: Trazodone .may enhance effects of .other CNS depressants . A review of PI for quetiapine (Seroquel) tablets, dated January 2025, retrieved from DailyMed, indicated, Most common adverse reactions .somnolence, dizziness . A review of PI for Gabapentin tablets, dated August 2023, retrieved from DailyMed, indicated, Warnings .Somnolence/Sedation and Dizziness .adverse reactions .Somnolence, dizziness, fatigue .drug interactions .Respiratory depression and sedation, sometimes resulting in death, have been reported following coadministration of gabapentin with opioids (e.g. [example] .oxycodone .) A review of PI for Oxycodone/acetaminophen tablets, dated January 2024, retrieved from DailyMed, indicated, Risks from concomitant (combined) use with Benzodiazepines or other CNS depressants profound sedation, respiratory depression, coma, and death may result from the concomitant use of oxycodone and acetaminophen tablets with benzodiazepines and/or other CNS depressants, including .non-benzodiazepine sedatives/hypnotics, anxiolytics .antipsychotics .Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 21 of 27 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 03/13/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure proper medication storage when one refrigerated injectable medication vial was identified stored unrefrigerated not according to manufacturer's specifications. This failure had a potential for residents to receive medications that were inadequately monitored with unsafe and reduced effectiveness, which could lead to unsafe and ineffective medications for the residents. Finding: An inspection of the 300 Hall Medication Cart on March 11, 2025 at 11:26 a.m. in the Nursing Station with Licensed Vocational Nurse (LVN) 6 identified one unrefrigerated, opened and used multi-dose vial (MDV) of Tuberculin PPD (test agent used in the diagnosis of tuberculosis) 5 TU (test unit) per 0.1 ml (milliliter; unit of measurement) in the top drawer of the medication cart. LVN 6 was unable to demonstrate how long the PPD vial was stored unrefrigerated inside the medication cart. LVN 6 said, It [The PPD vial] should be refrigerated. LVN 6 acknowledged the PPD vial should not have been stored inside the medication cart and said, I will discard it [the PPD vial]. A review of the PPD vial manufacturer's instructions dated March 2016, provided by the Director of Nursing (DON) on March 11, 2025 at 2:21 p.m., indicated, This product should be stored between 2° and 8°C [degrees Celsius, unit of measurement for temperature] (36° and 46°F [degrees Fahrenheit, unit of measurement for temperature]). During a concurrent interview and record review on March 11, 2025 at 4:59 p.m. with the DON, the PPD vial manufacturer's instructions were reviewed. The DON acknowledged the PPD vial's manufacturer instructions indicated the PPD vial should have been refrigerated and stated the expectation was for the PPD vial to have been stored in the refrigerator, not inside the medication cart. A review of the facility's policy and procedures (P&P) titled, Medication Storage, dated December 19, 2022, indicated, Refrigerated Products .All medications requiring refrigeration are stored in refrigerators . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 22 of 27 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 03/13/2025 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)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a recommended diet for Resident 51 after a change in health status. This failure had the potential for Resident 51 to have uncontrolled blood sugar levels and complications from type 2 diabetes mellitus (abnormal high sugar). Findings: Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus and hospice services (specialized end-of-life care). A review of Resident 51's Interdisciplinary Care Conference, dated December 5, 2024, indicated .Resident discharged from Hospice services and will remain in long term care . A review of Resident 51's Minimum Data Set (an assessment tool), dated July 16, 2024, indicated, Resident 51 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15, cognitively intact. A review of Resident 51's Care Plan, initiated on July 16, 2024, indicated, .The resident has Diabetes Mellitus .The resident will have no complications related to diabetes .Interventions .Dietary consult for nutritional regimen and ongoing monitoring . A review of Resident 51's Physician's Orders, dated July 3, 2024, indicated the order for a regular diet (foods with moderate levels of salt, fat and sugar). On March 11, 2025, at 1:50 p.m., an interview was conducted with Resident 51. Resident 51 stated he would like his meals to have less carbohydrates, such as bread, potatoes, and rice. Resident 51 stated he had diabetes, and his blood sugar levels have been fluctuating. On March 11, 2025, at 3:43 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated Resident 51 was admitted under hospice services but was removed from hospice on December 5, 2024, after his condition improved. LVN 3 stated, the resident was diabetic, on a regular diet, and had a recent Hgb A1c (average blood sugar over the past two to three months) of 8.8% (normal value 3.6 to 6). LVN 3 stated there was no documentation that the resident's diet was reviewed or clarified with the physician. LVN 3 stated Resident 51 should have been placed on a controlled carbohydrate (CCHO) diet to manage his diabetes. On March 12, 2025, at 8:55 a.m., a concurrent interview and record review was conducted with the Minimum Data Set Nurse (MDSN). The MDSN stated a significant change assessment was completed for Resident 51 on December 5, 2024, when hospice services ended. The MDSN further stated nursing or dietary staff should have notified the physician to clarify the resident's diet after the change in status. On March 12, 2025, at 11:15 a.m., a concurrent interview and record review were conducted with the Registered Dietitian (RD). The RD stated Resident 51, a diabetic, had a regular diet order. The RD stated during his last quarterly review on March 7, 2025, the resident remained on a regular diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 23 of 27 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 03/13/2025 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)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The RD stated Resident 51 had an Hgb A1c of 8.8% and fluctuating blood sugar levels. The RD stated, he should have consulted with the physician and recommended a controlled carbohydrate diet to help manage the resident's blood sugar and prevent complications from diabetes. A review of the facility's policy and procedure titled Therapeutic Diet Orders, dated December 2022, indicated, .the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care .therapeutic diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition .each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies .dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed . A review of the facility's policy and procedure titled Notification of Changes, dated September 2022, indicated, .the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification .significant change in the resident's physical, mental or psychosocial condition .discontinuation of current treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 24 of 27 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 03/13/2025 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)

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 practices were implemented when: Residents Affected - Some 1. For Residents 36 and 57, nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs, stethoscopes, and glucometers (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) according to the disposable Sani-Cloth Prime disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). 2. For Resident 18, the neurotherapy treatment nurse (healthcare provider who examines brain activity and function) did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) when providing therapy to Resident 18 on enhanced barrier precaution (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRObacteria that have become resistant to multiple antibiotics). These failures had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections. Findings: 1. During a medication pass observation on March 10, 2025 at 9:15 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed using a shared manual BP cuff and stethoscope to measure Resident 57's BP. LVN 4 was observed wiping the shared manual BP cuff and stethoscope with a Sani-Cloth Prime disposable wipe and said, Those are our one-minute wipes. LVN 4 did not disinfect the manual BP cuff and stethoscope according to the manufacturer specified contact time. During a medication pass observation on March 10, 2025 at 12:20 p.m. with LVN 3, LVN 3 was observed using a shared glucometer to measure Resident 36's concentration of blood glucose. LVN 3 was observed wiping the glucometer with a Sani-Cloth Prime disposable wipe and did not disinfect the glucometer according to the manufacturer specified contact time. LVN 3 said, This is a one-minute Sani-Cloth. When asked to describe what one-minute meant, LVN 3 stated it meant to wipe and wait for one minute. LVN 3 said, Drying time is one minute. During an interview on March 11, 2025 at 8:57 a.m. with the Infection Preventionist (IP), the IP stated the expectation was for nursing staff to have used the one-minute Sani-Cloth Prime disposable wipe to sanitize equipment shared between residents such as BP cuffs, stethoscopes and glucometers. When asked to describe what one-minute meant, the IP stated, nurses should have wiped down the shared equipment and waited one minute for the product to be efficient. When asked if nurses were expected to keep the shared equipment wet when wiping with the Sani-Cloth Prime disposable wipes, the IP said, No. During the same interview, the IP reviewed the manufacturer's labeled instructions on the Sani-Cloth Prime disposable wipe bottle and acknowledged nursing staff should have been instructed to keep equipment wet for one (1) minute to achieve contact time when they wiped shared resident care equipment according to the manufacturer's instructions. The IP stated it was important to follow the manufacturer's instructions to ensure the wipe worked effectively to kill the organisms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 25 of 27 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 03/13/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on March 11, 2025 at 10:01 a.m. with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to follow the disposable wipe manufacturer's instructions for contact time when they wiped shared resident care equipment. The DON stated it was important to follow the manufacturer's instructions to disinfect and kill bacteria to prevent the spread of infections. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Equipment, dated December 19, 2022, the P&P indicated, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention- a nationally recognized disease control and prevention organization) recommendations in order to break the chain of infection .Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs .Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (i.e. [example], use of EPA [Environmental Protection Agency, protects human health and the environment by enforcing environmental laws] - registered disinfectants) following manufacturer's instructions .Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .Multiple-resident use equipment shall be cleaned and disinfected after each use .Only EPA-registered disinfectants with kill claims for the common organisms found in the facility . During a review of the manufacturer's instructions for contact time for the Sani-Cloth Prime disposable wipes provided by the facility, the manufacturer's instructions indicated, Contact time .thoroughly wet surface. Allow surface to remain visibly wet for one (1) minute. Let air dry. 2. On March 10, 2025, at 11:04 a.m., during an observation of the Neurotherapy Nurse (NN), the NN was observed entering Resident 18's room without wearing an isolation gown while providing contact care and applying an electroencephalogram headset (EEG - a device that uses sensors (electrodes) to measure and record the brain's electrical activity). On March 10, 2025, at 11:07 a.m., during a concurrent observation and interview of the NN inside Resident 18's room with the Assistant Director of Nursing (ADON), the ADON stated the NN was not wearing an isolation gown, and stated the NN should have worn an isolation gown to prevent the spread of infections. On March 10, 2025, at 11:12 a.m., during an interview with the NN, the NN stated she forgot to check the sign on the door and forgot to wear PPE. The NN further stated she should have worn an isolation gown to protect the resident and prevent the spread of germs. On March 11, 2025, at 3:45 p.m., an interview with the Infection Preventionist nurse (IP) was conducted. The IP stated her expectation was for all staff to follow the designated precaution protocols designated for each resident and to wear the appropriate PPE as indicated. The IP further stated the NN should have worn PPE to prevent the spread of infections to residents. A review of Resident 18's medical record was conducted. Resident 18 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), dysphagia (difficulty swallowing), gastrostomy status (an opening into the stomach for food). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 26 of 27 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 03/13/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 18's Order Summary, dated March 12, 2025, included enteral feed (tube feeding) and enhanced standard precaution r/t gastrostomy tube use . A review of Resident 18's care plan titled, Resident on Enhanced Barrier Precautions R/T G Tube use, included the interventions, Apply Enhanced Barrier Precautions to prevent the spread of infections for specific care activities such as: Morning and Evening Care, Toileting and Changing Incontinence Briefs, Caring for Devices and Giving Medical Treatments, Wound Care, Mobility Assistance and Preparing to Leave the Room and Cleaning and Disinfecting the Environment . A review of facility policy and procedure titled, Enhanced Barrier Precautions, dated December 19, 2022, indicated, .it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .EBP/ESP are indicated for residents with any of the following .indwelling medical devices (e.g .feeding tubes .) .make gowns and gloves available prior to performing task .enhanced barrier precautions should be followed outside the resident's room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056185 If continuation sheet Page 27 of 27