Inspection visit
Inspection
23 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 23 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed, for one of seven residents (Resident 40)
reviewed, to ensure the resident was afforded the right to receive or refuse medical care and/or treatment.
Resident 40, who did not have the capacity to make decisions, sign the acknowledgements for advance
directive (AD - written instruction such as living will or durable power of attorney for health care about the
provision of care and services the resident preferred when he is no longer able to decide for himself) and
Bed Hold Notification. This failure had the potential for the resident to receive unnecessary care/treatment
and services.
Findings:
On November 5, 2019, at 12:02 p.m., an observation was conducted with Resident 40. Resident 40 was
observed in bed, agitated, and was swinging his arms and appeared to be talking to himself. Resident 40
was unable to answer questions appropriately when an interview was attempted.
On November 6, 2019, Resident 40's record was reviewed. Resident 40 was admitted to the facility on
[DATE], with diagnoses that included schizophrenia (type of mental illness) and anxiety. Resident 40's face
sheet indicated he was self-responsible.
The facility's acknowledegement form for an AD and Bed Hold Notification indicated it was signed by
Resident 40 on August 2, 2019.
The History and Physical (H&P), completed by Resident 40's physician on August 5, 2019, indicated
Resident 40 had the capacity to understand and make decisions. In addition, the physician further
documented, .confusion at times .can not (sic.) answer question .
The Minimum Data Set (MDS- an assessment tool) dated August 9 and 30, 2019, indicated Resident 40
had a short term and long term memory problem, and moderately impaired cognitive skills for daily decision
making.
The facility form titled, BEHAVIOR MANAGEMENT TEAM, dated August 14, 2019, September 11, 2019,
and October 9, 2019, indicated Resident 40 was alert with confusion and disorientation.
On November 6, 2019, at 11:35 a.m, Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she
was the charge nurse assigned to Resident 40. LVN 1 stated Resident 40 was able to make his simple
needs known but was not capable of making medical decisions.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 22
Event ID:
056186
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 - Few
On November 6, 2019, at 11:45 a.m., the Director of Nursing (DON) was interviewed. The DON stated she
had clarified Resident 40's H&P with the physician and the physician made an error in her entry on the
August 5, 2019's H&P. The DON stated Resident 40 did not have the capacity to understand and make
decisions.
The DON further stated the error in the decision making capacity of the resident should have been picked
up and clarified when the comprehensive assessment on Resident 40 was conducted on August 9, 2019.
The DON further stated the facility should not have let Resident 40 sign the acknowlegements for AD and
Bed Hold Notification upon admission because he did not have the capacity to understand and make
decisons.
The facility's policy and procedure titled, EPPLE COMMITEE (Surrogate Commitee for Healthcare Decision
Making), revised 2019, was reviewed. The policy indicated,
.When it is identified by the Physician and facility staff that a resident is not capable of making medical
treatment/health care decisions and there is no responsible party or surrogate decision maker .
1. Social Service staff will clarify that the resident does not have a responsible party or surrogate decision
maker .
When #1 has been clarified, the IDT (Interdisciplinary Team) and the resident's primary physician become
the resident's responsible party or surrogate decision maker .
The primary care physician and ID Team (Epple Commitee) will be responsible party to sign consent and
other related documents for the resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 2 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on obervation, interview, and record review, the facility failed, for one of 21 residents (Residents 16)
reviewed, to ensure the medication hydrocortisone (corticosteroid hormone medication used to treat
blood/hormone/immune system disorders, cancer and severe allergies) was given at breakfast, with food or
milk, as ordered by physician.
Residents Affected - Few
This failure had the potential for the resident to experience side effects of the medication if not given as
ordered by the physician; and
Findings:
On November 7, 2019, at 8:51 a.m., a medication pass observation was conducted on Resident 16 with
Licensed Vocational Nurse (LVN) 2. LVN 2 prepared Resident 16's medications that included one tablet of
hydrocortisone 5 milligrams (mg) that had a label instruction to give one tablet daily at breakfast and to give
it with food or milk.
On November 7, 2019, at 9 a.m., LVN 2 administered the hydrocortisone tablet to Resident 16 without
giving the medication with food or milk.
On November 7, 2019, at 9:37 a.m., an interview with a concurrent record review was conducted with LVN
2. LVN 2 verified the instruction on the label of the hydrocortisone tablet. LVN 2 stated the label indicated to
give the hydrocortisone tablet at breakfast with food or milk. LVN 2 stated Resident 16 had his breakfast
earlier between 7:10 a.m. to 7:30 a.m.
LVN 2 checked Resident 16's Medication Administration Record (MAR) for November 2019. Resident 16's
MAR indicated to give the hydrocortisone 5 mg tablet at 7 a.m., with breakfast. LVN 2 stated she should
have given the hydrocortisone 5 mg tablet to Resident 16 at breakfast with food or milk as ordered by the
physician.
On November 7, 2019, Resident 7's record was reviewed. Resident 7 was admitted to the facility with
diagnoses that included gastro-esophageal reflux disease (type of stomach disease in which stomach acid
or bile irritates the food pipe lining) and malignant neoplasm (cancer) of the pituitary.
The physician's order dated May 7, 2019, indicated to give one tablet of hydrocortisone 5 mg by mouth
daily at breakfast, with food or milk for malignant neoplasm of the pituitary.
On November 7, 2019, at 10:08 a.m., the Director of Nursing (DON) was interviewed. The DON stated LVN
2 should have administered the hydrocortisone tablet to Resident 16 at breakfast, with food or milk, as
ordered by the physician. The DON stated the medication should have been given with food so the resident
would not experience the medication's side effect such as upset stomach, and/or nausea and vomiting.
According to Lexicomp (drug reference), .Hydrocortisone .side effects of this drug .upset stomach or
throwing up .drug best taken .Use this drug as ordered by your doctor .Tablets .Take tablet with food .
The facility's policy and procedure titled, .Medications given with food, revised 2019, was reviewed. The
policy indicated, .Food and beverages can be given with the residents medication if the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 3 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0658
physician has ordered for it .When a resident has an order allowing him/her to eat or drink with the
medication, the nurse shall give the medication as ordered by the physician .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 4 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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** 3.On
November 5, 2019, at 3:57 p.m., a concurrent observation and interview was conducted with Certified
Nursing Assistant (CNA) 1 for Resident 83. CNA 1 stated he just gave Resident 83 a bedbath. Resident 83
was observed with multiple rashes on the right lower extremity (RLE). CNA 1 confirmed Resident 83 had
rashes on the RLE.
Residents Affected - Some
On November 6, 2019, at 1:36 p.m., a concurrent observation and interview was conducted with Licensed
Vocational Nurse (LVN) 6. LVN 6 confirmed Resident 83 had multiple rashes on the RLE. LVN 6 stated she
was not aware of Resident 83's rashes.
On November 6, 2019, Resident 83's record was reviewed. Resident 83 was admitted to the facility on
[DATE], with diagnoses including cerebrovascular disease (also called stroke - a condition when blood
supply to the brain is stopped either by a blockage or the rupture of a blood vessel).
On November 6, 2019, at 3:40 p.m., a concurrent interview and review of CNA's Daily Body Check Report
assessment form dated November 5, 2019, p.m.shift and November 6, 2019, noc (night shift) shift was
conducted with LVN 1.
The Daily Body Check form indicated CNA 1 identified the multiple rashes on Resident 83's RLE on
November 5, 2019, p.m. shift.
LVN 1 stated the assessment form completed by CNA 1 on the p.m. shift indicated the rashes on Resident
83's RLE was identified. LVN 1 stated the form was not acknowledged by the signature of the licensed
nurses.
LVN 1 stated the November 6, 2019, noc shift CNA's Daily Body Check Report form did not identify
Resident 83's rashes on her RLE.
On November 6, 2019. at 3:57 p.m., a concurrent interview and record review was conducted with LVN 7.
LVN 7 confirmed CNA 1 had identified Resident 83's multiple rashes on the RLE in the Daily Body Check
Report on November 5, 2019, p.m. shift. LVN 7 stated CNA 1 did not report Resident 83's multiple rashes
during her shift to the licensed nurses. LVN 7 stated CNA 1 should have reported the resident's skin
condition changes to the licensed nurses.
LVN 7 stated when CNA 1 identified the multiple rashes on Resident 83's RLE, CNA 1 should have
reported to the licensed nurses and the licensed nurses should have reported and obtained treatment
orders from the physician. LVN 7 stated there was no documented evidence this procedure was done.
The facility's policy and procedure titled, Activities of Daily living (ADLs), dated October 16, 2019, was
reviewed. The policy indicated, .During ADL care observe the resident's skin for any redness, rashes,
broken skin .and document and report findings as indicated to the supervisor .
Based on observation, interview, and record review, the facility failed, for four of 21 residents reviewed
(Residents 51, 1, 83, and 40), to ensure:
1. For Resident 51, the licensed nurses identified, assessed, monitored, and referred to the physician the
multiple skin discolorations identified on the resident's bilateral forearms on November 5,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 5 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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
2019.
Level of Harm - Minimal harm
or potential for actual harm
This failure had the potential for the resident to not be monitored for complications related to the multiple
skin discolorations such as bleeding, skin tears, and infection;
Residents Affected - Some
2. For Resident 1, the facility failed to administer the Emtriva (medication used to treat Human
Immunodeficiency Virus{HIV- type of virus infection}for five days as ordered bythe physician.
This failure resulted in Resident 1 to miss doses of the medication and had the potential to not receive the
desired therapeutic effect;
3. For Resident 83, the Certified Nursing Assistant (CNA) did not report the multiple rashes on the
resident's Right Lower Extremity (RLE) to licensed nurses.
This failure had the potential for the resident to not be monitored for complications related to the rash such
as bleeding, infection and receive the appropriate treatment timely; and
4. For Resident 40, the licensed nurses identified, and address a skin breakdown on the resident's right
buttock before the area worsened.
This failure resulted in the development of opened blisters to the resident's right buttock.
Findings:
1. On November 5, 2019, at 10:28 a.m., an observation was conducted for Resident 51. Resident 51 had
multiple bluish skin discolorations on her bilateral forearms.
On November 6, 2019, at 3:28 p.m., an observation, interview, and record review was conducted with
Licensed Vocational Nurse (LVN) 4. LVN 4 confirmed Resident 51 had multiple bluish skin discolorations on
her bilateral forearms.
Resident 51 was re-admitted to the facility on [DATE], with diagnoses which included anemia (iron
deficiency).
The physician's order dated September 27, 2019, indicated, .Apixaban (Eliquiz- anti-coagulant medication)
2.5 milligram (mg) one tablet two times a day (bid) by mouth - Deep Vein Thrombosis (DVT- a blood
circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or
spasm) .
The Minimum Data Set (MDS - an assessment tool) dated September 10, 2019, was reviewed. Resident 51
required extensive assistance in bed mobility and total assistance to transfer.
In a concurrent interview, LVN 4 stated if a skin discoloration, skin trauma was identified on a resident, the
resident should be assessed and the physician should be notified for treatment orders. LVN 4 further stated
a care plan should have been developed and initiated to prevent complications related to the skin
discolorations.
LVN 4 stated there was no documented evidence the multiple skin discolorations on Resident 51's bilateral
forearms were addressed and monitored by the licensed nurses.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 6 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On November 7, 2019, at 11:05 a.m., an interview, and record review was conducted with the Director of
Nurses (DON). The DON stated the discolorations on Resident 51's bilateral forarms should have been
identified, assessed, and monitored by the licensed nurses. The DON further stated Resident 51's
physician and responsible party should have been notified by the licensed nurses.
2. On November 5, 2019, at 10:26 a.m., Resident 1 was observed lying in bed, alert and verbally
responsive.
Resident 1 stated she did not receive her HIV medication for four days. Resident 1 further stated the
Licensed Nurses (LN) told her they will call the pharmacy to order her HIV medication, but until now the LN
did not give her medication.
On November 5, 2019, at 10:30 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3.
LVN 3 stated Resident 1's Emtriva 200 mg was not available. LVN 3 confirmed the Emtriva 200 mg was due
to be given on November 5, 2019, at 9 a.m. LVN 3 further stated he will call the paharmacy and order the
medication (Emtriva).
On November 6, 2019, at 9:30 a.m., Resident 1's record was reviewed. Resident 1 was admitted to the
facility on [DATE], and re-admitted on [DATE], with diagnoses that included HIV.
The History and Physical dated October 10, 2019, indicated, .Has the capacily to understand and make
decision .
The physician's order dated October 8, 2019, indicated, .Emtriva 200 mg one tablet by mouth every day for
HIV .
The Medication Administration Record (MAR) dated November 5, 2019, indicated the medication Emtriva
200 mg was due to be given at 9 a.m. daily.
Resident 1's MAR for the date of November 5, 2019, the 9 a.m. dose, indicated Resident 1's Emtriva 200
mg was not given to the resident.
On November 6, 2019, at 10:02 a.m., an observation, interview, and record review was conducted with LVN
3. LVN 3 stated Resident 1 was scheduled to receive Emtivra 200 mg on November 5, 2019, for 9 a.m.,
dose.
LVN 3 further stated he did not administer the medication Emtriva on November 5, 2019, because the
medication was not available.
LVN 3 stated the medication should have been given to Resident 1 timely as ordered by the physician.
On November 6, 2019, at 10:26 a.m., an observation, interview, and record review was conducted with LVN
4. LVN 4 stated he worked on November 4, 2019. LVN 4 stated Resident 1 was scheduled to receive
Emtivra 200 mg on November 4, 2019, for 9 a.m.
LVN 4 further stated he administered the medication Emtriva on November 4, 2019. LVN 4 stated he got the
medication Emtriva 200 mg from a medication bottle.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 7 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
There was no evidence of an Emtriva medication bottle. LVN 4 confirmed he was unable to provide the
Emtriva medication bottle he used to administer the Emtriva 200 mg dose on November 4, 2019, at 9 a.m.
On November 6, 2019, at 10:35 a.m., an interview was conducted with Resident 1. Resident 1 stated the
LN did not administer her medication Emtriva on November 1, 2, 3, 4, and 5, 2019. Resident 1 stated she
asked the LN multiple times to give her medication, but the LN told Resident 1 they needed to call the
pharmacy to order her medication Emtriva.
On November 7, 2019, at 8:48 a.m., an interview was conducted with the facility's contracted Pharmacist.
The Pharmacist stated the Emtriva 200 mg capsules were delivered on the following dates:
June 1, 2019, delivered 27 capsules;
June 28, 2019, delivered 30 capsules;
July 28, 2019, delivered 31 capsules;
August 28, 2019, delivered 31 capsules; and
September 20, 2019, delivered 30 capsules.
The pharmacist further stated Resident 1 was re-admitted to the facility on [DATE], and the resident did not
have a physician order for Emtriva 200 mg daily.
The pharmacist stated the facility ordered the Emtriva 200 mg via fax on November 5, 2019, at 2:52 p.m.
The Pharmacist stated the Emtriva 200 mg (30 capsules) were delivered stat (within four hours) on
November 5, 2019, at 6:55 p.m.
On November 7, 2019, at 2:26 p.m., an interview, and record review was conducted with LVN 5. LVN 5
confirmed Resident 1 was transfered to the acute hospital on September 26, 2019, and re-admitted to
facility on October 8, 2019.
LVN 5 confirmed the last time the medication Emtriva 200 mg (30 capsules) was delivered on September
20, 2019.
LVN 5 stated the LN who verified and faxed the admission physician orders on October 8, 2019, at 10:29
p.m., to the pharmacy did not order the Emtriva 200 mg daily.
LVN 5 confirmed the Emtriva 200 mg was not ordered until November 5, 2019, at 2:52 p.m, and delivered
on November 5, 2019, at 6:55 p.m.
LVN 5 confirmed the medication Emtriva for Resident 1 was not administered on November 1, 2, 3,4, and 5,
2019, due to the medication unavailability. LVN 5 further stated the licensed nurses should have ordered the
medication Emtriva 200 mg on October 8, 2019, when Resident 1 readmitted to the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 8 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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
LVN 5 stated the medications for Resident 1 should have been given timely as ordered by the physician.
Level of Harm - Minimal harm
or potential for actual harm
The facility's policy and procedure titled, Administering Medication, revised 2019, was reviewed. The policy
indicated, .Medications must be administered in accordance with the orders, including any required time
frames .
Residents Affected - Some
4. On November 5, 2019, at 3:23 p.m., Resident 40's record was reviewed. Resident 40 was admitted to the
facility on [DATE].
A physician's order dated November 3, 2019, indicated Resident 40 had opened blisters on his right upper
superior buttock (Site #1), right inferior buttock (Site #2), and right upper mid-buttock (Site #3). The
physician's order further indicated to cleanse the opened blisters with normal saline, pat dry and apply triple
antibiotic ointment, leave open to air for 14 days.
The care plan dated August 2, 2019, indicated, .AT RISK FOR OCCURENCE OF PRESSURE
ULCER/SKIN BREAKDOWN .AS EVIDENCED BY .Bowel Incontinence (inability to hold stool) .Urine
Incontinence (inability to hold urine) .Approach Plan .staff will monitor skin daily during ADL (Activities of
Daily Living) care .Nursing Assistants to notify charge nurse for any skin problem during care .LVN/RN
(Registered Nurse) will assess any skin prblem noted, identify unusual skin problems .Notify physician for
any alteration in skin integrity/skin breakdown .
The facility document titled. NON-PRESSURE SORE SKIN PROBLEM REPORT, dated November 3, 2019,
indicated the following assessment on Resident 40's opened blisters to his right buttock area:
- Right upper superior buttock (Site #1) open blister 3.5 centimeter (cm - unit of measurement) by (x) 1.5
cm, pink in color with no drainage;
- Right inferior buttock (Site #2) 1.8 x 1 cm, pink in color with no drainage; and
- Right upper mid-buttock (Site #3) 2 cm x 1.2 cm, pink in color with no drainage.
There was no documented evidence the facility indicated Resident 40 had a previous skin breakdown on
Resident 40's right buttock (three sites) before it developed into open blisters.
The Certified Nursing Assistants (CNAs) document titled, DAILY BODY CHECK REPORT, dated October
31, 2019 to November 2, 2019, indicated the CNAs had identified old scabs and old skin scratches on
Resident 40's buttocks area. The form also indicated the licensed nurses acknowleged through signature
they were made aware of the skin problems identified and documented by the CNAs.
There was no documented evidence the skin problems identified by the CNAs on Resident 40's buttock
area, from October 31 to November 2, 2019, were further assessed by the licensed nurses and were
referred to the physician for treatment orders.
On November 6, 2019, Resident 40's record was reviewed with Licensed Vocational Nurse (LVN) 6. LVN 6
stated there was no documented evidence a previous skin breakdown was identified on Resident 40's right
buttock area (three sites) before it developed into open blisters.
LVN 6 further stated the opened blisters on Resident 40's buttocks appeared like previous
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 9 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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
scratchmarks but she did not see previous treatment order for it.
Level of Harm - Minimal harm
or potential for actual harm
LVN 6 stated before the skin breakdown developed into opened blisters it should have started as a redness
first or fluid filled blisters. She further stated if
Residents Affected - Some
the previous skin breakdown was identified by the licensed nurses and treated earlier the opened blisters
(three sites) on Resident 40's right buttock could have been prevented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 10 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed, for one of four residents (Resident 23) reviewed
for limited Range of Motion (ROM), to ensure the change in the resident's ROM on his right elbow was
identified and addressed by the facility.
This failure had the potential for the resident to develop further contracture (shortening or hardening of the
muscles, tendons, or other tissues, often leading to rigidity and deformity of joints)on his right elbow if left
untreated.
Findings:
On November 5, 2019, at 9:54 a.m., an observation with a concurrent interview was conducted with
Resident 23. Resident 23's right arm and hand were observed to be flaccid (limp) and he supported it with
his left hand while being interviewed. Resident 23 stated he had weakness on his right arm and hand and
he did not do exercises on it.
On November 7, 2019, Resident 23's record was reviewed. Resident 23 was re-admitted to the facility on
[DATE], with diagnoses that included hemiplegia/hemiparesis (muscle weakness or paralysis to one side of
the body that can affect arms, legs, and facial muscles).
The facility's document titled JOINT MOBILITY ASSESSMENT (JMA), indicated the following:
- On July 16, 2018, Resident 23 had within functional limits (WFL - no limitation in ROM) ROM on his right
elbow; and
- On May 16, 2019, Resident 23 had a Moderate to Severe (M/S- only able to do 25 to 50% of ROM)) ROM
on his right elbow. The document further indicated the Physical Therapist (PT) documented on May 16,
2019, .CONTINUE WITH THE RNA (Restorative Nurse Assistant) program .
There was no documented evidence Resident 23 had a physician's order for RNA program exercises.
The Minimum Data Set (MDS- an assessment tool) indicated the following:
- On May 13, 2018, Resident 23 did not have impairments on the functional limitation in ROM to his upper
and lower extremity; and
- On May 13, 2019, Resident 23 had an impairment on the functional limitation to one side his upper and
lower extremity.
There was no documented evidence the change in Resident 23's functional limitation in ROM was
addressed by the facility. In addition, there was no documented evidence a care plan was initiated to help
prevent a further decline in Resident 23's ROM on his right elbow when it was identified on May 16, 2019.
On November 7, 2019, at 3:52 p.m., Resident 23's record was reviewed with the PT. The PT verified he
conducted the JMA on Resident 23 on May 16, 2019. The PT stated he identified Resident 23 had a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 11 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0688
change in the ROM on his right elbow from July 16, 2018 to May 16, 2019.
Level of Harm - Minimal harm
or potential for actual harm
The PT stated Resident 23 developed a limitation on the ROM on his right elbow. The PT stated it was
identified when he did the JMA on Resident 23 on May 16, 2019. The PT verified Resident 23 did not have
a physician's order for RNA program exercises to his right arm since the change in the functional ROM was
identified in May 16, 2019.
Residents Affected - Few
The PT stated he made an error when he documented for Resident 23 to continue with RNA program on
May 16, 2019.
The PT further stated the change in the functional ROM of Resident 23's right elbow should have been
referred to the physician for further evaluation and appropriate treatment. The PT stated this was not done.
On November 8, 2019, Resident 23's record was reviewed with the Director of Nursing (DON). The DON
reviewed Resident 23's MDS dated [DATE] and May 13, 2019. The DON stated Resident 23 developed a
change in the ROM on his right elbow.
The DON stated this was considered a change in the ROM and it should have been referred to the
physician for the appropriate treatment to help prevent further contracture. She further stated a care plan
should have been developed to help prevent further contracture of Resident 23's right elbow when it was
identified by the PT in May 16, 2019, and MDS in May 13, 2019.
The facility's undated policy and procedure titled, Prevention of Decline in Range of Motion, was reviewed.
The policy indicated,
.Resident who enter the facility without limited range of motion will not experience reduction in range of
motion unless the resident's clinical condition demonstrated that a reduction in range of motion if
unavoidable .
The facility shall establish and utilize a systemic approach for prevention of decline in range of motion,
including the assessment of range of motion, appropriate care planning and preventive care .
Licensed nurses will assess range of motion on admission/readmission, quarterly, and upon significant
change .Resident who exhibit limitations in range of motion, initially and thereafter, will be referred to the
therapy department for a focused assessment of range of motion .
Based on comprehensive assessment, the facility will provide treatment and care in accordance with the
professional standards of practice. This includes, but is not limited to .Appropriate services (specialized
rehabilitation, restorative, maintenance) .Appropriate equipment (braces or splints) .Assistance as needed
(active assisted, passive, supervision) .
Interventions will be documented on the resident's person-centered care plan in accordance with
recognized needs and the resident's preferences .
Residents will receive services from restorative aides or therapists as needed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 12 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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, for one of 21 residents reviewed for unnecessary
medications (Resident 51) to ensure monitoring for adverse consequences (such as signs and symptoms
of bleeding and/or bruising) of anticoagulant medication (Apixaban- medications that reduce or prevent
blood from clotting), since ordered on September 27, 2019.
Residents Affected - Few
This failure had the potential for the resident not to be monitored for the adverse effect of Apixaban such as
bruising and bleeding.
Findings:
On November 5, 2019, at 10:28 a.m., an observation was conducted with Resident 51. Resident 51 had
multiple bluish skin discolorations on her bilateral forearms.
On November 6, 2019, at 3:28 p.m., an observation, interview, record review, was conducted with Licensed
Vocational Nurse (LVN) 4. LVN 4 confirmed Resident 51 had multiple bluish skin discolorations on her
bilateral forearms.
Resident 51 was re-admitted to the facility on [DATE], with diagnoses which included anemia (iron
deficiency).
The physician's order dated September 27, 2019, indicated, .Apixaban 2.5 milligram (mg) one tablet two
times a day (bid) by mouth .
There was no documented evidence Resident 51's bluish skin discoloration on her bilateral forearms were
identified by the facility. In addition there was no documented evidence Resident 51 was monitored for the
adverse effect of Apixaban.
On November 7, 2019, at 11:05 a.m., the Director of Nurses (DON) verified and stated there was no
documented evidence Resident 51 was monitored for the adverse effect of Apixaban. The DON further
stated Resident 51 should have been monitored for adverse effects of Apixaban.
The facility's policy and procedure titled, Anticoagulation,dated October, 2019, was reviewed. The policy
indicated, .The staff should use a warfarin flow sheet or comparable monitoring tool to follow trend in
anticoagulant dosage and response .If an individual on anticoagulation therapy shows signs of excessive
bruising, hematuria, hemoptysis, or other evidence of bleeding the nurse will discuss the situation with the
physician before giving the next scheduled dose of anticoagulant .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 13 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 - Few
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** 2. On
November 5, 2019, at 12:02 p.m., an observation was conducted on Resident 40. Resident 40 was
observed in bed, agitated, and was swinging his arms and appeared to be talking to himself. Resident 40
was unable to answer questions appropriately when an interview was attempted.
On November 6, 2019, Resident 40's record was reviewed with Registered Nurse (RN) 1. Resident 40 was
admitted to the facility on [DATE], with diagnoses that included anxiety.
The physician's order dated August 20, 2019, indicated to give Ativan 0.5 milligram one table by mouth
every six hours as needed (PRN) for anxiety manifested by persistent restlessness. The physician's order
for PRN Ativan did not have a stop date of 14 days as regulatory requirement.
There was no documented evidence the physician documented an assessment to justify the rationale on
the use of PRN Ativan beyond 14 days.
In a concurrent interview, RN 1 stated the physician should have documented the reason for the PRN
Ativan to be used beyond 14 days. RN 1 stated there was no documented evidence the physician
documented the rationale for the PRN Ativan to be used beyond 14 days.
The facility's policy and procedure titled, Use of Psychotropic Drugs, revised 2019, was reviewed. The
policy indicated, PRN orders for psychotropic drugs are limited to 14 days, except as provided if the
attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be
extended beyond 14 days. He or she should document their rationale in the resident's medical record and
indicate the duration of the PRN order .
Based on interview and record review, the facility failed for two of six residents (Residents 55 and 40)
reviewed for unnecessary medications to ensure:
1. For Resident 55 the physician failed to document the rationale for the continued use of Ativan, (a
medication used to decrease anxiety), as needed (PRN) beyond the 14 days as required; and
2. Resident 40 the physician failed to document the rationale for the continued use of Ativan PRN beyond
the 14 days as required.
This failure had the potential for Residents 55 and 40 to receive unnecessary medications.
Findings:
1.On November 8, 2019, Resident 55's record was reviewed. Resident 55 was admitted on [DATE], with
diagnoses which included anxiety.
Resident 55's physician order dated January 11, 2019, indicated to give Ativan 1 milligram (MG), as
needed (PRN) for anxiety, manifested by (M/B) episodes of restlessness and verbalization of anxiety. The
physician's order for PRN Ativan did not have a stop date of 14 days as regulatory requirement.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 14 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 - Few
There was no documented evidence the physician documented an assessment to justify the rationale on
the use of PRN Ativan beyond the 14 days.
On November 8, 2019, at 10:25 a.m., a concurrent interview and record review was conducted with (LVN)
5. LVN 5 stated there was no documented evidence in Resident 55's record that the physician provided a
rationale for the continued use of Ativan beyond the 14 days.
On November 9, 2019, at 10:28 a.m., a concurrent interview and record review was conducted with the
Director of Nursing (DON). The DON stated there was no documented evidence that Resident 55's
physician provided a rationale for the continued use of Ativan beyond the 14 days. The DON further stated
Resident 55's physician should have provided an assessment to justify the rationale for the continued use
of PRN Ativan beyond the 14 days.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 15 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0760
Ensure that residents are free from significant medication errors.
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, for one of 21 residents (Resident 1), to ensure
the medication Emtriva (anti-viral medication used to treat HIV {type of viral infection}) was available and
administered to the resident in a timely manner as ordered by the physician.
Residents Affected - Few
This failure resulted in a significant medication error.
Findings:
On November 5, 2019, at 10:26 a.m., Resident 1 was observed lying in bed, alert and verbally responsive.
Resident 1 stated she did not receive her HIV medication for four days. Resident 1 further stated the
Licensed Nurses (LN) told her they will call the pharmacy to order her HIV medication, but until now the LN
did not give her medication.
On November 5, 2019, at 10:30 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3.
LVN 3 stated Resident 1's Emtriva 200 mg was not available. LVN 3 confirmed the Emtriva 200 mg was due
to be given on November 5, 2019, at 9 a.m. LVN 3 further stated he will call the pharmacy and order the
medication (Emtriva).
On November 6, 2019, at 9:30 a.m., Resident 1's record was reviewed. Resident 1 was admitted to the
facility on [DATE], and re-admitted on [DATE], with diagnoses that included HIV.
The History and Physical dated October 10, 2019, indicated, .Has the capacity to understand and make
decision .
The physician's order dated October 8, 2019, indicated, .Emtriva 200 mg one tablet by mouth every day for
HIV .
The Medication Administration Record (MAR) dated November 5, 2019, indicated the medication Emtriva
200 mg was due to be given at 9 a.m. daily.
Resident 1's MAR for the date of November 5, 2019, the 9 a.m. dose, indicated Resident 1's Emtriva 200
mg was not given to the resident.
On November 6, 2019, at 10:02 a.m., an observation, interview, and record review was conducted with LVN
3. LVN 3 stated Resident 1 was scheduled to receive Emtivra 200 mg on November 5, 2019, at 9 a.m.
LVN 3 further stated he did not administer the medication Emtriva on November 5, 2019, because the
medication was not available.
LVN 3 stated the medication should have been given to Resident 1 timely as ordered by the physician.
On November 6, 2019, at 10:26 a.m., an observation, interview, and record review was conducted with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 16 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0760
Level of Harm - Minimal harm
or potential for actual harm
LVN 4. LVN 4 stated he worked on November 4, 2019. LVN 4 stated Resident 1 was scheduled to receive
Emtivra 200 mg on November 4, 2019, for 9 a.m.
LVN 4 further stated he administered the medication Emtriva on November 4, 2019. LVN 4 stated he got the
medication Emtriva 200 mg from a medication bottle.
Residents Affected - Few
There was no evidence of an Emtriva medication bottle. LVN 4 confirmed he was unable to provide the
medication bottle of Emtriva administered to Resident 1 on November 4, 2019, at 9 a.m.
On November 6, 2019, at 10:35 a.m., an interview was conducted with Resident 1. Resident 1 stated the
LN did not administer her medication Emtriva on November 1, 2, 3, 4, and 5, 2019. Resident 1 stated she
asked the LN multiple times to give her medication, but the LN told Resident 1 they needed to call the
pharmacy to order her medication Emtriva.
On November 7, 2019, at 8:48 a.m., an interview was conducted with the facility's contracted Pharmacist.
The Pharmacist stated the Emtriva 200 mg capsule were delivered on the following dates:
June 1, 2019, delivered 27 capsules;
June 28, 2019, delivered 30 capsules;
July 28, 2019, delivered 31 capsules;
August 28, 2019, delivered 31 capsules; and
September 20, 2019, delivered 30 capsules.
The Pharmacist further stated Resident 1 was re-admitted to the facility on [DATE], and the facility did not
fax a physician's order for Emtriva 200 mg daily for the resident.
The Pharmacist stated the facility ordered the Emtriva 200 mg via fax on November 5, 2019, at 2:52 p.m.
The Pharmacist stated the Emtriva 200 mg (30 capsules) were delivered stat (within four hours) on
November 5, 2019, at 6:55 p.m.
On November 7, 2019, at 2:26 p.m., an interview, and record review was conducted with LVN 5. LVN 5
confirmed Resident 1 was transfered to the acute hospital on September 26, 2019, and re-admitted to
facility on October 8, 2019.
LVN 5 confirmed the last time the medication Emtriva 200 mg (30 capsules) was delivered on September
20, 2019.
LVN 5 stated the LN who verified and faxed the admission physician orders on October 8, 2019, at 10:29
p.m., to the pharmacy did not order the Emtriva 200 mg daily for Resident 1.
LVN 5 stated the Emtriva 200 mg was not ordered until November 5, 2019, at 2:52 p.m, and delivered on
November 5, 2019, at 6:55 p.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 17 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0760
Level of Harm - Minimal harm
or potential for actual harm
LVN 5 confirmed the medication Emtriva for Resident 1 was not administered on November 1, 2, 3,4, and 5,
2019, due to the medication unavailability. LVN 5 further stated the licensed nurses should have ordered the
medication Emtriva 200 mg on October 8, 2019, when Resident 1 readmitted to the facility.
LVN 5 stated the medications for Resident 1 should have been given timely as ordered by the physician.
Residents Affected - Few
The facility's policy and procedure titled, Administering Medication, revised 2019, was reviewed. The policy
indicated, .Medications must be administered in accordance with the orders, including any required time
frames .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 18 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure discontinued medications were not
stored in the medication cart readily available for use.
This failure increases the risk for the licensed nurses to administer discontinued medications to the
residents and may result in medication error.
Findings:
On November 7, 2019, an inspection of the medication cart with an interview and record review was
conducted with Licensed Vocational Nurse (LVN) 7. Stored inside the medication cart readily available for
use were the following:
- One box (25 count of 3 milliliter (ml) solutions) of Albuterol 0.83 % (medication used to treat difficulty of
breathing) inhalation solution, labeled as ordered for Resident 22; and
- 19 tablets of hydroxyzine HCL (hydrochloride) 25 milligrams (mg), labeled as ordered for Resident 77.
In a concurrent interview and record review, LVN 7 stated she did not see in the November 2019
Medication Administration Record, an active physician's order for the Albuterol inhalation solution for
Resident 22 and the hydroxyzine HCL for Resident 77.
LVN 7 further stated the medications may have been discontinued. LVN 7 further stated discontinued
medications should not have been stored in the medication cart to help prevent medication errors. LVN &
stated the discontinued medications should have been removed from the medication cart and stored in the
medication room for proper disposal.
On November 7, 2019, the following records were reviewed:
- Resident 22 was re-admitted to the facility on [DATE]. The physician's order for Albuterol 2.5 mg/3ml one
unit dose via nebulizer (machine used to deliver inhalation solution medications) every six hours as needed
(order date July 1, 2018), was discontinued on September 18, 2018; and
- Resident 77 was re-admitted to the facility on [DATE]. The physician's order for Atarax (brand name for
hydroxyzine HCL) 25 mg one tablet by mouth every 8 hours as needed (order date August 11, 2019), was
discontinued on August 25, 2019.
On November 8, 2019, at 9:33 a.m., the Director of Nursing (DON) was interviewed. The DON stated the
discontinued medications for REsidents 22 and 77 should have been removed from the medication cart and
stored in the medication room for disposal.
She further stated the discontinued medications should not have been left stored in the medication cart
because this had the potential for the licensed nurses to administer the medications and may result in
medication error.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 19 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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
The facility's policy and procedure titled, DISCONTINUED MEDICATIONS, revised 2019 was reviewed. The
policy indicated, .Staff shall destroy discontinued medications or shall return them to the dispensing
pharmacy in accordance with the facility policy .
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 20 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure safe, sanitary practices for
infection prevention for one of 21 residents reviewed (Resident 70) when an undated and unlabeled plastic
jar containing brownish liquid and Jalapeno mixture was stored at the resident's bedside.
This failure had the potential to result in the development of food-borne illnesses and the growth of
microorganism in vulnerable residents.
Findings:
On November 5, 2019, at 12:13 p.m., an observation and concurrent interview was conducted with
Resident 70. Resident 70 was observed lying in bed awake, alert and able to verbalize his needs. A
covered plastic container half filled with cut up mix vegetables with Jalapenos and brownish liquid was
observed on top of Resident 70's bedside table. The container was undated and unlabeled.
In a concurrent interview, Resident 70 stated the container was filled with Jalapeno mix from the can.
Resident 70 stated he would request the staff to open the container when he wanted to eat the food item
during meals. Resident 70 further stated a family member brought the food item from home. Resident 70
did not remember when a family member brought the food item from home.
On November 5, 2019, at 3 p.m. the plastic container with mix vegetables and Jalapenos was still observed
at the resident's bedside table.
On November 5, 2019, at 3:30 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she
was not aware of the plastic container containing the Jalapeno mix was at the Resident 70's bedside. LVN 1
stated the Jalapeno mix should have been dated, labeled with Resident 70's name and stored in the
resident's refrigerator.
On November 7, 2019, at 11 a.m., an interview was conducted with the Administrator. The Administrator
stated food items brought by a family member from home should be stored in the designated resident's
refrigerator located inside the medication storage area. The Administrator stated facility's staff should have
identified the risk of leaving food items left unrefrigerated at Resident 70's bedside.
The facility's policy and procedure titled, Infection Prevention and Control Program, dated October 16,
2019, was reviewed. The policy indicated, .It is a policy of this facility to establish and maintain an infection
prevention and control program designated to provide a safe, sanitary, and comfortable environment and to
help prevent the development and transmission of communicable diseases and infection .
The facility's policy and procedure titled, Food Receiving and Storage, dated October 16, 2019, was
reviewed. The policy indicated, .Foods shall be received and stored in a manner that complies with safe
food handling .All foods belonging to residents must be labeled with the resident's name, the item and the
use by date .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 21 of 22
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
056186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/08/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centinela Grand Inc
2225 North Perris Boulevard
Perris, CA 92571
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
Based on observation, interview, and record review, the facility failed to implement and observe an infection
control and prevention program when multiple residents were not provided withthe appropriate hand
hygiene prior to eating lunch.
Residents Affected - Some
This failure had the potential to result in the transmission of infection to an already vulnerable population of
residents in the facility.
Findings:
On November 5, 2019, at 12:15 p.m., a lunch meal dining observation was conducted in the central dining
room with multiple residents. At least 14 residents in the dining room were observed to not receive hand
hygiene prior to eating lunch.
On November 5, 2019, at 12:55 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 2.
CNA 2 stated she was assigned to the central dining room to pass trays and to assist residents as needed.
CNA 2 stated it was not the policy of the facility to provide hand hygiene to the residents prior to eating their
meals in the dining room. CNA 2 further stated all residents should have hand hygiene before eating.
On November 5, 2019, at 1 p.m., an interview was conducted with CNA 3. CNA 3 stated she was assigned
to assist residents in the central dining room for lunch. CNA 3 stated it was not the practice of the facility to
sanitize residents' hands before bringing them the dining room for meals. CNA 3 also stated that all
residents should have their hands washed or sanitized before eating.
On November 5, 2019, at 1:12 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 6.
LVN 6 stated she was assigned to supervise the lunch meal in the central dining room. LVN 6 stated the
residents in the central dining room during the lunch meal observation on November 5, 2019, at 12:15 p.m.,
did not receive hand hygiene prior to eating their lunch.
LVN 6 also stated that every resident should have been provided hand hygiene by the staff before entering
the dining room and before eating. She further stated, failure to provide hand hygiene could lead to the
spread of communicable infections.
On November 6, 2019, at 9:45 a.m., the Director of Nursing (DON) was interviewed. The DON stated the
policy of the facility was to wash residents' hands before eating. The DON stated the CNAs should have
provided hand hygiene before the lunch meal. She further stated that failure to provide hand hygiene could
result in the spread of infections.
On November 6, 2019, the facility's policy and procedure titled, Handwashing/Hand Hygiene dated 2019,
was reviewed. The policy indicated the following, .All personnel shall follow the handwashing/hand hygiene
procedures to help prevent the spread of infection to other personnel, residents, and visitors .Before and
after eating or handling food .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056186
If continuation sheet
Page 22 of 22
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
23 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0009GeneralS&S Dpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0222GeneralS&S Dpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0754GeneralS&S Dpotential for harm
Provide properly sized and located linen or trash receptacles.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
- 0034GeneralS&S Dpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0039GeneralS&S Epotential for harm
Conduct testing and exercise requirements.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
FAQ · About this visit
Common questions about this visit
What happened during the November 8, 2019 survey of CENTINELA GRAND INC?
This was a inspection survey of CENTINELA GRAND INC on November 8, 2019. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CENTINELA GRAND INC on November 8, 2019?
Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.