Health inspection·March 18, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm The History and Physical dated December 18, 2021, indicated Resident 25 had fluctuating capacity to understand and make decisions. There was no documented evidence information on the formulation of an AD was offered to the resident and/or responsible party upon admission. Residents Affected - Few On March 16, 2022, at 9:25 a.m., a concurrent interview and record review was conducted with the SSD. The SSD stated Resident 25 did not have an AD. The SSD stated information about the formulation of an advance directive was not offered to Resident 25 and to his responsible party. The SSD further stated this information should have been offered to Resident 25, or to his responsible party upon his admission to the facility on December 18, 2021. The facility's policy and procedure titled, Advanced Directives, revised 2022, indicated, .Prior to or upon admission of a resident upon admission to our facility, the Social Service Director or designeee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, and his/her family members, about the existence of any written advance directives . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 2 of 32 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 03/18/2022 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** 2. On March 14, 2022, at 11:34 a.m., a concurrent observation and interview was conducted with Resident 5. Resident 5 was awake, wearing vinyl gloves on both hands, and cleaning around his bed. In a concurrent interview, Resident 5 stated he had wounds on his right foot. Resident 5 proceeded to remove his sandals and socks, and pointed out the dressing to the inner side of his right great toe and the outer side of his right foot. The dressing on the right outer foot was dated March 13, 2022. Resident 5 stated he had surgery on the right great toe a few weeks ago and the dressing to the right great toe was changed on March 13, 2022. Resident 5 stated the dressing on the outer side of his right foot was placed there by the nurse about 2 days ago because he had scratched it and the skin became open. Residents Affected - Few Resident 5 was observed to remove the glove on his right hand. The skin was observed to be reddish, scaly and dry, with several reddish scabs on the upper surface of the hand. The joints appeared swollen and the fingernails were yellowish and thick. Resident 5 stated he had a sensitivity to alcohol-based products and used the gloves to protect his hands from harsh cleaning products. Resident 5 stated he applied Vitamin A and D ointment on his hands himself and asked for the ointment from the staff at the nurses' station or from the CNAs (Certified Nursing Assistants). Resident 5 stated he had this skin condition on his right hand for 104 days here in this facility as well as in the previous facility where he came from. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses including diabetes. The physician's orders for March 2022, indicated a diagnosis of right lower extremity cellulitis (a bacterial skin infection of lower leg) and a treatment order indicating .(R [right]) great toe surgical wound .Cleanse with NS (normal saline), pat dry, apply Vaseline and cover with band aid q (every) daily and PRN (as needed) x 7 days then re-evaluate. (3/2/22 - 3/08/22). There was no documented evidence treatment orders were obtained for Resident 5's scratch on the right outer foot or the skin conditions on the right hand. There was no doctor's order for Vitamin A and D ointment to be applied on Resident 5's right hand. The Nursing Weekly Summary Review for the period of March 1 to 7, 2022 indicated a right great toe surgical wound following a skin tag (a skin growth in which a short, narrow stalk sticks out) removal. The Nursing Weekly Summary Review for the period of March 7 to 14, 2022 indicated skin clear. There was no documented evidence the scratch on Resident 5's right outer foot or the skin conditions on his right hand were identified. The Treatment Administration Record for March 2022, indicated the treatment to Resident 5's right great toe was provided from March 2 to 13, 2022 (continued beyond the physician's order of March 8, 2022). There was no documented evidence for the treatment provided on Resident 5's right outer foot or the Vitamin A and D ointment for Resident 5's right hand. On March 15, 2022, a concurrent interview and record review was conducted with the Treatment Nurse (TN). The TN confirmed Resident 5 had a surgical wound on the right great toe and the treatment was continued beyond March 8, 2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 3 of 32 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 03/18/2022 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 - Few The TN stated the wound should have been re-evaluated on March 8, 2022, and a new order obtained to continue the treatment. The TN stated Resident 5's scratch should have been identified as a change in condition; the doctor notified; a treatment order obtained for the scratch; and a care plan formulated, before providing treatment to the resident. The TN stated she had not assessed Resident 5's right hand, nor identified the multiple skin conditions on it, since Resident 5 always wore vinyl gloves. The TN stated the skin conditions on Resident 5's right hand should have been identified; the doctor notified; treatment orders obtained to address the skin conditions on Resident 5's right hand; and a care plan formulated. On March 18, 2022 at 9:24 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 5's surgical wound on the right great toe should have been re-evaluated on March 8, 2022, and if resolved, the treatment discontinued. If it was not resolved, a new order should have been obtained from the doctor. If the order was renewed, then the care plan should have also been updated. The DON stated there should have been a change of condition done regarding Resident 5's scratch on the right outer foot, the doctor notified, a treatment order obtained before administering the treatment, and a care plan developed. The DON stated the facility's process was to perform skin assessments of the residents weekly by the licensed nurses. Resident 5's multiple skin conditions on the right hand should have been identified. The doctor should have been notified, treatment orders obtained, and a care plan developed. The facility's policy and procedure titled, Skin Assessment, revised 2019, indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions .A full body, head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition .Document observations .Document type of wound .Describe wound .Document other information as indicated or appropriate . The facility's policy and procedure titled, Change in a Resident's Condition or Status, revised 2022, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical .condition and/or status .notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical .condition or status .inform the resident of any changes in his/her medical care or nursing treatments .record in the resident's medical record information relative to changes in the resident's medical .condition or status . Based on observation, interview, and record review, the facility failed to ensure for two of three residents reviewed for skin condition (Residents 19 and 5) received the proper care and treatment when: 1a. For Resident 19, the physician's order to give Doxycycline (type of antibiotic medication) for pressure ulcers (PU- an injury caused by prolonged pressure on the skin) was not carried out upon admission to the facility and was not administered to the resident. This failure resulted in Resident 19 not receiving the complete course of antibiotic treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 4 of 32 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 03/18/2022 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 which may delay the healing process of the multiple infected pressure ulcers; Level of Harm - Minimal harm or potential for actual harm 1b. The facility failed to develop and initiate a baseline care plan to address Resident 19's admitting diagnosis of multiple infected pressure ulcers. Residents Affected - Few This failure had the potential to put Resident 19 at risk for the delay of treatment and intervention to promote the wound healing of the multiple infected PU; and 2. For Resident 5, treatments on the right great toe and right outer foot were performed without a doctor's order. In addition, multiple skin problems on the resident's right hand were not identified and treated. This failure resulted in Resident 5 not receiving the proper treatment to address his skin conditions. Findings: 1a. On March 14, 2022, at 10:37 a.m., Resident 19 was observed lying in bed on a low air loss mattress (special mattress used for wound management). On March 14, 2022, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses that included multiple infected PU. The acute hospital's discharge order document titled, Take Home Medication List, dated March 10, 2022, indicated to give Resident 19 Vibramycin (brand name for Doxycycline) 100 mg (milligrams - unit of measurement) PO (by mouth) BID (twice a day) to start on March 10, 2022, at 9 p.m., for seven days for infected multiple PU. The facility's admission physician's order dated March 10, 2022, did not indicate the Doxycycline discharge order from the hospital was carried out by the licensed nurse upon admission to the facility. The facility's Comprehensive Resident Assessment, dated March 10, 2022, indicated Resident 19 was admitted with infected PU on right upper buttock, sacrum (bottom of the spine), left ischium (lower and back part of the hip bone), and left lateral foot redness. On March 17, 2022, at 9:50 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 19 was admitted to the facility on [DATE], with a diagnosis of multiple infected PU. The ADON stated Resident 19 had a discharge order from the hospital to give Doxycycline 100 mg PO BID to start on March 10, 2022, at 9 pm. The ADON stated Resident 19 did not receive the Doxycycline as ordered by the physician since she was admitted to the facility on [DATE]. On March 17, 2022, at 10:30 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was the licensed nurse who admitted Resident 19 to the facility on March 10, 2022. RN 1 stated she carried out the discharge orders from the hospital and she missed transcribing the order for Doxycycline. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 5 of 32 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 03/18/2022 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 RN 1 stated the Doxycyline was ordered as a part of the wound treatment for Resident 19's multiple infected PU. RN 1 stated it should have been carried out as ordered by the physician. RN 1 further stated if the treatment was not completed or carried out as ordered, it may contribute to the delay of the healing process of the infected wounds. Residents Affected - Few 1b. On March 14, 2022, at 3:40 p.m., Resident 19's record was reviewed. Resident 19 was admitted on [DATE], with a diagnosis that included multiple infected PU. The facility's Comprehensive Resident Assessment, dated March 10, 2022, indicated Resident 19 was admitted with multiple infected PU on right upper buttock, sacrum, left ischium, and left lateral foot redness. There was no documented evidence a baseline care plan was initiated upon admission to address Resident 19's diagnosis of multiple infected PU. On March 14, 2022, at 3:40 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2. RN 2 stated upon admission of Resident 19 on March 10, 2022, the facility should have initiated a baseline care plan to address Resident 19's multiple infected pressure ulcers. RN 2 stated the baseline care plan should include interventions and treatment to help prevent the development of further complications of the wounds and/or monitoring of the resident's response to the wound treatment. RN 2 stated the baseline care plan should have been initiated within 48 hours of Resident 19's admission. The facility's policy and procedure titled, Baseline Care Plan, revised 2022, was reviewed. The policy indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care .The baseline care plan will be developed within 48 hours of a resident's admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 6 of 32 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for three of four residents reviewed for smoking (Residents 24, 3, 18 and 25), when: 1. Resident 24 was observed smoking inside the facility; 2. Resident 3 had his cigarettes and lighter in his possession, offered a cigarette to another resident, and smoked a cigarette himself without staff supervision; 3. Resident 18 stated he usually had his lighter in his possession; and 4. Resident 25 had a cigarette in his possession while inside the facility. These failures had the potential to result in accidents or injuries to the residents. Findings: 1. On March 14, 2022, at 1:20 p.m., Resident 24 was observed in the North hallway, by her room. Resident 24 had, in her possession, a cigarette and a lighter. Resident 24 lit up the cigarette and started smoking inside the facility. Resident 24 continued smoking inside the facility, walked passed several residents' rooms and the nursing station, towards the outside patio. On March 14, 2022, at 1:25 p.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 24 was not allowed to have the cigarette and lighter in her possession, and was not allowed to smoke inside the facility. On March 14, 2022, at 2:40 p.m., an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated residents were not allowed to smoke inside the facility. RN 2 also stated she did not know how Resident 24 got possession of the cigarette and the lighter. RN 2 stated Resident 24 could not smoke safely and she should not have possession of smoking materials, as this was a safety risk for her and the other residents in the facility. RN 2 stated residents were only allowed to smoke in the designated smoking area (the outdoor patio), and only with supervision. On March 16, 2022, at 11:10 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated no residents were allowed to smoke inside the facility. The DON also stated Resident 24 was not supervised and the incident should not have happened. Resident 24's record was reviewed. Resident 24 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder (mood disorder), schizoaffective disorder (hallucinations, delusions, disorganized behavior), unspecified psychosis (disturbance in thoughts and perception), and nicotine dependence. The care plan titled, Resident Care Plan for Smoking, initiated on June 7, 2021, indicated, .Concerns & Problems .Resident is at risk for self-injury related to smoking .Potential for accidental burns from cigarette smoking .Resident Goals .Will have no injuries to self and others .Will be able to verbalize understanding of risks and complications associated with smoking .Approach Plan .Explain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 7 of 32 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm to resident the facility's policy and procedures regarding smoking .Explain to resident that smoking inside the facility is prohibited . The Resident Smoking Assessment Form, dated June 7, 2021, indicated, .Resident is considered a safe smoker and may smoke at this time supervised . Residents Affected - Some 2. On March 14, 2022, at 9:55 a.m., a smoking observation was conducted. Several residents were observed waiting for facility staff to come outside and begin supervised smoking. Resident 3 was observed in a wheelchair by the East Wing patio, legs raised, with a blanket over his legs. On his chest was a small black bag containing one pack of cigarettes and a light blue disposable lighter. One resident was observed to approach him and talk to him. Resident 3 proceeded to hand him one cigarette and light the cigarette with the disposable lighter. Both residents had a conversation for a few minutes. Resident 3 then instructed the other resident to move away from him. Resident 3 was observed to get one cigarette from the pack in his bag and light the cigarette with the disposable lighter. Resident 3 was interviewed. Resident 3 stated the facility had nine different times for smoking. Resident 3 stated he was allowed to keep his lighter and cigarettes, Me anyway, because I know what I'm doing. Resident 3 stated he had no issues regarding smoking except the facility staff did not get out on time for the smoke breaks. Resident 3 was observed flicking the ashes from his cigarette to the left side of his wheelchair. When he was finished smoking, he disposed of the cigarette butt on the concrete to the left side of his wheelchair. There were two cigarette butts on the concrete, indicating Resident 3 finished two cigarettes prior to the staff coming out to supervise smoking. At 10:05 a.m., two facility staff were observed to exit the Central Dining Room door towards the outside patio and started setting up for the smoke break. The staff started distributing smoking aprons and cigarettes to the residents at 10:07 a.m. At 10:40 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she supervised the smoke breaks until 10 a.m., the Activities department supervised until 1:45 p.m., and the Certified Nursing Assistants supervised in the afternoon until the 10 p.m., smoke breaks. CNA 2 stated Resident 3 was not supposed to have his cigarettes or lighter with him because he had an issue before where he also gave another resident cigarettes. CNA 2 stated the agreement with him was 1-2 cigarettes per smoke break and We're the ones who are supposed to give it to him. CNA 2 stated Resident 3 should not have had his cigarettes and lighter with him and should not have offered the other resident a cigarette and lit it. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses including cerebral palsy (impaired muscle coordination), contractures (shortening of the muscles) of the right upper arm and both lower legs. The History and Physical, dated February 16, 2022, indicated Resident 3 had the capacity to understand and make decisions. The Resident Smoking Assessment Form, dated December 2, 2021, indicated Resident 3 was an .unsafe smoker and must be supervised at all times when smoking . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 8 of 32 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Resident Smoking Assessment Form, dated March 3, 2022, was not completed to indicate if Resident 3 was a safe smoker and may smoke supervised. The Resident Care Plan for Smoking, revised March 5, 2021, indicated, Concerns and Problems .Resident is at risk for self-injury related to smoking .Potential for accidental burns from cigarette smoking .Resident Goals .Will have no injury to self and others daily . The care plan did not indicate interventions to prevent the resident from keeping his smoking materials including his cigarettes and lighter, or offering cigarettes to other residents. At 3:00 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 confirmed Resident 3 was not safe to smoke unsupervised. RN 2 stated Resident 3 should not have had his cigarettes and lighter with him and should not have offered the other resident any cigarettes. On March 18, 2022, at 9:35 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated residents were assessed upon admission and quarterly if they were safe to smoke. If they were, then they are allowed to smoke supervised. The DON stated the smoking materials including cigarettes and lighters were stored in the lockbox at the nurses' station. During smoke breaks, the smoking monitors (staff who supervised smoking) would take the lockbox out to the smoking area, distribute the cigarettes, and light the cigarettes for the residents. The DON stated Resident 3 should not have had his smoking materials with him and should not have offered the other resident a cigarette. The DON confirmed Resident 3's care plan was not updated. The DON stated if Resident 3 did not follow the facility's smoking guidelines, then his smoking care plan should have been updated and modified. 3. On March 14, 2022, at 3:52 p.m., Resident 18 was interviewed. Resident 18 stated, They just took my lighter today. Resident 18 stated he usually had his lighter with him. Resident 18's record was reviewed. Resident 18 was admitted to the facility on [DATE], with diagnoses including COPD (chronic obstructive pulmonary disease - a lung condition causing breathing difficulties). The History and Physical, dated August 7, 2021, indicated Resident 18 had the capacity to understand and make decisions. The Resident Smoking Assessment Form, dated August 7, 2021, indicated Resident 18 was .considered a safe smoker and may smoke at this time supervised . The Resident Smoking Assessment Forms, dated September 21, 2021 and December 21, 2021, were not completed to indicate if Resident 18 was a safe smoker and may smoke supervised. There was no documented evidence Resident 18 had a care plan for smoking. At 4:00 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 stated Resident 18 should not have had his lighter with him. RN 2 confirmed Resident 18 did not have a care plan for smoking. RN 2 stated Resident 18 should have had a care plan for smoking. On March 18, 2022, at 9:35 am., the DON was interviewed. The DON stated Resident 18 should not have had his lighter with him and a care plan should have been developed for smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 9 of 32 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On March 14, 2022, at 3:39 p.m., an observation was conducted with Resident 25. Resident 25 was observed wheeling himself in the main dining room going towards the back patio. Resident 25 was observed holding one unlit cigarette in his left hand. Resident 25 stated, I need a lighter. Resident 25 then proceeded to the back patio smoking area while there was no staff present nearby. On March 14, 2022, at 3:43 p.m., a concurrent observation and interview was conducted with the Activities Director (AD). The AD was observed to go out in the back patio to assist another resident. The AD passed by Resident 25 and talked to him for a bit. Resident 25 was still observed holding the unlit cigarette in his left hand. After speaking with Resident 25, the AD went back to the dining room. On March 14, 2022, at 3:44 p.m., an interview was conducted with the AD. The AD stated residents in the facility were not allowed to keep their lighters and cigarettes in their own possession for safety reasons. The AD further stated the activity personnel kept the residents' cigarettes and lighters for safety. The AD was asked if she noticed Resident 25 holding the unlit cigarette. The AD stated she did not notice Resident 25 holding an unlit cigarette. The AD went back out to talk to Resident 25. The AD stated Resident 25 had an unlit cigarette in his possession and he stated he had his cigarette stashed in his room and did not want to give the cigarette to her. On March 18, 2022, Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses that included Schizoaffective disorder (type of behavioral disorder) and weakness. The History and Physical, dated December 18, 2021, indicated Resident 25 had fluctuating capacity to understand and make decisions. The Resident Care Plan, dated December 18, 2021, indicated .Concerns & Problems .Resident is at risk for self-injury related to smoking .Potential for accidental burns from cigarette smoking .Resident Goals .Will have no injuries to self and others daily .Approach plan .Explain to the resident the facility's policy and procedures regarding smoking .Explain to resident that smoking inside the facility is prohibited . The Resident Smoking Assessment Form, dated December 18, 2021, indicated .Resident is an unsafe smoker and must be supervised at all times when smoking . On March 18, 2022, at 11:33 a.m., Resident 25's Smoking Assessment Form, dated December 18, 2021, was reviewed with RN 2. RN 2 stated, Resident 25 was evaluated as an unsafe smoker and he should not be allowed to keep his own cigarette or lighter in his possession. RN 2 further stated residents in the facility were not allowed to keep cigarettes and lighters in their possession. The facility policy and procedure titled, Resident Smoking, revised 2019, was reviewed. The policy indicated, .Smoking is prohibited in all areas except the designated smoking area .Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 10 of 32 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 03/18/2022 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one out of 95 residents (Resident 75) received the appropriate services needed to maintain acceptable parameters of nutritional status when: Residents Affected - Few 1. Significant severe weight loss of 14 lbs (pounds, a unit of measurement), 6.7 percent (%) from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the Interdisciplinary Team (IDT) which may include, Physician (MD), Registered Nurse (RN), Dietary Manager/Dietitian (Registered Dietitian, RD), Social Services, Activity Director/Coordinator .weight variance meeting; nor were interventions implemented to prevent further significant severe weight loss, and 2. There was no documented order for a Physician prescribed weight loss regimen. These failures contributed to on-going unaddressed significant severe weight loss in one, three, and six-month time frames which posed a threat for further medical complications. Findings: A record review for Resident 75 was conducted beginning March 15, 2022. Resident 75 was readmitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition that cause breathing difficulties), schizoaffective disorder (a mental illness that can affect a person's thoughts, mood and behavior), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), hypothyroidism (a medical condition when thyroid gland does not produce enough thyroid hormones to meet one's body's needs, may affect breathing, heart rate, weight, digestion, and mood), hypertension (high blood pressure), Hyperlipidemia (elevated fat levels in the body), polyosteoarthritis (a type of arthritis that affects five or more joints with most common symptoms of joint pain and inflammation), and legal blindness (a form of visual impairment that the glasses or contact lenses cannot correct the vision). Resident 75 was self-responsible. The most recent Minimum Data Set (MDS, a resident assessment tool), dated February 4, 2022, showed Resident 75 had a BIMS (brief interview of mental status) score of six which indicated she had moderate cognitive impairment. A review of the facility document titled, History and Physical Examination, completed on August 22, 2021 by Resident 75's MD, indicated Resident 75 did not have the capacity to understand and make decisions. Section K (Swallowing/Nutritional Status) of the annual MDS assessment, dated November 5, 2021, indicated Resident 75's height was 68 inches () and weight was 194 lbs. Review of a quarterly MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 11 of 32 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 03/18/2022 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 0692 Level of Harm - Actual harm assessment, dated February 4, 2022, indicated Resident 75's height was 68 and weight was 185 lbs. Both MDS assessments indicated Resident 75 had an unplanned significant weight loss of 5% or more in the last month or loss of 10% or more in the last six months. The MDS assessments further indicated Resident 75 was not on a physician-prescribed weight loss regimen. Residents Affected - Few A review of the facility document titled, Monthly Weight Record, for the year of 2021 and 2022, indicated the following weights for Resident 75: 8/23/21: 210 lbs 9/14/21: 210 lbs 10/14/21: 208 lbs 11/11/21: 194 lbs (a significant severe weight loss of 14 lbs, 6.7% from 10/14/21) 12/10/21: 193 lbs (a significant severe weight loss of 17 lbs, 8% from 9/14/21 to 12/10/21) 1/18/22: 190 lbs (a significant severe weight loss of 18 lbs, 8.6% from 10/14/21 to 1/18/22) 2/8/22: 185 lbs (a significant severe weight loss of 25 lbs, 11.9% from 8/23/21 to 2/8/22) 3/2/22: 176 lbs (a significant severe weight loss of 34 lbs 16.2% from 9/14/21 to 3/2/22) A review of the monthly physician progress notes dated November 5, 2021, December 27, 2021, and February 14, 2022, indicated Resident 75 was being seen by the physician (MD) via telehealth (the use of digital information and communication technologies, such as computers and mobile devices, to access health care services remotely and manage one's health care) with assistance from the facility staff. The notes indicated Resident 75 did not have a recent change in condition, Resident 75's appetite was fair, and to continue skilled nursing care. The significant severe weight loss of 14 lbs, 6.7 % from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the physician progress notes. On March 16, 2022, at 12:29 p.m., Resident 75's lunch meal observation and a concurrent interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated Resident 75's meal intake average was about 50% but depended on her mood. CNA 3 showed the finished lunch meal tray and stated Resident 75 ate about 50-75% of her meal. CNA 3 further stated Resident 75 sometimes asked for snacks and specific food, which the CNA 3 would give Resident 75. 1. On March 16, 2022, at 3:34 p.m., an interview and a concurrent review of Resident 75's monthly weight record was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed the documented weights from August 23, 2021 to March 2, 2022 on Resident 75's monthly weight record. LVN 1 stated she would be concerned the 14 lbs weight loss from October 14, 2021 to November 11, 2021, and the 9 lbs weight loss from February 8, 2022 to March 2, 2022. LVN 1 acknowledged Resident 75 had a 34 lbs weight loss in a six-month time frame from September 14, 2021 to March 2, 2022. LVN 1 further stated gradual weight loss was fine since Resident 75 was over her Ideal body weight range (IBWR). When asked if the 34 lbs weight loss from September 14, 2021 to March 2, 2022, was significant, LVN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 12 of 32 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 03/18/2022 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 0692 stated she was not sure if the weight loss was significant. Level of Harm - Actual harm LVN 1 stated all significant weight changes were discussed in the weekly IDT weight variance meeting. When asked for documentation of the IDT weight variance meeting addressing the significant severe weight losses from August 23, 2021 to March 2, 2022, the LVN was unable to confirm documentation in Resident 75's medical record. Residents Affected - Few On March 17, 2022, at 8:14 a.m. an interview was conducted with RN 3. RN 3 confirmed all significant weight changes should be discussed in the IDT weight variance meeting. On March 17, 2022, at 10:00 a.m., an interview and concurrent record review for Resident 75 was conducted with the Dietary Supervisor (DS). The DS stated Resident 75's mental status was about the same as the previous admission. Resident 75 had verbalized she wanted to lose weight on her previous admission. The DS stated Resident 75 did not verbalize she wanted to lose weight or set any weight goal during the present admission because she was not able to answer those questions. The DS stated on the readmission on [DATE], the RD set the goal for Resident 75 to have safe weight loss; one to two lbs per month if medically feasible due to the resident's weight status without any significant weight change. The RD set the target weight goal range (TWGR) of 195 to 200 lbs. The document titled Nutrition Screening and Assessment-OBRA, completed by the DS on November 4, 2021 showed, Resident 75's weight was 194 lbs in November 2021, a 14 lbs, 6.73% significant severe weight loss from October 2021 to November 2021. Resident 75's weight was 208 lbs in October 2021, a 16 lbs, 7.62% significant severe weight loss from August 2021 to November 2021. Resident 75's appetite (meal intake) was 50-74%. The section titled Comments showed, Resident 75's intake was down. The section titled Weight Note showed, resident had a weight loss of 14# (6.73%) x 30 days. Readmit weight on August 22, 2021 was 210#. She continued to be on a planned weight loss of 1-2# per month until TWGR is reached. She is currently at her TWGR. I did explain to resident we want the weight loss to be safe .Will refer to RD due to annual assessment & weight note, at her TWGR. The DS confirmed the 14 lbs, 6.73% weight loss in 30 days was a significant severe weight loss. When asked if the 14 lbs, 6.73% weight loss in 30 days was safe, the DS stated the weight loss was not safe if it was a significant weight loss. The annual nutrition review indicated the DS referred the assessment to the RD. A review of the document titled, Nutrition Screening and Assessment-OBRA, completed by the RD on November 8, 2021, under the Section titled Evaluation showed, Intake meets estimated nutrition needs at this time, Continue POC (plan of care). Under the Section titled Goal showed, TWGR 195-200 lbs, Without significant weight change, as medically feasible and Safe weight loss POC to attain TWGR as medically feasible. The DS confirmed the RD did not change the TWGR and that Resident 75 was below the TWGR. The DS confirmed the goal for Resident 75 was to not experience significant weight change and for safe weight loss to attain TWGR. A review of the document titled, Dietary Note: Weight, Quarterly completed by the DS on February 8, 2022, and electronically signed by the RD on February 10, 2022 showed, Resident 75's TWGR had been reduced to 180-184 lbs, weight was 185 lbs, 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The section titled, % Meal Intake showed 50-74% for breakfast, lunch and dinner. The section titled, Refer to RD showed, Yes, weight loss, below TWGR, D/C the planned weight loss on 2/8/22. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 13 of 32 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 03/18/2022 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 0692 Level of Harm - Actual harm Residents Affected - Few section titled, Meeting care plan goal, if no reason? showed, yes. The section titled, RDN Recommendations: showed, to continue POC, Res (Resident 75) is obese, has a weight loss POC (plan of care) and meeting weight goal. Monitor. A review of facility document titled, Nurse Assistant Notes: A.M. Shift and Night Shift, from October 1, 2021 to February 28, 2022, indicated there were 453 meals (Breakfast, Lunch, and dinner) served between October 1, 2021, and February 28, 2022. Resident 75 refused eight% of her meals and consumed 50% or less 41.5% of the time. The DS confirmed she tried to communicate with Resident 75 about her weight loss with the goal of one to two lbs per month but Resident 75 was not able to interview about the weight. The DS stated she suggested to discontinue the weight loss plan at that time and referred to the RD. The DS stated the RD wanted to continue the same plan of care and lowered Resident 75's target weight goal to 180-184 lbs. The DS stated she did not remember if she talked to the RD about the change of Resident 75's target weight goal, but she changed the care plan per the RD's assessment plan. The DS confirmed Resident 75 was not involved in the decision to reduce her TWGR but should have been. The DS confirmed Resident 75's significant severe weight loss of 14 lbs, 6.73% weight loss in 30 days and the significant severe weight loss of 16 lbs, 7.62% in 90 days, and 22 lbs, 11.9% weight loss in 180 days were not discussed in the IDT weight variance meeting. She stated the nurses or herself (the DS) determined which residents should be followed in the IDT weight variance meeting. She confirmed that she did not know why Resident 75 was not included in the weight variance for monitoring the significant weight loss since November 2021. A concurrent review of Resident 75's weight record dated March 2, 2022, was conducted with the DS. Resident 75 had another weight loss of nine lbs in a month, and weight loss of 34 lbs, 16.2% in six months. The DS stated the weight loss should have been discussed in the IDT weight variance meeting and she did not know why it was not discussed until March 16, 2022. The DS stated she did not attend the IDT weight variance meeting on March 16, 2022, but she signed it because the nurse went over what they discussed in the meeting. During an interview on March 17, 2022, at 11:55 a.m., RN 4 stated she entered the February 2022, and March 2022 weights on Resident 75's monthly weight record. On February 22, 2022, Resident 75's weight was 185 lbs with a weight loss of five lbs in a month. RN 4 stated she did not calculate the weight change percentage. RN 4 stated dietary was responsible to calculate the weight percentages and put in a form. RN 4 explained the process of significant weight loss if identified. She stated she would check resident's meal intake, and if the residents had any edema or medical conditions. RN 4 stated she would notify the MD and the RD. She stated for Resident 75, the February 2022, and March 2022 weights were still within Resident 75's IBWR but she still notified the MD because the weight loss was a significant change. RN 4 stated she did not document on the nursing progress notes that she notified the MD. RN 4 stated she documented NNO which meant no new order from the MD next to the weight change on the comment column in Resident 75's monthly weight record. When asked what the appropriate time frame to address a significant weight change was or if significant weight loss was considered safe, the RN 4 did not answer. During a follow up interview on March 17, 2022, at 2:11 p.m., the DS explained the process of identifying significant weight changes. The DS stated the Restorative Nurse Assistant (RNA) weighed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 14 of 32 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 03/18/2022 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 0692 Level of Harm - Actual harm Residents Affected - Few residents on the first of each month and took four to five days to complete. The residents' weights were entered in the computer and a form with the weight changes was generated. The DS stated she would go over the weights with the nurse, usually with the Assistant Director of Nursing (ADON). The DS stated if a resident was on a planned weight loss regimen, the facility would monitor the weight monthly. The DS stated if the resident was on a weight loss plan but had a significant weight loss, the facility would monitor weights weekly. The DS would communicate with the RD and initiate the weight loss assessment form which was emailed to the RD. She stated the RD would email the completed assessment back to the DS. During an interview and a concurrent record review with the Director of Nursing (DON) on March 17, 2022, 3:02 p.m., when asked if Resident 75's significant weight loss from November 2021 to March 2022 was discussed in the IDT weight variance meeting, the DON did not answer. The DON stated the facility should address the significant weight loss after the weights were entered in the medical record. The process would be to notify the MD and the RD. She stated then she would carry out any order from the MD. She reviewed Resident 75's record and stated there was no MD order for Resident 75's weight loss plan. The DON stated the facility should have addressed the significant weight loss on February 8, 2022, even though Resident 75 was on weight loss plan. She stated Resident 75 should be included in the IDT weight variance meeting and monitored Resident 75's weights closely. The DON acknowledged the goal from the RD was to have safe weight loss of one to two lbs per month, but she did not answer when asked if 14 lbs weight loss in a month on November 11, 2021, was consider safe. The DON stated that she would monitor weights weekly for a resident who had a significant weight loss even though he or she was on a weight loss program. A concurrent review of the facility document titled, Dietary Care Plan for Nutrition Status, for Resident 75, initiated on August 22, 2021, and updated on November 4, 2021, was conducted with the DON. The DON confirmed the plan of care did not reflect a weight loss plan until Resident 75's TWGR was reduced to 180-184 lbs on February 10, 2022. A phone interview was conducted with the RD on March 18, 2022, at 10:08 a.m. The RD confirmed significant severe weight loss parameters of 5% in a month, 7.5% in three months and 10% in six months. The RD stated she was aware of the consequences of significant severe weight loss. When asked if Resident 75's significant severe weight loss between November 2021 to March 2022 was safe the RD stated obesity was more important to deal with than significant severe weight loss. When asked if she involved Resident 75 in the weight loss plan, the RD stated she could not remember if she spoke to Resident 75. When asked if a resident on a weight loss plan should have a Physician's order, the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. A concurrent review of Resident 75's annual nutrition assessment completed on November 8, 2021, was conducted with the RD during the phone interview. The RD was asked if the significant severe weight loss of 14 lbs, 6.73% in one month was safe weight loss. The RD did not answer the question but stated the November 2021 weight was an outliner weight. The RD further stated, we cannot control how many pounds people lose and how they eat. A concurrent review of Resident 75's quarterly nutrition assessment completed on February 10, 2022, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 15 of 32 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 03/18/2022 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 0692 Level of Harm - Actual harm Residents Affected - Few was conducted with the RD during the phone interview. Resident 75's weight in February 2022 was 185 lbs, a significant severe weight loss of 22 lbs, 11.9% weight loss in 180 days since August 23, 2021. The DS had a comment to hold the weight loss plan due to the weight loss and she referred to the RD. The RD disagreed and adjusted and reduced the TWGR to 180-184 lbs. When asked why the TWGR was decreased after Resident 75 had experienced a significant severe weight loss in the past 180 days, the RD stated she adjusted the weight goal as Resident 75 lost the weight. She added she would stop the weight loss plan now and the facility would start to follow Resident 75 more closely. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked what Resident 75's nutrition plan was since admission, the MD stated he did not remember. When asked if he remembered Resident 75 was on a weight loss regimen, he stated the RD would be the one to make those recommendations. When asked if he wrote an order for a physician-prescribed weight loss regimen, the MD stated he believe he gave the RD a verbal order for a planned weight loss regimen. The MD was asked if Resident 75's significant severe weight loss of 25 lbs, 11.9% in five months in February 2022 and the significant severe weight loss of 34 lbs, 16.2% in six months in March 2022 was safe, the MD stated he could not answer that question without reviewing Resident 75's medical record. A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations or interventions for Resident 75's significant weight losses which occurred between November 11, 2021 and March 2, 2022. A review of facility document titled, Dietary Care Plan for Nutritional Status, initiated on August 22, 2021, and updated on November 4, 2021, it indicated the plan of planned weight loss did not start until February 10, 2022, with one to two lbs weight loss per month to the goal of 180-184 lbs. The other goal was for Resident 75 to consume meals at least 75% of meals and minimize the risk for significant weight loss of five lbs per month. The care plan indicated the approach plan for the facility to encourage Resident 75 to consume 75-100% of her meal, the facility should monitor weight and report + or - five lbs or more per month to the MD, and to notify the MD for any significant weight loss. A review of the facility policy and procedure titled, Weight Monitoring, revised 2022, indicated, .the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range .the facility will utilize a system approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors. b. Evaluating/analyzing the assessment information. c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary .nutrition assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns .the care plan should address the following .a. identified causes of impaired nutritional status .c. Identify resident-specific interventions; d. Time frame and parameters for monitoring; e. Updated as needed such as when the resident's condition changes .interventions are determines to be ineffective or a new causes of nutrition-related problems are identified; f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate .Interventions will be identified, implemented, monitored, and modified, consistent with the resident's assessed needs .to maintain acceptable parameters of nutritional status .Residents with weight loss - monitor weight weekly .A significant change in weight is defined as: a. 5% change in weight in 1 month .b. 7.5% change in weight in 3 months .c. 10% change in weight in 6 months .Documentation: .the physician should be informed of a significant change in weight and may order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 16 of 32 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 03/18/2022 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 0692 Level of Harm - Actual harm nutritional interventions; b. The physician should be encouraged to document the diagnosis or clinical conditions that may contributing to the weight loss .e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .g. The interdisciplinary plan of care communicates care instructions to staff . Residents Affected - Few 2. On March 17, 2022, at 9:30 a.m., an interview and concurrent record review with the MDS Coordinator (MC) was conducted regarding Section K of Resident 75's annual assessment dated [DATE], and the quarterly assessment dated [DATE]. Section K for both the annual and quarterly assessments indicated Resident 75 experienced a significant unplanned weight loss of 5% or more in the last 30 days, or a significant unplanned weight loss of 10% or more in the last 180 days. The MC confirmed the significant unplanned weight loss in the quarterly and annual assessments for Resident 75 was not a physician-prescribed weight loss regimen. The MC stated physician-prescribed means a physician's order. The MC further stated he was aware Resident 75 was on a weight loss program with a weight loss goal of one to two lbs per month. The MC stated Resident 75 weight losses for the annual and quarterly assessments were more than one to two lbs per month and therefore not considered a physician-prescribed weight loss. The MC stated the MD should be aware of a planned weight loss regimen. The MD was responsible for any new orders or a change of the planned weight loss regimen. The MC confirmed Resident 75 did not have a physician order for the planned weight loss regimen of one to two lbs in a month. During an interview and a concurrent record review with the DON on March 17, 2022, at 3:02 p.m., the DON confirmed there was not a physician order for a weight loss regimen. During a phone interview with the RD on March 18, 2022, at 10:08 a.m., the RD stated nursing was responsible to get an order from the MD for a physician prescribed weight loss plan. The RD stated she did not enter a recommendation for a physician prescribed weight loss regimen for Resident 75 on the RD recommendation form. On March 18, 2022, at 10:50 a.m., an interview was conducted with the RN 2. When asked who was responsible to get a physician order for a physician prescribed weight loss regimen, the RN 2 stated a weight loss regimen was based on the RD recommendations. The RN 2 was unable to confirm the MD order for a weight loss regime for Resident 75. A phone interview was conducted with Resident 75's MD on March 18, 2022, at 11:59 a.m. When asked if he wrote an order for a physician-prescribed weight loss regimen, the MD stated he believe he gave the RD a verbal order for a planned weight loss regimen. A review of facility document titled, RDN (Registered Dietitian Nutritionist) Recommendations, dated August 2, 2021, to March 10, 2022, indicated the RD did not have any recommendations for a planned weight loss regimen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 17 of 32 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 03/18/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 57), when the physician's order for oxygen administration was not followed. Residents Affected - Few This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition. Findings: On March 14, 2022, at 9:48 a.m., Resident 57 was observed in bed with oxygen (O2) via nasal cannula (N/C - a tube used to deliver oxygen through the nose). Resident 57's oxygen administration was observed at one liter per minute (LPM). In a concurrent interview, Resident 57 stated she used O2 as needed, when she was short of breath (SOB), and the level should be at three LPM. Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a disease that causes obstructed airflow from the lungs). The physician's order dated January 14, 2022, indicated, .administer O2 inhalation at 2-3 LPM via NC as needed for SOB . On March 14, 2022, at 1:17 p.m., Resident 57 was observed in bed, with O2 on, at one LPM. A concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 went to Resident 57's room and checked the oxygen level. LVN 1 stated the oxygen level was at one LPM. LVN 1 stated the oxygen level should be between two and three LPM, as per physician's order. LVN 1 further stated the physician's order was not followed. The facility policy and procedure titled, Oxygen Administration, revised 2022, was reviewed. The policy indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 18 of 32 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 03/18/2022 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. 2. On March 16, 2022, at 10:23 a.m., an inspection of the treatment cart was conducted with the Treatment Nurse (TN). The following were found, readily available for use: - NYSTOP (Nystatin- an antifungal) powder labeled for Resident 22, with a fill date of February 10, 2022. The label further indicated APPLY TOPICALLY TO PERINEAL REDNESS 2 TIMES A DAY FOR 30 DAYS . The TN stated Resident 22 had the treatment before and did not have a current order for it. The TN stated she did not discard the bottle because the resident would ask for it. - One container of Cerave moisturizing cream labeled for Resident 72, with a fill date of January 5, 2022. The TN stated Resident 72 was already cleared so he did not need it anymore. - Eleven 4x4 gauze dressings with expiration dates of July 2020. The TN stated these were supplies from hospice. The TN stated she cleaned the treatment cart but missed these items and she should have removed them. The TN stated medications without a doctor's order and expired treatment supplies should not be in the treatment cart, readily available for use. On March 18, 2022, at 9:20 a.m., the Director of Nursing (DON) was interviewed. The DON stated unused and expired treatment medications and supplies should not have been in the treatment cart, readily available for use. The facility's policy and procedure titled, DISCONTINUED MEDICATIONS, revised 2022, was reviewed. The policy indicated, .Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with the facility policy . The facility's policy and procedure titled, Destruction of Unused Drugs, revised 2022, indicated .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with our established procedures . Based on observation, interview, and record review, the facility failed to ensure discontinued and expired medications were not stored in the medication and treatment carts, readily available for use. This failure increased the risk for the licensed nurses to administer discontinued and expired medications to the residents which could result in medication and treatment errors. Findings: 1. On March 16, 2022, at 11:36 a.m., an inspection of the medication cart in the medication room was conducted with RN 2. A medication cart was observed stored inside the medication room. In a concurrent interview, RN 2 stated the medication cart was not used since February 2022. RN 2 stated all medications inside the medication cart were readily available for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 19 of 32 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 03/18/2022 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 The following medications were stored in the medication cart: Level of Harm - Minimal harm or potential for actual harm -one open bottle of Vitamin C (vitamin/supplement) liquid with an expiration date of November 2021; -one open bottle of ProStat (protein supplement) with an expiration date of June 2021; Residents Affected - Some -one open bottle of Geritussin (cough medicine) with an expiration date of September 2021; -one open bottle of Normal Saline 250 ml (milliliter - unit of measurement) with an expiration date of February 2022; -one open box of needles with an expiration date of November 2021; -one open bottle of Loratadine (an antihistamine medicine that helps with the symptoms of allergies) 10 mg (milligram a unit of measurement) tablet with an expiration date of August 2021; -one open bottle of Docusate Sodium (stool softener) 100 mg tablet with an expiration date of November 2021; -one open bottle of Geri-dryl (allergy relief) 25 mg tablet with an expiration date of November 2021; -one open bottle of Bisacodyl (laxative) 5 mg tablet with an expiration date of January 2022; -one open bottle of Docusate Sodium 100 mg gel capsule with an expiration date of January 2021; -one open bottle of Ferrous Sulfate (iron supplement) 325 mg tablet with an expiration date of January 2022; -one open bottle of Vitamin E (vitamin/supplement) 400 IU (international unit) soft gel with an expiration date of June 2021; and -one open bottle of Acetaminophen (pain medicine) 500 mg tab with an expiration date of January 2022. In a concurrent interview with RN 2, RN 2 stated the discontinued and expired medications stored in the medication cart should have been discarded properly and should not have been stored readily available for use. RN 2 further stated, These medications are not effective anymore. On March 16, 2022, at 2:32 p.m., the Director of Nursing (DON) was interviewed. The DON stated the discontinued and expired medications from the medication cart should have been removed and should have been disposed of properly. The DON further stated the discontinued medications should not have been stored in the medication cart because this had the potential for the licensed nurses to administer the medications and may result in medication error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 20 of 32 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 03/18/2022 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when one [NAME] (Cook 1) did not monitor and did not know the process for ambient (current air temperature) cool down of Time/Temperature Control for Safety (TCS) foods (cross refer to F812, finding number 1). This failure had the potential to cause food borne illness in a potentially compromised population of 90 out of 95 residents who received food from the kitchen. Findings: During the review of facility document titled, Physician Orders List, dated March 14, 2022, it indicated there were 90 residents who had physician diet orders and received food from the facility kitchen. During the follow-up observation of the reach-in refrigerator in the kitchen on March 14, 2022, at 3:02 p.m., a batch of egg salad in a full sheet and deep metal pan was found with a temperature of 59.9 degrees Fahrenheit (F). During a concurrent interview with [NAME] 1, he stated he prepared it around 2:30 p.m., and stated he did not monitor the temperature before storing it away in the refrigerator. He stated used the cooling log for the boiled eggs. During a concurrent review of the cooling log, it showed he started the cool down of the boiled eggs at 140 degrees F at 12:00 p.m. [NAME] 1 stated he put the boiled eggs in the ice bath, took the temperature at 1:30 p.m., and it measured 70 degrees F. At 2:00 p.m. it was 34 degrees F. [NAME] 1 stated he then put the cooled down eggs in the processor and mixed them with celery, mayonnaise, and relish. Cook 1 stated he put the mixture of egg salad in the refrigerator around 2:30 p.m., without measuring the temperature. [NAME] 1 stated he did not use the cooling log to track the cooling down process of the egg salad. He stated he was not sure of the process for cooling down the egg salad. He stated he got the cooling down in-service last week from the Dietary Supervisor (DS). During a concurrent interview with the DS, she acknowledged [NAME] 1 did not monitor the temperature for the cooling down process of the egg salad. The DS stated [NAME] 1 needed to do cooling down after he mixed the ingredients of the egg salad by using the cooling log to track the temperature. A concurrent review of departmental document titled, Title of In-service: Cooling and Reheating PHF (potential hazardous foods), completed on August 27, 2021, was reviewed. It did not show the in-service included ambient food cooling down procedure. During the follow up interview with the DS on March 17,2022, at 10:15 a.m., she stated [NAME] 1 should know the process of ambient food cooling down, and that the kitchen made egg salad usually twice a week. During an interview with the facility Registered Dietitian on March 18, 2022, at 9:46 a.m., she stated [NAME] 1 needed to follow the cooling process and filled in the cooling log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 21 of 32 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 03/18/2022 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of [NAME] 1's personnel file (date of hire: August 24, 2018), included a facility document titled, Dietary Aide Competency: Annual Competency, completed on January 10, 2022, it indicated that [NAME] 1 was competent with food handling and evaluated by the DS. A review of undated departmental policy and procedure titled, Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), indicated PHF must be cooled within four hours to 41 degrees F or less when prepared from ambient temperature ingredients and using the cool down log to track the ambient temperature foods. According to the FDA Federal Food Code, 2017, Safe cooling required removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety food has been consistently identified as one the leading contributing factors to foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 22 of 32 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 03/18/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on March 15, 2022, when 11 residents with a CCHO (Consistent Carbohydrate to treat medical condition of diabetes) mechanical soft (food was broken down for easy chewing) diet and 21 residents with a CCHO regular (no modification made to food) diet received a whole piece of chocolate cake with whipped topping instead of a half piece. This failure had the potential to result in increased blood sugar levels of 32 residents with a CCHO diet. Findings: On March 15, 2022, at 1:15 p.m., the dietary staff was observed to serve the whole, size of two inches by two inches by half inch (2x 2x 1/2) chocolate cakes to residents receiving regular CCHO and mechanical soft CCHO diets. A concurrent review of the undated departmental menu spreadsheet titled, Spring Cycle menus, week 2 Tuesday 3/15/22 ., indicated residents with a CCHO regular diet and a CCHO mechanical soft diet should have received a half piece of 2x 2x 1/2 chocolate cake with whipped topping. A review of the physician order for all residents' diet titled, Physician orders list, dated March 14, 2022, indicated there were 21 residents receiving a regular CCHO and 11 residents receiving a CCHO mechanical soft diet. On March 15, 2022, at 1:50 p.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated the residents with a CCHO diet should have been served half of the regular 2x 2x 1/2 chocolate cake instead of the whole piece. A review of the facility's policy titled, Food Preparation Guidelines, dated 2022, indicated, .The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 23 of 32 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 03/18/2022 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture for one resident (Resident 76) who was on a NAS (no added salt), CCHO (consistent carbohydrate that treats medical condition of Diabetes Mellitus), mechanical soft texture diet (a diet texture with a soft and chopped or ground texture for one who has difficulty chewing or swallowing) received a whole grilled quesadilla with cubed chicken for an alternate meal at lunch meal on March 15, 2022. This deficient practice had potential for Resident 76 to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) which could further compromise his medical status. Findings: During lunch meal service observation on March 15, 2022, beginning at 12:09 p.m., Resident 76, with a mechanical soft texture diet order, received a whole grilled quesadilla (brown and crispy tortilla) with cubed chicken as an alternative meal. During a concurrent interview with the Dietary Supervisor (DS), she verified with the cook and stated it was not appropriate. The DS instructed the cook to grind the cubed chicken into ground chicken and cut the quesadilla, with a brown and crispy tortilla, in half. During an interview on March 17, 2022, at 10:15 a.m., the DS confirmed that the grilled quesadilla with cubed chicken was not appropriate for the mechanical soft textured diet. She stated the chicken needed to be ground and the tortilla needed to soft, not crispy. A chart review of Resident 76 on March 16, 2022, at 12:25 p.m., indicated that Resident 76 had a physician diet order of NAS, CCHO, Mechanical Soft diet with a starting date of July 30, 2021. Resident 76 had pertinent diagnosis with Chronic obstruction pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Parkinson's disease (a progressive disease of the nervous system that leads to shaking, stiffness, and difficulty with walking, talking, swallowing, balance, and coordination), Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), and Hypertension (high blood pressure). On the dental report completed on September 27, 2021, it indicated that Resident 76 was edentulous at upper and lower teeth and requesting new set of dentures. On the dietary care plan for nutrition status, dated July 30, 2021, it stated Resident 76 was on a mechanically altered diet due to chewing problems. On the nutrition screening and assessment completed on August 5, 2021, it indicated Resident 76 had chewing difficulties at times and needed mechanical altered food texture for ease of chewing. A review of departmental document titled, Diet Manual - Regular Mechanical Soft Diet, dated 2020, read, .the Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations .modified in texture to a soft, chopped and ground consistency . It also indicated whole or chopped meat needed to be avoided for meats, and hard or toasted breads or grain products needed to be avoided. A review of departmental policy and procedure titled, Food Preparation Guidelines, dated 2022, read, .4. Food shall be provided in a form (i.e. regular, cut, chopped, ground, pureed) that meets each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 24 of 32 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 03/18/2022 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 0805 resident's individual needs in accordance with his or her assessment and care plan . 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 25 of 32 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 03/18/2022 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 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 store, prepare, and distribute food in accordance with professional standards for food service safety when: Residents Affected - Many 1. A full sheet deep metal pan of egg salad prepared on March 15, 2022, was found in the reach-in refrigerator without food temperature monitoring for the cool down process; 2. Three various sized cooking pans, readily available for use, had dry and heavy black residue buildup on the cooking surface; 3. Several various sized plastic containers and metal pans were stacked and stored wet; and 4. The kitchen staff did not utilize the correct manufacturer's directions to sanitize the dishes for the manual dishware washing using the 3-compartment sink. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen. The facility census was 95. Findings: 1. On March 14, 2022, at 3:02 p.m., a full sheet deep metal pan of egg salad prepared on March 14, 2022, was observed in the reach-in refrigerator. Its temperature was taken and was 59.9 Fahrenheit (F). A concurrent interview and record review of the cooling log was conducted with [NAME] 1. [NAME] 1 stated the egg salad was done at 2:30 p.m., and put in the refrigerator. [NAME] 1 reviewed the cooling log and stated he did not do the cool down process or monitor the temperature for the egg salad. He stated he did the cool down process for the boiled eggs starting from 12:00 p.m. to 2:00 p.m. Cook 1 stated he started to pour the cooled down eggs into the processor then added celery, mayonnaise, and relish to mix into the egg salad. He stated he did not do the cooling process and did not take the temperature to monitor the cooling down process. [NAME] 1 stated he was not sure about the cooling process for the egg salad. On March 14, 2022, at 3:10 p.m., an interview was conducted with the Dietary Supervisor (DS). The DS stated [NAME] 1 needed to start the cooling process once the egg salad was done. On March 18, 2022, at 9:45 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated [NAME] 1 should have followed the cooling process and record the temperature in the cooling log. A review of the undated departmental policy and procedure titled, COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS (PHF) also called Time/Temperature Control for Safety (TCS), read, .Potentially hazardous foods shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted foods .Use cool down log . 2. During the follow up kitchen observation on March 15, 2022, at 9:38 a.m., three various sized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 26 of 32 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 03/18/2022 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 - Many cooking pans hanging on the pots and pans rack, ready to use, were observed to have dry heavy black residue buildup on the cooking surface. During a concurrent interview with the DS, she verified the three cooking pans had heavy black buildup and were not cleanable. The DS stated the black buildup might chip and could contaminate the food. The DS stated they needed new cooking pans. On March 18, 2022, at 9:47 a.m., an interview was conducted with the RD. The RD stated, To follow the facility's policy and take care of the issues. A review of the undated departmental policy and procedure titled, SANITATION, indicated, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 3. During the kitchen initial tour on March 14, 2022, at 9:50 a.m., and 10:25 a.m., there were two 2-quart (a unit of liquid capacity), three eight-quart and three four-quart plastic containers, and five one-quarter (1/4) sheet and one half (1/2) sheet metal pans were found stacked wet and stored in the clean storage areas. During a concurrent interview with the DS, she stated those containers and metal pans needed to be completely air-dry before being stored away. On March 18, 2022, at 9:48 a.m., an interview was conducted with the RD. The RD stated, To follow the facility's procedure. A review of the undated departmental policy and procedure titled, DISH WASHING was conducted. It indicated, .Dishes are to be air dried in racks and before stacking and storing . 4. During the kitchen initial tour on March 14, 2022, at 10 a.m., Dietary Aide (DA) 1 verbalized the process of manual dishware washing by using the three-compartment sink. DA 1 stated the sanitizing step was to immerse the washed dishes in the sanitizing solution for 45 seconds and stated she followed the instructions posted on the wall. A review of the instructions posted on the wall indicated the immersion time for all washed items was 45 seconds. A review of the instructions printed on the tub of the sanitizer solution indicated, Sanitization of food processing equipment, utensils, and other food contact articles .sanitizing by immersing articles .(200-400 ppm [parts per million - unit of measurement] active quaternary [a chemical sanitizer to sanitize the dishes]) for at least 60 seconds . A concurrent interview was conducted with the DS. The DS stated she was not aware that the posted immersion time was incorrect. She stated she needed to contact the manufacturer to confirm the immersion time information. During a follow up interview with the DS on March 15, 2022, at 9:15 a.m., she reviewed a new poster for instructions for the three-compartment sink dishwashing from the manufacturer and confirmed the immersion time should be at least 60 seconds. On March 18, 2022, at 9:50 a.m., an interview was conducted with the RD. The RD stated kitchen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 27 of 32 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 03/18/2022 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 staff should follow the manufacturer's guideline when operating the three-compartment sink. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 28 of 32 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 03/18/2022 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and implement a policy and procedure for Foods Brought by Family/Visitors, that included provisions on facility providing education and information about safe food handling (such as safe cooling/reheating process, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.) practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who were involved in preparing, handling, serving, or assisting the resident with meals or snacks. Residents Affected - Some This failure had the potential to cause foodborne illnesses in a medically vulnerable population of residents who could consume food and receive food from family or visitors. The facility census was 95. Findings: On March 12, 2022, at 3:35 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated family and visitors could bring food for the residents. She stated the food from outside, or leftovers would be kept in the designated resident's refrigerator for 72 hours. RN 2 was not able to verbalize the process of safe food handling and stated she did not receive any in-service regarding safe food handling for food brought in from outside of the facility. On March 15, 2022, at 9:45 a.m., an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated family and visitors could bring food for the residents and the leftovers could be kept in the designated resident's refrigerator. She stated she did not know how long the leftovers could be kept in the refrigerator. CNA 2 stated she had an in-service regarding food brought in from outside sources. CNA 2 was not able to verbalize the process of safe food handling. On March 15, 2022, at 10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated family and visitors could bring food from outside for the residents and the leftovers could be kept in the designated resident's refrigerator for three days. LVN 1 stated she had an in-service for food brought in from outside sources a long time ago, but she was not able to verbalize the process of safe food handling. On March 15, 2022, at 10:08 a.m., an interview was conducted with CNA 2. CNA 2 stated family and visitors could bring food for residents and the leftovers would be kept in the designated resident's refrigerator for one day. CNA 2 stated she had an in-service for food brought in from the outside but could not remember if the process of safe food handling was provided. On March 15, 2022, at 10:15 a.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated he was involved in the process of admitting new residents to the facility. The ADON stated the facility usually did not tell the new residents' families that they could bring food for them. The ADON stated the facility allowed family and visitors to bring food from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 29 of 32 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 03/18/2022 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some outside for the resident if necessary. He stated the leftovers could be kept in the designated resident's refrigerator for three days or 72 hours. On March 15, 2022, at 10:35 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility allowed the family and visitors to bring in food and home-cooked food for the residents. She stated the food could be kept in the resident's refrigerator for no more than a day because the facility tried to encourage the residents to consume in the same day. The DON reviewed the policy and procedure and stated she was not aware the food leftovers could be kept in the refrigerator for 2 days. She also acknowledged that the staff had inconsistent information regarding the time frame to keep the food and leftovers in the resident's refrigerator. A concurrent review with the DON regarding the facility's policy and procedure titled, FOOD FOR RESIDENTS FROM OUTSIDE SOURCES, undated, indicated, .3. Prepared food brought in for the resident must be consumed within one (1) hour of receiving it .Unused food will be disposed of immediately thereafter .5. Prepared food .If opened .disposed of in 2 days after opening . The DON acknowledged number three and number five of the policy and procedure contradicted each other, and she was not able to clarify both statements The DON acknowledged and agreed the policy and procedure did not include the provision for the facility to provide education or material for family or visitors regarding safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 30 of 32 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 03/18/2022 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain the ice machine in safe operating condition when the ice machine was not cleaned, and the manufacturer's manual was not followed. Residents Affected - Many This failure had potential to cause food-borne illness in a highly susceptible population of 90 out of 95 residents who received food from the kitchen. Findings: A review of facility document titled, Physician Orders List, dated March 14, 2022, indicated 90 residents were on diets and received food from the kitchen. During an observation of the ice machine on March 14, 2022, at 11:25 a.m., there were significant amounts of black and gelatinous residue found behind the bottom of the harvester (a part of ice machine looks like a panel where a sheet of ice cubes slides into the storage bin during the harvest cycle) and could be easily removed with a white paper towel. In addition, there were white deposits found located on the top at the side of the ice storage bin. During an interview on March 14, 2022, at 11:25 a.m. and the follow up interview on March 14, 2022, at 3:41 p.m., with the Maintenance Supervisor (MS), he stated the maintenance department was responsible to do deep cleaning for the ice machine monthly and there was a technician from an outside company to clean the ice machine every two months. The MS stated the last deep cleaning for the ice machine was on February 27, 2022. He stated the technician from the outside company was responsible to clean the harvester part and he was not supposed to clean that area. The MS stated he did not take components of ice machine apart except the hose to clean. He stated he was not licensed and just tried his best to clean the ice machine. He stated he was responsible to run the cleaning and sanitizing cycles of the ice machine and cleaning the ice storage bin during the deep cleaning monthly. The MS stated he used the cleaning solution to pour into the machine and run the cleaning cycle for 20-45 minutes, then ran the sanitizing cycle for 20-45 minutes with sanitizing solution, and next to rinse with warm water for few cycles. For the ice storage bin, the MS stated he would use four drops of bleach mixed with 12 ounces of water to clean the interior area of the bin with a clean cloth, and then he would use plain water to rinse and let it dry before making ice. The MS acknowledged that he did not follow the proper steps to clean and sanitize the ice machine. He stated he never received training from anyone, but learned by mistakes and what the surveyors taught him during the prior annual surveys. He added he learned from the employees who worked for the industrial supply store by asking questions about the ice machine. The MS stated he did not follow the manufacturer's manual because he did not have one. He stated he followed the steps of cleaning and sanitizing instructions inside the ice machine cover. During an interview with the technician from the outside company (TOC) on March 14, 2022, at 4:33 p.m., he stated he provided cleaning service for the ice machine every two months, and he replaced the filter for the ice machine during each of his visits. He stated he would clean the machinery part for the ice machine. He stated he would use the cleaner solution to run the cleaning cycle for 45 minutes and then using plain water to run two cycles as rinsing. Then the ice machine started making ice and needed to discard first two batches of ice and the ice could be used when making the third batch. He stated he followed the manufacturer's manual. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 31 of 32 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 03/18/2022 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During the follow up interview on March 15, 2022, at 8:31 a.m., the MS provided the manufacturer's manual from the TOC, and stated the manual was not for the right model. He stated he did not know the model number of the ice machine and could not obtain the right manufacturer's manual. A review of the cleaning and sanitizing instructions inside of the ice machine titled, Scale Removal and Sanitizing Instructions, undated, indicated there were 22 steps to clean and sanitize the ice machine. The ice machine needed to use cleaning solution for the cleaning cycle and sanitizing solution for the sanitizing cycle. In addition, components of the ice machine needed to be taken apart to clean and sanitize with cleaning and sanitizing solutions respectively. A review of an undated departmental policy and procedure titled, Ice Machine Cleaning Procedures, read, .the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly .information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and /or in the directional panel on the inside of the ice machine . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 32 of 32