Inspection·August 4, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The physician order dated July 10, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation .The care plan dated July 1, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.The nursing progress notes indicated the following:On July 20, 2025, at 10:38 a.m., Resident 3 left the faciity on pass to the store.On July 20, 2025, at 8:00 p.m., nursing staff contacted Resident 3 via phone and Resident 3 stated he called 911 due to anxiety and right leg pain.On July 21, 2025, at 7:31 a.m., the facility called (name of hospital) and was informed by (name of hospital) staff Resident 3 was on a 5150 hold ( 72-hour hold for a person experiencing a mental health crisis).On July 23, 2025, at 5:50 p.m., Resident 3 was re-admitted into the facility.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 20, 2025, at 10:30 a.m., Resident 3 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 3 during the LOA.The Leave of Absence Logbook further indicated on June 24, June 25, June 26, July 3, July 7, July 12-19, and July 24-31, 2025, Resident 3 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 3 during the LOA.1d. On July 30, 2025, Resident 4's medical record was reviewed.The admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness) and psychosis (loss of reality).The history and physical completed by the physician on August 9, 2024, indicated Resident 4 can make needs known but cannot make medical decisions.The physician order dated July 30, 202, indicated .may go on temporary leave of absence for sensory stimulation with staff.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 10 and July 21, 2025, Resident 4 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 4 during the LOA.1e. On July 30, 2025, Resident 6's medical record was reviewed.The admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included psychosis (loss of reality).The history and physical completed by the physician on July 2, 2025, indicated Resident 6 had the capacity to understand and make decisions.The physician order dated July 2, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The progress note nursing dated July 11, 2025, indicated Resident 6 .left via Uber (transportation service) for appt and LOA to stay overnight with a friend.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 3, July 6, and July 11, 2025, Resident 6 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 6 during LOA.There was no documented evidence an assessment was conducted to ensure Resident 6 was safe to go out overnight on LOA independently on July 11, 2025.1f. On July 30, 2025, Resident 7's medical record was reviewed.The admission record indicated Resident 7 was admitted to the facility on [DATE], with the diagnoses which included Dementia (loss of intellectual functioning), depressive disorder (persistent feeling of sadness), and Alzheimer (slowly destroys memory).The history and physical completed by the physician on September 27, 2025, indicated Resident 7 does not have the capacity to understand and make decisions with a BIMS (measurement of cognitive function 0 to 15) score of 05 (higher the score higher the cognitive function).The physician order dated September 6, 2024, indicated .may go on temporary leave of absence with staff for therapeutic sensory stimulation.The care plan dated July 3, 2025, indicated .Focus.elopement.Goal.resident will be kept in safe environment.Intervention.allow resident to wander within the unit; assure that environment is safe and secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 2 of 10 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 08/04/2025 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 May 10, June 18, June 20, June 21, June 25, and July 2, 2025, Resident 6 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 6 during the LOA.1g. On July 30, 2025, Resident 9's medical record was reviewed.The admission record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), major depressive disorder (persistent feeling of sadness), and auditory hallucinations (perception of something not present),suicidal ideations (thinking, considering, or planning suicide), anxiety disorder (feeling nervousness), cannabis dependency (need of marijuana), alcohol abuse (need of alcohol).The facility was unable to provide a history and physical for Resident 9.The physician order dated June 20, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The care plan dated June 20, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 22 and June 23, 2025, Resident 9 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 9 during the LOA.1h. On July 30, 2025, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included Anxiety disorder (feeling nervousness) and major depressive disorder (persistent feeling of sadness).The history and physical completed by the physician dated May 1, 2025, indicated Resident 10 had the capacity to understand and make decisions.The physician order dated May 8, 2024, indicated .may go on temporary leave of absence for sensory stimulation with staff.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 6, June 17, June 20, and June 25, 2025, Resident 10 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 10 during the LOA.1i. On July 30, 2025, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included Depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness) disorder, delusional (belief of things not true), bipolar (manic and depressive episodes).The history and physical completed by the physician on May 19, 2025, indicated Resident 12 had the capacity to understand and make decisions.The physician order dated May 19, 2025, indicated the following, .may go on temporary leave of absence with staff for therapeutic stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on April 22, April 25, May 2, May 20, May 22, May 25, June 1, June 2, June 7, and July 10, 2025, Resident 12 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 12 during the LOA.1j. On July 30, 2025, Resident 13's medical record was reviewed.The admission record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality) and anxiety (feeling nervousness disorder) depression (persistent feeling of sadness).The history and physical completed by the physician on May 19, 2025, indicated Resident 13 had the capacity to understand and make decisions.The physician order dated June 17, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.The care plan dated July 4, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 2 -7, June 18 - 22, June 28 - June 30, July 5, July 7 - 15, July 17 - 20, July 26, and July 28 - 30, 2025, Resident 13 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 13 during the LOA.1k. On July 30, 2025, Resident 14's medical record was reviewed.The admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), anxiety (feeling of nervousness), suicidal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 3 of 10 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 08/04/2025 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 ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on May 30, 2025, indicated Resident 14 had the capacity to understand and make decisions.The physician order dated May 30, 2025, indicated .may go on a temporary leave of absence with staff for sensory stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on June 10, June 13, June 15 -18, June 20, June 28 - 30, July 2, July 4-5, July 9-11, July 13 - 15, July 18, July 25, and July 27 -30, 2025, Resident 14 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 14 during the LOA.1l. On July 30, 2025, Resident 15's medical record was reviewed.The admission record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes) and depressive disorder (persistent feeling of sadness).The history and physical completed by the physician on October 2, 2025, indicated Resident 15 had the capacity to understand and make decisions.The physician order dated October 2, 2024, indicated .may go on temporary leave of absence with staff for therapeutic stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on July 28, 2025, at 8:20 a.m., Resident 15 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 15 during the LOA.1m. On July 30, 2025, Resident 16's medical record was reviewed.The admission record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), depressive disorder (persistent feeling of sadness), and anxiety (feeling of nervousness).The history and physical completed by the physician on May 1, 2025, Resident 16 had the capacity to understand and make decisions.The physician order dated May 4, 2025, indicated .may go on temporary leave of absence with staff for sensory stimulation.The care plan dated July 10, 2025, indicated .Focus.elopement.goal.resident will be kept in safe environment.allow resident to wander within the unit; ensure environment is safe & secured.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on May 13 - 14, May 16 - 20, June 23 - 26, July 3, July 6, and July 8, 2025, Resident 16 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 16 during the LOA.1n. On July 30, 2025, Resident 17's medical record was reviewed.The admission record indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included Anxiety (feeling nervousness) and Bipolar (manic and depressive episodes).The history and physical completed by the physician on June 23, 2025, indicated Resident 17 had the capacity to understand and make medical decisions.The physician order dated June 23, 2025, indicated .may go on temporary leave of absence with staff for sensory stimulation.A review of the facility Leave of Absence Logbook was conducted. The logbook indicated on March 25-27, April 22-23,and June 6, 2025, Resident 17 signed out for a leave of absence pass with no documented evidence staff accompanied Resident 17 during the LOA.On August 1, 2025, at 12:41p.m., a concurrent interview was conducted with the Director of Staff Development (DSD). The DSD stated there is no daily assigned staff to cover residents' LOA passes. The DSD stated staff is only assigned to LOA passes for physician appointments and activities that are far from the facility. The DSD stated residents who have LOA are self-responsible and do not require staff to accompany them. The DSD stated if a physician order indicates residents should be accompanied on LOA than the resident should be accompanied by staff on LOA. The DSD further stated Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 should have been accompanied while on LOA.On August 1, 2025, at 4:32 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process for determining a residents' LOA is the resident must be alert and oriented to participate in LOA pass. The DON stated Residents 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 physicians order indicated they may go on temporary leave of absence with staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 4 of 10 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 08/04/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete for sensory stimulation. The DON further stated that Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 should have been accompanied by staff on LOA passes.A review of the facility policy and procedure titled, Therapeutic Leave, revised November 2017, indicated .the nurse will obtain and order from the practitioner specifying approval of a therapeutic leave.the facility will document in the medical record the resident's leave of absence.A review of the facility policy and procedure titled, Physician Orders, not dated, indicated .physician orders are those given to the nurse by the physician.all physician orders shall be noted by a licensed nurse and carried out accordingly.2. On July 30, 2025, Resident 3's medical record was reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), anxiety disorder (feeling nervousness), depression (persistent feeling of sadness), abuse of non-psychoactive substances (excessive use of illegal drug), neuropathy (nerve problem), and suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The physician order dated July 1, 2025, indicated .suicidal ideations.Intervention .remove sharp objects.On August 1, 2025, at 12:19 p.m., Resident 3's lunch tray was observed with a fork, spoon, and knife. The lunch tray was placed on the bedside table readily available for Resident 3 to use.On August 1, 2025, at 12:24 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated the contents of Resident 3's lunch tray included a fork, spoon, and knife. Resident 3's care plan was reviewed. LVN 1 stated the knife and fork on Resident 3's tray would be considered sharp objects. LVN 1 stated according to Resident 3's care plan he should not have sharp objects.On August 4, 2025, at 11:51 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that when a care plan is developed it should be followed through. The DON stated if the care plan indicated resident should not have sharp objects the resident should not have sharp objects. The DON stated the sharp objects should not have been on Resident 3's meal tray. Event ID: Facility ID: 056186 If continuation sheet Page 5 of 10 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 08/04/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure mental health services were provided when:1. The physician or psychiatrist was not notified for one resident (Resident 3) of Resident 3's concern regarding his methadone addiction and possibly experiencing a relapse; and 2. The facility did not arrange psychological evaluations for 12 of 12 residents reviewed (Resident's 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15).This failure had the potential for Resident's 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 to have a delay in the necessary care and services to address their behavioral health needs. Findings:1.On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.On July 30, 2025, at 12:17 p.m., Resident 3 was interviewed. Resident 3 was alert and oriented. Resident 3 stated he felt the facility was not addressing his problem with methadone (synthetic opioid medication) addiction.On July 30, 2025, Resident 3's medical record was reviewed.The admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality), anxiety disorder (feeling nervousness), depression (persistent feeling of sadness), abuse of non-psychoactive substances (excessive use of illegal drug), neuropathy (nerve problem), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on July 10, 2025, indicated Resident 3 had the capacity to understand and make decisions.The (Name of Facility - methadone clinic) After Visit Summary dated June 18, 2025, indicated .member stated, I am an addict on methadone my last dose was June 10, 2025 I need .services to help me I am withdrawing from not having my medication.member is willing to enter treatment member has been on methadone since 2016 and is having stronger urges to use.member is high risk for relapse due to his current state of withdrawal from methadone.member lacks coping skills to cope with life on life's terms.member reports he is currently in nursing home for physical health issues.The physician order dated July 16, 2025, indicated .consult/appointment with methadone clinic secondary to opioid use disorder.There was no documented evidence indicating Resident 3's concerns about his methadone addiction, withdrawal, and high risk for relapse were addressed with the physician or the psychiatrist until July 16, 2025, when the physician ordered another consult/appointment be made with the methadone clinic.On August 1, 2025, at 4:32 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the Registered Nurse (RN) supervisor is in charge of reading the residents after visit summary and scheduling follow up appointments. The DON stated, after reading Resident 3's after visit summary dated June 18, 2025, the RN supervisor should have contacted the psychiatrist or the physician regarding Resident 3's high risk of relapse. The DON stated there is no documented evidence that the RN supervisor contacted the psychiatrist or the physician regarding Resident 3.A review of the facility policy and procedures titled Specialized Rehabilitative Services, not dated indicated .mental health services and supportive psychotherapy for mental illness.specialized rehabilitative services will be provided under the written order of a physician.the services will be provided or coordinated by qualified personnel.the care plan for individuals receiving specialized rehabilitative services will be monitored by a licensed professional.specialized rehabilitative services are considered a facility service and included within the scope of facility services.2a.On July 30, 2025, Resident 4's medical record was reviewed.The admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness) and psychosis (loss of reality).The history and physical completed by the physician on August 9, 2024, indicated Resident 4 can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 6 of 10 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 08/04/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some make needs known but cannot make medical decisions.The physician order dated July 30, 2025, indicated psychology consult & follow up treatment as indicated & prn (as needed).depression.psychosis.The facility could not provide documented evidence Resident 4 received a psychology evaluation as ordered by the physician.2b.On July 30, 2025, Resident 5's medical record was reviewed.The admission record indicated Resident 5 was admitted to the facility on [DATE], with the diagnoses which included bipolar (manic and depressive episodes) and dementia (loss of intellectual functioning);The history and physical completed by the physician on June 4, 2025, indicated Resident 5 had the capacity to understand and make decisions;The physician order dated June 4, 2025, indicated .psychology consult, treatment, follow up.The psychiatric note dated July 3, 2025, indicated .exhibiting aggressive behavior and is observed talking to himself.continue monitoring and follow ups.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 5 received a psychology evaluation as ordered by the physician.2c.On July 30, 2025, Resident 6's medical record was reviewed.The admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included psychosis (loss of reality).The history and physical completed by the physician on July 2, 2025, indicated Resident 6 had the capacity to understand and make decisions.The physician order dated July 2, 2025, indicated .psychology consult, treatment, and follow up.The care plan dated July 2, 2025, indicated .Focus.psychosis m/b auditory hallucinations.Intervention.reality orientation daily and prn.psychiatry/psychology evaluation with treatment and follow ups.The facility could not provide documented evidence Resident 6 received a psychology evaluation as ordered by the physician.2d.On July 30, 2025, Resident 7's medical record was reviewed.The admission record indicated Resident 7 was admitted to the facility on [DATE], with the diagnoses which included Dementia (loss of intellectual functioning), depressive disorder (persistent feeling of sadness), and Alzheimer (slowly destroys memory).The history and physical completed by the physician on September 27, 2025, indicated Resident 7 does not have the capacity to understand and make decisions with a BIMS (measurement of cognitive function 0 to 15) score of 5 (higher the score higher the cognitive function).The physician order dated September 6, 2024, indicated .psychology consult, treatment, and follow up.The facility could not provide documented evidence Resident 7 received a psychology evaluation as ordered by the physician.2e.On July 30, 2025, Resident 8's medical record was reviewed.The admission record indicated Resident 8 was admitted to the facility on [DATE], with the diagnoses which included Bipolar (manic and depressive episodes), depression (persistent feeling of sadness), history of suicidal behavior (thinking, considering, or planning suicide), psychoactive substance abuse (chemical changes to mood, cognition, and behavior);The history and physical completed by the physician on September 12, 2024, indicated Resident 8 has the capacity to understand and make decisions;The physician order dated November 8, 2024, indicated .psychology consult and follow up treatment.The care plan dated June 16, 2025, indicated the following: .Focus.resident diagnosis psychosis.Goal.resident will note decreased psychotic features.Intervention.psychiatry/psychology evaluation with treatment and follow up.Focus.resident uses psychotropic medication.Intervention.behavioral management program.Focus.resident is a long-term stay with no discharge plan.Goal.resident will receive appropriate care to meet needs daily.Intervention.assess and provide residents' psychosocial.needs.-The psychiatry note indicated the following dated May 17, 2025, indicated .continue to implement .Supportive Therapy.The facility could not provide documented evidence Resident 8 received a psychology evaluation as ordered by the physician, behavioral management as indicated in Resident 8's care plan, and Supportive Therapy as indicated in the psychiatrist note.2f.On July 30, 2025, Resident 9's medical record was reviewed.The admission record indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 7 of 10 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 08/04/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Psychosis (loss of reality), major depressive disorder (persistent feeling of sadness), and auditory hallucinations (perception of something not present),suicidal ideations (thinking, considering, or planning suicide), anxiety disorder (feeling nervousness), cannabis dependency (need of marijuana), alcohol abuse (need of alcohol).The facility was unable to provide a history and physical for Resident 9.The physician order dated June 20, 2025, indicated the following: .psychiatry consult, treatment, follow up.psychology consult, treatment, follow up.The facility could not provide documented evidence Resident 9 received a psychology and/or psychiatrist evaluation as ordered by the physician.2g.On July 30, 2025, Resident 10's medical record was reviewed.The admission record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included Anxiety disorder (feeling nervousness) and major depressive disorder (persistent feeling of sadness).The history and physical completed by the physician dated May 1, 2025, indicated Resident 10 had the capacity to understand and make decisions.The physician order dated May 8, 2024, indicated .psychology consult & follow up treatment.The facility could not provide documented evidence Resident 10 received a psychology evaluation as ordered by the physician.2h.On July 30, 2025, Resident 11's medical record was reviewed.The admission record indicated Resident 11 was admitted to the facility on [DATE], with the diagnoses which included Major depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness), and psychosis (loss of reality).The history and physical completed by the physician dated December 13, 2024, indicated Resident 11 had the capacity to understand and make decisions.The physician order dated December 12, 2024, indicated .psychologist consult, treatment, and follow up.The behavior management team note dated January 2025 through July 2025, indicated .medications Ativan (anti-anxiety medication).Zoloft (anti-depressant medication).behaviors.anxiety.depression.plan.refer to psychologist.The psychiatrist note dated June 5, 2025, indicated .inability to relax.continue monitoring and follow-ups.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 11 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 11 received supportive psychotherapy as indicated by the psychiatrist.2i.On July 30, 2025, Resident 12's medical record was reviewed.The admission record indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included Depressive disorder (persistent feeling of sadness), anxiety (feeling nervousness) disorder, delusional (belief of things not true), and bipolar (manic and depressive episodes);The history and physical completed by the physician on May 19, 2025, indicated Resident 12 had the capacity to understand and make decisions;The physician order dated May 19, 2025, indicated .psychology consult, treatment, and follow up.The care plan dated July 24, 2025, indicated the following: .Focus.resident requires skilled nursing.Intervention.monitor psychosocial.refer to psychologist.Focus.psychosis.Intervention.psychiatry/psychology evaluation.-The behavior management team note dated June 4, 2025, and July 7, 2025, indicated .medications.behavioral problems.plan of action.refer to psychologist.-The psychiatrist note dated June 6, 2025, indicated .inability to sleep accompanied by angry Outbursts.continue monitoring.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 12 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 12 received supportive psychotherapy as indicated by the psychiatrist.2j.On July 30, 2025, Resident 13's medical record was reviewedThe admission record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included Psychosis (loss of reality) and anxiety (feeling nervousness disorder) depression (persistent feeling of sadness).The history and physical completed by the physician on May 19, 2025, indicated Resident 13 had the capacity to understand and make decisions.The physician order dated June 17, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 8 of 10 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 08/04/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2025, indicated .psychology consult, treatment and follow up.The care plan date July 4, 2025, indicated the following: .Focus.resident is a long term stay with no discharge plan.Intervention. assess and provide resident psychosocial needs.Focus.care plan for discharge.Intervention.refer to psychologist.The psychiatrist note dated July 4, 2025, indicated .sudden anger outburst.poor impulse control.continue to monitor and follow-up.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 13 received a psychology evaluation as ordered by the physician. The facility could not provide documented evidence Resident 13 received supportive psychotherapy as indicated by the psychiatrist.2k.On July 30, 2025, Resident 14's medical record was reviewedThe admission record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes), anxiety (feeling of nervousness), suicidal ideations (thinking, considering, or planning suicide).The history and physical completed by the physician on May 30, 2025, indicated Resident 14 had the capacity to understand and make decisions.The physician order dated May 30, 2025, indicated .psychology consult, treatment, follow up.The psychiatrist note dated June 6, 2025, indicated .exhibiting mood swings.physical aggression.continue to monitor.plan.supportive psychotherapy.The facility could not provide documented evidence Resident 14 received a psychology evaluation as ordered by the physician. The facility could not provide documented evidence Resident 14 received supportive psychotherapy as indicated by the psychiatrist. 2l.On July 30, 2025, Resident 15's medical record was reviewed.The admission record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included Bipolar (manic and depressive episodes) and depressive disorder (persistent feeling of sadness).The history and physical completed by the physician on October 2, 2025, indicated Resident 15 had the capacity to understand and make decisions.The physician order dated October 2, 2024, indicated .psychology consult, treatment, follow up.;The psychiatrist note dated April 1, May 5, and June 6, 2025, indicated .mood swings signs of paranoia.continue to monitor.plan.supportive psychotherapy.The behavioral management team note dated January 8, February 5, March 5, April 2, May 7, and June 4, 2025, indicated .medications.behavioral problems.plan of action.refer to psychologist.The facility could not provide documented evidence Resident 15 received a psychology evaluation as ordered by the physician and behavioral management team. The facility could not provide documented evidence Resident 15 received supportive psychotherapy as indicated by the psychiatrist.On August 4, 2025, at 11:44 a.m., a concurrent interview and record review was conducted with the Social Worker (SW). The SW stated she is the one to schedule appointments for psychiatry and psychology evaluations and follow ups. The SW also stated she is in charge of reviewing psychiatry and psychology notes. The SW stated she is on the behavioral management team and is the one to schedule appointments for the recommendations. The SW further stated Resident 8 supportive services were not scheduled and should have been scheduled. The SW stated Resident 11 and Resident 12 psychology evaluation should have been scheduled. The SW stated the facility should have located a psychologist that accepts Medi-Cal to schedule Resident 4 and 17 psychology evaluations.On August 4, 2025, at 11:51 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated she is a part of the behavioral management team. The DON stated depending on the recommendation it can be nursing or social services who scheduled evaluations and follow up appointments. The DON stated the social service department is responsible of scheduling psychology and psychiatry evaluations. The DON stated the facility should have scheduled the psychology evaluations and that the possible outcome to the residents would be a delay in mental health care.A review of the facility policy and procedures titled Specialized Rehabilitative Services, not dated indicated .mental health services and supportive psychotherapy for mental illness.specialized rehabilitative services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056186 If continuation sheet Page 9 of 10 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 08/04/2025 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete will be provided under the written order of a physician.the services will be provided or coordinated by qualified personnel.the care plan for individuals receiving specialized rehabilitative services will be monitored by a licensed professional.specialized rehabilitative services are considered a facility service and included within the scope of facility services. A review of the facility policy and procedures titled Social Services, not dated indicated .the facility regardless of size will provide medically related social service to each resident attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.any need for medically related social services will be documented in the medical record.the social worker or social worker designee will pursue the provision of any identified need for medically related social services of the resident.services to meet resident's needs may include.providing or arranging for needed mental and psychosocial counseling services.the resident's plan of care will reflect any ongoing medically related social services needs and how these needs are being addressed.the social worker or social worker designee will monitor the residents progress in improving physical, mental, and psychosocial functioning. Event ID: Facility ID: 056186 If continuation sheet Page 10 of 10