Other·April 23, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey to investigate Complaint Nos: CA00571404 and CA00572221. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors 37689, HFEN; Surveyor 39670, HFEN; and Surveyor 39683, HFEN. FOR COMPLAINT No: CA 00571404, THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION (S) AND FINDINGS WERE CITED AT F580, F689, and F692. FOR COMPLAINT No: CA 00572221, THE DEPARTMENT WAS ABLE TO PARTIALLY SUBSTANTIATE THE COMPLAINT ALLEGATION(S) AND FINDINGS WERE CITED AT F580. DURING THE INVESTIGATION, THERE WAS A VIOLATION OF REGULATIONS UNRELATED TO THE COMPLAINT(S) AND FINDINGS WERE CITED AT F558, F641, and

F656. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADON - Assistant Director of Nursing DON - Director of Nursing IDT- Interdisciplinary Team LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 1 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) mg/dL - milligram(s) per deciliter P&P - policy and procedure PCP - Primary Care Physician RD - Registered Dietician RNA - Restorative Nursing Assistant SSA - Social Service Assistant

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility P&P review, the facility failed to ensure four of four nonsampled residents (Residents A, B, D, and E) had access to and prompt response to their call lights. * Resident E's call light was not answered timely, resulting in Resident E having an incontinent episode. * Residents A, B and D's call lights were not within their reach, which prevented them from being able to activate their call lights in the event they needed to assistance from staff. These failures had the potential for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 2 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents' care needs not being met. Findings: Review of the facility's P&P titled Answering the Call Light revised 10/2010 showed when the resident is in bed or confined to a chair, the staff is to ensure the residents' call lights are within easy reach of the residents. 1. Medical record review for Resident E was initiated on 2/7/18. Resident E was readmitted to the facility on 11/9/16. Review of the History & Physical Exam dated 11/30/17, showed Resident E had the capacity to understand and make decisions. On 2/7/18 at 0745 hours, during a facility tour, Resident E was observed in bed eating breakfast. Resident E stated she did not think her call light was working. When asked what made her say this. Resident E stated when she pressed her call light, she knew the light outside her room door turned on; however, she thought the one at the nurses' station did not light up. Resident E stated nobody would come to answer her call light even though she could hear voices at the nurses' station. Resident E recalled an incident when she turned her call light on because she needed to use the bathroom. No one answered her call light and she had an accident (incontinent episode). Resident E stated she decided to call a family member who lived 10 minutes away. The family member came and changed her. When asked how did this make her feel. Resident E frowned and stated "bad." 2. On 2/7/18 at 0805 hours, Resident D's call light was observed on the floor on the right side of his bed. When the resident was asked where his call bell was, Resident D stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 3 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE could not find it. On 2/27/18 at 0810 hours, CNA 2 was called to the room and verified Resident D' call light was on the floor, out of the resident's reach. CNA 2 verified Resident D was able to use his call light. 3. On 2/7/18 at 0832 hours, Resident A was observed sitting up in bed eating breakfast. The resident's bedside table drawer was open and the call light was inside the bedside drawer, out of Resident A's reach. On 2/7/18 at 0835, an interview was conducted with CNA 1 regarding Resident A. CNA 1 stated Resident A "sometimes uses the call light." CNA 1 moved the call light from Resident A's bedside table drawer and placed in within the resident's reach, stating she had "forgot to put it back after getting her ready for breakfast." CNA 1 verified Resident A's call light was not within reach. On 2/7/18 at 1515 hours, Resident A was observed in her room sitting in her wheelchair by the foot of her bed. The call light was laying on the middle of Resident A's bed out of Resident A's reach. On 2/7/18 at 1517 hours, an interview was conducted with CNA 3. CNA 3 stated Resident A has used her call light in the past. Upon entering Resident A's room, CNA 3 verified the call light was not within Resident A's reach. 4. On 2/7/18 at 0855 hours, Resident B was observed laying in his bed, with the bed in low position and a floor mat next to his bed. On 2/7/18 at 0857 hours, an interview with CNA 2 was conducted. CNA 2 was asked to locate Resident B's call light. CNA 2 looked under Resident B's bedding, under and around FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 4 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the bed. The CNA finally located the call light wrapped around the overhead light, located on the wall above the head of the Resident B's bed. CNA 2 verified the call light was out of Resident B's reach.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 5 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of two sampled residents' (Residents 1 and 2) physicians and family were immediately notified of a change in the residents' conditions. * The facility failed to notify Resident 1's physician of severe and continued weight losses a timely manner, resulting in a delay in interventions. * Resident 2 had sustained a fall. There was an approximately two hours delay in Resident 2's physician and responsible party being notified Resident 2 had sustained a fall which resulted in a minor injury. This had the potential for the resident to have a delay in care and treatment. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 6 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 9/2013 showed the nurse supervisor/charge nurse will notify the attending physician or the resident's family/ representative when there has been a significant change in the resident's physical, emotional, or mental conditions. Review of the facility's P&P titled Acute Condition Changes - Clinical Protocol revised 12/2015 showed the staff will monitor and document the resident's progress and responses to treatment and the physician will adjust the treatment accordingly. The physician will help staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on 12/9/17, with diagnoses including gastro-intestinal bleed. Review of the Nutrition Assessment dated 12/14/17, showed Resident 1 was 72" inches in height (6 feet tall) and his usual body weight was 190 pounds. Staff documented the resident's "desired" weight was 183 +/- 5 pounds. His most recent weight was 183 pounds. The goal was for the resident to consume 70% or more of each meal. Review of the Weight Summary showed Resident 1's initial/baseline weight obtained on 12/11/17, showed 183 pounds. On 12/19/17, an IDT Weight Management Assessment showed Resident 1's weight was 174 pounds, a 9 pound loss in one week. The RD documented the resident was receiving a regular diet, his oral meal intake was variable, would provide house shakes twice a day FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 7 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE between meals, recommended 1:1 feeding assistance with meals, and would continue to monitor. There was no documentation the resident's physician was notified of the resident's weight loss. On 12/27/17, an IDT Weight Management Assessment showed Resident 1 weighed 172 pounds, a loss of 2 pounds in a week. The resident's oral meal intake was "mostly" 75 to 100% and was receiving house shakes twice a day. The RD documented Resident 1 continued to lose weight despite supplements and relatively good oral intake, and would recommend the RNA feeding program and fortified diet. Review of the Weight Summary showed Resident 1's weight on 12/24/17 (two weeks after admission) as 172 pounds (11 pounds or 6% weight loss from baseline; identifying a severe weight loss in two weeks). There was no documentation Resident 1's family and attending physician were notified of the resident's severe weight loss on 12/24/17. Review of the physician's progress notes showed Resident 1 was examined by his PCP on 12/25/17. The note showed Resident 1's condition was stable. There was no documentation of the resident's weight loss. On 1/8/18, an IDT Weight Management Assessment showed Resident 1 weighed 150 pounds a loss of 18% in one month. Resident's oral intake was variable. Resident 1 continued to have weight loss despite dietary interventions of house shakes three times a day, Prostate twice a day, and fortified meals. The plan was for Resident 1 to be transferred to another facility. Present in the IDT meeting were the RD, ADON and SSA. There was no documentation to show the physician was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 8 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE made aware of the resident's 18% weight loss. Review of the Weight Summary showed Resident 1's weight on 1/4/18 was 150 pounds (33 pound or 18% weight loss in 25 days). Review of the medical record failed to show a change in condition assessment was completed for Resident 1 to address the 33 pound weight loss. There was no documentation Resident 1's family and attending physician were notified of this identified severe weight loss on 1/4/18. Review of the physician's progress notes showed Resident 1 was seen by his PCP on 1/4/18. However, there was no documentation of Resident 1's weight loss was mentioned in the physician's progress notes. Review of the Change in Condition Evaluation dated 1/8/18, showed Resident 1 had lost 33 pounds since admission. The PCP was notified and gave an order for the RD to evaluate Resident 1. Review of the physician's progress notes showed Resident 1 was examined by his PCP on 1/9/18. The PCP noted Resident 1 had a 33 pound weight loss and was ordering Remeron (antidepressant medication used to stimulate appetite). On 3/14/18 at 1120 hours, an interview was conducted with Resident 1's PCP. When asked if the facility had informed him when Resident 1 was identified to have severe weight losses (on 12/24/17 and 1/4/18), the PCP stated he could not remember. When informed there were physician progress notes dated 12/24/17 and 1/4/18, which identified he had examined Resident 1, but there was no notation of the resident's weight. The physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 9 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated, "It could be that they did not inform me." The physician stated, otherwise, he would have ordered laboratory tests to be done and followed up on the resident right away. Cross reference to F692. 2. Review of the facility's P&P titled Change in a Resident's Condition or Status dated 9/2013 showed the facility shall promptly notify the resident's attending physician and representative of changes in the resident's medical/mental condition, including when an accident involving the resident occurred. Resident 2's medical record review was initiated on 2/7/18. Resident 2 was admitted to the facility on 1/17/18. Resident 2 was identified to be confused. Review of the Progress Notes dated 1/18/18 at 1531 hours, showed Resident 2 was found on the floor. The resident had an unwitnessed fall and sustained a hematoma (collection of blood under the skin) to the right side of his face. Review of Resident 2's Neurological Assessment Flow Sheet initiated on 1/18/18, showed Resident 2's first post fall neuro checks being completed at 1/18/18 at 1516 hours. Review of Resident 2's Change in Condition Evaluation form showed on 1/18/18, Resident 2 sustained a fall, resulting in a swelling to the right side of his face. The staff documented they notified the resident's physician of the fall on 1/18/18 at "05:17" PM (1717 hours) and Resident 2's responsible party on 1/18/18 at "05:14) PM (17.14 hours). This was approximately two hours after the resident had actually fallen and sustained a hematoma. On 2/8/18 at 1111 hours, an interview and concurrent medical record review with LVN 1 was conducted concerning Resident 2's fall on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 10 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/18/18. LVN 1 stated Resident 2 fell on 1/18/18 around 1510 hours. Documentation showed Resident 2's physician was notified on 1/18/18 at 1717 hours, and Resident 2's family was notified at 1714 hours. LVN 1 confirmed there was a delay in approximately 2 hours before notifying Resident 2's physician and family Resident 2 had fallen. When asked about the time entries documented on the Change of Condition Evaluation, LVN 1 stated she had failed to change the electronic charting time from standard time to military time.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure the MDS assessment for one to two sampled residents (Resident 1) accurately reflected the resident's status. This had the potential for Resident 1 to not receive an individualized plan of care based on the resident's specific care needs. Findings: Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on 12/9/17. Review of the Admission Nursing Data Tool dated 12/9/17, showed Resident 1 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 11 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moderate difficulty in hearing and used bilateral hearing aids to assist with hearing. Review of the initial MDS assessment dated 12/16/17, under Section B, the assessment showed Resident 1 had adequate hearing without hearing aids. Review of the plan of care failed to show a care plan problem was developed to address the resident's hearing loss and need for bilateral hearing aids. On 2/8/18 at 1108 hours, an interview was conducted with the Social Service Designee. The Social Service Designee stated she was responsible for coding Section B of the MDS assessment and acknowledged Resident 1's hearing was coded in error.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 12 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to develop a comprehensive plan of care to address the problems of impaired visual function, communication, dehydration/fluid maintenance and urinary incontinence for one of two sampled residents (Resident 1). This posed the risk of not providing the necessary care and services in accordance with the resident's care needs. Findings: Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on 12/9/17. Review of the initial MDS dated 12/16/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 13 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE showed Resident 1 had impaired vision, was usually understood and understands others. Resident 1 was frequently incontinent of bowel and bladder. Review of Resident 1's Care Area Assessment Summary (CAAS) dated 12/16/17, showed visual function, communication, urinary incontinence, and dehydration/fluid maintenance were identified as the care area triggers. Review of the CAAS Worksheet dated 12/16/17, showed Resident 1's care concerns of visual function, communication, urinary incontinence, and dehydration/fluid maintenance would be addressed in the comprehensive plan of care. However, review of Resident 1's plan of care showed no care plan problems to address visual function, communication, urinary incontinence, and dehydration/fluid maintenance. On 2/28/18 at 0804 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator verified there were no care plan problems developed to address visual function, communication, urinary incontinence, and dehydration/fluid maintenance for Resident 1.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 14 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided adequate supervision to prevent falls. Resident 1 sustained three falls in less than two weeks. The facility failed to conducted 72 hour neurological assessments as ordered by the physician and update the resident's plan of care to address new interventions after each fall in an attempt to prevent additional falls. This had the potential to negatively impact the resident's well-being. Findings: According to the facility's P&P titled Assessing Falls and their Causes revised 10/2010, the procedures after a fall included nursing staff to observe for complications of a fall for approximately 48 hours after a fall, and to document the findings in the medical record. Within 24 hours after a fall, the nursing staff will begin to identify possible or likely causes of the incident. Documentation when a resident falls included a completion of a fall risk assessment. Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on 12/9/17, and was transferred to the acute care hospital on 1/12/18. Review of the Admission/Readmission Nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 15 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Data Tool dated 12/9/17, showed an entry for Fall Risk Assessment identifying Resident 1 as a risk for falls. Review of the plan of care failed to show a care plan problem was developed on admission to address Resident 1's risk for falls. Review of the medical record showed Resident 1 sustained three falls on 12/15, 12/21, and 12/23/17. a. Review of the Change in Condition Evaluation dated 12/15/17, showed Resident 1 was found lying on the floor parallel to his bed at 2030 hours. The fall was unwitnessed. Review of the plan of care showed a care plan problem to address Resident 1's fall was initiated on 12/15/17. The interventions included to monitor the vital signs and neuro checks for 72 hours. Review of the Neurological Assessment Flow Sheet dated 12/15/17, showed the neurological assessment including vital signs was only done for 48 hours, not the 72 hours as ordered. In addition, the neurological assessment was incomplete; in the 48 hours, there were six assessments times that were left blank. Further review of the medical record failed to show a fall risk assessment was completed after this fall. b. Review of the Change in Condition Evaluation dated 12/21/17, showed Resident 1 sustained a witnessed fall. Review of the plan of care failed to show a care plan problem to address Resident 1's second fall was developed. There were no new interventions added to address the current fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 16 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and prevent Resident 1 from further falls. Review of the physician's order dated 12/21/17, showed an order for neurological assessment for 72 hours. Review of the Neurological Assessment Flow Sheet dated 12/21/17, showed the neurological assessment was only completed for 32 hours instead of 72 hours as ordered. c. Review of the Change in Condition Evaluation dated 12/23/17, showed Resident 1 had an unwitnessed fall. Resident 1 was found lying in the floor in the hallway in front of his room. Review of the plan of care failed to show new interventions added to address the current fall and or new preventative measure to prevent Resident 1 further falls. Further review of the medical record did not show a fall risk assessment was completed. On 2/8/18 at 0838 hours, an interview and concurrent closed medical record review was conducted with the ADON. The ADON verified Resident 1 was identified as a fall risk on admission. The ADON verified the neurological assessments after the falls on 12/15 and 12/21/17, were not completed for 72 hours as ordered by the physician. The ADON stated the IDT was not able to meet and discuss the fall on 12/21/17, because it was a holiday. The ADON verified there were no new interventions address before Resident 1 sustained another fall on 12/23/17. The IDT met on 12/26/17, to review Resident 1's falls. A follow-up interview was conducted with the ADON on 3/5/18 at 1354 hours, regarding Resident 1. The ADON verified there were no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 17 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE fall risk assessments completed after Resident 1 fell on 12/15 and 12/23/17.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received the appropriate services to meet their nutritional needs and maintain desirable weight. The facility failed to accurately and consistently assess Resident 1's nutritional status to address the weight loss with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 18 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE approaches in a timely manner to prevent further weight loss. The facility failed to identify, implement, monitor, and modify the interventions specific to Resident 1's needs. These failures had contributed to a severe weight loss of 33 pounds in 26 days for Resident 1. Findings: According to the facility's P&P titled Weight Assessment and Intervention revised 1/12/18, the nursing staff will measure resident weights on admission, the morning after admission and weekly for three weeks thereafter (a total of four weeks). The threshold for significant unplanned and undesired weight change will be based on the following criteria: one week = 3% weight change is significant; one month = greater than 5% is severe. An individualized care plan shall address the following - The identified causes of weight change; - Goals and benchmarks for improvement; and - Time frames and parameters for monitoring and reassessment. The dietitian will discuss weight change with the resident and/or family. Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on 12/9/17, with diagnoses including gastro-intestinal bleed. On 1/12/18, Resident was transferred to the acute care hospital on 1/12/18. Review of the Nutrition Assessment dated 12/14/17 showed Resident 1 was 72" inches in height (6 feet tall) and his usual body weight was 190 pounds. Staff documented the resident's "desired" weight was 183 +/- 5 pounds. His most recent weight was 183 pounds. The goal was for the resident to consume 70% or more of each meal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 19 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Documentation showed Resident 1 had +1 edema (swelling, the degree of indentation when an edematous area is pressed) to his lower extremities. Review of the initial MDS dated 12/16/17, showed Resident 1 was cognitively intact. Review of the Weight Summary failed to show Resident 1's weights were obtained on the day of admission (12/9/17) and the morning after admission (12/10/17). Review of the Weight Summary for Resident 1 showed the following: * On 12/11/17 = 183 pounds (initial weight taken two days after admission). * On 12/17/17 = 174 pounds (9 pounds, a 4.91% weight loss in six days). * On 12/24/17 = 172 pounds (11 pounds, a 6% weight loss in 15 days since admission date). * Third weekly weight was due on 12/31/17; however, documentation failed to show a weight was obtained on this date. * On 1/4/18 = 150 pounds (33 pounds, a 18% weight loss in 26 days since admission date). There were no further weights recorded after 1/4/18. Review of laboratory results dated 12/12/17 showed the following: - BUN was 16 mg/dL (normal range 7-21 mg/dL; blood urea and nitrogen, a test on kidney and liver function); - Creatinine was 0.9 mg/dL (normal range 0.5 1.4 mg/dL; a test on kidney function); - Albumin was 2.2 g/dL (normal range was 3.5 5.0 g/dL; low albumin levels can also be seen in malnutrition and conditions where the body did not properly absorb and digest protein or in which large volumes of protein). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 20 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's acute care hospital emergency department History and Physical record dated 1/12/18, showed the following laboratory values: - BUN = 72 mg/dl - Creatinine 1.6 mg/dl - Albumin = 1.6% g/dl Review of Resident 1's plan of care showed a care plan problem to address nutrition initiated on 12/14/17. The care plan failed to address Resident 1's target weight range nor his dietary preferences. On 12/19/17, an IDT Weight Management Assessment showed Resident 1's weight was 174 pounds, a 9 pound loss in one week. The RD documented the resident was receiving a regular diet, his oral meal intake was variable, would provide house shakes twice a day between meals, recommended 1:1 feeding assistance with meals, and would continue to monitor. There was no documentation the resident's physician was notified of the weight loss. There was no documentation of the RD discussing the weight loss with Resident 1 and/or his family or documentation of Resident 1's edema. Further review of the medical record failed to show any documentation regarding Resident 1's edema. Review of the nurses' progress notes showed Resident 1 was transferred to the acute care hospital on 12/19/17 at 1430 hours, for episode of confusion, and returned to the facility on the same day (12/19/17) at 2000 hours. Review of the Discharge Instructions from the acute care hospital dated 12/19/17, showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 21 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 did not have edema. Review of Resident Specific Dietitian Recommendations dated 12/19/17, showed the RD recommended 1:1 feeding assistance with meals and house shakes 120 ml two times a day in between meals. Review of the nutrition care plan failed to show the new interventions recommended by the RD. Review of the physician's orders failed to show an order for house shakes 120 ml two times a day as recommended by the RD. Review of Resident Specific Dietitian Recommendations dated 12/20/17, showed the RD recommended Resident 1 to be placed in RNA feeding program for all meals. Review of Resident 1's plan of care failed to show a care plan problem was created to address Resident 1's participation in the RNA feeding program for all meals. Review of the Order Summary Report dated 12/29/17, showed a physician's order dated 12/28/17, for RNA feeding program for all meals. However, the facility failed to show any documented evidence Resident 1 was placed on the RNA feeding program. On 12/27/17, an IDT Weight Management Assessment showed Resident 1 weighed 172 pounds, a loss of 2 pounds in a week. The resident's oral meal intake was "mostly" 75 to 100% and was receiving house shakes twice a day. The RD documented Resident 1 continued to lose weight despite supplements and relatively good oral intake, would recommend RNA feeding program and fortified diet, and complete the entries for meal and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 22 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intake supplement percentages. There was no documentation to show the weight loss as an 11 pounds or 6% weight loss in 15 days had been discussed with the physician or family. Review of the CNA - ADL Tracking Form for the month of December 2017 showed the following entries for meal intake: Breakfast Lunch Dinner - 12/20/17 = 0-25% 26-50% 76-100% - 12/21/17 = 0-25% 0-25% 26-50% - 12/22/17 = 76-100% 76-100% 76-100% - 12/23/17 = 26-50% 26-50% 76-100% - 12/24/17 = 76-100% 0-25% 26-50% - 12/25/17 = 76-100% 76-100% 51-75% - 12/26/17 = 0-25% 0-25% 76-100% Further medical record failed to show documentation of Resident 1's intake of the house shakes. Review of the nutrition care plan failed to show new interventions nor approaches to address Resident 1's severe weight loss. On 1/8/18, an IDT Weight Management Assessment showed Resident 1 weighed 150 pounds a loss of 18% (33 pounds) in one month. Resident's oral intake was variable. Resident 1 continued to have weight loss despite dietary interventions of house shakes three times a day, Prostate twice a day and fortified meals. The plan was for Resident 1 to be transferred to another facility. Present in the IDT meeting were the RD, ADON and SSA. The note stated the plan was for Resident 1 to be transferred to another facility and to continue with the current plan of care. The entries of recent labs, meal and intake supplement percentages. There was no documentation to show the physician was made aware of the 18% weight loss. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 23 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the nutrition care plan failed to show new interventions nor approaches to address Resident 1's severe weight loss. Review of the ADL flowsheet from 12/9/17 to 1/12/18, showed inconsistencies in the support or assistance with provided for eating. On 2/7/18 at 1132 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 could feed himself at time. CNA 2 stated he would only feed Resident 1 whenever he left his food untouched. On 2/7/18 at 1343 hours, an interview and concurrent closed medical record review was conducted with the RD and DSS. The RD stated she did not observe Resident 1 eat when she did the Nutrition Assessment on 12/14/17. The RD stated Resident 1's weight losses were undesirable. The RD verified the plan of care was not revised to address Resident 1's weight loss. When asked how she identified if the interventions were suitable for Resident 1. The RD stated she did not know whether her recommendations of house shakes were carried out or not. When asked if she had discussed the weight loss with Resident 1 and/or his family regarding his severe weight loss identified on 12/27/17. The RD stated no, the charge nurses usually called the resident's family members. The RD stated she wrote Resident 1's intake as 75-100% during the IDT Weight Management Update on 12/27/17, based on the CNA's ADL flowsheet. When the CNA flowsheet was reviewed, the entries showed Resident 1's intake were mostly 0-25% and 26-50%. The RD stated she must have looked at the wrong resident's meal intake. The RD stated she did not have new interventions or recommendations when the severe weight loss of 6% was identified on 12/27/17, because she thought Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 24 of 25 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056110 (X3) DATE SURVEY COMPLETED 03/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAGUNA HILLS HEALTH AND REHABILITATION CENTER 24452 Health Center Dr Laguna Hills, CA 92653 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE eating well. When asked if she had recommended any laboratory tests to be done, the RD stated no. On 2/7/18 at 1602 hours and on 2/27/18 at 1500 hours, an interview was conducted with the ADON. The ADON verified Resident 1's weights were not obtained timely per the facility's P&P. The ADON verified the dietary recommendations for house shakes two times a day (dated 12/19/17) were not carried out. The ADON could not find documentation to show Resident 1 was placed on the RNA feeding program for all meals as per the RD recommendations on 12/20/17. The ADON stated Resident 1 was not appropriate for the RNA feeding program; the RNA feeding program was designed for the residents who could feed themselves and only needed assistance and cuing. She could not explain why this was not addressed in the IDT meetings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PXZ411 Facility ID: CA060000042 If continuation sheet 25 of 25