Other·June 29, 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 the concurrent RECERTIFICATION and RELICENSING surveys. Representing the California Department of Public Health: Surveyor 37689, HFEN; Surveyor 35346, HFEN; Surveyor 37726, HFEN; Surveyor 38660, HFEN; Surveyor 39199, HFEN; Surveyor 39281, HFEN; Surveyor 39453, HFEN; Surveyor 39670, HFEN; Surveyor 39999, HFEN; Surveyor 26288, HFES; Surveyor 39856, Nutrition Consultant; Surveyor 38924, Nutrition Consultant; and Surveyor 34975, Nutrition Consultant. The surveyors entered the facility on 5/8/18 at 0740 hours. The census was 130 with no bed holds. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADON - Assistant Director of Nursing AROM - active range of motion AV shunt - arterial venous shunt (a U shaped tube surgically inserted between a vein and an artery) used for dialysis treatments CAI - community acquired infection CDPH, L&C Program: California Department of Public Health, Licensing and Certification Program cm - centimeter(s) CNA - Certified Nursing Assistant Dialysis/hemodialysis - a treatment to rid the body of toxins and waste when the kidneys fail to function DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor 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: BVUW11 Facility ID: CA060000715 If continuation sheet 1 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 End stage renal disease - loss of kidney function F - Fahrenheit GT - gastrostomy tube (a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) HAI - healthcare associated infection IDT - Interdisciplinary Team IV - intravenous LVN - Licensed Vocational Nurse LUC - left upper chest MDS - Minimum Data Set (a standardized assessment tool) mg - milligram(s) ml - milliliter(s) P&P - policy and procedure PICC - peripherally inserted central catheter) used for prolonged intravenous access POC - plan of care POLST - Physician's Orders for Life Sustaining Treatment PRAFO - pressure relief ankle foot orthosis (a device worn on the feet to prevent pressure ulcers on the back of the heel) Pressure ulcer - localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device PRN - as needed RD - Registered Dietitian RN - Registered Nurse RNA - Restorative Nursing Aide SSA - Social Services Assistant SSD - Social Services Director Stage 2 - partial thickness loss of skin with exposed dermis Stage 3 - full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] {dead tissue} may be visible. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 2 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Unstageable - full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined UTI - urinary tract infection

F550 SS=G Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 09/09/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 3 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide care and promote dignity and respect for one of 26 final sampled residents (Resident 43) and one nonsampled resident (Resident 18). * Resident 43's braided hair was cut off by a CNA against Resident 43's will while providing care for Resident 43. This resulted in Resident 43 becoming tearful and not wanting to leave her room because her hair had been cut off. * The facility failed to answer Resident 43 and 18's call lights in a timely manner. This resulted in Residents 43 and 18 becoming distressed, disturbed, and upset when they had to sit in wet, soiled diapers for long periods of time. These failures lead to the residents and family members feeling devastated and frustrated. Findings: Review of the facility's P&P title Concern & Comment Program dated 2/2007 showed if the concern is of major importance, the staff should contact the Administrator, DON, or designee as soon as possible. The Concern & Comment Form is routed to the Administrator or designee, and to the appropriate department FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 4 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 manager who will investigate and resolve the concern. 1. Medical record review for Resident 43 was initiated on 5/8/18. Resident 43 was admitted to the facility on 6/12/17. Review of Resident 43's MDS dated 3/16/18, showed Resident 43 was cognitively intact. a. On 5/14/18 at 0957 hours, an interview was conducted with Resident 43 and Family Member 2. Family Member 2 stated while providing care to Resident 43, CNA 3 could not remove the rubber band from Resident 43's braided hair. Resident 43 stated she told CNA 3 not to cut off Resident 43's braided hair; Family Member 2 would come and help her. CNA 3 cut Resident 43's braided hair off anyway. Family Member 2 stated she reported the incident to the nurses at the nurses' station, SSA 2, and the Assistant Administrator. Family Member 2 also discussed this incident in the care plan meeting. Family Member 2 stated the facility acknowledged the incident and did not assign CNA 3 to Resident 43 again. Family Member 2 stated Resident 43 was a hair stylist and felt devastated about her hair being cut and cried every day. Resident 43 did not want to see CNA 3. Family Member 2 stated Resident 43 remembered the incident each time she saw CNA 3 and cried. On 5/14/18 at 1340 hours, an interview was conducted with the Administrator regarding the incident of CNA 3 cutting off Resident 43's braided hair. The Administrator stated he was not aware of the incident. On 5/14/18 at 1345 hours, an interview was conducted with the Assistant Administrator. When asking about CNA 3 cutting off Resident 43's braided hair, the Assistant Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 5 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 he was not aware of the incident. The Assistant Administrator stated he had not had any report or investigation regarding this incident. On 5/15/18 at 0822 hours, an interview was conducted with CNA 3. CNA 3 stated the former Assistant DON asked her (CNA 3) why she cut Resident 43's hair. CNA 3 stated, "I never cut her hair. I did not have scissors. I made a ponytail for her." CNA 3 stated Family Member 2 came to the nurses' station and asked why Resident 43's hair had been cut off. On 5/15/18 at 0848 hours, an interview was conducted with CNA 4. When asked about Resident 43's braided hair being cut off, CNA 4 stated she was aware of this incident. CNA 4 stated someone cut Resident 43's hair. CNA 4 came back to work the day after Resident 43's hair had been cut off and saw Resident 43's hair was very short and could not be braided. CNA 4 stated Resident 43 had long hair before. CNA 4 stated Resident 43 told her (CNA 4) she felt worse and stated it was not right to cut her hair. On 5/15/18 at 1500 hours, an interview was conducted with the DSD. The DSD stated she was given a report about CNA 3 cutting off Resident 43's hair. The DSD stated she did not assign CNA 3 to Resident 43 again. When asked if she reported the incident to anyone, the DSD stated she talked to SSA 2 and the former DON; however, she did not recall what they had discussed. On 5/16/18 at 1527 hours, a concurrent interview and facility document review was conducted with the DSD. The DSD stated she asked CNA 3 if CNA 3 had cut off Resident 43's hair against Resident 43's will. CNA 3 told the DSD no. The DSD stated she did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 6 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 believe there was an investigation; she just took CNA 3's word. When asked if she assessed Resident 43, the DSD stated, "I was kind of new at that time. I don't think I knew her well to assess her." The DSD verified she did not assess Resident 43 and could not provide any documented evidence she had spoken to Resident 43 about the incident. On 5/16/18 at 1655 hours, an interview was conducted with Resident 43 at the bedside. Resident 43 stated CNA 3 had cut off her hair. Resident 43 stated she felt devastated, wanted to stay in her room, and thought she could not go out with her hair like that. Resident 43 stated she reported the incident to the facility. On 5/18/18 at 1042 hours, a telephone interview was conducted with SSA 2. SSA 2 stated around August, Resident 43 reported CNA 3 cut off her hair. SSA 2 stated Resident 43 had short braided hair, and the hair was matted. CNA 3 could not undo the rubber band from around the braided hair so CNA 3 cut Resident 43's braided hair. SSA 2 assessed Resident 43's hair and saw the difference of Resident 43's hair before and after being cut. Resident 43's hair was shorter and uneven. SSA 2 stated she reported to this to the DSD. The DSD talked to Resident 43. After the DSD learned CNA 3 was the person who cut Resident 43's hair, the DSD did not assign CNA 3 to Resident 43 again. When asked if Family Member 2 brought up this incident in Resident 43's care plan meeting, SSA 2 stated yes, but she could not find the quarterly care plan meeting for September 2017 in Resident 43's medical record. b. Review of Resident 43's MDS dated 3/16/18, showed Resident 43 was cognitively intact and required one to two persons' extensive assistance for transfers and toileting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 7 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 43's care plan showed a care plan problem dated 4/2/18, to address Resident 43's weak bladder control. The approaches included to offer Resident 43 scheduled toileting every 2 hours. On 5/14/18 at 0957 hours, an interview was conducted with Resident 43 and Family Member 2. Family Member 2 stated Resident 43 had to wait at least 45 minutes for her call light to be answered, and there were several times the call light waiting times were one and a half hours. Family Member 2 stated she asked the Assistant Administrator what the realistic time was for the call light to be answered. The Assistant Administrator stated five to twenty minutes. Family Member 2 stated she called from outside the facility to get the nurses to help Resident 43 to the bathroom. Family Member 2 read the text messages between herself and Resident 43 from the phone. The text messages showed on Thursday 5/10/18, Resident 43 called Family Member 2 at 0603 hours; she had not been helped by 0643 hours. On 5/13/18 at 2233 hours, Resident 43 texted Family Member 2, to please call in as it had been 45 minutes. Resident 43 texted she was crying and wanting to go to the bathroom; she did not want to go in her diaper. On 4/2/18 at 1350 hours, a CNA came to answer the call light and refused to take Resident 43 to the bathroom. The CNA told Resident 43 she would get off work in 10 minutes. Family Member 2 insisted the CNA take Resident 43 to the bathroom. The CNA roughly transferred Resident 43 to the wheelchair. Without cleaning Resident 43, the CNA pulled the diaper up and put Resident 43 to bed. Family Member 2 stated the facility put Resident 43 on a toileting schedule every two hours, and the toileting schedule was posted on the resident's bathroom door. However, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 8 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 toileting schedule every two hours had not been carried out. Resident 43 stated they wanted me to go in her diaper. They put another diaper inside her diaper to absorb. One time the gown and the diaper were wet, and she had to eat while sitting in the soaking wet diaper and wet gown. Family Member 2 stated the CNA told her they did not have time to help Resident 43 because the resident went to the bathroom too many times. On 5/15/18 at 0848 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 43 needed two persons' assistance for transfers and toileting. CNA 4 was aware of Resident 43's toileting schedule. CNA 4 stated she had helped Resident 43 to the bathroom every two hours; however, CNA 4 did not document she had helped Resident 43 to the bathroom every two hours in Resident 43's medical record. On 5/15/18 at 0933 hours, a concurrent interview and medical record review was conducted with RN 4. When asked how she monitored the nursing staff answering the call lights and implementing the toileting schedule every two hours for Resident 43, RN 4 stated they monitored the call lights and the call light waiting time was about 15 minutes. RN 4 stated the facility arranged a toileting schedule for Resident 43. However, there was no documentation in Resident 43's medical record showing the toileting schedule was carried out and monitored by nursing staff. 2. On 5/8/18 at 1035 hours, during an initial tour, a concurrent observation and interview was conducted with Resident 18. Resident 18 was observed resting in bed, wearing a diaper. Resident 18 had a second diaper folded inside his diaper. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 9 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Medical record review for Resident 18 was initiated on 5/8/18. Resident 18 was admitted to the facility on 8/4/17. Review of Resident 18's MDS dated 8/11/17, showed Resident 18 was cognitively intact and required two persons' extensive assistance for transfers and toileting. On 5/14/18 at 1414 hours, an interview was conducted with Resident 18 at the bedside. Resident 18 stated it took ridiculously long, four to five hours for his call light to be answered. Resident 18 stated he called at night and fell to sleep while waiting for the staff to change him. Resident 18 stated when he woke up, he was still wet, and the call light was off. In the morning, the call light waiting was often one to one and a half hours. Resident 18 stated he looked at the clock on the wall to determine the call light waiting time. Resident 18 was observed wearing a diaper and had a second diaper folded inside his original diaper. Three clean diapers were observed on top of Resident 18's bedside table. When Resident 18 was asked why he had another diaper inside his diaper, Resident 18 stated he put another diaper inside his diaper so he would not wet the bed when the CNAs could not change him. Resident 18 stated he felt disturbed and upset. On 05/15/18 at 0848 hours, an interview was conducted with CNA 4. CNA 4 stated she was aware Resident 18 put another diaper inside his diaper. CNA 4 stated Resident 18 was alert and oriented. On 5/16/18 at 1607 hours, an interview was conducted with LVN 2. LVN 2 stated she was aware Resident 18 had a second diaper folded inside of his original diaper. When asked if LVN 2 educated Resident 18 regarding the risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 10 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 of having another diaper inside his diaper, LVN 2 stated she did not provide any education to Resident 18; however, the CNA told Resident 18 not to put another diaper inside his diaper. LVN 2 stated she did not have documentation regarding this concern. No education was provided to Resident 18 and no care plan problem and approaches were developed to address Resident 18's use of two diapers being used to prevent wetting the bed linens.

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 06/18/2018 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility document review, the facility failed to determine if it was safe for one of 26 final sampled residents (Resident 100) to self-administer medications. This had the potential for Resident 100 to administer medications inaccurately. Findings: On 5/8/18 at 0905 hours, an observation was conducted of Resident 100. SSA 1 was observed taking out a clear plastic bag with eye drops from Resident 100's bedside drawer. On 5/8/18 at 0939 hours, an interview was conducted with Resident 100. Resident 100 was asked about the eye drops. Resident 100 stated per her physician, the resident could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 11 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 keep the eye drops at the bedside. Resident 100 stated the nurses were aware she kept the eye drops in her drawer and she administered the eye drops by herself. Medical record review for Resident 100 was initiated on 5/8/18. Resident 100 was admitted to the facility on 4/7/18, with diagnoses including glaucoma (a condition in which the optic nerve could be damaged due to increased pressure in the eye). Review of the History and Physical Examination form dated 4/8/18, showed Resident 100 had the capacity to understand and make decisions. Review of Resident 100's physician's orders showed an order dated 4/7/18, to administer dorzolamide (eye drops to treat glaucoma ) eye drops to the left eye twice a day for glaucoma/eye pressure. Another order dated 4/11/18, showed per the resident's request, the eye drops may be kept at the bedside and selfadminister dorzolamide ophthalmic solution to left eye two times per day and sodium chloride one drop to the right eye. Further review of Resident 100's physician's orders showed an order dated 4/12/18, to discontinue the order for the resident to have the eye drops at the bedside. Review of the Medication Administration Record dated 4/18, showed Resident 100 was scheduled to receive the dorzolamide ophthalmic solution eye drops at 0900 and 1700 hours. Further review of the Medication Administration Record dated 4/18, showed an entry "may have eye drops at bedside per patient's request." Review of Resident 100's care plan failed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 12 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 show a care plan problem was developed to address the resident's self-administration of the eye drops. Review of the medical record failed to show Resident 100 was assessed by the IDT for the ability to self-administer medication. On 5/14/18 at 1153 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 100 did not have an assessment, a physician's order, or a care plan problem addressing the self-administration of medications. On 5/14/18 at 1141 hours, an interview was conducted with LVN 8. When asked about Resident 100's eye drops, LVN 8 stated Resident 100 had the eye drops at the resident's bedside. When asked how the eye drops were administered, LVN 8 stated the licensed nurses got the eye drops from the resident's drawer, placed the eye drops on the resident's bedside table, and Resident 100 administered the eye drops by herself. On 5/15/18 at 0929 hours, an interview was conducted with SSA 1. SSA 1 stated when she answered the call light for Resident 100 on 5/8/18, the resident asked for the eye drops from her bedside drawer. SSA 1 stated she took the eye drops in a plastic bag from Resident 100's bedside drawer and gave them to LVN 8. On 5/15/18 at 0945 hours, an interview was conducted with the DON. The DON stated she was not aware of the eye drops taken from Resident 100. The DON stated when a resident had requested to self-administer her own medication, the resident needed to be assessed whether or not they could administer their own medication. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 13 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 100 needed to have a physician's order to have a medication at the bedside.

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

F558 06/18/2018 §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 medical record review, the facility failed to meet the needs for one of four nonsampled residents (Resident 36) by failing to ensure the resident was able to turn his room light on and off per the resident's needs and preferences. This failure had the potential to decrease the resident's mental, physical and psychosocial well-being. Findings: Review of Resident 36's medical record was initiated on 5/15/18, and showed the resident was readmitted to the facility on 12/4/17. On 5/15/18 at 0845 hours, Resident 36 was observed and interviewed. Resident 36 was lying in bed, awake, and alert. He was able to answer simple questions appropriately. Resident 36's room was dark and the window blinds were closed. The light switch near the bedroom door did not activate any room lights when turned on. Resident 36 was asked if he could turn on the light located above his bed. Resident 36 was observed attempting to reach the pull cord to the light above his bed using his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 14 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 right arm and hand but he was not able to reach it. The pull cord from the light fixture was approximately three inches long, and approximately nine inches away from the resident's reach. Resident 36 stated he was not able to turn any lights on or off in his room, " ...they (staff) always leave me in the dark." Resident 36 stated he wished he could turn the light on and off when he wanted. On 5/15/18 at 0850 hours, CNA 6 was interviewed. CNA 6 acknowledged Resident 36's pull cord to activate the light was too short for the resident to reach it. CNA 6 stated he would notify the maintenance staff. On 5/15/18 at 0945 hours, LVN 2 was interviewed. LVN 2 stated all residents were supposed to have reachable light cords to activate their room lights.

F577 SS=D Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 06/18/2018 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 15 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure the results of the most recent surveys (complaint investigations) were located in a place readily accessible to the residents and the public. The facility also failed to ensure the residents' identifying information was not made available to the public. This posed the risk for residents, their families, and visitors not being able to examine the most recent survey results without having to ask facility staff, and violation of the residents' rights to privacy. Findings: On 5/15/18 at 1345 hours, a white binder containing survey results was observed on the wall by the facility's front desk. The binder contained the last recertification survey results. Review of the binder showed the confidential resident roster was inside the binder. The binder did not contain the results from the abbreviated surveys dated 6/22, 7/10, 8/9, 10/25, 10/31/17, and 3/21, 4/6 and 4/19/18. On 5/15/18 at 1404 hours, an interview was conducted with the Administrator and Assistant Administrator. The Administrator and Assistant Administrator were informed and acknowledged the findings.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir FORM CMS-2567(02-99) Previous Versions Obsolete

F578 Event ID: BVUW11 06/18/2018 Facility ID: CA060000715 If continuation sheet 16 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v) §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 17 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to inquire about the existence of advance directives and failed to provide and document in the medical records information regarding the rights to formulate the advance directives for two of 26 final sampled residents (Residents 54 and 382). This had the potential for the residents' decisions regarding their health care and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives dated 2/2018 showed residents will receive information regarding formation of advance directives upon admission. For residents who have executed advance directives, the social worker will request a copy to include in the resident's medical record and document this information in the social services progress notes. 1. Medical record review for Resident 382 was initiated on 5/8/18. Resident 382 was admitted to the facility on 4/9/18, and readmitted on 4/27/18. Review of the POLST dated 4/11/18, showed Resident 382 had the capacity to understand and make decisions and did not have an advance directive. Review of the MDS dated 5/4/18, showed Resident 382 did not have an advance directive. Review of Resident 382's medical record failed to show documentation the facility provided information regarding her right to formulate an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 18 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 advance directive. On 5/9/18 at 1448 hours, an interview was conducted with Resident 382. Resident 382 stated, since being admitted to the facility, no one had inquired if she had an advance directive. On 5/10/18 at 1412 hours, an interview and concurrent medical record review was conducted with SSA 1. SSA 1 reviewed Resident 382's medical record and verified there was no documentation showing formulation of an advance directive was discussed with Resident 382. 2. Medical record review was initiated for Resident 54 on 5/8/18. Resident 54 was admitted to the facility on 3/6/18, and readmitted to the facility on 3/28/18. Review of the History and Physical Examination form dated 3/29/18, showed Resident 54 had the ability to make his own medical decisions. Review of Resident 54's medical record showed an undated POLST. The section under Information and Signatures, to document if the availability of an advance directive was discussed with the resident, was left blank. Further review of Resident 54's medical record failed to show a copy of an advance directive. Review of the Social Services Assessment dated 3/28/18, under the resident profile section showed the sections where advance directive and code status should be documented were left blank. Review of Resident 54's MDS dated 4/4/18, showed the POLST section for advance directive was not completed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 19 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/10/18 at 1346 hours, an interview and concurrent medical record review was conducted with SSA 1 regarding an advance directive for Resident 54. SSA 1 reviewed the medical record for Resident 54 and verified there was no documentation of education or attempts to obtain an advance directive, if available, from the resident.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 06/18/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility's P&P review, the facility failed to investigate an abuse allegation for one of 26 final sampled residents (Resident 43). * Resident 43's braided hair was cut off by a CNA even though Resident 43 and Family Member 2 told the CNA not to cut the hair. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 20 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility failed to immediately complete a body assessment, interview some potential witnesses, such as other staff and other residents, and failed to complete an investigation. This resulted in Resident 43 to suffer psychological distress. Findings: Review of the facility's P&P titled Protection of Residents: Reducing the Threat of Abuse and Neglect dated 2/2018 showed following the identification of alleged abuse, the resident receive prompt medical attention as necessary. The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment if needed. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. The administrator/designee will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation. The administrator/designee will review the Incident Report for completeness and assure the physician and resident representative have been notified of the circumstance. On 5/14/18 at 0957 hours, an interview was conducted with Resident 43 and Family Member 2. Family Member 2 stated, while providing care to Resident 43, CNA 3 could not remove the rubber band from Resident 43's braided hair. CNA 3 cut off Resident 43's braided hair against her will. Family Member 2 stated she reported the incident to nurses at the nurses' station, SSA 2, and the Assistant Administrator. Family Member 2 stated she discussed this incident in the care plan meeting. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 21 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/14/18 at 1340 hours, an interview was conducted with the Administrator regarding the incident of CNA 3 cutting off Resident 43's braided hair. The Administrator stated he was not aware of the incident. On 5/14/18 at 1345 hours, an interview was conducted with the Assistant Administrator. When asked about CNA 3 cutting off Resident 43's braided hair, the Assistant Administrator stated he was not aware of the incident. When asked if he thought it was an abuse allegation, the Assistant Administrator stated yes and stated he had not had any report or investigation regarding this incident. On 5/15/18 at 1019 hours, an interview was conducted with SSA 2. SSA 2 stated Resident 43 had braided hair. CNA 3 could not open the hair knot around the rubber band holding the braided hair. CNA 3 cut Resident 43's braided hair. SSA 2 stated Family Member 2 was very upset, she talked to Resident 43 and Family Member 2, and reported the incident to the DSD. SSA 2 stated she did not have any documentation regarding this incident in Resident 43's medical record. On 5/16/18 at 1527 hours, an interview and facility record review was conducted with the DSD. The DSD stated she asked CNA 3 if CNA 3 had cut off Resident 43's hair against Resident 43's will, and CNA 3 stated no. The DSD stated she did not believe there was an investigation; the DSD just took CNA 3's word. When asked if she assessed Resident 43, The DSD stated she was kind of new at that time and thought she did not know Resident 43 well enough to assess her. The DSD verified she did not assess Resident 43, and she could not provide documentation showing she spoke to Resident 43 about the incident. When asked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 22 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 about CNA 3's last performance evaluation, the DSD showed CNA 3's last performance evaluation was on 5/25/15, and no corrective action or in-services were provided for CNA 3 regarding this incident. The DSD stated employees were supposed to have an annual evaluation. When asked if the DSD reported the incident to anyone, the DSD stated she informed the former DON. On 5/18/18 at 1042 hours, a telephone interview was conducted with SSA 2 about CNA 3 cutting off Resident 43's hair. SSA 2 stated she reported the incident to the DSD. The DSD talked to Resident 43. After the DSD learned CNA 3 was the person who cut Resident 43's hair, the DSD did not assign CNA 3 to Resident 43 again. When asked if SSA 2 thought Resident 43's hair being cut off against her will was abuse, SSA 2 stated she would not consider it abuse, she stated she did not know, she thought the CNA cut Resident 43's braided hair for a good reason. SSA 2 confirmed there was no investigation regarding this incident. Cross reference to F550.

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

F641 08/08/2018 §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 observation, interview, and medical record review, the facility failed to ensure the MDS was accurate for one of 26 final sampled residents (Resident 110). The MDS failed to show Resident 110 had no natural teeth. This posed the risk of Resident 110 not receiving an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 23 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 individualized plan of care based on her specific needs. Findings: On 5/8/18 at 1144 hours, Resident 110 was observed in bed without teeth. Resident 110 asked to have her dentures placed back in. Medical record review for Resident 110 was initiated on 5/8/18. Resident 110 was admitted to the facility on 12/27/16, and readmitted to the facility on 5/3/18. Review of the MDS dated 12/28/17, showed the facility was unable to examine Resident 110's oral/dental status and failed to show Resident 110 had no natural teeth. Review of the Monthly Assessment dated 4/30/18, showed Resident 110 had missing teeth and had upper and lower dentures. On 5/14/18 at 1033 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 was asked how MDS assessments were conducted. MDS Coordinator 1 stated MDS assessments were conducted by assessment of the resident, interview with direct care staff and the resident's family, and based on documentation in the medical record. MDS Coordinator 1 stated he was unable to assess Resident 110's oral/dental status for the MDS dated 12/28/17. On 5/14/18 at 1051 hours, an interview was conducted with MDS Coordinator 2. MDS Coordinator 2 stated Resident 110's dentures were not new. MDS Coordinator 2 stated if an assessment of Resident 110's oral/dental status was unable to be completed, then information could have been obtained from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 24 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 interviewing direct care staff and Resident 110's family. MDS Coordinator 2 verified the MDS dated 12/28/17, should have shown Resident 110 had no natural teeth. On 5/14/18 at 1112 hours, an interview was conducted with Resident 110's family member. Resident 110's family member was at Resident 110's bedside and was asked about Resident 110's dentures. Resident 110's family member stated Resident 110's dentures were not new and Resident 110 had dentures prior to admission.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 06/18/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care planFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 25 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: 2. Medical record review for Resident 131 was initiated on 5/8/18. Resident 131 was admitted to the facility on 5/3/18. Review of History and Physical Examination form dated 5/4/18, showed Resident 131 had the capacity to understand and make decisions. The physical examination by the physician showed Resident 131 was short of breath. Review of the Physician Order form dated 5/3/18, showed an order to administer oxygen inhalation at two liters per minute via nasal cannula (flexible tube to deliver oxygen into the nose). On 5/8/18 at 0915 hours, a concurrent observation and interview was conducted with Resident 131. Resident 131 was observed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 26 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 with oxygen being administered at two liters via nasal cannula. Resident 131 stated she was on continuous oxygen upon admission, and the oxygen helped with her breathing. Review of Resident 131's plan of care failed to show a care plan problem to address the resident's use of oxygen. On 5/15/18 at 0829 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified there was no care plan problem to address Resident 131's use of oxygen. RN 2 stated the licensed nurses should have initiated the baseline care plan upon Resident 131's admission. Based on interview and medical record review, the facility failed to ensure baseline care plans were developed to reflect the specific care needs for two of 26 final sampled residents (Residents 131 and 133). This had the potential for the residents' care needs not being met. * The facility failed to ensure a baseline care plan was developed to address Resident 133's activities. * Resident 131's care plan problem failed to address the use of oxygen. This had the potential of Resident 131 not receiving the necessary care and services in accordance with the resident's needs. Findings: 1. Medical record review for Resident 133 was initiated on 5/8/18. Resident 133 was admitted to the facility on 5/4/18. Review of Resident 133's Baseline Care Plan and Initial Discharge Plan dated 5/5/18, showed only the signature and title of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 27 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 activities staff, but failed to show Resident 133's activities needs were addressed and failed to identify activities goals and assistance to attain activities goals. Review of Resident 133's medical record failed to show a comprehensive plan of care to address activities. On 5/10/18 at 1428 hours, an interview and concurrent medical record review was conducted with the Activities Director. The Activities Director verified Resident 133 did not have a baseline and comprehensive plan of care to address activities. The Activities Director stated the baseline care plan only required a signature from the activities staff. The Activities Director acknowledged the baseline care plan problem for activities did not identify the resident's needs, goals, or instructions to provide resident-centered care.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/18/2018 §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 but are not provided due to the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 28 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 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 observation, interview, medical record review, and facility document review, the facility failed to develop and implement the plans of care to reflect the individual care needs for eight of 26 final sampled residents (Residents 54, 123, 110, 111, 43, 70, 100, and 142). * The facility failed to develop a comprehensive person centered care plan to address Resident 54's impaired vision, activity preferences, and functional ADL care. * The facility failed to develop a care plan to address Resident 123 had dialysis access sites to the left upper chest, and the right and left upper arms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 29 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility failed to develop a care plan problem to address Resident 110's dentures. * The facility failed to develop a care plan problem to address Resident 111's PICC. * The facility failed to develop a care plan to address monitoring Resident 43 for bleeding complications related to the use of clopidogrel (anticoagulant medication). * The facility failed to implement a plan of care to address Resident 70's activity needs. * The facility failed to develop a care plan to address Resident 62's use of PRAFO boots for skin management. The facility also failed to implement the use of PRAFO boots while Resident 62 was in bed. * The facility failed to develop a care plan to address Resident 100's skin tear on her left arm. * The facility failed to develop a care plan to address Resident 142's UTI. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 54 was initiated on 5/8/18. Resident 54 was admitted to the facility on 3/6/18, and readmitted on 3/28/18. a. Review of the MDS dated 4/4/18, showed Resident 54 had moderately impaired vision. Review of the MDS Care Area Assessment (CAA) Summary showed visual function was to be addressed in Resident 54's plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 30 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/15/18 at 0821 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. Review of Resident 54's plan of care failed to show a care plan problem to address visual impairment. MDS Coordinator 1 verified the above finding and stated a care plan problem should have been developed to address Resident 54's visual impairment. b. Review of the MDS dated 4/4/18, showed Resident 54 required extensive two-person assistance with bed mobility, transfers, and toilet use. Further review of the MDS showed Resident 54 required extensive one-person assistance with dressing, eating, and personal hygiene. Review of the MDS Care Area Assessment (CAA) Summary showed ADL functional/rehabilitation potential was to be addressed in Resident 54's care plan. On 5/15/18 at 1005 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated a resident's plan of care was a guide to the care provided to the resident's specific are needs. Review of Resident 54's plan of care showed two preprinted care plan problems titled Activities of Daily Living (ADL). RN 2 reviewed them and verified both care plan problems to address Resident 54's ADL care was blank. RN 2 stated Resident 54 should have a care plan problem to address his ADL function. c. Review of the MDS dated 4/4/18, showed Resident 54's activity preferences included listening to music, keeping up with the news, and going outside when the weather was good. On 5/15/18 at 1017 hours, an interview and concurrent medical record review was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 31 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 conducted with the Activity Director. Review of Resident 54's care plan failed to show a care plan problem to address activity preferences and approaches to care for activities. The Activity Director verified the findings and stated a care plan problem should have been developed to address Resident 54's activities. 2. Medical record review for Resident 123 was initiated on 5/8/18. Resident 123 was admitted to the facility on 4/6/18, with diagnoses including end stage renal disease (kidney failure) requiring hemodialysis. Review of the Physician Orders for May 2018 showed an order dated 4/6/18, for hemodialysis on Tuesday, Thursday, and Saturday at a dialysis clinic. Review of the plan of care showed a care plan problem to address dialysis. One of the approaches included to monitor LUC (left upper chest) for signs and symptoms of infection and bleeding. The care plan failed to show monitoring of Resident 123's AV shunts to the right and left upper arms. On 5/10/18 at 1405 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 123 had just left for dialysis. When asked where Resident 123's access site was, LVN 5 stated the access site was at the left upper arm AV shunt. On 5/14/18 at 1427 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 123 had AV shunts to the bilateral upper arms but they were not working. The access site currently used for dialysis was the left upper chest catheter. LVN 7 verified there was no care plan problem developed to address the AV shunts to the bilateral upper arms. 3. On 5/8/18 at 1144 hours, Resident 110 was observed in bed without teeth. Resident 110 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 32 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 asked to have her dentures placed back in. On 5/8/18 at 1451 hours, an interview was conducted with Resident 110's family member at Resident 110's bedside. Resident 110's family member stated the CNA removed Resident 110's dentures after breakfast to clean them, but did not place them back in. Resident 110's family member stated Resident 110 preferred to keep the dentures in until bedtime. Medical record review for Resident 110 was initiated on 5/8/18. Resident 110 was admitted to the facility on 12/27/16, and readmitted to the facility on 5/3/18. Review of the Monthly Assessment dated 4/30/18, showed Resident 110 had missing teeth and had upper and lower dentures. Review of Resident 110's plan of care failed to show a care plan problem was developed to address Resident 110's dentures. On 5/14/18 at 0905 hours, an interview was conducted with CNA 2. CNA 2 stated he was familiar with Resident 110. CNA 2 stated Resident 110 had full upper and lower dentures and the CNAs were responsible for placing the dentures in before breakfast. CNA 2 stated he wasn't aware Resident 110 preferred to keep the dentures in until bedtime. On 5/14/18 at 1033 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 verified Resident 110's plan of care failed to show a care plan problem to address the dentures. MDS Coordinator 1 stated a care plan problem should have been developed to address Resident 110's dentures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 33 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 4. On 5/8/18 at 1110 hours, Resident 111 was observed in bed with a PICC to the right upper arm. When asked about the PICC, Resident 111's family member who was in the room, stated the PICC was inserted at the acute care hospital. Resident 111's family member stated he visited Resident 111 daily and usually stayed throughout the day, but had not seen the nurses assess or clean the PICC site. Resident 111 stated she did not recall when the last time the nurses assessed or cleaned the PICC site. Medical record review for Resident 111 was initiated on 5/8/18. Resident 111 was admitted to the facility on 4/12/18. Review of the Daily Skin Check Record dated 4/12/18, showed Resident 111 had a single lumen PICC to the right upper arm. Review of Resident 111's plan of care failed to show a care plan problem was developed to address Resident 111's PICC. On 5/14/18 at 0912 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 111's plan of care failed to show a care plan problem to address the PICC. RN 2 acknowledged a care plan problem should have been developed to address Resident 111's PICC. RN 2 was asked what approaches the care plan problem should have identified. RN 2 stated the approaches for the PICC included dressing change to the site every seven days and PRN, weekly flushes with normal saline when the PICC was not in use to maintain patency, and to assess the PICC site every shift for bleeding, pain, and swelling. 5. Medical record review for Resident 43 was initiated on 5/8/18. Resident 43 was admitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 34 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 to the facility on 6/12/17. Review of the Physician Orders dated March 2018 showed an order dated 6/12/17, to administer 75 mg of clopidogrel (anticoagulant medication) by mouth daily for prophylaxis. Review of Resident 43's medical record failed to show a care plan problem was developed to address the use of clopidogrel. Review of the Consultation Report dated 10/24/17, showed the Pharmacy Consultant recommended to include in Resident 43's plan of care, monitoring for bleeding complications such as rusty, discolored urine, black or tarry stools, bruising, and sudden changes in mental status or vital signs related to the use of clopidogrel. On 5/15/18 at 0933 hours, an interview and concurrent medical record review was conducted with RN 4. RN 4 verified Resident 43's medical record failed to show a care plan problem was developed to address the use of clopidogrel. RN 4 acknowledged a care plan problem to address the use of clopidogrel should have been developed. 6. On 5/9/18 at 0815 hours, Resident 70 was observed lying in bed, awake, with the head of the bed elevated. The television was observed turned off. Medical record review for Resident 70 was initiated on 5/9/18. Resident 70 was admitted on 4/6/16. Review of Resident 70's plan of care showed a care plan problem dated 4/6/16, revised date 4/19/18, addressing Resident 70's activities preferences. The plan of care showed Resident 70 enjoyed current events, baseball games, and wrestling on television. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 35 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 interventions included staff will turn on television for resident and will assist finding program of choice. Enjoyed foreign language and English channels. On 5/10/18 at 0819 hours, Resident 70 was observed awake, eating breakfast in her bed with the head of the bed elevated. The television was observed to be turned off. CNA 1 was in the room with the resident. CNA 1 was observed talking to Resident 70 and Resident 70 replied by smiling back at CNA 1. On 5/10/18 at 0830 hours, an interview was conducted with CNA 1. CNA 1 was asked if Resident 70 participated in activities. CNA 1 stated Resident 70 attended activities in the activity room and did not watch television, CNA 1 stated the television was turned off because it was not functioning. On 5/10/18 at 1153 hours, an interview was conducted with LVN 1. LVN 1 stated she was not aware Resident 70's television was not functioning. LVN 1 stated she would inform maintenance to fix it. On 5/15/18 at 0834 hours, Resident 70 was observed lying in bed, awake, watching television. At 0840 hours, CNA 1 was asked if there was any foreign language channel for Resident 70. CNA 1 said, "none." On 5/15/18 at 0845 hours, during an interview with LVN 1, LVN 1 stated she was not aware of a foreign language channel for Resident 70. LVN 1 stated she would ask the management. On 5/15/18 at 0903 hours, during an interview and concurrent medical record review with the Activities Director, the Activities Director stated she was aware of no foreign language channel available for Resident 70 and was in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 36 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 process of communicating with the provider. The Activities Director acknowledged the care plan problem addressing activities was not implemented and she stated the plan of care needed to be revised. 7. Medical record review for Resident 62 was initiated on 5/8/18. Resident 62 was admitted to the facility on 4/2/18. Review of Resident 62's Physician Orders for May 2018 showed an order dated 4/5/18, for PRAFO boots to be applied to the bilateral lower extremities, "device on at all times when in bed for skin management." Review of Resident 62's plan of care showed a care plan problem dated 4/2/18, to address a pressure ulcer on the right heel. Another care plan problem dated 4/2/18, addressed a pressure ulcer on the left heel. The care plan failed to address the use of PRAFO boots as ordered. On 5/14/18 at 0853 hours, Resident 62 was observed in bed without PRAFO boots on. On 5/14/18 at 0853 hours, an interview was conducted with CNA 7. CNA 7 verified Resident 62 did not have PRAFO boots while in bed. CNA 7 stated she had not seen Resident 62 wear PRAFO boots, and she had not seen any boots inside Resident 62's room or bathroom. On 5/14/18 at 1044 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the facility failed to develop a care plan problem to address the use of PRAFO boots. 8. Medical record review for Resident 100 was initiated on 5/8/18. Resident 100 was admitted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 37 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 to the facility on 4/7/18. Review of the MDS dated 4/14/18, showed Resident 100 had no cognitive impairment. On 5/8/18 at 0949 hours, an observation and interview was conducted with Resident 100. Resident 100 was observed with steri-strips (thin adhesive strips to keep wound edges closed) and bruises on her left arm. When asked what happened to her left arm, Resident 100 stated she had a skin tear from the wheelchair while the staff was transferring her from the bed to a wheelchair. Review of Resident 100's plan of care showed a care plan problem dated 4/7/18, to address impaired skin integrity. However, the care plan problem failed to address Resident 100's skin tear. On 5/14/18 at 1117 hours, an interview and concurrent medical record review was conducted with LVN 3. When asked what happened to Resident 100's left arm, LVN 3 stated she was not aware of a problem to the resident's left arm. LVN 3 went to Resident 100's room and asked Resident 100 about her left arm. LVN 3 verified Resident 100 had a skin tear covered with steri-strips on her left arm. LVN 3 verified there was no care plan problem to address Resident 100's skin tear. 9. Medical record review for Resident 142 was initiated on 5/8/18. Resident 142 was admitted to the facility on 5/3/18. Review of the History & Physical Examination form dated 5/4/18, showed Resident 142 had the capacity to understand and make decisions. Review of physician order dated 5/6/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 38 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 an order for Macrobid (an antibiotic to treat or prevent urinary tract infections) 100 mg for seven days for a UTI. Review of the physician's orders showed an order dated 5/7/18, to discontinue the Macrobid. The physician's orders showed an order dated 5/7/18, for Levaquin (antibiotic) 500 mg for five days. Review of Resident 142's plan of care showed a care plan problem dated 5/6/18, to address abnormal laboratory results. The approaches included Macrobid for abnormal urinalysis. Further review of Resident 142's plan of care showed a care plan problem dated 5/7/18, to address pain. The approaches included to discontinue the Macrobid, and to give Levaquin for five days. There was no documentation to show a care plan problem was developed to address Resident 142's UTI. On 5/15/18 at 0837 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the findings. RN 2 stated Resident 142 should have had a care plan problem developed to address the UTI.

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 06/18/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 39 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure three of 24 final sampled residents (Residents 100, 62, and 54) participated in the development, review, and revision of a person-centered care plan. This had the potential of Residents 54, 62, and 100 not being involved in making decisions about their care. Findings: 1. Medical record review for Resident 100 was initiated on 5/8/18. Resident 100 was admitted to the facility on 4/7/18. On 5/8/18 at 0943 hours, an interview was conducted with Resident 100. When Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 40 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 100 was asked if she was involved in any meetings to discuss her plan of care, Resident 100 stated she had never been a part of any meeting nor was her family. Resident 100 stated she would like to be involved in any meetings to discuss her care, treatment, and goals. On 5/10/18 at 1419 hours, an interview was conducted with SSA 1. When asked if a care plan conference was conducted for Resident 100, SSA 1 answered no. SSA 1 stated a care plan conference was not conducted for shortterm residents. SSA 1 stated the department heads or directors would do their own assessment of their own care area. On 5/11/18 at 1425 hours, an interview was conducted with LVN 15. When asked if the IDT had met for Resident 100, LVN 15 answered no. LVN 15 stated the department directors went to Resident 100's room and conducted their assessments individually. LVN 15 stated the IDT never met to discuss the plan of care for Resident 100. When asked if the facility involved the attending physician, registered nurse, and direct care staff assigned to the resident, dietary staff, resident, and resident representative, LVN 15 answered no. LVN 15 verified there were only assessments completed by each department director. 2. Medical record review for Resident 62 was initiated on 5/8/18. Resident 62 was admitted to the facility on 4/2/18. Review of the MDS dated 4/9/18, showed Resident 62 had severely impaired cognition. On 5/15/18 at 0829 hours, an interview and concurrent medical record review was conducted with RN 2. When asked about care plan conferences for Resident 62, RN 2 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 41 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 he was not aware of any care plan conferences for the resident. RN 2 verified there was no documentation of a care plan conference for Resident 62. On 5/15/18 at 0900 hours, an interview was conducted with LVN 10. When asked when and how the facility conducted their care plan conference, LVN 10 stated she met with the resident and the family within 48 hours after admission. LVN 10 stated when the resident and/or family had any concerns, LVN 10 referred them to the appropriate department. LVN 10 stated each department director individually assessed the resident. LVN 10 stated it would be impossible to meet with other department staff such as activity, rehabilitation, attending physician, and direct care staff as per regulation to discuss Resident 62's plan of care. 3. Medical record review was initiated for Resident 54 on 5/8/18. Resident 54 was admitted to the facility on 3/6/18, and readmitted to the facility on 3/28/18. Review of the History and Physical form dated 3/29/18, showed Resident 54 had the ability to make his own medical decisions. Review of the MDS comprehensive admission assessment showed a completion date of 4/8/18. On 5/8/18 at 1229 hours, an interview was conducted with Resident 54 and Family Member 1 at the bedside. When asked if they were invited to attend a meeting with the staff to discuss goals and treatment approaches, Resident 54 stated no. Review of Resident 54's Progress Notes showed Case Management notes documented by LVN 10 dated 4/17, 4/18, 4/19, 4/26, 5/1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 42 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 5/3, 5/8, and 5/10/18. All of the notes addressed meetings with the resident's insurance provider, the IDT and the physician to discuss the plan of care or the resident's progress. None of the notes included documentation to show the resident or his representative were invited or were present. On 5/10/18 at 1437 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 was asked if care planning was discussed in the meetings. LVN 10 stated they sometimes recommended a care planning meeting. If one was scheduled, they invited the family or resident to attend. When asked if a care plan meeting had been held since Resident 54 was admitted to the facility, LVN 10 reviewed Resident 54's medical record and verified no care plan meeting had been held for Resident 54 since admission. On 5/14/18 at 1445 hours, an interview was conducted with Resident 54. When asked if he would be interested in attending a meeting to discuss his goals, treatments, and overall care, Resident 54 stated yes.

F679 SS=E Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 06/18/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 43 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of six of 26 final sampled residents (Residents 132, 11, 126, 9, 62, and 70) and two nonsampled residents (Residents 56 and 83). This had the potential for the residents to experience feelings of social isolation and depression. * The facility failed to provide resident group outings/outside activities for Residents 11, 126, 56, and 83. * The facility failed to provide activities for Residents 9, 70, 132, and 62 which met their identified preferences and were meaningful to the residents. Findings: 1. Review of the facility's P&P titled Activities (undated) showed the goals of the facility's activity program includes encouragement of resident participation in activities suited to their interests and reflection of the wishes and concerns of the resident body. On 5/8/18 at 0858 hours, a concurrent observation and interview was conducted with Resident 132. Resident 132 was observed in his room with the TV off. There was no radio or reading material observed in Resident 132's room. Resident 132 stated he preferred to stay in his room most days. On 5/8/18 at 1420 hours, Resident 132 was observed sitting in his room with the TV off and with no radio or reading material observed in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 44 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 his room. When asked what he did in his room most days, Resident 132 stated, aside from his family visiting in the mornings, he sat in his room all day and did nothing except watching people pass by in the hallway. Resident 132 was asked what he liked to do. Resident 132 stated he liked to read books, magazines, newspapers, complete crossword puzzles, and occasionally watch TV. When asked if the staff had visited his room to offer activities, Resident 132 stated no. Medical record review for Resident 132 was initiated on 5/8/18. Resident 132 was admitted to the facility on 4/29/18. Review of the History and Physical form dated 5/3/18, showed Resident 132 had the capacity to understand and make decisions. Review of the Activities Evaluation dated 5/1/18, showed Resident 132 had good vision with glasses on and was interested in activities, had a cooperative attitude, and was motivated. Further review of the Activities Evaluation failed to show Resident 132's activity preferences included reading and crossword puzzles. Review of Resident 132's plan of care showed a care plan problem dated 4/29/18, to address activities preferences related to Resident 132's preference for self-initiated activities in the room. The approaches included activities staff was to provide room visits to the resident on a regular basis. Review of Resident 132's plan of care showed a care plan problem dated 4/29/18, to address impaired communication. The approaches included to provide a program of activities that was of interest and accommodated the resident's problem. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 45 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/9/18 at 0800, 0904, 1249, 1434, and 1607 hours, Resident 132 was observed awake in his room with the TV off and with no radio or reading material observed in his room. On 5/10/18 at 1334 hours, Resident 132 was observed awake, sitting in his bed in the dark with the lights off. The TV was observed off with no radio or reading material was observed in the room. On 5/10/18 at 1413 hours, an interview and concurrent medical record review was conducted with the Activities Director. The Activities Director stated the Activities Evaluation did not identify Resident 132 enjoyed reading and crossword puzzles because it was done at admission and Resident 132 could have been depressed or tired. The Activities Director stated Resident 132 had impaired vision. The Activities Director verified the Activities Evaluation dated 5/1/18, showed Resident 132 was interested in life/activities, had a cooperative attitude, was motivated, and had good vision with glasses. The Activities Director stated she offered Resident 132 reading material, but he declined. However, the Activities Director failed to show documented evidence reading material was offered to Resident 132 or Resident 132 declined the reading material. On 5/10/18 at 1452 hours, an interview was conducted with Resident 132 with the Activities Director present. The Activities Director stated she had not seen Resident 132 before and confused him with another resident. The Activities Director stated she did not offer reading material or crossword puzzles to Resident 132. Resident 132 stated he would like reading material such as the Reader's Digest and crossword puzzles. The Activities Director asked Resident 132 if he could see. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 46 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 132 stated he could see fine with his glasses on. 2. Medical record review was initiated for Resident 9 on 5/9/18. Resident 9 was admitted to the facility on 6/5/15. Review of the History and Physical form dated 9/23/17, showed Resident 9 did not have the capacity to understand and make decisions. Review of the MDS dated 4/26/18, showed Resident 9 was totally dependent on staff for all activities of daily living. Review of the Physician Orders for May 2018 showed an order dated 6/23/15, for nursing to assist Resident 9 up into the wheelchair by 1000 hours to attend activities. Review of the MDS dated 4/26/18, showed Resident 9's activity preferences included listening to music, being around animals, keeping up with the news, going outside when the weather was good, and participating in religious services. Review of the annual activities evaluation dated 5/3/18, showed Resident 9's activity preferences included animals/pets, current events/news, family/friend visits, gardening/patio, movies, music, religious services, sports, and television. Review of the Resident 9's care plan titled Activities Preferences revised date 2/21/18, showed the approaches to activities included to turn on the television to a channel showing sports, movies, or current events. To provide regular room visits, encourage the resident to attend group activities of choice, and encourage volunteers to provide blessings Sundays and Tuesdays to the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 47 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/10/18, multiple observations were conducted of Resident 9. Resident 9 was observed awake in his room, lying in bed, with no television or other sensory stimulation being provided at 0806, 1011, 1134, 1150, and 1447 hours. On 5/14/18 at 0810 hours, Resident 9 was observed awake in his room, lying in bed, with the television on. The television screen had an unclear picture and no volume. On 5/14/18 at 0839 hours, an observation, interview, and concurrent medical record review was conducted with the Activities Director. Resident 9 was observed awake, lying in bed, with the television on without any volume. The Activities Director verified the above findings. During review of the care plan problem addressing activities, the Activities Director was asked to define what regular room visits meant for Resident 9. The Activities Director stated regular visits would be three times per week. Review of the form titled Record of One-To-One Activities dated 3/1/18 to 5/6/18, showed the frequency of one-to-one activities was scheduled twice per week. Review of the documentation on the activities form showed one room visit was provided by the facility to the resident from 3/1 to 5/6/18, on 4/5/18. The amount of time spent with Resident 9 was blank and crossed out. The form showed no documentation of any one to one activities were provided to Resident 9 from 5/7 to 5/14/18 (seven days). The Activities Director verified the above findings and stated the documentation did not reflect the care planned approaches for Resident 9's room visits. The Activities Director stated individual activities and group activities were documented on the Individual Resident Daily Participation Record form. Review of the Individual Resident Daily Participation Record dated April FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 48 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 2018 and May 2018 showed Resident 9 participated in educational programs, current events, family/friend visits, movies at station "C," religious services on Sundays, television, and blessings. The Activities director stated educational programs, current events, and television reflected the resident was watching the news or other programs on the television in his room. The Activities Director verified the group activities Resident 9 attended were watching a movie in the activities room and blessings. The Activities Director acknowledged there was an order for Resident 9 to be up in the chair by 1000 hours daily for activities and stated she had been bringing that up with nursing frequently. Review of the documentation failed to show Resident 9 was offered or encouraged to attend other activities of interest as identified in the MDS or annual activities assessments conducted by the facility, such as going outside and listening to music. The Activities Director verified the documentation did not reflect Resident 9's activity preferences or care planned approaches to activities. 3. Review of the facility's Activity and Recreation Services Manual showed resident access to the facility bus is indispensable to the functioning of the activities program, in order to provide residents with trips such as sightseeing and entertainment. Review of the resident council minutes for the months of January, February, March, and April 2018 showed no resident outings were conducted as a result of the facility not having a bus driver. On 5/9/18 at 1000 hours, a confidential resident group interview was conducted with six cognitively intact residents in attendance. During the interview, the residents were asked if the facility's activities program met their FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 49 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 interests and needs and how the facility responded to their concerns. Resident 11 stated the residents needed to get out of the facility at least once a month, and residents used to go on therapeutic outings at least once a month. Resident 11 stated they felt like prisoners, even prisoners got to go outside for at least 15 minutes. Resident 11 stated residents would like to go outside to the facility rose garden for at least 10 to 15 minutes; however, they did not get to go outside to the rose garden often. Resident 56 stated she wanted to go outside to the facility rose garden, but she had to beg staff to be pushed outside to the rose garden. Resident 83 stated the residents had not been on scenic drives for a long time. Resident 126 stated residents should be outside of the facility at least a couple of times a month. Resident 126 stated the residents had not been out for six months, and the facility used to take the residents to Walmart; however, the bus driver quit. Resident 126 stated she informed the facility volunteers and the pastor offered to take the residents on outings; however, the facility told her they could not take them on outings, as the bus driver was required to be employed by the facility. On 5/9/18 at 1123 hours, an interview was conducted with the Activities Director. The Activities Director stated facility outings ceased in 12/2017 as the facility did not have a bus driver. On 5/15/18 at 0904 hours, an interview was conducted with the Administrator. The Administrator stated he was aware residents at the facility wanted to go on outings. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 50 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Administrator stated four to five residents from the resident council informed him of their desire to go on outings to Walmart and take scenic drives. The Administrator stated the facility had not had a bus driver since 12/17. The Administrator stated a facility staff member was in the process of obtaining a class B drivers license in order to drive the bus, and he had informed the residents. On 5/15/18 at 0915 hours, an interview was conducted with the Activities Director. The Activities Director stated Residents 56 and 126 had informed her on several occasions staff was unavailable to take them outside to the facility rose garden. The Activities Director stated she informed the residents she would attempt to find available staff; however, staff was often unavailable. 4. On 5/8/18 at 0800 hours, Resident 70 was observed in bed eating breakfast. The television was off. On 5/8/18 at 0900 hours, 1000 hours, and 1100 hours, Resident 70 was observed sitting in her wheelchair across from the nurses' station looking at people pass by, but there was no staff interaction. On 5/9/18 at 0815 hours, Resident 70 was observed lying in her bed, awake. The television was observed to be off and no other stimulation was provided. Medical record review for Resident 70 was initiated on 5/9/18. Resident 70 was admitted to the facility on 4/6/16. Review of the History and Physical form dated 9/23/17, showed Resident 70 did not have the capacity to understand and make decisions. Review of Resident 70's Activities Evaluation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 51 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 form dated 4/2/18, showed Resident 70 spoke a foreign language and watching television was very important for her. Review of Resident 70's plan of care showed a care plan problem, revised date 4/19/18, addressing Resident 70's activities preferences. The plan of care showed Resident 70 enjoyed current events, baseball games, and wrestling in a foreign language and English channels on television. The approaches included staff was to turn on the television for the resident and assist in finding a program of choice, encourage the resident to attend activities of choice to increase positive affect and socialization, and to maintain current level of function. On 5/10/18 at 0819 hours, Resident 70 was observed awake, eating breakfast in her bed. The television was observed turned off. CNA 1 was in the room with the resident. On 5/10/18 at 0830 hours, an interview was conducted with CNA 1. CNA 1 was asked if Resident 70 participated in activities. CNA 1 stated Resident 70 attended activities in the activities room and did not watch television. CNA 1 stated the television was turned off because it was not functioning. On 5/10/18 at 0835 hours, and 1115 hours, Resident 70 was observed sitting in her wheelchair across from the nurses' station looking at people passing by. There was no staff interaction. On 5/10/18 at 1123 hours, an interview was conducted with LVN 1. LVN 1 stated she was not aware Resident 70's television was not functioning. LVN 1 stated she would inform maintenance to fix it. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 52 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/10/18 at 1133 hours, an interview and concurrent medical record review was initiated with the Activities Assistant. The Record of One-To-One Activities dated 5/10/18, showed Resident 70 refused to join the activities and preferred to stay across from the nurses' station. However, the Individual Daily Participation Record dated 5/10/18, showed Resident 70 actively participated in educational programs, exercise/wheeling around, family/friends visits, movies, and television. The Activities Assistant was asked to clarify the records. The Activities Assistant was unable to explain the discrepancy in the records. On 5/15/18 at 0834 hours, Resident 70 was observed lying in bed, awake, watching an English channel on the new television set. At 0840 hours, CNA 1 was asked if any foreign language was channel available for Resident 70. CNA 1 said, "none." On 5/15/18 at 0845 hours, during an interview with LVN 1, LVN 1 stated she was not aware of any foreign language channel for Resident 70. LVN 1 stated she would ask the management. On 5/15/18 at 0903 hours, an interview was conducted with the Activities Director. The Activities Director stated she was aware of no foreign language channel available for Resident 70 and was in the process of communicating with the television provider. The Activities Director acknowledged Resident 70's activities were not provided and activities preferences were not met. 5. Medical record review for Resident 62 was initiated on 5/8/18. Resident 62 was admitted to the facility on 4/2/18. Review of the History and Physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 53 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Examination form dated 4/3/18, showed Resident 62 did not have the mental capacity to make decisions. Review of Resident 62's plan of care showed a care plan problem dated 4/2/18, addressing activities preferences. The approaches included current events and music programs on television for sensory stimulation, room visits on a regular basis, and group activities. Review of the Physician Orders showed an order dated 4/22/18, for Resident 62 to be placed in contact isolation. Another order dated 5/18/18, showed to discontinue isolation. On 5/8/18 at 0909, 1040, and 1212 hours, Resident 62 was observed in her room lying quietly in bed. The television was observed off. Resident 62 was observed twirling the call light cord with her left hand. On 5/9/18 at 0758 hours, Resident 62 was observed in her room lying quietly in bed. Resident 62 was observed staring at the wall with no television or sensory stimulation activities. On 5/14/18 at 0940 hours, Resident 62 was observed in her room lying quietly in bed. Resident 62 was observed playing with her hands and placing them in her mouth. On 5/14/18 at 0940 hours, an interview was conducted with CNA 7. When asked what kind of activities she had provided for Resident 62, CNA 7 stated she had assisted Resident 62 with exercises to her upper and lower extremities. When asked about the activities based on Resident 62's care plan, CNA 7 stated she was not aware of the resident's care plan. When CNA 7 was asked if she had seen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 54 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 activities staff come to the room for room visits, CNA 7 replied no. On 5/14/18 at 1421 hours, an interview and concurrent medical record review was conducted with the Activities Director. When asked what kind of activities had been provided for Resident 62, the Activities Director stated Resident 62 had family visits, and the staff turned the TV on for the resident. When asked what kind of activities had been provided when Resident 62 was in isolation, the Activities Director stated she was not aware Resident 62 was in isolation, or what kind of isolation she was in. When asked what kind of activities were provided while Resident 62 was in isolation, the Activities Director stated Resident 62 could have come out of the room as long as the wound was covered and not seeping. Review of the Activities Evaluation (undated) showed Resident 62's current interests as were beauty/barber, current events/news, exercise, family/friend visits, music, religious services, sing-alongs, and walking. Review of the Record of One-to-One Activities from 4/2 to 5/8/18, showed nine entries for of the 42 days the resident had been in the facility. Five of the entries showed the television was turned on for Resident 62, and two entries were for family visits. Review of the Individual Resident Daily Participation Record dated 4/2018 and 5/2018 showed entries with "P" on each date for current events/news, family/friend visits, and television; religious visits showed "P" on 4/12, 4/19, 4/26, 5/4; and one "P" entry for movies on 5/9. On 5/14/18 at 1451 hours, an interview and concurrent medical record review was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 55 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 conducted with Activity Assistant 2. When asked about Resident 62's activities, Activity Assistant 2 stated "P" meant passive, or when the resident could not communicate to the staff or to the family member. When asked what kind of activities were provided for "passive" residents, Activity Assistant 2 stated they turned the TV on for educational programs, or for the resident to watch any TV programs. When asked for any documentation to show activities were actually provided to Resident 62, Activity Assistant 2 stated she documented on the Record of One-to-One Activities. Activity Assistant 2 verified the record only showed documentation until 4/24/18. Activities Assistant 2 stated she was not done charting for May.

F684 SS=D Quality of Care CFR(s): 483.25

F684 08/08/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure four of 26 final sampled residents (Residents 54, 62, 100, and 123) attained and maintained their highest practicable physical well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 56 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility failed to ensure Resident 62 was up in a chair during meals as per the physician's order. This had the potential for Resident 62 not being provided appropriate care and treatment. * The facility failed to notify the physician when Resident 100 sustained a skin tear and obtain treatment orders for the injury. This posed the risk of the resident not receiving appropriate wound care and failure to inform the nursing staff of needed treatments. * The facility failed to ensure Resident 54's physician's orders for positioning were followed. * The facility failed to ensure the injection sites for Resident 123's heparin (anticoagulant medication to prevent blood clots) and insulin (antidiabetic medication) injections were rotated. This failure posed the risk for development of complications related to nonrotation of injection sites. Findings: 1. On 5/8/18 at 1230 hours and 5/9/18 at 1230 hours, Resident 62 was observed in bed, being fed lunch by CNA 2. Medical record review was initiated for Resident 62 on 5/8/18. Resident 62 was admitted to the facility on 4/2/18. Review of the MDS dated 4/9/18, showed Resident 62 had severely impaired cognition. Review of Resident 62's physician's orders showed an order dated 4/27/18, for one-to-one feeding up in chair with meals. Review of Resident 62's plan of care showed a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 57 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 care plan problem to address nutrition dated 4/27/18. One of the approaches included oneto-one feeding up in a chair with meals. On 5/14/18 at 0853 hours, an interview was conducted with CNA 7. CNA 7 stated Resident 62 was being fed meals and it was okay for Resident 62 to be in bed while eating, as long as the head of the bed was elevated. On 5/14/18 at 1044 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated she fed Resident 62 while the resident was in bed. LVN 3 stated Resident 62 could tolerate being in her wheelchair for two hours. LVN 3 verified Resident 62 had to be up in a chair during meals. 2. On 5/8/18 at 0949 hours, an observation and interview was conducted with Resident 100. Resident 100 was observed with steristrips (thin adhesive strips to keep wound edges closed) and bruises on her left arm. When asked what happened to her left arm, Resident 100 stated she had a skin tear from the wheelchair while the staff was transferring her from the bed to a wheelchair. Medical record review for Resident 100 was initiated on 5/8/18. Resident 100 was admitted to the facility on 4/7/18. Review of the MDS dated 4/14/18, showed Resident 100 had no cognitive impairment. On 5/10/18 at 1341 hours, an observation and interview was conducted with Resident 100. When asked to elaborate on the incident that caused her skin tear and bruises on her left arm, Resident 100 stated, while the therapist and her assistant were transferring her from the bed to a wheelchair last Thursday (5/3/18), her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 58 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 left arm swung and she sustained a skin tear from the wheelchair. Resident 100 stated the therapy staff took her to the therapy room while the resident pressed her left arm with a tissue paper. Resident 100 stated the staff found a nurse to "fix" it by pushing the skin back and applying the "strips." On 5/14/18 at 1117 hours, an interview and concurrent medical record review was conducted with LVN 3. When asked what happened to Resident 100's left arm, LVN 3 stated she was not aware of a problem with Resident 100's left arm. LVN 3 went to the room and asked Resident 100. LVN 3 verified Resident 100 had a skin tear covered with steri-strips on the resident's left arm. LVN 3 verified there was no documentation the licensed nurse notified the physician, and obtained wound treatment orders for Resident 100's skin tear. The facility also failed to investigate Resident 100's injury to her left arm. On 5/14/18 at 1131 hours, an interview was conducted with LVN 6. LVN 6 verified there was no treatment order for Resident 100's skin tear on her left arm. On 5/15/18 at 0958 hours, an interview was conducted with the DON. When asked if she was aware of what happened to Resident 100's left arm, the DON stated they had started an investigation when it was identified yesterday. When asked about the policy on investigating any injuries or accidents, the DON stated any type of injuries or accidents especially when it involved any type of skin alteration should be reported by any staff immediately. The DON stated the nurses should have started an investigation, change of condition, incident report, and care plan; the nurses should have notified the physician and family, and ensured there was a treatment for the resident; and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 59 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 IDT should have met for further investigation. 3. Medical record review was initiated for Resident 54 on 5/8/18. Resident 54 was admitted to the facility on 3/6/18, and readmitted to the facility on 3/28/18. Review of the History and Physical form dated 3/29/18, showed Resident 54 had a history of VP shunt placement. Review of the Physician Orders dated May 2018 showed an order dated 4/12/18, to keep the head of the bed higher than 30 degrees at all times for low intracranial pressure (the amount of pressure within the skull) and keep the head supported upright/midline. Review of Resident 54's care plan showed a care plan problem titled abnormal labs dated 4/19/18. One of the approaches showed do not lay Resident 54 flat, keep the head of the bed greater than 30 degrees at all times. On 5/9/18 at 0745 hours, Resident 54 was observed lying in bed with the head of the bed flat. A sign showing keep the head of the bed elevated more than 30 degrees was observed hung on the wall above Resident 54's bed. On 5/10/18 at 0802 hours, Resident 54 was observed lying in bed with the head of the bed flat. The sign to keep the head of the bed elevated more than 30 degrees remained hung on the wall above Resident 54's bed. On 5/14/18 at 1431 hours, Resident 54 was observed lying in bed with the head of the bed flat. The sign to keep the head of the bed elevated more than 30 degrees was observed hung on the wall above Resident 54's bed. On 5/14/18 at 1439 hours, and observation and interview was conducted with CNA 5. CNA 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 60 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 verified Resident 54 was lying flat in bed and stated the resident should always be sitting up at least 45 degrees. When CNA 5 was asked why the resident was required to sit up at least 30 degrees, CNA 5 stated Resident 54 coughed a lot if the head of the bed was lower than 30 degrees. On 5/14/18 at 1446 hours, an interview and concurrent medical record review was conducted with LVN 11. LVN 11 was asked why Resident 54's head of the bed was required to be elevated 30 degrees at all times. LVN 11 stated Resident 54 had a GT with formula feedings in the past. The sign was to remind CNA staff to keep the head of the bed elevated for the formula feedings. LVN 11 reviewed the physician's orders and verified Resident 54's head of the bed was to be elevated at least 30 degrees at all times to keep the intracranial pressure low. 4. According to the facility's undated P&P titled Subcutaneous Injection, when administering heparin or insulin, follow the listing of common injection sites and rotate the sites. Rotate the sites to prevent unnecessary trauma and to aid in absorption. Medical record review for Resident 123 was initiated on 5/8/18. Resident 123 was admitted to the facility on 4/6/18. Review of the Physician Orders showed the following orders dated: - 4/6/18, heparin 5000 units/ml solution (units per milliliter), inject 1 ml subcutaneously (needle is inserted under the skin) every 12 hours; - 4/6/18, insulin Lispro 100 units/ml solution inject subcutaneously per sliding scale before meals and at bedtime; - 4/7/18, Basaglar KwikPen (injectable medication to control high blood sugar levels) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 61 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 100 units/ml, inject 10 units subcutaneously daily. Review of the Sliding Scale Insulin form and the Anticoagulant Administration Record showed the indicated sites for the administration of insulin and heparin injections were as follows: Site 1 - left buttock Site 2 - right buttock Site 3 - left arm Site 4 - right arm Site 5 - left thigh Site 6 - right thigh Site 7 - left abdomen Site 8 - right abdomen Site 9 - left upper back Site 10 - right upper back Site 11 - left upper chest Site 12 - right upper chest Review of the Diabetic and Anticoagulant Administration Records from 4/8 to 5/14/18, showed the injection sites used to administer the insulin and heparin injections were Sites 7 and 8 only. There were dates when Resident 123 received all injections on the same site. For example, on 5/13/18, Resident 123 received the Basaglar KwikPen at 0900 hours on Site 8; Lispro injection at 2100 hours on Site 8; and heparin injection at 0900 and 2100 hours on Site 8. On 5/14/18 at 1412 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified the injection sites were given in the same area. LVN 7 acknowledged the injection sites had to be rotated. On 5/15/18 at 0745 hours, Resident 123 was observed with scattered skin discoloration to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 62 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 abdominal area.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 08/08/2018 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary treatments and services to prevent the worsening of pressure ulcers for one of 26 final sampled residents (Resident 88). * The facility failed to follow their P&P to complete a weekly assessment on Resident 88's pressure ulcer. In addition, the facility failed to show consistent and accurate documentation of the assessments done for Resident 88's pressure ulcer. This lack of consistent and accurate assessment resulted in the resident's pressure ulcer worsening from Stage 2 to Unstageable. Findings: According to the facility's P&P titled Wound Care/Treatment Guidelines revised 5/21/04, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 63 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 guidelines for wound care included to complete a weekly assessment on all wounds, including measurement and description. Label the dressing with the nurse's initials, date, and time. Medical record review for Resident 88 was initiated on 5/8/18. Resident 88 was admitted to the facility on 3/16/18, and was readmitted on 5/2/18. Review of the History and Physical form dated 5/3/18, showed Resident 88 did not have the capacity to understand and make decisions. a. Review of the Daily Skin Check Record dated 3/17/18, showed a diagram of Resident 88's wounds. The diagram showed a Stage 2 pressure ulcer measured 3 cm (length) x 3 cm (width) at the coccyx (tailbone). Review of Resident 88's Wound Assessment failed to show an assessment was completed on the day of admission, nor the following day, 3/17/18. The initial wound assessment was dated 3/21/18, showing a Stage 2 pressure ulcer to the coccyx measuring 3 cm x 3 cm. There was no wound assessment done on 3/23/18, a week after admission. The Wound Assessment dated 3/30/18, showed Resident 88 had a Stage 3 pressure ulcer to the coccyx measuring 6 cm x 5 cm. The wound base was described as 100% eschar. The entry for Treatment Response showed "deteriorated." Review of the Wound Consultant's notes dated 3/29/18, showed an Unstageable pressure ulcer to the coccyx measuring 6 cm (length) x 5 cm (width) x 0.1 cm (depth). The wound bed was described as 100% eschar. However, LVN 6 ' s wound assessment dated 3/30/18, showed a Stage 3 pressure ulcer at the coccyx measuring 6 cm x 5 cm with 100% eschar. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 64 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Wound Consultant's notes dated 4/12/18, showed an Unstageable pressure ulcer to the coccyx measuring 7 cm x 9 cm x 0.3 cm. The wound bed was 80% slough and 20 % granulation (healing tissue). However, LVN 6 did not document a wound assessment on 4/12/18. LVN 6's wound assessment dated 4/15/18, showed a Stage 3 pressure ulcer at the coccyx measuring 6 cm x 5 cm. The wound base was 50% granulation and 50% eschar. On 5/14/18 at 1432 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated she was responsible for performing the wound assessments for Resident 88. LVN 6 stated the initial wound assessment for Resident 88 was done on 3/17/18; however, she got busy and was only able to enter her wound assessment in the computer on 3/21/18. That was the reason why the measurement and description of the wounds were the same. LVN 6 stated Resident 88 was referred to the Wound Consultant for wound management on 3/29/18, due to deterioration of the pressure ulcer at the coccyx. LVN 6 stated she measured the wound together with the Wound Consultant, so their assessments should match. When asked why her wound assessment was dated the following day (3/30/18) and the staging of the pressure ulcer was different, LVN 6 stated she did not have time to enter the assessment in the computer on 3/29/18, but the assessment she entered on 3/30/18, was reflective of the wound assessment done with the Wound Consultant on 3/29/18. LVN 6 stated she normally did not enter her wound assessments on the same day it was done, depending on how busy she was. LVN 6 verified there was no wound assessment done on 3/23/18, a week after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 65 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 admission, and the next assessment was done with the Wound Consultant when the wound deteriorated from Stage 2 to an Unstageable pressure ulcer. b. On 5/14/18 at 0840 hours, a wound care observation was conducted with LVN 6. LVN 6 provided wound treatment to Resident 88's wounds located on the coccyx, the left lateral leg, and bilateral heels. LVN 6 was not observed labeling the dressing with her initials, date, and time. LVN 6 verified the findings.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/18/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment 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 observation and interview, the facility failed to ensure one nonsampled resident (Resident 36) was free from potential hazards when an electrical outlet behind the resident's bed had a missing cover plate with exposed electrical wires. This failure placed the resident at potential risk for injuries. Findings: On 5/15/18 at 0845 hours, Resident 36 was observed lying in bed, awake and alert. Resident 36 was able to answer simple questions appropriately. There was an electrical outlet observed behind the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 66 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 bed that was missing a cover plate over the outlet, allowing electrical wires to be exposed. Resident 36's electric bed was plugged into this outlet. On 5/15/18 at 0850 hours, CNA 6 was interviewed. CNA 6 confirmed the electrical outlet was missing the cover plate. CNA 6 stated he would notify the maintenance department. On 5/15/18 at 1050 hours, the Environmental Manager was interviewed. He stated the electrical outlet should have had a cover plate to prevent the wires being exposed and stated it was unsafe.

F694 SS=D Parenteral/IV Fluids CFR(s): 483.25(h)

F694 08/08/2018 § 483.25(h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 26 final sampled residents (Resident 111) received appropriate care regarding the PICC. The facility failed to ensure the PICC was assessed on admission and ongoing assessment and care was provided. This posed the risk for Resident 111 to develop complications such as catheterrelated infection or catheter-associated venous thrombosis (blood clot inside the vein). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 67 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Findings: Review of the facility's P&P titled Central Vascular Access Device (CVAD) Dressing Change revised 5/1/15, showed CVADs included PICCs and the catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Sterile dressing change using transparent dressings is performed at least weekly and as needed. Assessment of the vascular access site is performed upon admission and during dressing changes and at least once every shift when not in use. The length of the external catheter is obtained upon admission and during dressing changes. For PICCs, upper arm circumference 10 cm above the antecubital fossa (elbow) is obtained upon admission and then weekly. If signs or symptoms of complications are present, compare the upper arm circumference to the baseline measurement to detect possible catheter-associated venous thrombosis (3 cm increase in arm circumference and edema are associated with upper-arm deep vein thrombosis). On 5/8/18 at 1110 hours, Resident 111 was observed in bed with a PICC to the right upper arm. When asked about the PICC, Resident 111's family member who was in the room, stated the PICC was inserted at the acute care hospital. Resident 111's family member stated he visited Resident 111 daily and usually stayed throughout the day, but had not seen the nurses assess or clean the PICC site. Resident 111 stated she did not recall when the last time the nurses assessed or cleaned the PICC site. Medical record review for Resident 111 was initiated on 5/8/18. Resident 111 was admitted to the facility on 4/12/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 68 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Daily Skin Check Record dated 4/12/18, showed Resident 111 had a single lumen PICC to the right upper arm. Review of Resident 111's medical record failed to show documented evidence the PICC was assessed upon admission and ongoing assessment and maintenance care was provided. On 5/14/18 at 0912 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated he was the IV nurse. RN 2 was asked how PICCs were assessed and what ongoing maintenance care was required. RN 2 stated upon admission and at least weekly, the PICC site should be assessed for bleeding, pain, and swelling and the PICC should be assessed for patency. RN 2 stated the PICC site dressing should be changed on admission, weekly, and as needed. RN 2 stated the PICC assessment and dressing change should be documented on the Central Vascular Access Device Treatment Record. RN 2 verified Resident 111's medical record failed to show documented evidence the PICC was assessed upon admission and ongoing assessment and maintenance care was provided that included assessment for patency, measurements of the upper arm circumference, measurements of external catheter length, PICC site condition, and PICC site dressing change. RN 2 stated the PICC should have been assessed and the PICC site dressing should have been changed but did not recall when it was done. On 5/14/18 at 0940 hours, an observation of Resident 111's PICC site was observed with RN 2. Resident 111's PICC site was observed covered with a transparent dressing dated 4/30/18. RN 2 verified the transparent dressing was dated 4/30/18, and stated the date showed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 69 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 last time the dressing was changed. RN 2 acknowledged the dressing was changed two weeks ago.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 06/18/2018 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to manage pain during wound care for one of 26 final sampled residents (Resident 28). This had the potential for the resident experiencing unnecessary pain. Findings: Medical record review for Resident 28 was initiated on 5/8/18. Resident 28 was admitted to the facility on 5/26/16, and readmitted to the facility on 2/20/18. Review of Resident 28's Treatment Administration Record dated May 2018 showed Resident 28 had a pressure ulcer to the sacrum (tailbone) and moisture associated dermatitis (inflammation or skin erosion caused by prolonged exposure to a source of moisture) to the perirectal area. Review of the Physician Orders for May 2018 showed an order dated 2/20/18, to administer Norco 5-235 mg, one tablet by mouth every four hours as needed for pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 70 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 According to Lexicomp (a drug resource for healthcare professionals), the peak serum time for Norco 5/325 tablets is one hour. The peak level is the highest concentration of a drug in the patient's bloodstream. Review of a physician's order dated 5/3/18, showed Resident 28 was to be medicated for pain prior to the wound treatment. On 5/10/18 at 0908 hours, an interview and concurrent record review was conducted with LVN 12. Review of the Controlled or Antibiotic Drug Record and Pain Flow Sheet for 5/10/18, showed Norco 5/325 mg, one tablet by mouth was administered to Resident 28 on 5/10/18, at 0900 hours. The documented pain level at the time of administration was 6/10 (moderate pain). LVN 12 stated pain medications given by mouth were effective 15 to 30 minutes after administration. On 5/10/18 at 0916 hours, an observation of Resident 28's wound treatments was conducted with LVN 6. Resident 28's wound treatment was started 16 minutes after the Norco was administered. During the wound treatment Resident 28 was observed moaning on multiple occasions and stated, "I hurt all over." LVN 6 continued providing Resident 28's wound treatment until 0940 hours (24 minutes) then LVN 6 stated she would contact the physician regarding Resident 28's pain. On 5/14/18 at 1352 hours, an interview was conducted with RN 2. RN 2 stated pain assessments were conducted before pain medication was given and 30 minutes to an hour after the medication was given to evaluate the effectiveness of the medication. RN 2 stated pain medication should be administered at least 30 minutes prior to wound care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 71 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F698 Dialysis CFR(s): 483.25(l)

F698 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/08/2018 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical wellbeing for two of 26 final sampled residents (Residents 88 and 123). * The facility failed to ensure Resident 88's medications were administered as ordered by the physician on the days she was out for dialysis. * The facility failed to ensure Resident 123's dialysis access sites were assessed accurately. These had the potential for the residents not being provided with appropriate care and treatment, and the possibility of medical complications. Findings: 1. Medical record review for Resident 88 was initiated on 5/8/18. Resident 88 was admitted to the facility on 3/16/18, and was readmitted on 5/2/18, with diagnoses including end stage renal disease requiring hemodialysis. Review of a physician's order dated 5/2/18, showed Resident 88 was to receive dialysis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 72 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 every Monday, Wednesday, and Friday at a dialysis center. On 5/9/18, Resident 88 was observed to be out of the facility during the hours of 0945 through 1535. Review of the Physician Admission Orders dated 5/2/18, showed the following orders for midodrine (medication to increase the blood pressure) 10 mg, one tablet three times a day and sevelamer carbonate (medication to prevent the increase of phosphates) 800 mg, two tablets three times a day. On 5/14/18 at 1118 hours, an interview and concurrent medical record review was conducted with LVN 7. Review of the Medication Administration Record for the month of May 2018 showed the midodrine 10 mg one tablet was to be administered every day at 0900, 1300, and 1700 hours. The nursing staff documented the medication was administered on 5/4, 5/7, and 5/9/18 at 1300 hours, when Resident 88 was out of the facility for dialysis. However, the medication was held on 5/11/18 at 1300 hours, because Resident 88 was out for dialysis. The sevelamer carbonate 800 mg, two tablets were to be administered every day at 0800, 1200, and 1700 hours. The nursing staff documented the medication was administered on 5/4, 5/7, and 5/9/18 at 1200 hours, when Resident 88 was out for dialysis. However, the medication was held on 5/11/18 at 1200 hours, because Resident 88 was out for dialysis. LVN 7 verified the above findings. LVN 1 stated the medications scheduled to be given at 1200 and 1300 hours when Resident 88 was out of the facility for dialysis were given when she came back to the facility at 1530 hours, then Resident 88 received the next scheduled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 73 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 dose at 1700 hours within an hour and a half time frame. When asked about a physician's order to hold the medications, LVN 7 was unable to show a physician's order to hold the medications on dialysis days. 2. Medical record review for Resident 123 was initiated on 5/8/18. Resident 123 was admitted to the facility on 4/6/18, with diagnoses including end stage renal disease requiring hemodialysis. Review of the physician's orders showed an order dated 4/7/18, to monitor the right and left upper medial arm AV shunt for signs of infection every shift. Review of the physician's order dated 4/6/18, showed Resident 123 was to receive dialysis every Tuesday, Thursday, and Saturday at a dialysis center. Review of the Medication Administration Record for the month of May 2018 showed the left upper arm was to be monitored for bruit (the sound heard with a stethoscope over the AV shunt of blood flowing through the shunt) and thrill (the feel of the blood passing through the AV shunt); and the LUC was to be monitored for signs and symptoms of infection and bleeding. There was no monitoring for the right upper arm AV shunt. On 5/8/18 at 1345 hours, Resident 123 was observed to be out of the facility for dialysis. On 5/10/18 at 1405 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated she assessed the dialysis access site before Resident 123 left for dialysis today. LVN 5 stated Resident 123's access site was the left upper arm AV shunt and she assessed for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 74 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 bruit and thrill by touching the arm until she felt the bruit and thrill. LVN 5 stated she could feel for the bruit and thrill by using her fingers. LVN 5 was asked what was the LUC they were monitoring. LVN 5 reviewed the Medication Administration Record and stated the LUC was a mistake and should have been written as LUA which means left upper arm because that was where the access site was. LVN 5 stated Resident 123 had no other access sites. Review of the Pre/Post Dialysis Communication form dated 5/10/18, showed LVN 5 did not assess the access site pre and post dialysis treatment. On 5/14/18 at 1447 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 123's dialysis access site was the catheter at left upper chest; however, Resident 123 also had AV shunts to the bilateral upper arms which were not being used but needed to be monitored. LVN 7 could not provide documentation the AV shunt at the right upper arm was being monitored. On 5/15/18 at 0745 hours, Resident 123 was observed with a catheter at the left upper chest and AV shunts to the bilateral upper arms.

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 06/18/2018 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 75 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure six of 26 final sampled residents (Residents 9, 73, 88, 110, 111, and 133) remained free from accident hazards due to the use of side rails. * The facility failed to attempt alternative measures prior to the use of side rails for Residents 9, 73, 110, 111, and 133. * The facility failed to assess for the risk of entrapment from side rails prior to use of side rails for Residents 88, 111, and 133. * The facility failed to review the risks and benefits and obtain informed consent prior to the use of side rails for Residents 9, 88, 111, and 133. These had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 76 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 1. Medical record review for Resident 73 was initiated on 5/8/18. Resident 73 was admitted to the facility on 5/14/13, and readmitted on 4/26/17. Review of a care plan problem titled risk for falls/injury revised date 4/17/18, showed Resident 73 was at high risk for injury related to poor body control and balance. Review of the physician's order dated 6/15/17, showed an order for bilateral side rails as an enabler for turning and repositioning. Review of Resident 73's medical record failed to show any alternative measures were attempted prior to the use of side rails. On 5/9/18 at 0842 hours, an observation and concurrent interview was conducted with Resident 73. Resident 73's bed was observed with bilateral side rails elevated at the head of the bed. Resident 73 stated she used the side rails to reposition herself in bed. On 5/10/18 at 1019 hours, an interview and concurrent medical record review was conducted with RN 1. Review of Resident 73's Evaluation for Use of Side Rails form dated 4/17/18, failed to show any alternative measures were attempted prior to the use of side rails. RN 1 verified alternative measures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 77 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 prior to use of side rails for Resident 73 were not attempted. 2. On 5/9/18 at 1438 hours, 5/10/18 at 0804 hours, and 5/14/18 at 0848 hours, Resident 9 was observed in bed with a side rail elevated on the right side of the bed. Medical record review was initiated for Resident 9 on 5/9/18. Resident 9 was admitted to the facility on 6/5/15. Review of the History and Physical form dated 9/23/17, showed Resident 9 did not have the capacity to understand and make decisions. On 5/14/18 at 1008 hours, an observation, interview, and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 9 had a side rail on the right side of the bed to aid in repositioning. When the medical record was reviewed, RN 2 was unable to show documentation alternatives were attempted prior to the installation of the side rail for Resident 9. When asked if informed consent was obtained prior to the use of side rails for positioning, RN 2 stated yes. Review of the medical record failed to show the risks, benefits, and alternatives to side rails were discussed with Resident 9's representative and failed to show an informed consent had been obtained prior to the use of the side rail. 3. Medical record review for Resident 88 was initiated on 5/8/18. Resident 88 was admitted to the facility on 3/16/18, and was readmitted on 5/2/18. Review of the History and Physical form dated 5/3/18, showed Resident 88 did not have the capacity to understand and make decisions. On 5/8/18 at 0936 and at 5/10/18 at 0812 hours, Resident 88 was observed lying in bed with bilateral side rails elevated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 78 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/10/18 at 1131 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 88 had bilateral side rails elevated to aid in repositioning. When the medical record was reviewed, LVN 9 failed to show documentation Resident 88 was assessed for the risk of entrapment prior to the use of side rails, nor had informed consent been obtained from Resident 88's responsible party reviewing the risks and benefits of the use of side rails. 4. On 5/8/18 at 1124 hours, 5/9/18 at 1431 hours, and 5/10/18 at 0945 hours, Resident 133 was observed in bed with bilateral side rails elevated at the head of the bed. Medical record review for Resident 133 was initiated on 5/8/18. Resident 133 was admitted to the facility on 5/4/18. On 5/10/18 at 1145 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 133's medical record failed to show documented evidence an assessment for the risk of entrapment from side rails was conducted, what alternatives were attempted prior to the use of the side rails, the risks and benefits of the side rails were reviewed with the resident or the resident's representative, and failed to show informed consent was obtained. 5. On 5/8/18 at 1104 and 1444 hours, Resident 111 was observed in bed with bilateral side rails elevated at the head of the bed. Medical record review for Resident 111 was initiated on 5/8/18. Resident 111 was admitted to the facility on 4/12/18. On 5/10/18 at 1139 hours, an interview and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 79 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 111's medical record failed to show documented evidence an assessment for the risk of entrapment from side rails was conducted, alternatives attempted prior to the use of the side rails, the risks and benefits of the side rails were reviewed with the resident or the resident's representative, and failed to show informed consent was obtained. 6. On 5/8/18 at 1209 hours, and on 5/9/18 at 1437 hours, Resident 110 was observed in bed with bilateral side rails elevated at the head of the bed. Medical record review for Resident 110 was initiated on 5/8/18. Resident 110 was admitted to the facility on 12/27/16 and readmitted to the facility on 5/3/18. On 5/10/18 at 1136 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified Resident 110's medical record failed to show documented evidence alternatives were attempted prior to the use of the side rails.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 09/09/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 80 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate reconciliation of controlled medications for four nonsampled residents (Residents 77, 986, 67, and 85). This posed the risk for diversion of controlled medications and medication administration errors. * The facility failed to ensure Resident 77's controlled medications were disposed of when Resident 77 was discharged. * The facility failed to ensure administration of controlled medications for Residents 986 and 67 were accurately documented to ensure accurate reconciliation and to prevent medication administration errors. * Controlled medication for Resident 85 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 81 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 maintained in the medication cart, even though Resident 85 no longer resided in the facility. These failures posed the risk for diversion of controlled medications. Findings: Review of the facility's P&P titled Disposal/Destruction of Expired or Discontinued Medications revised 1/1/13, showed the facility staff should remove discontinued medication from the resident's medication supply. Review of the facility's undated P&P titled Administration of Medication showed to initial each medication in the correct box on the MAR (Medication Administration Record) after the medication is given and PRN (as needed) medication is documented with initials and time given in the corner of the box. 1. On 5/9/18 at 1030 hours, an inspection of Station B's Medication Cart 3 was conducted with LVN 11. LVN 11 was asked what the facility's policy was regarding the disposition of controlled medications. LVN 11 stated discontinued controlled medications and controlled medications for discharged residents were given to the DON for disposition. Inspection of Station B's Medication Cart 3 showed Resident 77 had a quantity of 30 oxycodone-acetaminophen (controlled pain medication) 10-325 mg tablets. LVN 11 stated the medication was delivered after Resident 77 was transferred and admitted to the acute care hospital. Medical record review for Resident 77 was initiated on 5/9/18. Resident 77 was admitted to the facility on 4/10/18, and readmitted to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 82 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility on 5/1/18. Review of the telephone orders dated 4/27/18, showed to transfer Resident 77 to the acute care hospital. Review of the Progress Notes dated 4/27/18, showed Resident 77 was transferred to the acute care hospital. Review of the Progress Notes dated 5/2/18, showed Resident 77 was readmitted to the facility on 5/1/18. On 5/9/18 at 1045 hours, an interview and concurrent medical record review was conducted with LVN 11. Review of the prescriptions delivered receipt dated 4/28/18, showed a quantity of 30 oxycodoneacetaminophen 10-325 mg tablets were delivered to the facility for Resident 77. LVN 11 verified the medication was delivered after Resident 77 was transferred and admitted to the acute care hospital. LVN 11 stated residents admitted to the acute care hospital are considered discharged from the facility. LVN 11 acknowledged Resident 77's controlled medications should have been given to the DON for disposition after Resident 77 was discharged. On 5/15/18 at 0810 hours, an interview was conducted with the DON regarding disposition of controlled medications. The DON was asked if controlled medications for residents transferred and admitted to the acute care hospital were supposed to be given to her for disposition. The DON stated yes, because residents admitted to the acute care hospital are considered discharged from the facility. 2. On 5/9/18 at 1030 hours, an inspection of Station B's Medication Cart 3 was conducted with LVN 11. LVN 11 was asked what the facility's policy was regarding the administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 83 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 of controlled medications. LVN 11 stated the process for administering controlled medications was to verify the physician's orders, reconcile the observed quantity of the controlled medication against the quantity recorded on the Controlled or Antibiotic Drug Record, remove the medication from the bubble pack (a card where medications are placed in individual, clear, and sealed compartments), document the removal of the controlled medication on the Controlled or Antibiotic Drug Record, administer the medication to the resident, and document the medication administration on the Medication Administration Record. Inspection of Station B's Medication Cart 3 showed Resident 986's bubble pack for hydrocodone-acetaminophen (controlled pain medication) 10-325 mg had two tablets removed. Review of the label on the bubble pack showed to administer one tablet by mouth every four hours as needed for moderate pain and to administer two tablets by mouth every four hours as needed for severe pain. Review of the Controlled or Antibiotic Drug Record for Resident 986 failed to show two tablets of hydrocodone-acetaminophen 10-325 mg was removed. Review of Resident 986's Medication Administration Record dated 5/18 failed to show documented evidence two tablets of hydrocodone-acetaminophen 10-325 mg were administered to Resident 986. On 5/9/18 at 1057 hours, an interview and concurrent medical record review was conducted with LVN 11. LVN 11 stated she administered two tablets of the hydrocodoneacetaminophen 10-325 mg to Resident 986, but did not document the administration on the Controlled or Antibiotic Drug Record and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 84 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Medication Administration Record. 3. Medical record review for Resident 67 was initiated on 5/9/18. Resident 67 was admitted to the facility on 3/21/18. Review of the Controlled or Antibiotic Drug Record for Resident 67 showed two tablets of oxycodone-acetaminophen 5-325 mg was removed on 5/7 at 1400 and 2100 hours, and on 5/8 at 1400, 1900, and 2300 hours. However, review of the Medication Administration Record for May 2018 showed only one initial under 5/7 and one initial under 5/8. The Medication Administration Record failed to show an initial and time for each time Resident 67 was administered the controlled medication. Review of the Physician Admission Orders dated 3/21/18, showed to administer two tablets of oxycodone-acetaminophen 5-325 mg every four hours as needed for moderate to severe pain. On 5/9/18 at 1107 hours, an interview and concurrent medical record review was conducted with LVN 11. LVN 11 verified the Medication Administration Record did not show an initial and time for each time Resident 67 was administered oxycodone-acetaminophen 5 -325 mg. LVN 11 stated for every as needed medication administered, it should be documented with the nurse's initials and time administered on the Medication Administration Record. 4. On 5/9/18 at 1433 hours, an inspection of one of six medication carts (Medication Cart 4) was conducted with LVN 8. The following controlled medications for Resident 85 were observed inside the medication cart: - 27 tablets of oxycodone hydrochloride (opioid analgesic) 5 mg/tablet; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 85 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 - 13 ml of morphine sulfate (opioid analgesic) 20 mg/ml solution; - 25 tablets of morphine sulfate immediaterelease 15 mg/tablet; and - 4 tablets of lorazepam (anti-anxiety medication) 1 mg/tablet LVN 8 stated Resident 85 was no longer in the facility, so these medications should have been given to the DON for disposition. LVN 8 was not sure when Resident 85 was discharged, but was no longer in the facility when she worked yesterday. On 5/15/18 at 1027 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 reviewed Resident 85's medical record and stated Resident 85 expired on 5/6/18.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/08/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 86 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 26 final sampled residents (Resident 382) was free from an unnecessary psychotropic drug (any drug that affects brain activity). * The facility failed to ensure Resident 382's prescription for Ativan PRN was limited to 14 days. This had the potential to negatively impact the resident's well-being. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 87 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Medical record review for Resident 382 was initiated on 5/8/18. Resident 382 was admitted to the facility on 4/9/18, and readmitted on 4/27/18. Review of the physician's order dated 5/1/8, showed an order for Ativan (antianxiety medication) 1 mg by mouth every 8 hours PRN for anxiety. The physician's order for Ativan failed to show a duration for use. On 5/10/18 at 1359 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 382's physician's order for Ativan had no end date for duration of use.

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 06/18/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8.57%. One of four licensed nurses (LVN 5) who administered medications was found to have errors. * LVN 5 failed to administer two medications as ordered. This posed the risk of the resident not receiving the prescribed medications or appropriate doses. LVN 5 failed to follow the manufacturer's specifications in the administration of an extended release capsule. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 88 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Findings: Review of the facility's P&P titled Administration of Medication (undated), the procedure in safely and appropriately administering the medications includes to read and follow any special instructions written on the medication labels. Crush medications only after checking with the pharmacy and/or supervisor since the medication may be timereleased capsules or enteric coated. A medication pass observation was conducted on Station A with LVN 5 on 5/10/18 at 0824 hours. The following was observed: LVN 5 was observed preparing and administering phenytoin (anticonvulsant medication) extended release 100 mg, one capsule to Resident 333 by mouth. LVN 5 opened the extended release capsule and mixed the medication with apple sauce and gave it to Resident 333. However, review of the medication label showed "do not chew or crush" the medication. LVN 5 was observed looking for docusate sodium (stool softener) 100 mg as ordered on 5/5/18, by the physician. LVN 5 was unable to locate docusate sodium 100 mg in the medication cart and omitted administering the docusate sodium to Resident 333. LVN 5 was observed looking at two different entries for Bactrim DS (antibiotic) one tablet scheduled to be given at 0900 hours. LVN 5 could not locate the Bactrim DS in her medication cart and omitted administering the Bactrim DS to Resident 333. LVN 5 acknowledged the above findings and stated she should not have crushed the phenytoin extended release capsule. LVN 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 89 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 also stated she was not able to give the docusate sodium, which was a house stock, because the medication was not available in her medication cart. On 5/10/18 at 1009 hours, an interview was conducted with RN 3. RN 3 stated he called the pharmacy and was told the Bactrim DS was not requested; however, the medication was available in their automated medication dispensing cabinet. RN 3 also acknowledged docusate sodium was a house stock.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 06/18/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 26 final sampled residents (Resident 142) and one nonsampled resident (Resident 333) were free of a significant medication error. * Resident 142 was administered an extra dose of Percocet (same as oxycodoneacetaminophen, a controlled pain medication) 10/325 mg after the medication was discontinued by the physician. * LVN 6 was observed administering an extended release capsule of phenytoin (antiseizure medication) to Resident 333 crushed in apple sauce. These had the potential to negatively impact the residents' well-being. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 90 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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. On 5/9/18 at 1433 hours, a medication cart observation was conducted with LVN 8. A random inspection of the controlled medications showed Resident 142 had bubble packs of oxycodone-acetaminophen 10-325 mg tablets and 5-325 mg tablets. Review of the narcotic count sheet showed one tablet was taken on 5/9/18 at 0000 hours from both the oxycodone-acetaminophen 10-325 mg tablets and 5-325 mg tablets by LVN 13. Review of the physician's orders showed an order dated 5/4/18 for Percocet 10-325 mg one tablet by mouth every 4 hours for pain management; and an order dated 5/8/18, to discontinue current Percocet order (10-325 mg) and decrease to Percocet 5-325 mg one tablet by mouth every four hours. On 5/9/18 at 1602 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 verified Percocet 10-325 mg was discontinued on 5/8/18, and should have not been administered to Resident 142 on 5/9/18 at 0000 hours. LVN 8 verified Resident 142 also received the prescribed dose of Percocet 5-325 mg, one tablet on 5/9/18 at 0000 hours. Review of the nurses' notes failed to show documented evidence Resident 142 was assessed after the medication error was discovered on 5/9/18. On 5/16/18 at 1612 hours, an interview was conducted with the DON. The DON stated she was only informed of the medication error on 5/10/18. On 5/16/18 at 1710 hours, an interview was conducted with LVN 8. LVN 8 stated she did not report the medication error to her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 91 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 supervisor nor the DON when it was identified on 5/9/18. LVN 8 failed to show documented evidence Resident 142 was assessed after the medication error was identified on 5/9/18. On 5/18/18 at 0810 hours, a telephone interview was conducted with LVN 13. LVN 13 stated when a controlled medication was taken from the bubble pack, and the narcotic count sheet was signed, the medication was given to the resident. 2. According to Lexi-Comp (a pharmacy resource for healthcare professionals), medications which should not be crushed fall into one of the following categories: Extended Release Products: The formulation of some tablets is specialized as to allow the medication within it to be slowly released into the body. This may be accomplished by centering the drug within the core of the tablet, with a subsequent shedding of multiple layers around the core. Wax melts in the GI tract, releasing the drug contained within the wax matrix. Capsules may contain beads which have multiple layers which are slowly dissolved with time. On 5/10/18 at 0824 hours, a medication pass observation was conducted with LVN 6. LVN 6 was observed preparing and administering phenytoin 100 mg extended release capsule to Resident 333. LVN 6 opened the capsule and mixed the contents with apple sauce and administered the mixture to Resident 333. Review of the medication label showed the medication should not be chewed or crushed. LVN 6 verified the above findings and stated she should not have crushed the medication.

F790 Routine/Emergency Dental Srvcs in SNFs FORM CMS-2567(02-99) Previous Versions Obsolete

F790 Event ID: BVUW11 08/08/2018 Facility ID: CA060000715 If continuation sheet 92 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.55(a)(1)-(5) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facility§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; §483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; §483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 93 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to provide dental services to one of 26 final sampled residents (Resident 126). The facility failed to ensure Resident 126 received an emergency tooth extraction as recommended by the dentist. This posed the risk of not addressing the resident's dental needs, which could contribute to potential malnutrition. Findings: On 5/8/18 at 1229 hours, an observation and interview was conducted with Resident 126. Resident 126 stated she had a loose tooth on the bottom left side of her mouth and pointed to it. Resident 126 stated social services was responsible for setting up her dental appointment. However, Resident 126 stated it had been two weeks already and she did not know when her appointment would be. Resident 126 stated she could only chew food on the right side of her mouth. Medical record review for Resident 126 was initiated on 5/8/18. Resident 126 was admitted to the facility on 7/29/16. Review of the Dental Notes dated 4/23/18, showed Resident 126 had a very loose tooth and had discomfort, pain, and sensitivity. The Dental Notes showed the dentist recommended an emergency tooth extraction. On 5/9/18 at 1000 hours, an interview and concurrent medical record review was conducted with SSA 2. SSA 2 was asked if Resident 126 had an appointment for the emergency tooth extraction. SSA 2 stated she had not heard back from the dental office, but contacted them on 5/8/18. SSA 2 was unable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 94 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 to show documented evidence the dental office was contacted to set up an appointment for Resident 126's emergency tooth extraction. SSA 2 acknowledged it had been over two weeks since the dentist recommended the emergency tooth extraction.

F802 SS=F Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 06/18/2018 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility P&P review, and facility document review, the facility failed to have competent staff to carry out the functions of food and nutrition services in a safe and sanitary manner as evidenced by: * The DSS did not have a cleaning schedule for all areas and equipment in the kitchen and did not ensure the cleaning was being completed according to the cleaning schedule. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 95 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 DSS did not report maintenance issues. * The DSS did not report pests. * Cook 1 and the DSS did not take temperatures of chicken appropriately. * Cook 1 did not document temperatures of food served. * The Dietary Assistant Supervisor did not know the cleaning procedures for the juice machine. * The DSS did not know the appropriate temperature for the dish machine. These failures had the potential to result in contamination of food leading to food borne illnesses for the residents who received food from the kitchen. Findings: Review of the CMS 672 completed by the facility dated 5/10/18, showed 124 of 130 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Cleaning Schedule revised 1/1/07, showed, "The Director of Food and Nutrition Services Develops a cleaning schedule, with assistance from the Registered Dietitian, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times ... the Director of Food and Nutrition Services develops a cleaning schedule to include all equipment and areas to be cleaned ... the Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 96 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 document titled CompetencyBased Position Description and Performance Review Director of Food and Nutrition Services revised 1/09 and signed by the DSS showed the following specific requirements: - Must possess the ability to make independent decisions when circumstances warrant such action. - Must be knowledgeable of dietary practices and procedures as well as the laws, regulations, and guidelines governing dietary functions in the long-term care facility. - Must possess leadership ability and willingness to work harmoniously with and supervise professionals and non-professional personnel. - Must have the ability to plan, organize, implement, and interpret the programs, goals, objectives, policies, and procedures of the dietary department. - Must understand and follow company policies. Review of the kitchen cleaning schedule provided by the facility for the months of March and April 2018 showed the can opener was to be cleaned by all staff after each use. For the entire month of March 2018, the cleaning schedule did not have a signature to show the can opener was cleaned. The cleaning schedule also showed the plate warmer was to be cleaned after each use. The signatures showed the plate warmer was cleaned almost every day for the months of March, April, and May 2018; however, the observation showed it was not cleaned. The dry storeroom, including the walls, light switch covers, walk-in freezer, and dome drying rack were not included on the cleaning schedule. Cross reference to F812. 2a. During an interview with the Environmental Manager on 5/8/18 at 1100 hours, the Environmental Manager stated he did not receive a maintenance request from the DSS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 97 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 about the freezer in the kitchen and was not aware the freezer temperature was high. The Environmental Manager produced his log book to verify there was no documentation for the freezer that day. b. On 5/8/18 at 1120 hours, a concurrent observation of the handwashing sink and interview with the Environment Manager was conducted. The Environmental Manager confirmed the water was cold and took several minutes to warm up. The Environmental Manager stated he was unaware of the cold water temperature and time to warm up; it had not been brought up in the daily stand-up meetings by the DSS or entered in the maintenance requests log book. Cross reference to F812. c. On 5/9/18 at 1620 hours, a concurrent observation of the janitor room and interview was conducted with the Environmental Manager. A strong, foul odor was noted in the janitor room. When asked if he was aware of the janitor room drain, the Environmental Manager stated he was not aware of the problem. The Environmental Manager stated the drain problem was not noted in the maintenance log book or brought up in the stand-up meetings. The Environmental Manager stated he would have the drain "snaked" (a tool to clear drains). Cross reference to F925. 3. On 5/8/18 at 0810 hours, eight flies (gnats) were observed on the wall in the chemical room. In a concurrent interview with the DSS, the DSS stated the flies were a problem, but the pest company had been coming once a month. On 5/8/18 at 0915 hours, 16 small flies were observed on the wall in the coffee preparation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 98 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 area in the kitchen. On 5/8/18 at 1120 hours, when the food was being set up for trayline service, more than four small flies were observed flying above the steamtable where the meals were served. 4. Review of the facility's P&P titled Safe Food Handling revised 11/11/16, showed, "The following foods are cooked to these internal temperatures: Poultry ... 165 [degrees] for 15 seconds." On 5/9/18 at 1130 hours, during the trayline food service, a concurrent observation and concurrent interview was conducted with Cook 1 and the DSS. Cook 1 confirmed he took one temperature of the chicken when it was placed on the trayline. The temperature on his thermometer measured 187˚ F. The surveyor noted he measured the temperature of a chicken breast by inserting his thermometer in the edge of the breast, not in the thickest part. The temperature of the chicken was measured at the thickest part to check for accuracy. The surveyor's calibrated thermometer read 159.4˚, 161˚, and 162˚ F for three separate pieces of chicken with the thermometer inserted in the thickest part. When Cook 1 was asked where the thermometer should be placed in the chicken, Cook 1 stated the thermometer should be placed in the middle of the pan. When the DSS was shown the temperature of the chicken was 159.4˚ F, it was okay because other parts of the chicken were at a higher temperature. On 5/10/18 at 0955 hours, an interview was conducted with RD 2. RD 2 stated she expected the thermometer to be placed in the "meatiest" part of the chicken when the temperature was measured. RD 2 stated chicken had to be cooked to the proper temperature before it was served and had to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 99 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 show documentation it was cooked to the proper temperature. 5. Review of the facility's P&P titled Food Temperature Control dated 11/11/16, showed "...Food temperatures are checked and recorded prior to meal service on the Food Temperature Record Form ... If the food temperatures are unsatisfactory, the problem areas are corrected before serving the food item (s) ... " On 5/10/18 at 1138 hours, during an observation of the trayline food service and concurrent interview with Cook 1, Cook 1 stated the alternate entrée item was fish, but Cook 1 did not document the temperature because "it [fish] is not on the menu." 6. On 5/9/18 at 1650 hours, the Dietary Assistant Supervisor stated he cleaned the juice machine and it was cleaned twice a day. The Dietary Assistant Supervisor stated the juice machine was used a lot so it needed to be cleaned quite a bit. When asked to demonstrate how he cleaned the machine, the Dietary Assistant Supervisor stated there were no cleaning procedures he followed, but he wiped the outside off with a white rag and hot water to "break down the sugar on the machine" and removed the nozzles and put them through the dish machine. The DSS and the Dietary Assistant Supervisor were asked to provide the manufacturer ' s instructions for the machine. On 5/10/18 at 1500 hours, the Dietary Assistant Supervisor stated he did not have the manufacturer's instructions to show how to clean the juice machine. The Dietary Assistant Supervisor stated the machine was so old there was not a company to request a copy of the cleaning instructions. When the Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 100 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Assistant Supervisor was asked how he knew how to clean the juice machine properly, he shrugged his shoulders. Review of the manufacturer's manual found online showed the juice machine was to be cleaned daily using a two part procedure. For the rinse procedure, the product container was to be removed from the machine and an empty container was to be placed under the dispensing nozzles. Each nozzle was to be turned on until clear water flows. Then the product containers were to be reconnected. For the second step of the cleaning procedure, the nozzles and drip tray cover were to be cleaned with a brush using a mild detergent. A brush and mild detergent was to be used to clean the dispense area where the nozzles were removed, then rinsed. The Dietary Assistant Supervisor did not demonstrate or verbalize he did any of the above steps for cleaning the machine. 7. Review of the information plate attached to the dish machine showed "Hot Water Sanitizing ... 180 [degrees] F Minimum Final Rinse Temperature ..." On 5/9/18 at 1020 hours, an observation and concurrent interview was conducted with Dish Washer 2 and the DSS. Dish Washer 2 was observed washing the dishes in the dish machine. During the interview, Dish Washer 2 stated he was a dish washer for 30 years at the facility. When Dish Washer 2 was asked what the final rinse temperature should be, he stated 160° F and then said 170° F was "okay also." Dish Washer 2 stated he did not know if the dish machine was a high temperature or low temperature machine. The DSS was concurrently interviewed and stated the dish machine was a high temperature machine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 101 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 DSS acknowledged Dish Washer 2 stated 170° F was an adequate rinse temperature. The DSS also stated 170° F was an adequate minimum temperature for the rinse cycle. When the DSS was shown the information plate attached to the side of the dish machine showing the minimum rinse temperature for the machine was 180° F, the DSS stated he still thought 170° F was an appropriate minimum rinse temperature for sanitizing items put through the dish machine.

F803 SS=F Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 09/09/2018 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 102 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure puree, renal (a diet for residents with kidney disease), and alternate menus were followed as evidenced by: * Meal alternates were not prepared as per menu guidelines. * Mashed potatoes were not served to puree diets. * Puree pasta was not served to renal pureed diets. * The facility's emergency menu and emergency food supply were not available and consistent. These failures resulted in residents not receiving the menu as planned and not having a choice of an alternate meal, which had the potential for residents to consume fewer nutrients resulting in nutrient related disease for the residents who received food prepared in the facility's kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/10/18, showed 124 of 130 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Menus revised 11/11/16, showed menus are to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 103 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 served as written and the Director of Food and Nutrition Services/Registered Dietitian documents the substitution on the extended menu and menu substitution form. Review of the facility's P&P titled Substitutions and Alternates revised 11/11/16, showed alternates are planned at each meal for the entrée/meat, starch and vegetable. Review of the facility's diet spreadsheet titled Menu 3, "Spring/Summer 2018" dated week 3, day 11 showed the alternate menu was oven fried fish, sauce of choice, seasoned beans, and confetti coleslaw for the lunch meal. On 5/9/18 at 1215 hours, an observation of the lunch trayline was conducted with Cook 1 and the DSS. The meal tray for Resident 123 contained an egg salad sandwich and a 4 ounce cup of fruit cocktail. Resident 123 was not provided with a vegetable on her tray. The tray card showed the resident was to receive a "Regular Texture, Lib [liberal] Renal..." diet. When asked why the resident received an egg salad sandwich, Cook 1 stated because the resident did not like beef or chicken. When asked what the alternate menu was, Cook 1 stated he prepared chicken. When asked about the alternate menu on the diet spreadsheet, Cook 1 stated he did not follow the spreadsheet but followed a different alternate menu. The DSS stated Cook 1 should have followed the posted diet spreadsheet for the alternate menu. The DSS provided a list titled Always Available Menu and Cook 1 stated he used to select the lunch alternate. Review of the undated document provided by the DSS titled Always Available Menu showed the list did not include therapeutic diets and did not include chicken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 104 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 On 5/10/18 at 1000 hours, an interview was conducted with RD 2. RD 2 confirmed all menus and spreadsheets signed by the RD should be followed. RD 2 stated any substitutions or changes to the menus must be approved by the RD. RD 2 stated this was an identified concern on the RD Monthly Facility Report performed by the RD, and this report was reviewed with the DSS. RD 2 confirmed Resident 123 should have received oven fried fish and confetti coleslaw for lunch. RD 2 confirmed Resident 123's lunch was not balanced when served without a vegetable. RD 2 stated the "Always Available Menu" was for residents who did not like the main entrée or the alternate entrée; the resident would fill out this menu prior to meal service. It was noted there was no documentation showing Resident 123 requested an item from the "Always Available Menu" for lunch on 5/9/18. On 5/10/18 at 1150 hours, an interview was conducted with the DSS. The DSS stated the alternate menu did not always make sense and he and the cook decided what alternate to prepare. The DSS stated he had been informed by the RD to follow the alternate menu. Review of the facility's document titled RD Monthly Facility Visit Report showed an entry dated 1/29 and 1/30/18, under section Production - general comments: "need to initiate menu substitution log, menu changed without RD notification." An entry dated 2/23/18 under section Serving Line showed appropriate alternates for the meat, starch and vegetable were not planned and prepared. An entry dated 3/29/18, under section Production general comments showed "no menu substitution log." Entries dated 4/24 and 4/26/18, under section Serving Line showed appropriate alternates for the meat, starch and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 105 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 vegetable were not planned and prepared and, under general comments showed "Please make sure to provide appropriate alternate and notify RD." 2. Review of the facility's P&P titled Menus revised 11/11/16, showed menus are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Review of the facility's diet spreadsheet titled Menu 3, "Spring/Summer 2018" and dated week 3, day 11 showed puree diets received: puree veal cacciatore, sauce of choice, mashed potato, puree capri vegetables, puree bread, margarine, and puree chocolate chip bar. On 5/9/18 at 1200 hours, an observation of puree meal trays during lunch trayline was conducted with Dietary Aide 2. Four puree trays were placed in the lunch tray cart without mashed potatoes or an equivalent starch. The tray ticket for Resident 20 showed the diet was "Puree Regular." The tray ticket did not show Resident 20 had an allergy or dislike to potatoes. When asked why the tray for Resident 20 did not contain mashed potatoes, Dietary Aide 2 went to the stove behind the tray line and scooped out a portion of mashed potatoes and added it to Resident 20's meal. The four puree meal trays placed in the lunch tray cart were served without potatoes or an equivalent starch. On 5/10/18 at 1000 hours, an interview was conducted with RD 2. RD 2 stated she expected all menus and spreadsheets to be followed. 3. Review of the facility's diet spreadsheet titled Menu 3, "Spring/Summer 2018" and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 106 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 dated week 3, day 9 showed puree renal diets received puree baked veal patty salt free (SF), puree parsley noodles SF, puree capri vegetables SF, puree dinner roll, margarine, and puree fruit cocktail. On 5/9/18 at 1130 hours, an observation and interview was conducted with Cook 1 and the DSS of the trayline. Observation of the lunch tray ticket for Resident 29 showed the diet was "Puree Liberal Renal, diet condiment, fluid restriction 1200 ml, large portions." The tray for Resident 29 included one portion of puree veal, one portion of puree capri vegetables, one portion of puree bread, and one portion of puree fruit. When asked about the missing puree noodles, Cook 1 stated he did not need to make the puree noodles because there was only one resident who needed it. The DSS stated cook 1 would make pureed rice for the resident. On 5/10/18 at 1000 hours, an interview was conducted with RD 2. RD 2 confirmed all menus and spreadsheets signed by the RD should be followed. 4. Review of the facility's P&P titled Menus revised 11/11/16, showed, "Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines ... The Director of Food and Nutrition Services and Registered Dietitian sign and approve the menus..." On 5/9/18 at 1550 hours, an observation and concurrent interview was conducted with the DSS. A room with a sign on the outside showed "food storage." The DSS stated the room stored the emergency food. When asked to see the three day emergency menu, the DSS provided a stack of loose papers sitting on top of the emergency food supply. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 107 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 loose stack of papers the DSS identified as the emergency menu included a faxed copy addressed to RD 1 of an undated menu titled "[name of another facility] Emergency Menu." This menu was a six day plan which included therapeutic diets. The faxed copies of this menu were illegible for Days 1 and 4's dinner, Days 3 and 6's dinner, and Days 3 and 6's lunch. For instance, the menu items and the portion sizes could not be deciphered. Other documents included in the loose stack of papers were an undated document titled Emergency Menus. This was a three day menu that did not include therapeutic diets. There was also an undated document titled Three-Day Emergency Diet Plan For Dialysis Residents, an undated document titled Emergency Menu Addendum Pureed Diets, and an undated document titled Emergency Menu Addendum One: Mechanical Soft Diets. It was noted the three day menu and the therapeutic diet addendums were not signed by an RD. As the concurrent interview and observation continued with the DSS, it was not clear which menu in the stack of loose papers the facility followed. When the surveyor asked the DSS to clarify, he looked at the papers for a few minutes then stated the facility followed the six day menu that was not completely legible. He confirmed the menu was not legible but stated it was what the facility used. The DSS confirmed although the menu showed six days, the facility only had emergency food on hand for three days. It was noted this menu was signed by an RD and a Dietary Manager, but the DSS confirmed the RD and Dietary Manager were not staff from this facility. The menu contained menu items such as tuna salad and pasta. The DSS confirmed there were no recipes to show the portion of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 108 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 ingredients and how they were to be made. When asked for an inventory of the food to show how much they were to have on hand, the DSS stated he did not have an inventory. The DSS stated he did not keep all of the emergency food in the room designated for emergency food, but also kept emergency foods in the dry storeroom commingled with the food available for daily use. When asked how many people the menu was planned for, the DSS' answer was vague. First the DSS stated it was for 170 licensed beds then he stated it was for 200 people. The DSS stated he did not have a nutrient analysis for this menu. In an interview on 5/10/18 at 0945 hours, the Administrator stated the emergency food was only planned for the residents, not staff, family, visitors or any other persons who could be at the facility during a disaster. On 5/10/18 at 1135 hours, an observation of the emergency food supply and concurrent interview with the DSS showed there was no beef stew available. The DSS confirmed there was no beef stew. Review of the emergency menu showed beef stew was for dinner on Day 2 of the six day emergency menu and on dinner for Day 3 of the three day emergency menu the DSS stated they did not use. On 5/10/18 at 1350 hours, an interview was conducted with the DSD. The DSD stated she trained the staff on the location of the emergency food supply, which was in the kitchen behind the door with the sign "food storage." The DSD did not say the emergency food was also stored in the dry storeroom. The DSD stated there was no training regarding using the emergency menus or preparing the food. When she was shown the six day emergency menu, she stated portions were "difficult to read and make out." The DSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 109 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 a binder with clear directions about how to prepare the menu would be helpful if kitchen staff was not available to prepare the food. On 5/15/18 at 0954 hours, an interview was conducted with RD 1. RD 1 stated the six day menu the DSS stated was the facility's emergency menu, not the emergency menu, it was the three day menu. RD 1 confirmed the three day menu was not signed. Review of the document provided by the facility titled Facility Assessment Tool dated 10/2017 showed the assessment did not include anything for emergency or disaster. It was also noted there was no emergency/disaster menu in the facility's Emergency Preparedness Binder that was provided to the surveyor's for review.

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 06/18/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview and medical record review, the facility failed to ensure food FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 110 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 preferences were honored for two of 26 final sampled residents (Residents 126 and 43). * Resident 126 stated she was a vegetarian; however, she was often served chicken on her lunch tray. * Resident 43 was not provided apple juice and a second slice of toast when requested. These had the potential to negatively impact the residents' well-being. Findings: 1. On 5/8/18 at 1216 hours, Resident 126 was observed to receive her lunch tray. Her meal contained a piece of chicken on the plate. Resident 126 stated she was a vegetarian and she could not eat meat. Resident 126 stated the facility kept giving her meat, including at times bacon. Resident 126's lunch tray was observed with chicken, zucchini, peas and bread. Resident 126 stated they have given her the wrong foods items several times before. She stated, "I think it was awful. I opened the tray and was excited about eating but I could not eat." Medical record review for Resident 126 was initiated on 5/8/18. Resident 126 was admitted to the facility on 7/29/16. Review of Resident 126's Nutrition Data Collection/Assessment dated 7/27/17, showed Resident 126's diet order was regular diet. The resident's food allergies and dislikes included red meats, seafood, and poultry. On 5/14/18 at 1504 hours, a concurrent interview and medical record review was conducted with RD regarding Resident 126. The RD stated the facility did not have a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 111 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 vegetarian menu; the residents had to substitute when residents could not eat meats. The RD was asked who monitored to make sure the residents' diet order and preferences matched the residents' meal tray. The RD stated the nutrition staff checked residents' food trays in the kitchen, and the nurses checked the food trays again on the floor before delivering the trays to the residents. The RD stated Resident 126 requested her meals from alternate menu of her choice and the kitchen tried to accommodate to their maximum potential. 2. On 5/8/18 at 0839 hours, during an initial tour, an interview was conducted with Resident 43. Resident 43 stated she was served a half a slice of toast for breakfast, and she wanted to have another half slice of toast. Resident 43 stated she spoke to CNA 9 about her request; however, CNA 9 told her she couldn't get her another piece of toast because the kitchen was busy. Resident 43 also stated she asked CNA 9 for apple juice this morning, but CNA 9 told her the kitchen did not let CNA 9 in to get any apple juice. Resident 43 had to get her own apple juice she had brought in from home. Resident 43 stated the facility did not often give her apple juice so she had her own supply in her room. On 5/8/18 at 0842 hours, an interview was conducted with CNA 9 present. CNA 9 was asked about Resident 43's request for apple juice and toast this morning. CNA 9 state she had to go back, they were too busy, it was tray line time. CNA 9 stated she would come back with the toast. Resident 43 was observed finishing her breakfast and the toast had not been brought to her. Resident 43 stated she already drank her own apple juice.

F812 Food Procurement,Store/Prepare/Serve- FORM CMS-2567(02-99) Previous Versions Obsolete

F812 Event ID: BVUW11 09/09/2018 Facility ID: CA060000715 If continuation sheet 112 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=F Sanitary CFR(s): 483.60(i)(1)(2) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * Staff washed their hands in a handwashing sink with cold water. * Staff did not follow proper hand hygiene procedures. * Surfaces including floors, walls, and equipment were dirty. * Food contact surfaces were dirty. * Trays and pitchers were not air dried. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 113 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 * Clean dessert bowls were stored next to chemicals. * Food was stored in containers not approved for food storage. * Food items were not labeled and dated. * The steam table did not have an air gap. * Staff did not wear aprons and their street clothing appeared dirty. These failures had the potential to result in cross contamination and cause food borne illnesses in a medically vulnerable population of residents who consumed food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/10/18, showed 124 of 130 residents residing in the facility received food prepared in the kitchen. 1. According to the 2017 Federal Food Code, the standards of practice are to wash hands in water that is 100-108˚ F. Handwashing sinks shall provide water of at least 100˚ F. On 5/8/18 at 0755 hours, an observation of the handwashing sink was conducted. The water was cold and took over four minutes to warm up. The temperature was 66.7˚ F. The DSS acknowledged the water was cold and stated he did not know what the appropriate handwashing water temperature should be. Subsequently, at 0805 hours, the DSS washed his hands in the cold water, then immediately handled a new roll of paper towels to load into FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 114 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 empty paper towel dispenser above the handwashing sink. On 5/9/18 at 1700 hours, an additional observation of the handwashing sink and interview was conducted with Dietary Aid and Dietary Aid 2. Both Dietary Aids washed their hands in the handwashing sink and confirmed the water felt cold. The water temperature taken with surveyor's thermometer was 75.2˚ F. Both Dietary Aids stated they knew they needed to wash their hands in warm/hot water but "the water takes too long to heat up." On 5/8/18 at 1120 hours, an observation of the handwashing sink and concurrent interview was conducted with the Environment Manager. The Environmental Manager confirmed the water was cold and took several minutes to warm up. The Environmental Manager stated he was unaware of the cold water temperature and time to warm up; it had not been brought up in daily stand up meetings by the DSS or entered in the maintenance request log book. 2a. Review of facility's P&P dated 11/11/16, titled "Handwashing" showed "...Staff washes hands and exposed portions of arms as necessary to remove contamination and after the following ...handling soiled utensils or equipment ...after engaging in other activities that contaminate the hands ..." On 5/8/18 at 1620 hours, an observation showed Dishwasher 1 loaded dirty dishes into a rack on the dirty side of the dish machine. He then handled the sprayer on the dirty side of the dish machine and sprayed the dishes before he put them inside the machine. Then Dishwasher 1 wiped his hands on a white rag and removed dishes from the clean side of the dish machine without washing his hands first. Dishwasher 1 stated he did not wash his hands FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 115 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 because he wiped them on a clean rag. Dishwasher 1 confirmed he should have washed his hands before handling the clean dishes. The DSS, who was present, acknowledged Dishwasher 1 should have washed his hands before touching the clean dishes during dishwashing. b. An observation on 5/8/18 at 1626 hours, showed the DSS washed his hands in the handwashing sink by turning on the water with the handle and, with his bare hands, turned the handle to turn the water off. After washing his hands, the DSS stated he should have used a paper towel to turn off the water. However, the DSS did not rewash his hands correctly before continuing tasks in the kitchen. c. On 5/9/18 at 1115 hours, an observation and concurrent interview was conducted with Dishwasher 2 and the DSS. Dishwasher 2 was observed entering the kitchen without washing his hands in the handwashing sink. Dishwasher 2 stated he just got back from a break and washed his hands in another sink inside the facility close to the entrance down the hall past a set of doors from the kitchen. The DSS stated the staff were adults and they should know when to wash their hands; it was his expectation all kitchen staff wash their hands in the handwashing sink located inside the kitchen, each time they enter the kitchen. In an interview with RD 1 on 5/15/18 at 0954 hours, RD 1 stated she did monthly sanitation audits and reviewed the results, discussed any deficiencies, and discussed what to do about the problems with the DSS. She also stated the results were discussed with the Administrator if he was available. Review of the kitchen sanitation audit form provided by the facility titled "RD Monthly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 116 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 Facility Visit Report" dated 1/29 and 1/30/18, showed hands were not washed between the dirty and clean side of the dish machine when handling dishes. Under the heading of ideas and actions, it showed two people should operate the dish machine to alleviate one person going from the dirty side to the clean side of the dish machine. 3a. On 5/8/18 at 0815 hours, an observation and concurrent interview was conducted with the DSS. Dark brown dried spots of residue and smeared brown residue were observed scattered on a wall inside of the dry storeroom. Boxed of juice were observed stored against the wall with the brown residue. A light switch was observed by the door. The light switch and cover plate were covered with dark brown and black residue. The DSS stated the dry storage room was cleaned two times per week. The DSS stated he did not know what the residue on the wall was. When the wall was wiped with a wet paper towel, the residue was easily removed. The DSS acknowledged the wall was not clean and stated the walls needed to be painted but did not state they should be cleaned. An interview was conducted with Dietary Aid 2 on 5/14/18 at 1445 hours. Dietary Aid 2 stated he was responsible for cleaning the dry storeroom, he cleaned it after the delivery each week, but cleaning did not include the walls or the light switch, only the floors. b. On 5/8/18 at 0820 hours, an observation of the walk-in freezer and interview was conducted with the DSS. The floor under the food storage racks had a clear brownish residue that appeared sticky with a significant amount of food and non-food debris, such as mushrooms, wood ice-cream spoons, and bits of paper stuck inside the residue. The DSS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 117 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 the floor was not clean. c. On 5/8/18 at 0905 hours, an observation of the piece of equipment used to warm the residents' food plates showed the surface of the warmer rings had a build up of tarnish, brown colored residue and a thick, black residue. The DSS stated the plate warmer rings were not cleaned because the warmer got too hot. d. On 5/8/18 at 0925 hours, an observation and concurrent interview was conducted with the DSS. A black residue was observed over the entire surface of a floor sink drain. The caulking (a substance that makes a seal) between the drain and the floor was also caked with a black residue. The floor tiles surrounding the sink had a black residue on the surface. The DSS stated the drain was inoperable because there was a drain pipe that was broken since July 2017. e. On 5/8/18 at 0935 hours, the can opener was observed. The can opener base was covered with an orange residue and the can opener holder that was connected to the preparation table, had a brown sticky substance covering its surface. The DSS stated the can opener base was rusty and the holder was dirty but said he it was "okay" because it did not touch the food. f. On 5/8/18 at 1610 hours, an observation of the walk-in refrigerator and interview was conducted with the DSS. The plastic around the refrigerator door frame was chipped and a piece over eight inches long was missing. The chipped and missing plastic resulted in a rough surface. The door frame had a significant amount of black residue on the surface and the area with the missing plastic was covered with a white and yellow residue that was rough to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 118 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 touch. The rubber gasket in the door frame that sealed the door when it is closed was also covered with a significant amount of black residue. When the area was wiped with a paper towel, black residue wiped off. The DSS confirmed the residue wiped off. As the observation of the walk-in refrigerator continued, the floor was observed with a gap between the metal threshold (a piece that fits under a door to help seal the door) and the metal diamond plate floor that was the length of the door. Inside the gap was brown, caked debris, crumbs, and residue. The refrigerator floor under the racks was not covered with the diamond metal plate and the floor was covered with orange and brown residue that the DSS stated was rust. The wall of the refrigerator had was covered with orange and white residue. The DSS confirmed there was residue on the walk-in refrigerator wall and floor. g. An observation on 5/8/18, at 1612 hours, showed a standing fan located in the dish machine room with a thick, gray, fuzzy residue on the grill that covered the fan blades. The fan was blowing directly toward the clean side of the dish machine where there were clean dishes on a dish rack. The DSS acknowledged the fan was dirty and dusty, and stated the fan was used because the dish room was humid. The DSS stated the kitchen staff was not responsible for cleaning the fan because it belonged to housekeeping. h. On 5/9/18 at 1120 hours, an observation and concurrent interview with the DSS showed a dome (a cover for plates to keep food warm) drying rack had a fuzzy brownish residue covering the surface. When the surface of the rack was wiped with a white napkin, the dark brown residue wiped off. The DSS confirmed the rack was dirty but stated it was "okay" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 119 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 because the domes did not come into contact with food. i. On 5/9/18 at 1215 hours, an observation during trayline food service and a concurrent interview was conducted with the DSS. Six bases were so scratched, the surface appeared white and there was black residue in the scratches. When the base was wiped with a paper towel, black residue wiped off. The DSS was not concerned and stated it was okay because the plates did not directly touch the plastic base. In an interview on 5/14/18 at 1450 hours, the DSS confirmed the dome drying rack was not on the cleaning schedule. In regard to cleaning the plate warmer, when the DSS was asked who was responsible for cleaning it, he stated that maintenance took the plate warmer apart every six months and cleaned the internal components, such as the springs. On 5/14/18 at 1615 hours, an interview was conducted with the Environmental Manager regarding the cleaning of the plate warmer. The Environmental Manager stated he was not involved with any cleaning of the plate warmers, he just checked the functioning of all the kitchen equipment during monthly rounds. On 5/15/18 at 0954 hours, an interview was conducted with RD 1. RD 1 stated she did monthly sanitation audits and reviewed the results, discussed any deficiencies and discussed what to do about the problems with the DSS. The DSS stated the results were discussed with the Administrator if he is available. On 5/15/18 at 1040 hours, an interview was conducted with the Dietary Assistant Supervisor. The Dietary Assistant Supervisor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 120 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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, although the DSS said the Dietary Assistant Supervisor was responsible for cleaning the walk-in refrigerator, he never cleaned it, the DSS cleaned it. In a consecutive interview with the DSS, the DSS stated he was responsible for cleaning the walk-in refrigerator. The DSS stated when the weekly food delivery came in, he removed any old produce, swept, and mopped the floor. The DSS confirmed this was done one time per week. Review of the kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 1/29, and 1/30/18, showed the walls and equipment were dirty. Overall sanitation was "poor" and "confusion over who was responsible." Review of the sanitation audit form provided by the facility titled RD Monthly Facility Visit Report dated 2/23 (2018) showed the equipment was still dirty and "overall kitchen does not look survey ready. Power cleaning for equipment and walls is needed." Review of the sanitation audit form provided by the facility titled RD Monthly Facility Visit Report dated 3/29/18, showed there were gaps in the cleaning schedule that included the can opener. The general comments about the overall sanitation showed "poor" and "there is lack of responsibility among staff." Review of the sanitation audit form titled RD Monthly Facility Visit Report dated 4/24 and 4/26/18, showed 50% of the cleaning log was complete and the plate warmer was dirty. Review of the kitchen cleaning schedule for the months of March and April 2018 showed the can opener was to be cleaned by all staff after each use. For the entire month of March, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 121 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 cleaning schedule did not have a signature to show the can opener was cleaned. The cleaning schedule also showed the plate warmer was to be cleaned after each use. Signatures showed the plate warmer was cleaned almost every day for the months of March, April and May. The dry storeroom, the walk-in freezer, and the dome drying rack were not on the cleaning schedule. Review of the kitchen cleaning schedule for the months of March, April, and May 2018 showed floor drains were to be cleaned daily. The initials showing the drains were cleaned were initialed seven times total for the months of March and April. In May it showed the floor drains were cleaned 10 times up until May 17. Review of the facility's P&P titled Sanitation and Maintenance revised 11/11/2016, showed, "Physical facilities are cleaned as often as necessary to keep them clean ..." Review of the facility's P&P titled Safe Food Handling revised 11/11/16, showed, "... All plasticware that cannot be sanitized, is chipped and/or has lost its glaze will be discarded ... All working surfaces, utensils and equipment are cleaned and sanitized appropriately after each use and if contaminated." j. During the initial tour of the kitchen on 5/8/18 at 0945 hours, an observation showed a large black bin with several miscellaneous items such as lids, plastic serving spoons, knives, and trays stored on a rack for clean dishes, pans, and utensils. The black bin was scratched inside enough to make the surface appear white. Two trays stored in the bin were dusty and a large knife had an orange residue on the blade. The DSS stated he did not know why the dishware was stored in the black tub, but acknowledged the trays were dirty and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 122 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 knife was rusty. Sixteen pitchers were observed with a yellow, sticky residue on top of the lid surfaces. One pitcher had a pink liquid inside. The DSS stated the pitchers were used for residents on honey thick liquids and were supposed to be clean, but confirmed they were dirty. One ¼ inch steam table pan with a white rough to touch residue on the inside surface and melted plastic on the rim was observed on the clean dish rack. The DSS was interviewed and stated the white substance was dried sanitizer. 4. On 5/8/18 at 0950 hours, an observation and concurrent interview was conducted with the DSS. The DSS was shown spoons, forks, and knives in a plastic container used for storing utensils on the storage rack that held clean dishes, utensils, and pans. The DSS stated the utensils were clean. The plastic container had crumbs and residue on the inside surface that came into contact with the utensils. The DSS stated the plastic container had to be cleaned. On 5/15/18 at 0954 hours, an interview was conducted with RD 1. RD 1 stated she did monthly sanitation audits and reviewed the results, discussed any deficiencies and discussed what to do about the problems with the DSS. The DSS stated the results were discussed with the Administrator if he was available. Review of kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 1/29 and 1/30/18, showed, "silverware had food particles ..." Review of kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 2/23/18, showed, "water stains on silverware [space] proper washing - filthy not acceptable." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 123 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility's P&P titled Sanitation and Maintenance" revised 11/11/16, showed, "Physical facilities are cleaned as often as necessary to keep them clean ..." According to the 2017 Federal FDA Food Code, food-contact surfaces and utensils are to be clean to sight and touch and nonfoodcontact surfaces of equipment are to be free of accumulation of dust, dirt, food residue and other debris. 5. During the initial tour of the kitchen on 5/8/18 at 0855 hours, an observation and concurrent interview was conducted with the DSS. Thirteen sheet pans were stacked, wet, and stored on a rack for clean utensils, dishes, and pans. The DSS was interviewed and confirmed the pans should be dried before they are stacked. On 5/8/18 at 0945 hours, an observation and concurrent interview was conducted with the DSS. Sixteen pitchers with lids were standing upright on a rack which stored clean dishes, pans, and utensils. The pitchers were wet inside. The DSS stated they should be stored upside down so they could dry. On 5/8/18 at 1620 hours, during a subsequent kitchen visit, Dietary Aide 1 was observed wiping wet meal trays with a white rag. When the DSS saw the surveyors watching Dietary Aid 1 drying the trays with a rag, he told Dietary Aid 1 not to dry the trays that way. Dietary Aid 1 stated this was her normal procedure for drying the trays and she did not know any other way to dry the trays. The DSS did not give her more direction on how to dry them. On 5/9/18 at 1645 hours, Dietary Aid 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 124 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 observed wiping wet meal trays with paper towels. During an interview with RD 2 on 5/10/18 at 1000 hours, RD 2 stated storing wet trays was identified as a problem in the past. RD 2 stated it was not okay for staff to use a towel to dry trays or sheet pans, and there may not be enough equipment in the kitchen to air dry all the dishes. In an interview on 5/15/18 at 0954 hours, with RD 1, RD 1 stated she did monthly sanitation audits and reviewed the results, discussed any deficiencies and discussed what to do about the problems with the DSS. RD 1 stated the results were discussed with the Administrator if he was available. Review of the kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 1/29 and 1/30/18, showed, "trays stacked wet." Review of the kitchen sanitation audit form titled "RD Monthly Facility Visit Report" dated 3/29/18, showed, "observed trays being dried with towel by dishwasher and dietary aide during trayline." Review of facility's P&P dated 11/11/16, titled Sanitation and Maintenance showed, "...Manual Warewashing ...All items are air dried before storing... Fixed and mobile equipment in the foodservice area will be located to assure sanitary and safe operation and will be sufficient size to handle the needs of the facility." 6. During the initial tour of the kitchen on 5/8/18 at 0905 hours, three racks of bowls were stacked on top of each other and stored on a shelf under the three-compartment sink. An opened 2.5 gallon container of concentrated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 125 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 sanitizer intended for industrial and commercial use was stored touching the racks of bowls. The DSS stated the bowls were used to serve desserts and it was not a problem for the bowls to be stored next to the chemical sanitizer because it was used to sanitize the dishes. A rack of plastic cups were also stored at the end of the three-compartment sink. During an interview with RD 2 on 5/10/18 at 1000 hours, RD 2 stated chemicals should not be stored next to clean dishes. According to the Federal Food Code, 2017, the standards of practice would be to ensure dishware is protected from contamination including toxic residues due to drip, drain, fog, splash or spray on ..., utensils. 7. On 5/8/18 at 0812 hours, an observation and concurrent interview was conducted with the DSS. The DSS was shown dry white rice and dried beans stored in large, plastic containers that resembled a storage tote for general household items. When the DSS was asked if the containers were safe to store food, he stated yes, and he would provide documentation to verify. The DSS stated he sometimes bought plastic containers from a wholesale retailer instead of the contracted food vendor. As of 5/15/18 at 1040 hours, the DSS did not provide the documentation showing the containers were safe for storing food. Review of the facility's P&P titled "Food Safety" revised date 11/11/16 showed "Pre-packaged food is placed in a leak-proof, pest-proof, nonabsorbent, sanitary (NSF) [National Science Foundation - certifies appliances such as food storage containers for safe food storage] container with a tight-fitting lid ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 126 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 8. On 5/8/18 at 0820 hours, an observation in the walk-in freezer and a concurrent interview was conducted with the DSS. Two unlabeled, opened bags filled with what the DSS stated was cookie dough, an undated bag of spinach, and an undated bag of meat patties were observed stored in a box labeled bread. The DSS stated the cookie dough and the meat should not be in the box. The DSS confirmed there were no dates on these items to identify when they were received or when they were to be used by. On 5/8/18 at 0920 hours, an observation and concurrent interview was conducted with the DSS. Two visibly different white substances were observed in a large bin labeled "powdered sugar" dated 3/30/18, and use by 3/30/19. Inside the bin was at least ¼ full of what the DSS confirmed as granulated sugar and about 1/8 full of what the DSS confirmed as powdered sugar. The DSS stated the powdered sugar was in the bin first and then staff filled the bin with granulated sugar at a later date. The DSS stated the dates on the bin were for the granulated sugar and he could not confirm the expiration date of the powdered sugar. The DSS stated it was not a problem to store them together because "they are both sugar." During an interview with RD 2 on 5/10/18 at 1000 hours, she stated the expectation was kitchen staff were to follow the facility policy on labeling and dating, which included labeling and dating all foods in the kitchen. RD 2 stated mixing two types of sugar in one bin was unacceptable and her expectation was the staff clean the bin before adding a new item. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 127 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 In an interview on 5/15/18 at 0954 hours, RD 1 stated she did monthly sanitation audits and reviewed the results, discussed any deficiencies and discussed what to do about the problems with the DSS. She also stated the results were discussed with the Administrator if he was available. Review of a kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 2/23/18, showed an open and use-by date were missing on a food item. A written comment showed, once an item was opened, date the item. Potentially hazardous foods in the refrigerator and the freezer needed two dates with no exception. Review of the kitchen sanitation audit form titled "RD Monthly Facility Visit Report" dated 3/29/18, included a comment, "items not labeled/dated." Review of the kitchen sanitation audit form titled RD Monthly Facility Visit Report dated 4/24 - 4/26/18, included a comment, "vanilla pudding packs out of original container and [no] date ... breadcrumbs in bag not labeled ... [DSS] - Label each [and] everything in each refrigerator [and] dry storage no acception [exception]!!" Review of the facility's P&P dated 11/11/16, titled Food Safety showed, "... Food is labeled with the date received, if date received is not on the item ... Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable." According to the Federal Food Code 2017, a food label is to contain a common name of food and it is the standard of practice to label food after it is removed from the original container FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 128 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 because it may be difficult to identify. Refrigerated foods are to be dated when opened and if kept longer than 24 hours, a date when it is to be discarded or used is also required. 9. On 5/9/18 at 1620 hours, an observation and concurrent interview was conducted with the DSS and Environmental Manager. A red hose lead from the underside of the steam table into a floor sink. The DSS stated the red hose was the drain for the steam table. The DSS stated the hose was not currently used because of a broken drain pipe that made the drain inoperable, but the steamtable was still used to keep food warm during trayline food service. Over three inches of the surface of the hose inside the floor sink was covered with a black residue and the inside surface of the floor sink had a black residue over almost the entire surface. The hose rested on the surface of the floor sink in contact with the black residue. The Environmental Manager confirmed there was no air gap between the steam table drain hose and the floor sink. According to the 2017 Federal FDA Food Code, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, such as a floor sink, shall be at least twice the diameter of the water supply inlet (the hose) and not less than one inch. 10. On 5/8/18 at 1625 hours, an observation and concurrent interview was conducted with the DSS. Dishwasher 1 was observe wearing street clothes while operating the dish machine and handling clean and dirty dishes. Dishwasher 1 did not wear an apron while he rinsed the dirty dishes to protect his clothing, but aprons were hanging on a hook in the dish machine area. Dishwasher 1's shirt and pants had a significant amount of marks such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 129 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 water marks and stains. When the DSS was asked if Dishwasher 1 should wear an apron, the DSS stated "it is up to the dishwasher if he wants to wear an apron or not." Review of the document titled Dietary Aide Job Description Primary dated 5/16/16, showed Dishwasher 1's name written at the top of the page. Under the category of position summary showed, "The Dietary Aide provides assistance in all food service functions to ensure patients' dining needs are met ..." The standards of practice according to the 2017 Federal Food Code is food employees are to wear clean outer clothing to prevent contamination of food, equipment, and utensils.

F849 SS=D Hospice Services CFR(s): 483.70(o)(1)-(4)

F849 06/18/2018 §483.70(o) Hospice services. §483.70(o)(1) A long-term care (LTC) facility may do either of the following: (i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices. (ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer. §483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements: (i) Ensure that the hospice services meet professional standards and principles that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 130 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 apply to individuals providing services in the facility, and to the timeliness of the services. (ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following: (A) The services the hospice will provide. (B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter. (C) The services the LTC facility will continue to provide based on each resident's plan of care. (D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. (E) A provision that the LTC facility immediately notifies the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. (F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. (G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 131 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 (H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility. (J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. (K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff. §483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 132 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: (i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services. (ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. (iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. (iv) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient. (B) Hospice election form. (C) Physician certification and recertification of the terminal illness specific to each patient. (D) Names and contact information for hospice personnel involved in hospice care of each patient. (E) Instructions on how to access the hospice's 24-hour on-call system. (F) Hospice medication information specific to each patient. (G) Hospice physician and attending physician (if any) orders specific to each patient. (v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 133 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 hospice staff furnishing care to LTC residents. §483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure a designated IDT member was responsible for the coordination of resident care between the facility and the hospice agency for one of 26 final sampled residents (Resident 40). This posed the risk for Resident 40 not receiving necessary care and services. Findings: Medical record review for Resident 40 was initiated on 5/8/18. Resident 40 was admitted to the facility on 3/13/18. Hospice Agency A provided hospice services to Resident 40. Review of the Hospice Services Agreement dated 3/12/18, and Resident 40's medical record failed to show a designated facility IDT member was responsible for the coordination of resident care between the facility and the hospice agency. On 5/14/18 at 1450 hours, an interview was conducted with RN 2. When asked how Resident 40's care was coordinated between the facility and Hospice Agency A, RN 2 stated the nurse assigned to provide care for Resident 40 was responsible for the coordination of care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 134 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 the facility and Hospice Agency A. RN 2 stated the facility did not have a specific facility designee responsible for the coordination of care between the facility and Hospice Agency A. On 5/14/18 at 1620 hours, an interview was conducted with the DON. The DON stated she was uncertain if the facility had designated a facility IDT member responsible for the coordination of care between the facility and Hospice Agency A. The DON stated the facility's social services would have that information. On 5/14/18 at 1630 hours, an interview was conducted with SSA 2. When asked how Resident 40's care was coordinated between the facility and Hospice Agency A, SSA 2 stated the facility did not have one specific designee responsible for the coordination of care between the facility and Hospice Agency A.

F865 SS=D QAPI Prgm/Plan, Disclosure/Good Faith Attmpt F865 CFR(s): 483.75(a)(2)(h)(i) 08/08/2018 §483.75(a) Quality assurance and performance improvement (QAPI) program. §483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation; §483.75(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. §483.75(i) Sanctions. Good faith attempts by the committee to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 135 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 identify and correct quality deficiencies will not be used as a basis for sanctions. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to implement their action plans including monitoring of the effects of the plans to achieve and sustain improvement for two repeated deficient practices cited at F554 and F880 in accordance with their POC from the last recertification survey completed on 5/30/17. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 5/15/18 at 1345 hours, an interview and concurrent facility document review was conducted with the Administrator and Assistant Administrator. The Administrator verified Resident 100 was found with medications at her bedside, was not assessed for self-administration of medications, and a physician's order was not obtained for self-administration of medication. The POC submitted to the CDPH, L&C Program for F554 cited from the last recertification survey completed on 5/30/17, showed the assigned managerial leader would conduct daily room rounds to check and ensure no medications were left at the bedside, without meeting their P&P requirements. The unit managers would conduct weekly audits of the facility room rounds and findings would be presented to the monthly Quality Assurance meeting. The Administrator failed to show documented evidence the weekly audits were done as per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 136 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 their submitted POC and the findings were presented to the monthly Quality Assurance meeting. The POC submitted to the CDPH, L&C Program for F880 cited from the last recertification survey completed on 5/30/17, showed the facility would monitor compliance weekly with audits of the infection control surveillance logs by the Infection Control Nurse, Unit Manager, or the ADON. A random audit of infection surveillance would be completed by the Regional Director of Clinical Services. Findings would be reported to the monthly Quality Assurance committee and an action plan would be formulated in the Quality Assurance meeting. The Administrator failed to show documented evidence the weekly audits of the infection control surveillance logs were completed, nor a random audit of infection surveillance was completed by the Regional Director of Clinical Services as per their submitted POC. The Administrator stated no findings regarding infection control surveillance audits were reported to the monthly Quality Assurance meeting. On 5/16/18 at 1620 hours, a telephone interview was conducted with the Regional Director of Clinical Services. The Regional Director of Clinical Services stated she was not aware she needed to complete a random audit of the infection surveillance. When asked if she had done the audit, the Regional Director of Clinical Services stated no, she had not done any audits regarding infection surveillance for the facility.

F880 SS=F Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) FORM CMS-2567(02-99) Previous Versions Obsolete

F880 Event ID: BVUW11 06/18/2018 Facility ID: CA060000715 If continuation sheet 137 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 138 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility document review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections. * The facility failed to conduct accurate surveillance of incidents of infections as per McGeer's Criteria (a set of criteria used in long term care facilities to identify if residents' symptoms meet the criteria of a true infection). The facility failed to track and develop an action plan to address the increase in the number of incidents of HAIs. The Infection Preventionist failed to report the infection surveillance for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 139 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 months of November and December 2017 in the monthly infection control meeting. In addition, the facility failed to address the use of antibiotics for residents whose symptoms did not meet the McGeer's criteria. This posed the risk of the facility not accurately investigating and preventing new infections from developing and an outbreak going unrecognized within the facility. * The facility failed to ensure the licensed nurse performed appropriate wound care treatment and hand hygiene during wound care treatment for Resident 62. * The facility failed to ensure the licensed nurse performed hand hygiene during wound care for Resident 100. Findings: 1. According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. On 5/15/18 at 1004 hours, an interview and concurrent facility document review was conducted with the facility's Infection Control Nurse (who is the DSD). The DSD stated the facility utilized McGeer's Criteria to define infection surveillance activities. The DSD stated the licensed nurses completed the Surveillance Data Collection Form for each antibiotic ordered. She collected these forms FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 140 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 on a daily basis and used the data to determine if the infections met the McGeer's Criteria. Review of the Surveillance Data Forms for the months of March and April 2018 showed the forms were not completely filled out. The DSD stated she checked the residents' medical records for signs and symptoms. Review of the Infection Prevention and Control Surveillance Logs from July 2017 through March 2018 showed the number of infections reported to the monthly infection control meetings were inaccurate. For example, for the month of March 2018, the DSD reported 50 total infections; however, the log showed 52 total infections. For the month of February 2018, the DSD reported a total of 43 infections with 20 CAIs, 4 HAIs and 5 not meeting McGeer's criteria but did not account for the remaining 14 infections. For the month of January 2018, the DSD reported 43 total infections; however, the surveillance log showed 47 total infections, five infections in January 2018 were included in the February 2018 surveillance log. Review of the Infection Prevention and Control Surveillance and the DSD's infection control report from July 2017 through April 2018 showed the summary of infections for the months of November and December 2017 were not reported to the monthly infection control meeting. Further review of the surveillance log showed the following number of HAIs: - September 2017 - 4 - October 2017 - 9 - November 2017 - 6 (was not reported in the monthly infection control meeting) - December 2017- 8 (was not reported in the monthly infection control meeting) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 141 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 - January 2018 - 17 The DSD acknowledged the increase in the number of HAIs was not identified and no action plan was developed to address this. Review of the surveillance logs showed the following number of infections not meeting the McGeer's Criteria: - September 2017 - 7 - October 2017 - 11 - November 2017 - 15 - December 2017 - 12 - January 2018 - 17 The DSD failed to provide documented evidence the increase in the number of antibiotic use not meeting the McGeer's criteria was addressed in the monthly infection control meeting, or evidence an action plan was developed. When asked what was done for the antibiotic use not meeting the McGeer's Criteria, the DSD stated she had not informed the physician. The DSD verified above findings. 2. Medical record review for Resident 62 was initiated on 5/8/18. Resident 62 was admitted to the facility on 4/2/18. On 5/10/18 at 1004 hours, a wound care observation was conducted with LVN 4. LVN 4 was observed removing the old dressing from Resident 62's right trochanter (top of the femur) wound. Without changing gloves and washing her hands, LVN 4 proceeded to clean the wound with normal saline solution. LVN 4 then removed her gloves and donned clean gloves, and patted the wound with a gauze. LVN 4 was observed touching Resident 62's legs to assist the resident in repositioning. Without changing her gloves and washing her hands, LVN 4 was observed applying wound prep around Resident 62's right trochanter wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 142 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 area. LVN 4 donned clean gloves and proceeded to perform wound treatment to Resident 62's sacrococcyx (tailbone) wound. LVN 4 was observed cutting calcium alginate (absorbent) dressing with her scissors, and placing the cut pieces of the calcium alginate dressing on the bed. LVN 4 picked up the calcium alginate and applied it to Resident 62's sacrococcyx wound. 3a. On 5/10/18 at 1112 hours, a wound care observation was conducted with LVN 4. LVN 4 washed her hands and put on clean gloves, then touched Resident 100's pants, legs and diaper. Without changing gloves and washing her hands, LVN 4 proceeded to clean Resident 100's coccyx (tailbone) wound with normal saline solution. LVN 4 did not change gloves before patting the wound dry with gauze, applying wound treatment and covering the coccyx wound with foam dressing. On 5/4/18 at 1451 hours, LVN 4 was informed of the observations during the wound care treatments for Residents 62 and 100. LVN 4 acknowledged she did not change gloves and did not wash her hands after contact with the residents, and old dressings. b. On 5/10/18 at 0854 hours, a medication administration observation was conducted with LVN 14 for Resident 100. LVN 14 administered oral medications to Resident 100. LVN 14 was observed changing gloves after administering Resident 100's oral medications, but was not observed performing hand hygiene. LVN 14 was then observed administering one eye drop to Resident 100's left eye. On 5/10/18 at 0902 hours, LVN 14 verified she did not perform hand hygiene prior to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 143 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 administering Resident 100's eye drops because someone was in the bathroom.

F908 SS=F Essential Equipment, Safe Operating Condition F908 CFR(s): 483.90(d)(2) 08/08/2018 §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility P&P review, the facility failed to maintain essential equipment as evidenced by: * The freezer temperature was too high. * The dish machine, walk-in and reach-in refrigerator doors, kitchen floor, and dish racks were in disrepair. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food, leading to foodborne illnesses for the residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/10/18, showed 124 of 130 residents residing in the facility received food prepared in the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 144 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility's P&P dated 11/11/16, titled Food Safety showed, "Cold Food Storage: Ambient temperatures in freezers remain at 0˚ F or lower ... Temperatures recorded at least twice daily ... any problems will be reported immediately to the Director of Food and Nutrition Services/Maintenance." On 5/8/18 at 0820 hours, an observation and concurrent interview was conducted with the DSS and Cook 1. Observation of the walk-in freezer showed the thermometer registered 3˚ F. Six bagels in a bag located at the back of the freezer were soft. The DSS stated the bagels were placed in the freezer yesterday. An opened box contained soft ice-cream sandwiches and a large tub of soft rainbow sherbet. The DSS acknowledged the freezer temperature was warm. The freezer temperature documentation log showed the freezer temperature was 10˚ F at 1000 hours that morning. Cook 1 stated he informed the DSS about the freezer temperature that morning. The DSS confirmed Cook 1 told him about the high freezer temperature and stated he contacted the maintenance department concerning the freezer temperature. During an interview with the Environmental Manager on 5/8/18 at 1100 hours, he stated he did not receive a maintenance request from the DSS about the freezer and was not aware the freezer temperature was high. He showed the surveyor his log book to verify there was no documentation for the freezer that day. On 5/9/18 at 1047 hours, a concurrent observation and interview was conducted with an outside company freezer technician. Observation of the thermometer in the freezer showed the temperature was 19˚ F. The freezer technician was working in the back of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 145 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 freezer and stated the freezer was leaking refrigerant (a substance used for cooling) outside which caused the temperature of the freezer to increase. 2. Review of the facility's P&P titled Sanitation and Maintenance revised 11/11/16, showed, "There is a reporting procedure for all maintenance issues." The facility did not provide the procedure for reporting maintenance issues. The Federal Food Code 2017 showed equipment is to retain their characteristic qualities under normal use and be maintained in good repair. Equipment such as doors and seals are to be kept intact and tight. a. On 5/8/18 at 0905 hours, an observation and concurrent interview was conducted with the DSS. Observation of the area where the dish machine steam vent went into the ceiling showed a significant amount bulging paint coming away from the ceiling around the circumference of the vent. The ceiling area in direct contact with the vent showed sheetrock and paint peeling away, exposing a brownish colored substance. The DSS stated steam from the dish machine ruined the ceiling. The DSS stated he did not know how long it had been in disrepair. b. On 5/8/18 at 0910 hours, an observation and concurrent interview was conducted with the DSS. Observation of the seal around the door of the reach-in refrigerator showed it was coming away in three areas. There was a piece of cardboard placed at the end of the track for the door and rubber seal so the door was not fully closed. The two sliding doors were very difficult to slide in order to open and close them. The DSS stated there was no documentation showing the disrepair of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 146 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 refrigerator was reported to maintenance. c. On 5/8/18 at 0940 hours, an observation and concurrent interview was conducted with the DSS. Observation showed the grout (a form of concrete used to fill the spaces between tile) between the tiles on the floor was very deep or missing around the heavily trafficked areas, such as around the stove. Crumbs were observed embedded deep down in the missing grout spaces. On 5/8/18 at 1100 hours, an interview was conducted with the Environmental Manager and the Regional Plant Operations Manager. The Regional Plant Operations Manager stated items in need of repair were reported during a daily stand-up meeting or were documented in the maintenance log book. The Environmental Manager stated kitchen staff did not log anything in the maintenance log book. d. On 5/8/18 at 1115 hours, an observation showed three stacked racks used to hold dishes and utensils in the dish machine were cracked and broken. The racks were located on the floor next to the dirty side of the dish machine. The DSS stated he was aware the racks were in disrepair. e. On 5/8/18 at 1609 hours, an observation showed the plastic frame around the door of the walk-in refrigerator was cracked and broken. On 5/9/18 at 1630 hours, an interview was conducted with the Environmental Manager and the Regional Plant Operations Director. The Environmental Manager confirmed the broken and cracked plastic lining around the door frame of the walk-in refrigerator and stated he was not aware of the condition. The Environmental Manager also confirmed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 147 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 disrepair of the reach-in refrigerator and stated he was unaware it needed to be repaired. The Environmental Manager also confirmed the deep and missing grout in the kitchen floor and stated he was not aware of the condition. The Facility Maintenance Supervisor confirmed he was aware of the ceiling around the dish machine vent; he had been notified about three days ago. The Regional Plant Operations Director stated he could tell the vent was blocked or not working, causing the steam to come out of the side of the dish machine instead of up and out the vent.

F925 SS=F Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 08/08/2018 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain an effective pest control program to prevent the presence of small flies in the kitchen and janitor's room, located adjacent to the walk-in refrigerator. The janitor's room contained a drain with foul smelling, standing water and multiple drains were inoperable within the kitchen. These created an environment for the harboring of pests and the potential for contamination of the food prepared in the facility. Findings: Review of the facility's P&P titled Pest Control revised 5/21/04, showed, "The facility will have a pest contract that provides frequent treatment of the environment for pests. It will allow for additional visits when a problem is detected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 148 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 facility's staff will do monitoring of the environment. Pest control problems will be reported promptly." Review of the facility's document titled Pest Control (undated) showed, "We want to keep pests ...out of our department because they contaminate the food and work areas." On 5/8/18 at 0755 hours, an initial tour of the kitchen was conducted with the DSS. A hand sink, located next to the door leading to the dining room, was observed covered with plastic with an out of order sign. When asked about the sink, the DSS stated it had a broken drain pipe and had been inoperable since July, 2017. On 5/8/18 at 0806 hours, an interview and concurrent observation of the janitor's room was conducted with the DSS. The janitor's room door was observed opened to the kitchen and contained mops, mop buckets, and chemicals. The drain in the janitor's room had more than a half inch of foul smelling, dark colored water. Eight small flies were observed on the wall and flying around the mop room. The DSS stated the pest company came once a month and the maintenance department kept a log of the visits. When asked if he thought the flies were a problem, the DSS stated, "Yes." On 5/8/18 at 0915 hours, 16 small flies were observed on the walls of the kitchen in the coffee preparation area adjacent to the tray-line steam table. When asked about the flies, the DSS stated the flies were in that area because it was hot. When asked if he thought the flies were a problem, the DSS stated the flies were a problem. On 5/8/18 at 0925 hours, a large red hose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 149 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 attached to the bottom of the steamtable was observed in the floor drain. The floor drain was covered with a black substance. When asked about the hose, the DSS stated it was the drain hose for the steam table but the drain was inoperable because the drain pipe needed replacing. On 5/8/18 at 1120 hours, when the food was being set up for the trayline service, more than four small flies were observed flying above the steamtable where meals were served. On 5/9/18 at 1100 hours, an observation of the janitor's room was conducted with the DSS. The drain in the janitor's room continued to have foul smelling, dark colored water. When asked if he had reported the drain in the janitor's room to maintenance, the DSS stated he had not reported the drain to maintenance. On 5/15/18 at 0954 hours, an interview and concurrent facility document review was conducted with RD 1. RD 1 stated flying insects were noted to be a problem in the RD Monthly Facility Report for the months of March and April 2018. RD 1 stated she reviewed the RD Monthly Facility Reports with the DSS and Administrator each month. Review of the facility's customer service report from the pest control company dated 5/3/18, showed, "small fly activity growing ... Floor drains in need of cleaning next to stacked warmers under expo line. Please clean in and around drains frequently to help prevent pest breeding sites." Review of the facility's document titled Kitchen Cleaning Schedule for the month of March 2018 showed floor drains with a cleaning schedule of daily were only cleaned three times during the month. For the month of April 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 150 of 151 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: _______________ 555308 (X3) DATE SURVEY COMPLETED 05/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (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 daily cleaning schedule for the floor drains showed the drains were only cleaned four times during the month. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BVUW11 Facility ID: CA060000715 If continuation sheet 151 of 151