Other·January 23, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of two linked complaints. Complaint numbers CA00605651 and CA00605671. Representing the California Department of Public Health: Surveyor Federal ID number 38478, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for linked complaint numbers CA00605651 and CA00605671.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 12/01/2018 §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 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: V7YY11 Facility ID: CA240000098 If continuation sheet 1 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or §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 exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the interdisciplinary comprehensive care plans were revised to reflect the current individualized care needs, pertinent history, and interventions for safety and the prevention of fall and/or incidents for one of three sampled residents (Resident A). The facility also failed to ensure the plan of care for providing total assistance (full staff performance) with toileting was properly implemented for Resident A. These failures increased the potential for a lack of staff communication and safety interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 2 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 prevent Resident A from experiencing a fall or incident while in the facility. Findings: On October 2, 2018, an unannounced visit to the facility was conducted to investigate a complaint related to quality of care concerns. Resident A's record was reviewed on October 2, 2018. Resident A was admitted to the facility on September 13, 2018, with diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness of one entire side of the body), and intracranial hemorrhage (bleeding inside the skull or brain). The facility's history and physical, dated September 15, 2018, indicated, "...This resident: does not have the capacity to understand and make decisions..." The acute care hospital's history and physical, dated September 6, 2018, indicated, "...Patient is a 66-year-old...who presented to (the) emergency room with left-sided weakness, sudden onset slurred speech, right side gaze and left-sided vision field loss...Problem list...At risk for falls..." The acute care hospital's occupational therapy (applied science and health profession that provides skilled treatment to help individuals achieve and maintain functionality of ADLsactivities of daily living), dated September 10, 2018, at 2:44 p.m., indicated, "...Patient was unable to participate in LE (lower extremity) / UE (upper extremity) dressing. Reported no sensation and no demonstration of movement in L (left) UE/LLE..." The facility's "Admission Assessment," dated September 13, 2018, indicated the following, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 3 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 - "...history of falls (in the) last 30 days...number of falls: 1...What was patient doing at time of fall? getting out of shower... - Speech...is slurred, slow or difficult to understand... - Paralysis/Weakness: yes... - Fine motor skills: Is patient able to grasp, hold, feel with hands? No...(has) left sided weakness... - Assistive Devices: bed pan..." The baseline care plan titled, "At Risk for Falls," dated September 14, 2018, indicated, "...unsteady ambulation...L side weakness...Resident Goal:...will not experience a fall related injury that requires hospitalization through next review...assistive devices in reach...assist with transfers...assist with toileting..." The occupational therapy (OT) evaluation notes, dated September 14, 2018, at 12:56 p.m., indicated Resident A had impairment with strength, sensation, and balance due to severe left side body neglect and flaccidity (soft and hanging loosely or limply). The notes indicated the resident required total assistance from staff with toileting, dressing, and functional transfers. The notes further indicated Resident A was given left half-tray to support her left upper extremity while in the wheelchair. Resident A's Activities of Daily Living (ADLS) care plan, dated September 22, 2018, indicated, "Resident is at risk of developing complications R/T (related to) the needing (of) total assistance in the following ADLS...toilet use...personal hygiene..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 4 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 A's interdisciplinary care plans for Falls and Activities of Daily Living-Self Care Deficit did not reflect or indicate the resident's history of fall as identified in the admission assessment. The comprehensive care plans did not reflect the use of the safe adaptive device: half lap tray for support while in the wheelchair. The nursing progress notes, dated September 23, 2018, at 4:34 p.m., indicated, "...Summary of Findings: Pt. noted on (the) floor in (the) bathroom...Can's (sic) (CNA- Certified Nursing Assistant) assisting pt. to (the)restroom in back of 300 hall bathroom... while cna (was) standing by (the) door, pt. leaned forward and fell onto (the) floor lying on (her) stomach. Noted with laceration to left eyebrow..." The nursing progress notes, dated September 23, 2018, at 6:21 p.m., indicated, "...Late entry...at about 2:40 p.m....cna...yelled out to me that they needed help. As I arrived at the back...hall shower, pt. from (room) 313b was lying on (the) floor face down with left arm behind her and right arm in front (of her). Pt. noted with laceration to left eyebrow. When asked pt. what happened she stated she was sitting on (the) toilet and leaned forward and fell...pt c/o (complained of) pain to head and to right elbow...MD notified with orders to send to (the) ER (emergency room) for EVAL (evaluation)..." On October 2, 2018, at 10:53 a.m., the Occupational Therapist (OT) for Resident A was interviewed. The OT stated Resident A was falling on her left side due to "left side neglect" and "poor trunk (upper body) control." The OT stated Resident A was "impulsive" and was unsafe to stand. The OT stated Resident A required 2 persons providing max assistance for transfers. The OT stated Resident A also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 5 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 had "poor sitting balance" and "poor sitting dynamics." The OT stated they used the half lap tray on Resident A's left side to support her arm because "she would just drop her arm." The OT stated due to Resident A's poor trunk control and sitting balance, they had not evaluated or attempted the resident for out-ofbed toileting. The OT stated Resident A should require "100 percent" support from staff for toileting. When asked about the incident, the OT stated staff should have stayed with the resident, providing support and balance to her body. On October 3, 2018, at 9:52 a.m., CNA 4 was interviewed. CNA 4 stated she was the CNA assigned for the "first time" for Resident A on September 23, 2018. CNA 4 stated she worked a "couple of days a month" as "part time" in the facility. CNA 4 stated the fall incident happened "around 2:30 p.m." on September 23, 2018. CNA 4 stated she brought Resident A, with the assistance of CNA 3, to the shower room to use the toilet. CNA 4 stated she stayed in the shower room with her body in between the selfclosing door to "prop the door open." CNA 4 stated she closed the privacy curtain in front of Resident A. CNA 4 stated Resident A fell "too fast" onto the floor. CNA 4 stated she did not provide physical support to Resident A's body or trunk while she was sitting on the commode. CNA 4 stated she was not aware of Resident A's history of fall. CNA 4 stated she was not aware if the therapist had cleared Resident A to safely use the toilet or commode without physical support. On October 4, 2018, at 9:55 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated she was the supervisor on September 23, 2018 when the incident happened. The RNS stated Resident A was "not stable to sit by herself" as she was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 6 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 "constantly sliding" while in the wheelchair. The RNS stated she was not aware that the therapists had not done toilet transfers or the use of a commode for Resident A. The RNS stated staff should have used a bed pan temporarily until the therapist had cleared Resident A for safe toilet or commode use. On October 4, 2018, at 3:23 p.m., Resident A's record was reviewed with the ADON. The ADON confirmed the use of the half lap tray for Resident A while in the wheelchair was not included in the interdisciplinary comprehensive care plans. The ADON confirmed Resident A's fall history was not reflected in the baseline and comprehensive care plans. The ADON confirmed that staff did not provide total assistance and support to the resident while toileting in the commode. When asked about how resident care was communicated to the CNAs, the ADON stated they used the "Care Directives," the facility's form of communication to the CNAs regarding the plan of care, precautions, and care needs of the residents. The ADON stated the "Care Directives" were done on "admission" and were "updated regularly." The ADON confirmed and stated there was no "Care Directives" completed for Resident A.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 12/01/2018 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 7 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 and record review, the facility failed to ensure provision of safety and supervision for one of three sampled residents (Resident A) when: 1. Resident A, who had left-sided body weakness, poor trunk (upper body) control, and poor sitting balance, was placed on a commode (movable toilet chair) without adequate physical support to prevent imbalance, leading to the resident's fall onto the floor; 2. Facility staff did not complete a fall risk assessment/evaluation for Resident A during her admission to the facility, as per the facility's policy and procedure for fall prevention and management; 3. Resident A's interdisciplinary team (IDTgroup of health care professionals) care plans did not reflect the use of a half-lap tray (device used to provide support to the arm and shoulder when sitting in a wheelchair) to manage the resident's safety due to her leftsided body weakness and neglect (disabling condition following brain damage in which patients fail to be aware of items to one side of space) and did not reflect or indicate the resident's history of fall as identified in the admission assessment; and 4. The facility staff failed to ensure the plan of care for providing total assistance (full staff performance) with toileting was properly implemented for Resident A. These failures resulted in a fall incident for Resident A, requiring re-hospitalization and intensive care treatment and management for sustained injuries from the fall, such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 8 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 contusion (bruise), abrasion (skin scrape), headache, vomiting, and worsening of the resident's intracranial hemorrhage (bleeding inside the skull or brain). Findings: On October 2, 2018, an unannounced visit to the facility was conducted to investigate a complaint related to quality of care concerns. Resident A's record was reviewed on October 2, 2018. Resident A was admitted to the facility on September 13, 2018, with diagnoses which included hemiparesis (weakness of one entire side of the body) and intracranial hemorrhage (bleeding inside the skull or brain). The facility's history and physical, dated September 15, 2018, indicated, "...This resident: does not have the capacity to understand and make decisions..." The acute care hospital's history and physical, dated September 6, 2018, indicated, "...Patient is a 66-year-old...who presented to (the) emergency room with left-sided weakness, sudden onset slurred speech, right side gaze and left-sided vision field loss...Problem list...At risk for falls..." The acute care hospital's occupational therapy (applied science and health profession that provides skilled treatment to help individuals achieve and maintain functionality of ADLsactivities of daily living), dated September 10, 2018, at 2:44 p.m., indicated, "...Patient was unable to participate in LE (lower extremity) / UE (upper extremity) dressing. Reported no sensation and no demonstration of movement in L (left) UE/LLE..." The facility's "Admission Assessment," dated September 13, 2018, indicated the following, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 9 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 - "...history of falls (in the) last 30 days...number of falls: 1...What was patient doing at time of fall? getting out of shower... - Speech...is slurred, slow or difficult to understand... - Paralysis/Weakness: yes... - Fine motor skills: Is patient able to grasp, hold, feel with hands? No...left sided weakness... - Assistive Devices: bed pan..." There was no documented evidence a fall risk assessment/evaluation was completed on Resident A's admission. The baseline care plan titled, "At Risk for Falls," dated September 14, 2018, indicated, "...unsteady ambulation...L side weakness...Resident Goal:...will not experience a fall related injury that requires hospitalization through next review...assistive devices in reach...assist with transfers...assist with toileting..." The occupational therapy (OT) evaluation notes, dated September 14, 2018, at 12:56 p.m., indicated Resident A had impairment with strength, sensation, and balance due to severe left side body neglect and flaccidity (soft and hanging loosely or limply). The notes indicated the resident required total assistance from staff with toileting, dressing, and functional transfers. The notes further indicated Resident A was given left half-tray to support her left upper extremity while in the wheelchair. Resident A's interdisciplinary care plans for Falls and Activities of Daily Living-Self Care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 10 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 Deficit did not reflect or indicate the resident's history of fall as identified in the admission assessment. The comprehensive care plans did not reflect the use of the safe adaptive device: half lap tray for support while in the wheelchair. The physical therapy (PT) evaluation notes, dated September 14, 2018, at 1:11 p.m., indicated Resident A had poor static sitting balance (ability to balance while holding one position) and dynamic sitting balance (ability to balance while moving or changing between positions). The notes indicated the resident required max (maximum) assistance of two persons with transfers. The notes indicated Resident A had poor motor coordination and impaired sensation or sensory processing. The OT treatment progress notes from September 14, 2018 to September 18, 2018, indicated Resident A had poor safety awareness, requiring total dependence on staff with toileting in bed. The PT treatment progress notes from September 17, 2018 to September 21, 2018, indicated Resident A remained to have poor sitting balance. There was no documented evidence the physical therapists and occupational therapists conducted and/or completed an evaluation, training, or safety clearance with toileting, using a commode or a regular bathroom toilet for Resident A. Resident A's Activities of Daily Living care plan, dated September 22, 2018, indicated, "Resident is at risk of developing complications R/T (related to) the needing (of) total assistance in the following ADLS...toilet use...personal hygiene..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 11 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 nursing progress notes, dated September 23, 2018, at 4:34 p.m., indicated, "...Summary of Findings: Pt. noted on floor in bathroom...Can's (sic) (CNA- Certified Nursing Assistant) assisting pt. to restroom in back of 300 hall bathroom... while cna (was) standing by (the) door, pt. leaned forward and fell onto (the) floor lying on (her) stomach. Noted with laceration to left eyebrow..." The nursing progress notes, dated September 23, 2018, at 6:21 p.m., indicated, "...Late entry...at about 2:40 p.m....cna...yelled out to me that they needed help. As I arrived at the back...hall shower, pt. from (room) 313b was lying on (the) floor face down with left arm behind her and right arm in front (of her). Pt. noted with laceration to (her) left eyebrow. When asked pt. what happened she stated she was sitting on (the) toilet and leaned forward and fell...pt c/o (complained of) pain to head and to right elbow...MD notified with orders to send to (the) ER (emergency room) for EVAL (evaluation)..." The document titled, "Fall Risk Evaluation," dated September 23, 2018, indicated, "Instructions: To be completed upon admission and quarterly. When resident's total score is 10 or more, interventions should promptly be put in place...Total Score = 17 (A resident who scores a 10 or higher is at risk)..." Resident A's general acute care hospital (GACH) record was requested and reviewed on October 2, 2018. The acute care hospital's emergency notes, dated September 23, 2018, at 7:47 p.m., indicated, "...(Resident A was) transferred here after she fell, hit her head (and) has worsening of her intracranial bleeding...This was a trauma FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 12 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 transfer..." The acute care hospital's history and physical, dated September 24, 2018, at 1:38 p.m., indicated, "...Chief Complaint/Reason for Consultation: s/p (status post) ground level fall, brought to (name of General Acute Care Hospital [GACH] 1) where they found patient to have a bleed in CT (computed tomography scan- use of computer-processed combinations of many x-ray measurements taken from different angles of the brain)...pt was in the bathroom and fall (sic) forward and was brought to (name of GACH 1). She was found to have a 4 X 2.5 cm (centimeters) right basal ganglia bleed (brain bleed)...Pt was transferr (ed) to (name of GACH 2) for trauma. At (name of GACH 2), repeat CT scan 3.5 hours later showed 4.3 X 2.7 cm right basal ganglia bleed...Neurosurgeon was consulted. Pt is admitted to ICU. Pt endorses headache, vomiting X 1, left side paralysis and decrease sensation on left side...contusion/abrasion above her left eye...This patient is critically ill due to vital organ failure including: Intraparenchymal brain hemorrhage (bleeding in the brain), brain compression. The patient has a high probability of imminent or life threatening deterioration due to the above and requires critical care management...including high complexity medical decision making and the assessment, manipulation and support of vital organ functions in an attempt to prevent further clinical decline. This included: brain hemorrhage and compression management..." On October 2, 2018, at 9:52 a.m., Certified Nursing Assistant (CNA) 1 was interviewed regarding Resident A. CNA 1 stated Resident A was alert with periods of confusion and had the "tendency of moving" while in the wheelchair. CNA 1 stated resident A was "not stable with her standing balance," requiring maximum FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 13 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 assistance from two staff during transfers. CNA 1 stated Resident A should not be left by herself on a chair. On October 2, 2018, at 10:23 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed regarding Resident A. LVN 1 stated Resident A had the tendency to lean forward when in a sitting position. On October 2, 2018, at 10:45 a.m., LVN 2 was interviewed. LVN 2 stated Resident A was noted frequently leaning forward or on her left side. On October 2, 2018, at 10:53 a.m., the Occupational Therapist (OT) for Resident A was interviewed. The OT stated Resident A was falling on her left side due to "left side neglect" and "poor trunk control." The OT stated Resident A was "impulsive" and was unsafe to stand. The OT stated Resident A required two persons providing max assistance for transfers. The OT stated Resident A also had "poor sitting balance" and "poor sitting dynamics." The OT stated they used the half lap tray on Resident A's left side to support her arm because "she would just drop her arm." The OT stated due to Resident A's poor trunk control and sitting balance, they had not evaluated or attempted the resident for out-ofbed toileting. The OT stated Resident A should require "100 percent" support from staff for toileting. When asked about the incident, the OT stated staff should have stayed with the resident, providing support and balance to her body. On October 2, 2018, at 11:07 a.m., the Physical Therapist (PT) was interviewed. The PT stated Resident A needed max assistance with transfers. The PT stated the latest therapy progress notes indicated the resident still had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 14 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 poor sitting dynamics. The PT confirmed there was no safety evaluation or clearance from the PT or the OT for Resident A to use the toilet or the commode. On October 2, 2018, at 11:15 a.m., CNA 2 was interviewed. CNA 2 stated she provided care to Resident A while in the facility. CNA 2 stated she used the bed pan for Resident A's toileting needs. CNA 2 stated Resident A was "not strong...not able to support herself...not safe for a commode." On October 2, 2018, at 11:18 a.m., LVN 3 was interviewed. LVN 3 stated she was the licensed nurse assigned to Resident A when the incident occurred on September 23, 2018. LVN 3 stated her attention was called by a staff for help for a resident who fell in the shower room. LVN 3 stated she saw Resident A lying on her "stomach" on the floor in the shower room. LVN 3 asked Resident A about the incident, and she stated, "I just fell forward." LVN 3 stated she investigated the fall incident. LVN 3 stated prior to Resident A's fall, CNA 3 and CNA 4 assisted the resident to use the toilet in the shower room. LVN 3 stated CNA 4 told her she stayed at the door of the shower room with her body in between the door while Resident A was on the toilet. When asked about ADLs and toileting for newly admitted residents, LVN 3 stated they followed therapy (PT/OT) clearance before getting a resident out of bed for toileting. When asked about Resident A's toileting evaluation, LVN 3 stated she was not aware if the resident was evaluated or cleared by the therapists for the use of the commode or the toilet. On October 2, 2018, at 11:24 a.m., CNA 3 was interviewed. CNA 3 stated she assisted CNA 4 in transferring Resident A from the wheelchair to the commode in the shower room toilet. CNA 3 stated she left Resident A with CNA 4 while FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 15 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 she "grabbed the linens" outside of the shower room. CNA 3 stated while she was outside she heard a loud noise from the shower room. When asked about the facility's toileting ADL process for new admit residents, CNA 3 stated before they could bring a newly-admitted resident to the toilet, the therapists (PT/OT) would first assess the resident for safety. CNA 3 stated they would use a urinal or a bed pan for the resident temporarily while pending PT or OT evaluation and clearance for toileting. CNA 3 stated she was not aware if the resident was evaluated or cleared by the therapists for toileting. On October 2, 2018, at 11:33 a.m., the Assistant Director of Nursing (ADON) was interviewed regarding Resident A's fall incident. The ADON stated, based on her investigation, CNA 4 was positioned in between the selfclosing door of the shower room when Resident A fell onto the floor. The ADON stated the distance of the shower door to the toilet was approximately 3-4 feet. On October 3, 2018, at 9:52 a.m., CNA 4 was interviewed. CNA 4 stated she was the CNA assigned for the "first time" for Resident A on September 23, 2018. CNA 4 stated she worked a "couple of days a month" as "part time" in the facility. CNA 4 stated the fall incident happened "around 2:30 p.m." on September 23, 2018. CNA 4 stated she brought Resident A, with the assistance of CNA 3, to the shower room to use the toilet. CNA 4 stated she stayed in the shower room with her body in between the selfclosing door to "prop the door open." CNA 4 stated she closed the privacy curtain in front of Resident A. CNA 4 stated Resident A fell "too fast" onto the floor. CNA 4 stated she did not provide physical support to Resident A's body or trunk while she was sitting on the commode. CNA 4 stated she was not aware of Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 16 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 A's history of fall. CNA 4 stated she was not aware if the therapist had cleared Resident A to safely use the toilet or commode without physical support. On October 4, 2018, at 9:55 a.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated she was the supervisor on September 23, 2018 when the incident happened. The RNS stated Resident A was "not stable to sit by herself" as she was "constantly sliding" while in the wheelchair. The RNS stated she was not aware that the therapists had not done toilet transfers or the use of a commode for Resident A. The RNS stated staff should have used a bed pan temporarily until the therapist had cleared Resident A for safe toilet or commode use. On October 4, 2018, at 3:23 p.m., Resident A's record was reviewed with the ADON. The ADON confirmed the use of the half lap tray for Resident A while in a wheelchair was not included in the interdisciplinary comprehensive care plans. The ADON confirmed Resident A's fall history was not reflected in the baseline and comprehensive care plans. When asked about the fall risk evaluation of the residents, the ADON stated the fall risk evaluation should be conducted on admission, quarterly, and/or after a fall incident. The ADON confirmed there was no documented evidence a fall risk evaluation was completed during Resident A's admission. The ADON confirmed that staff did not provide total assistance and support to the resident while toileting in the commode. The ADON stated staff should have used a bed pan for toileting until Resident A was evaluated by the therapist to safely use the toilet in the bathroom or shower room. The facility's policy and procedure titled, "Falls Management," dated February 2017, indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 17 of 18 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: _______________ 056185 (X3) DATE SURVEY COMPLETED 10/31/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (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 "Policy Each resident will be assessed throughout the course of treatment for different parameters such as: cognition, safety awareness, fall history, mobility, sensory status, medications, or predisposing health conditions that may contribute to fall risk. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions... Procedure ...Assessment of Fall Risk & Care Plan Development...All residents will have a falls (sic) risk assessment completed on admission, following serious injury, after a significant change, quarterly, and as necessary..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V7YY11 Facility ID: CA240000098 If continuation sheet 18 of 18