Other·January 29, 2020

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 annual recertification survey conducted September 16 to 19, 2019. Representing the California department of Public Health: Surveyor 37536, HFEN; Surveyor 21211, HFEN; Surveyor 39920, HFEN; Surveyor 40308, HFEN; and Surveyor 42395, HFEN. The facility census was 73 residents. One facility reported incident was linked to the survey, Facility Reported Incident number CA00654151. No deficiencies were issued to Facility Reported Incident number CA00654151.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 10/10/2019 §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 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: CJRO11 Facility ID: CA240000098 If continuation sheet 1 of 28 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 09/19/2019 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 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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was in the resident's record for one of nine residents reviewed for AD (Resident 44). This failure had the potential for Resident 44's advance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 2 of 28 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 09/19/2019 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 directive to not be readily retrievable by the staff and by the physician and not knowing the wishes of the resident regarding medical treatment. Findings: Resident 44's record was reviewed. Resident 44 was admitted to the facility on May 23, 2018. The Physician Orders for Life-Sustaining Treatment (POLST - end-of-life planning tool) indicated Resident 44 had no advance directive. There was no documentation Resident 44 was offered or provided information regarding AD. On September 18, 2019, at 8:52 a.m., Social Service Director (SSD) was interviewed. The SSD stated she was responsible for residents' AD. The SSD stated Resident 44 had an advance directive and was provided by his sister on November 16, 2018. In a concurrent review of Resident 44's record, the SSD stated Resident 44's AD was not in his record. The SSD stated Resident 44's AD should be in his record. The policy and procedure titled, "Advance Directives," dated August 21, 2019, was reviewed. The policy and procedure indicated, "...If the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record...The advance directive copy should always remain in the resident's record..."

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 10/10/2019 Facility ID: CA240000098 If continuation sheet 3 of 28 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 09/19/2019 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 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 4 of 28 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 09/19/2019 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 by: Based on observation, interview, and record review, the facility failed to ensure an adequate lighting was provided in Room 404. This failure had the potential to affect residents' comfort and safety. Findings: On September 16, 2019, at 10:45 a.m., Resident 158 was interviewed and he stated the room (Room 404) was dark. Resident 158 stated he was filling up paperwork last night and he could not see. Resident 158 stated he complained about the room being dark. He stated a staff tried to fix the light but was not able to fix it. On September 17, 2019, at 8:49 a.m., a concurrent observation of Room 404 and interview were conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the overhead center light bulb for A bed was not working. CNA 1 stated two overhead light bulbs were not working for B bed (Resident 158's bed). CNA 1 stated the light bulbs should have been replaced. On September 18, 2019, at 9:34 a.m., the Director of Nursing (DON) was interviewed. The DON stated there is a maintenance log to list down the equipment that needs repairing. The DON stated maintenance staff should check the log daily. In a concurrent review of the maintenance log, there was no documentation that the light bulbs in Room 404 was reported as not working. On September 18, 2019, at 9:40 a.m., the Maintenance Director (MD) was interviewed. The MD stated he was unaware that Room 404's light bulbs were not working. The MD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 5 of 28 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 09/19/2019 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 stated the staff would tell him verbally or list the issue in the maintenance log for him to know which equipment was not working. On September 18, 2019, at 9:51 a.m., the Maintenance Assistant (MA) was interviewed. The MA stated CNA 1 reported the issue of the light bulbs not working at Room 404, on September 17, 2019. The policy and procedure titled, "Work Request System," dated June 26, 2019, was reviewed. The policy and procedure indicated, "The Work Request System was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature..."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 10/10/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 6 of 28 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 09/19/2019 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 §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 and record review, the facility failed to ensure an allegation of physical abuse involving Residents 19 and 27 was reported to the California Department of Public Health (CDPH) immediately, but not later than two hours after the allegation was made. This failure had the potential to delay the identification and implementation of appropriate action and placed the residents at risk for further abuse. Findings: On September 17, 2019, at 9:08 a.m., a telephone interview was conducted with Resident 19's Responsible Party (RP). The RP stated Resident 19 had an injury during an incident with her roommate (Resident 27) involving the curtain. On September 18, 2019, at 2:16 p.m., Resident 27 was interviewed. Resident 27 stated she was unable to remember the incident and refused to talk about it. Resident 19's record was reviewed. Resident 19 was admitted to the facility on April 19, 2019, with diagnoses which included Alzheimer's disease (memory disorder). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 7 of 28 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 09/19/2019 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 19's progress notes dated July 11, 2019, indicated, "...Pt. (patient) noted with Skin tear to left hand. pt. stating she was unsure how it happened but she and her roommate were fighting over the curtain..." Resident 27's record was reviewed. Resident 27 was admitted to the facility on September 21, 2018, with diagnoses which included essential hypertension (high blood pressure) and major depressive disorder (mood disorder). On September 18, 2019, at 2:28 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated on July 11, 2019, around lunch time, she came to answer Resident 19's call light. CNA 2 stated when she came into the room, Residents 19 and 27 were yelling at each other. CNA 2 stated Resident 27 said she wanted the curtain closed and Resident 19 was saying "nurse it hurts." CNA 2 stated she went to check Resident 19 and saw her hand was bleeding. CNA 2 stated she asked Resident 19 what happened and the resident pointed at Resident 27 and said "she did it, she hurt me." On September 18, 2019, at 3:38 p.m., the Administrator (ADM) was interviewed. The ADM stated she was aware of the incident with Residents 19 and 27 involving the curtain. The ADM stated the incident was not reported to CDPH. On September 19, 2019 at 11:09 a.m., CNA 2 stated she reported the incident to the licensed nurse and the Director of Nursing (DON) the same day the incident happened on july 11, 2019. The facility policy and procedure titled, "...Protection of Residents: Reducing the Threat of Abuse and Neglect, revised January FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 8 of 28 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 09/19/2019 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 21, 2019," indicated, "...Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made...to the administrator of the facility and to other officials (including the State Survey Agency and adult health protective services where the state law provides for jurisdiction in long-term care facilities)..."

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

F655 10/10/2019 §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 plan(i) Is developed within 48 hours of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 9 of 28 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 09/19/2019 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'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.) On September 6, 2019, at 4:01 p.m., Resident 55 was interviewed. Resident 55 stated she had not attended any care plan meeting. Resident 55's record was reviewed. Resident 55 was admitted to the facility on August 30, 2019, with diagnoses which included fracture (break in the continuity of the bone) of the right femur (broken long bone). Resident 55's History and Physical Examination dated September 1, 2019, indicated Resident 55 has the capacity to understand and make decisions. The Minimum Data Set (MDS - an assessment tool) dated September 6, 2019, indicated Resident 55's comprehensive care plan was completed on September 11, 2019. There was no documented evidence Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 10 of 28 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 09/19/2019 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 55 was provided with a written summary of the baseline care plan. On September 19, 2019, at 8:39 a.m., the Director of Nursing (DON) was interviewed. The DON stated residents were provided with a copy of the baseline care plan. The DON stated there is a form where resident signed acknowledging receipt of the baseline care plan. On September 19, 2019, at 9:34 a.m., the Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she could not find the documentation indicating Resident 55 was provided with a written summary of the baseline care plan. The policy and procedure titled, "Baseline Care Plan," dated April 29, 2019, was reviewed. The policy and procedure indicated, "To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed...A bseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident...Provide the resident and/or representative with copies of the baseline care plan..." Based on interview, and record review the facility failed, for two of 19 residents reviewed for baseline care plan (Residents 55 and 108), the following: 1) For Resident 108, the baseline care plan did not include instructions to address the resident's dietary and nutritional need. This failure placed Resident 108 at risk for not receiving an effective and person centered care to maintain optimal physical and mental wellbeing; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 11 of 28 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 09/19/2019 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 2) For Resident 55, the facility failed to provide a written summary of the baseline care plan to the resident and/or the resident's responsible party. This failure had the potential to result in the resident not being aware of the care and services he would receive while at the facility. Findings: 1.) Resident 108's record was reviewed. Resident 108 was admitted to the facility on September 11, 2019, with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness on one side of the body) following cerebral infarction (stroke) affecting left nondominant side (left arm and leg) and dysarthria (difficulty speaking). A review of the facility form titled, "HISTORY AND PHYSICAL EXAMINATIONS," dated September 13, 2019, indicated; "...This resident: has the capacity to understand and make decisions..." A review of the physician orders for September 12, 2019, indicated, "... Dietary - Diet No Added Salt (NAS) diet Puree texture, Nectar consistency, fortified diet." A review of the facility form titled, "Speech Therapy SLP (speech language pathology) Evaluation and Plan of Treatment, "indicated; "Certification Period: 9/12/2019 - 10/9/2019, Dysphagia (difficulty in swallowing) Therapy... Reason for Therapy... ST (speech therapy) services recommended to reduce the risk of aspiration..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 12 of 28 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 09/19/2019 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 review of Resident 108's baseline care plan dated September 13, 2019, did not address Resident 108's diet, diet precautions, and skilled instructions regarding feeding strategies. In an interview with the Director of Staff Development (DSD)on September 17, 2019, at 3:18 p.m., the DSD confirmed the baseline care plan did not address the diet or diet type. In an interview with the Director of Nursing (DON) on September 18, 2019, at 12:08 p.m., the DON stated "I think it (diet/nutrition) should be on there (baseline care plan)." In an interview with the Registered Dietician (RD) on September 18, 2019, at 12:14 p.m., the RD stated the base line care plan should address the diet and nutrition.

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

F679 10/10/2019 §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: CJRO11 Facility ID: CA240000098 If continuation sheet 13 of 28 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 09/19/2019 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 observation, interview, and record reivew, the facility failed to provide the preferred activity for one of one resident reviewed for activity care issues (Resident 18). This failure had the potential to affect Resident 18's physical, mental, and psychosocial wellbeing. Findings: Resident 18 was observed in bed. There was no music playing inside the resident's room and the television was turned off, as observed on multiple occasions: a. On September 16, 2019, at 10:15 a.m.; b. On September 17, 2019, at 9:39 a.m.; c. On September 17, 2019, at 2:40 p.m.; and d. On September 18, 2019, at 10:13 a.m. Resident 18's record was reviewed. Resident 18 was re-admitted to the facility on September 18, 2017, with diagnoses which included multiple sclerosis (disabling disease of the brain and the spinal cord). The Progress Notes titled, "Activity Participation Note," dated July 9, 2019, indicated, "...Resident is alert but is unable to verbally respond...functional mobility may impede his ability to join activities. Staff will continue to assist resident to join activities that offer sensory stimulation such as musical programs...and movie matinees..." The Care Plan dated July 20, 2019, indicated, "...Resident needs to engage in activity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 14 of 28 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 09/19/2019 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 programming to provide social stimulation for recreation participation...Interventions...Provide activities that are: Compatible with physical and mental capabilities; compatible with known interests and preferences..." The Annual Minimum Data Set (MDS - an assessment tool) dated October 17, 2018, indicated, "...How important is it to you to listen to music you like...Very important...How important is it to you to do things with groups of people?...Very important...How important is it to you to do your favorite activities...Very important..." The document "Individual Resident Daily Participation Record," for the month of September 2019, indicated, Resident 18 was not provided with music. On September 18, 2019, at 10:13 a.m., the Activity Assistant (AA) was interviewed. The AA stated she was familiar with Resident 18. The AA stated the resident (Resident 18) loved watching football games. The AA stated Resident 18 loves music. In a concurrent review of Resident 18's record, the AA verified Resident 18 was not provided with music. The AA stated Resident 18 should have been provided music since he likes music. On September 18, 2019, at 11:57 a.m., the Activity Director (AD) was interviewed. The AD stated she did activity assessments for the residents. The AD stated an assessment was done for each resident to provide an activity according to resident's preference. The policy and procedure titled, "Activity Evaluation," dated May 2, 2019, was reviewed. The policy and procedure indicated, "...The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 15 of 28 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 09/19/2019 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 facility must provide, based on comprehensive assessment and care plan and the preferences of each patient, an ongoing program to support patients in their choice of activities...Personcentered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to...preferred activities..."

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

F684 10/10/2019 § 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 interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice when: 1. For Resident 29, there was no physician notification of the constant potassium supplement refusals. In addition, there was no plan of care formulated to address the resident's constant refusal of medications. 2. For Resident 24, there was no assessment conducted when Resident 24 had multiple episodes of hypotension (low blood pressure). In addition, the physician was not notified of Resident 24's multiple episodes of hypotension. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 16 of 28 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 09/19/2019 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 These failures had the potential to cause a delay in treatment and care for Resident 29's low potassium levels and Resident 24's low blood pressure. Findings: 1. On September 19, 2019, Resident 29's record was reviewed. Resident 29 was admitted to the facility on February 7, 2019, with diagnoses which included localized edema (swelling), atherosclerotic heart disease (narrowing of the arteries), and major depressive disorder (mood disorder). The physician orders indicated the following: a. On April 20, 2019 (start date), "Potassium Chloride ER tablet Extended Release 20 MEQ (milliequivalent) Give 2 tablet by mouth one time a day for supplement (40 MEQ)..." ; and b. On April 23, 2019 (start date), "Furosemide (water pill) 40 MG (milligrams) TAB (tablet) Give 1 tablet by mouth one time a day for edema..." The laboratory result dated June 8, 2019, indicated,"Potassium 3.3 L (normal range: 3.55.0). The Medication Administration Record (MAR) for August and September 2019, indicated Resident 29 refused Potassium supplement on August 13, 18, 20, 21, 25, 2019, and September 2, 7, 8, 10, and 18, 2019. On September 19, 2019, at 2:28 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated there was no documented evidence an intervention was developed to address Resident 29's multiple refusal of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 17 of 28 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 09/19/2019 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 medications. The DON further stated there were no documented evidence the physician was informed of Resident 29's refusal of the potassium supplement. On September 19, 2019, at 3:38 p.m., the Attending Physician (AP) was interviewed. The AP stated he was not informed that the resident had refused potassium multiple times. The AP stated Resident 29 had an order for potassium as a supplement for the use of Lasix (furosemide). The AP further stated the facility was supposed to inform him every time the resident refused the medication. According to Lexicomp, Furosemide contains the following US Boxed Warning: "...If given in excessive amounts, furosemide...therapy should not be initiated unless... potassium, are normalized. Risk of hypokalemia (low potassium levels) may be increased...predispose a patient to serious cardiac arrhythmias (irregular heart rate)..." The facility's policy and procedure titled, "Medication Administration General Guidelines (revised September 2018)," indicated, "...If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time...If two consecutive doses of a vital medication are withheld or refused, the physician is notified..." 2. On September 16, 2019, at 3: 35 p.m., Resident 24 was observed in bed with the Responsible Party (RP) at the bedside. In a concurrent interview with the RP, the RP stated Resident 24 did not have the energy these past few days. The RP stated the resident sleeps even when she has company. Resident 24's record was reviewed. Resident 24 was admitted to the facility on December 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 18 of 28 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 09/19/2019 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 2016, with diagnoses which included heart failure and hypertension (high blood pressure). The "Order Summary Report," for the month of September 2019, indicated Resident 24 has the following medications: a. Furosemide (water pill) 40 milligram (mg) two times a day and to hold medication for systolic blood pressure below 90; b. Metoprolol (used to treat high blood pressure) 25 mg every 12 hours; and c. Bumetanide (used to treat swelling) 1 mg two times a day. The Medication Administration Record (MAR) indicated the following: a. For the month of August, Furosemide was not administered on August 3, 11, 17, 21, 27, 28, 30, 2019, and Metoprolol was not administered on August 17, 21, 27, 28, and 30, 2019. b. For the month of September, Furosemide was not administered on September 3, 6, 7, 11, 12, 15, 2019, and Metoprolol was not administered on September 2, 3, 10, and 11, 2019. Further review of the MAR, indicated Furosemide and Metoprolol were not administered due to Resident 24's systolic blood pressure (first number recorded) which ranges from 72 to 98 (normal systolic blood pressure between 90 to 120). There was no documentation the physician was notified of Resident 24's multiple episodes of low blood pressure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 19 of 28 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 09/19/2019 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 There was no documentation indicating Resident 24 was assessed with regards to the multiple episodes of low blood pressure. On September 18, 2019, at 2:13 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified Furosemide and Metoprolol were not administered to Resident 24 multiple times. LVN 2 stated Resident 24's blood pressure was outside the parameter (below 90) and the medications were put on hold as indicated in the physician order. LVN 2 stated if licensed nurses were consistently holding the medications, the physician should be notified and if the blood pressure was not within the baseline, it would be a change of condition. On September 18, 2019, at 3:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated if the blood pressure was "way below" the parameter, the licensed nurse would have to call the physician. The DON stated, Resident 24's low blood pressure should have been reported to the doctor. The DON stated she could not find documentation indicating Resident 24's low blood pressure was reported to the physician. In addition, she stated there was no documentation which indicated an evaluation or assessment was done for Resident 24's low blood pressure. The policy and procedure titled, "Changes in Resident's Condition or Status," dated April 15, 2019, was reviewed. The policy and procedure indicated, "...This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status...A facility must immediately inform the resident; consult with the resident's physician...when there is...A need to alter treatment significantly (that is, a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 20 of 28 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 09/19/2019 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 need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) ..."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 10/10/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled properly when unlabeled tablets were observed in a Loratadine (medication for allergy symptoms) box. This failure had the potential to result for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 21 of 28 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 09/19/2019 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 licensed staff to administer the wrong medications to the residents. Findings: On September 17, 2019, at 3:56 p.m., an inspection of Medication Cart 400 was conducted with Licensed Vocational Nurse (LVN) 4. Six unidentified round, white tablets were observed inside a Loratadine box. In a concurrent interview with LVN 4, LVN 4 stated she could not identify the six round pills. LVN 4 stated the unidentified pills should not be in the Loratadine box. LVN 4 stated those identified pills could be mistaken for Loratadine and could be administered to the residents. The policy and procedure titled, "Storage of Medication," dated September 2018, was reviewed. The policy and procedure indicated, "Medications and biologicals are stored properly...to maintain their integrity and to support safe effective drug administration...Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 10/10/2019 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 22 of 28 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 09/19/2019 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 (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 record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when the kitchen ice machine was noted to have a soft gray and light brownish substance on the edge of the ice chute (inclined channel) located in the inner upper portion of the ice bin. In addition, the ice machine was not sanitized according to the manufacturer's instructions. This failure had the potential to result in cross contamination and food borne illness in a highly susceptible resident population of 68 residents on oral diets out of a universe of 73 facility census. Findings: On September 18, 2019, at 10:53 a.m., an observation of the facility ice machine was conducted with the Dietary Supervisor (DS). A clean white napkin was used to wipe the upper edge of the ice bin chute. A smear of soft grayish and light brownish substance was observed on the napkin. In a concurrent interview with the DS, she confirmed the white napkin had a smear of grayish and brownish substance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 23 of 28 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 09/19/2019 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 On September 19, 2019, at 8:45 a.m., the Maintenance Director (MD) was interviewed. He stated he cleans the ice bin once a month, by pouring hot water into the ice bin to melt the ice, and cleans and wipes down the inside of the bin with 1:100 solution of chlorine bleach. A review of the facility maintenance log indicated the following: a. On June 30, 2019, "Task Description: Check filters (if present), clean coils, sanitize interior, delime as necessary,"; b. On July 31, 2019, "Task Description: Visual check on ice machine."; and c. On August 31, 2019, "Task Description: Visual Check on ice machine." The document did not indicate whether the ice machine was cleaned in July and August 2019. A review of the ice machine manufacturer's user manual dated April 2016, indicated, "...Cleaning, Sanitation and Maintenance ...It is the User's responsibility keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained... ...Sanitize the ice storage bin as frequently as local health codes require, and every time the ice machine is cleaned and sanitized. ...Ice Storage Bin 1. Remove and discard all ice. 2. Mix a solution of 7 ounces Scotsman Clear 1 ice machine scale remover to 84 ounces of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 24 of 28 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 09/19/2019 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 potable water and wash all interior surfaces of the ice storage bin to remove any mineral scale build up. Pour excess cleaner solution into the bin's drain. 3. Mix a solution of sanitizer and thoroughly wash all interior surfaces of the ice storage bin. Pour excess sanitizer solution into the bin's drain..." A review of the Food Code 2017, indicated, "Chapter 4-6 Cleaning of Equipment and Utensils...(A) EQUIPMENT FOOD-CONTACT SURFACES AND UTENSILS shall be clean to sight and touch...IN EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers...(a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 10/10/2019 §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, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 25 of 28 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 09/19/2019 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 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 (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 26 of 28 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 09/19/2019 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 §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, and record review, the facility failed to follow infection control measures for one of two residents reviewed for infection (Resident 409) when one staff member was observed entering and exiting an isolation room without following the proper infection control precautions. This failure had the potential to result in spreading infection to a vulnerable resident population. Findings: On September 16, 2019, at 11:45 a.m., the Maintenance Director (MD) was observed entering Resident 409's room and handling the TV remote. Resident 409's room has an isolation cart by the resident's door. The MD did not perform hand hygiene when entering or exiting the room, and did not wear appropriate PPE (Personal Protective Equipment- gown, face mask, and gloves) while in the room of Resident 409. On September 16, 2019, at 11:47 a.m., during an interview with the MD, the MD stated he should have worn appropriate PPE while in Resident 409's room, and should have performed hand hygiene when entering and exiting Resident 409's room. Resident 409's record was reviewed. Resident 409 was admitted to the facility on September FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 27 of 28 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 09/19/2019 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 9, 2019, with diagnoses that included Urinary Tract Infection (UTI). The physician's order dated September 16, 2019, indicated, "Contact isolation precautions for VRE (Vancomycin Resistant Enterococcus a hard to treat bacterial infection) UTI every shift..." A review of the facility policy titled, "Transmission-based Precautions and Isolation Procedures," reviewed July 25, 2019, indicated, "...When a resident is placed on transmission-based precautions, the staff should implement the following...Don (put on) appropriate PPE upon entry into the environment (e.g., room or cubicle) of resident on transmission-based precautions (e.g., contact precautions);...Contact precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-toperson) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering (before making contact with the resident or resident's environment) the room or cubicle. Prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is performed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CJRO11 Facility ID: CA240000098 If continuation sheet 28 of 28