Health inspection·January 24, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool), for three of three residents reviewed for resident assessment (Resident 5, 18, and 27) when: Residents Affected - Some 1. One of Resident 5's active diagnoses was not coded. 2. Resident 18's Clopidogrel, an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as an anticoagulant (medication that prevents the formation of blood clots) in Resident 18's MDS, dated [DATE]. 3. Resident 27's Clopidogrel, an antiplatelet was coded as anticoagulant in Resident 27's MDS, dated [DATE]. These failures had the potential to result in unmet care needs for Resident 5, 18, and 27 which can negatively affect their health and safety. Findings: 1. A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses included depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 5's Physician Order Sheet, dated November 5, 2021, indicated Resident 5 was prescribed Celexa (anti-depressant medication) 10 milligram (mg- unit of measurement) by mouth once a day for depression. A concurrent interview and review of Resident 5's clinical record was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:10 AM. The DON reviewed Resident 5's MDS dated [DATE] and stated Resident 5's depression was not coded under Section I Active Diagnoses. He stated the MDS-LVN should have coded it. He stated, providing accurate assessment of the resident's status will help different health care disiplines be able to provide care dependent upon resident's status and needs. During a concurrent interview and record review with the DON, on January 20, 2020 at 9:39 AM, the Page 1 of 13 555025 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some DON reviewed Centers for Medicare and Medicaid Services' (CMS) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, under Section I, page I-1, which indicated Steps for Assessment 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available . Include the primary medical condition coded in this item in Section I: Active Diagnoses in the last 7 days . He stated the manual was not followed. 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), cerebral infarction (damage to the brain from reduced/interrupted blood supply), and hypertension (elevated blood pressure). A review of Resident 18's Order Summary Report, dated January 19, 2022, indicated Resident 18 was prescribed, Clopidogrel 75 milligram (mg- unit of measurement) by mouth once a day for atherosclerosis (deposition of fatty materials) of the aorta (blood vessel) starting September 29, 2020. A concurrent interview and record review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:11 PM. Section N indicated Resident 18 received anticoagulant for seven days. He stated Resident 18 was taking Clopidogrel but should not be coded as anticoagulant. He further stated he coded it incorrectly. 3. During a review of Resident 27's clinical record, the face sheet indicated Resident 27 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a disease that results in high blood sugar), cerebral infarction, and hypertension. A review of Resident 27's Order Summary Report, dated January 19, 2022, indicated Resident 27 was prescribed by her physician Clopidogrel 75 milligram (mg- unit of measurement) by mouth once a day for stroke prevention starting May 8, 2021. A concurrent interview and record review of Resident 27's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:19 PM. Section N indicated Resident 27 received anticoagulant for 7 days. He stated Resident 27 was also taking Clopidogrel and made a mistake in coding these two assessments for Resident 18 and 27. A review of CMS's (Centers for Medicare and Medical Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, revised October 2019, N041E, Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), indicated Record the number of days an anticoagulant medication was received at any time during the 7-day look back period (or since admission, entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyrimadole, or clopidogrel here. 555025 Page 2 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three of three residents reviewed for PASRR (Residents 9, 18, and 33). These failures had the potential for Residents 9, 18, and 33 not to receive the care and services most appropriate for their needs. Findings: 1. During a review of Resident 9's clinical record, the face sheet (contains demographic and medical information) indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), schizophrenia (a mental disorder which affects how a person thinks, feels and acts), and bipolar disorder (disorder associated with episodes of mood swings). A concurrent interview and record review of Resident 9's MDS dated [DATE] was conducted with the MDS Coordinator (MDS-LVN) on January 20, 2022, at 2:05 PM. He stated Resident 9's SCSA was done because of a decline in Activities of Daily Living (ADLs). During an interview and review of Resident 9's clinical record with MDS-LVN, he stated Resident 9's most current PASRR was completed on January 12, 2021, and he was not re-evaluated for a new PASRR after the completion of this SCSA. 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), major depressive disorder (mental disorder characterized by depressed mood or loss of interest in activities), and schizoaffective disorder (mental illness that affects thoughts, mood and behavior). A concurrent interview and review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 1:54 PM. He stated Resident 18's SCSA was done because of a decline in ADLs and multiple elevated blood sugar levels and blood pressure readings. He further stated the latest PASSR on file was completed on September 28, 2020, and her PASRR was also not re-evaluated after the completion of the SCSA. 3. During a review of Resident 33's clinical record, the face sheet indicated Resident 33 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and impulse disorder (a condition in which a person has trouble controlling emotions and behaviors). 555025 Page 3 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0646 Level of Harm - Minimal harm or potential for actual harm A concurrent interview and record review of Resident 33's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 2:00 PM. He stated Resident 33's SCSA was done because of a change in the hospice (providing care for the sick and terminally ill) provider. He further stated the latest PASSR on file was completed on June 02, 2021, and her PASRR was not re-evaluated as well after the completion of the SCSA. Residents Affected - Some During a follow up interview with MDS-LVN, on January 20, 2022 at 2:15 PM, he stated he did not know that PASRR had to be done after SCSA and the facility did not follow the PASRR Guidelines for Residents 9, 18 and 33. A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening, dated May 2018, indicated Select Resident Review (RR) (Status Change) if the individual has already been admitted to your facility and you are updating the existing PASRR on file for either of the following reasons .B. There is a significant change in an individual's physical or mental condition. According to the MDS 3.0 manual a significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3. Requires interdisciplinary review and/or revision of the care plan. 555025 Page 4 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for one resident reviewed for mood/behavior (Resident 5) when a care plan was not initiated for Resident 5's diagnosis of depression and use of anti-depressant medication in accordance with the facility's policy and procedure. This failure had the potential to cause inadequate management of Resident 5's medical condition, affecting Resident 5's health and safety. Findings: A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses included depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 5's Physician Order Sheet, dated November 5, 2021, indicated Resident 5 was prescribed Celexa (anti-depressant medication) 10 milligram (mg- unit of measurement) by mouth once a day for depression. A concurrent interview and review of Resident 5's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 8:59 AM. The ADON was unable to find documentation of a care plan addressing Resident 5's diagnosis of depression and her use of anti-depressant medication. She stated it is important that care plan is developed so the facility can identify, set realistic goals, implement, and re-evaluate the needs of the resident. A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:44 AM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed. 555025 Page 5 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised in a timely manner when there was a change in anti-anxiety medication for one of five residents (Resident 8). This failure had the potential to result in inadequate treatment and management of resident's overall clinical condition. Findings: During a concurrent observation and interview with Resident 8, on January 19, 2022 at 8:22 AM, in the dining room, Resident 8 was sitting up on her wheelchair. She was alert and oriented to self. She was calm and not in any acute distress. She stated she was fine. A review of Resident 8's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 8's Physician Order Sheet, dated December 6, 2021, indicated Resident 8 was prescribed Buspar (anti-anxiety medication) 10 milligram (mg- unit of measurement) by mouth every eight hours for anxiety. A concurrent interview and review of Resident 8's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 2:05 PM. The ADON reviewed Resident 8's Care Plan for Anti-Anxiety medications, revised August 5, 2021, and stated it was for her use of Ativan (anti-anxiety medication). She further stated it was not revised after her anti-anxiety medication was changed to Buspar (more than a month ago). A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 2:20 PM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed. He further stated the care plan should have been revised so the facility can provide the appropriate care for their residents current medical condition. 555025 Page 6 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure an opened emergency drug kit (eKIT) containing Schedule II (two) controlled substances (drugs stored and handled with additional restrictions to prevent abuse, addictions, and unauthorized use) in the Medication/Supply Room was replaced in a timely manner in accordance with the facility's policy. This failure had the potential to result in increased risk of drug diversion (illegal distribution) and/or medication availability issues for a universe of 43 residents. Findings: During a concurrent observation and interview on January 18, 2022, at 9:43 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). An opened eKIT was observed with a quantity of three (3) tablets of Norco (Schedule II combination of two drugs - hydrocodone and acetaminophen) 5 milligrams (mg - a unit of measurement for dose)/325 mg. The list of contents indicated the eKIT should contain a quantity of four (4) tablets of Norco 5 mg/325 mg. The Emergency Drug Kit Slip in the opened eKIT indicated one tablet of Norco 5 mg/325 mg was removed on January 13, 2022 at 7 PM (time period appropriately 110 hours from the time of opening to the time of discovery). During a concurrent interview, the ADON/DSD acknowledged the eKIT slip indicated the eKIT was opened on January 13, 2022, at 7 PM, three (3) tablets of Norco 5 mg/325 mg were observed, and the list of contents indicated four (4) tablets of Norco 5/335 mg. The ADON/DSD stated the eKIT should have been replaced. During a concurrent interview and record review on January 18, 2022, at 10:25 AM, the policy was reviewed with the Director of Nursing (DON) and the ADON/DSD. The policy titled Policy and Procedure Manual - Section M. EMERGENCY KIT (E-KIT) USE reviewed October 1, 2021, indicated The pharmacy is to be notified as soon as possible that the E-Kit has been opened so it can be replaced within 72 hours. The DON and the ADON/DSD acknowledged the policy was not followed. 555025 Page 7 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Two medication errors for Resident 3 occurred out of a total 34 medication pass opportunities. The medication administration error rate was 5.88%. Residents Affected - Few This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety. Findings: During a concurrent observation and interview on January 20, 2022, from 8:41 to 8:56 AM, a medication pass observation for Resident 3 was conducted with Licensed Vocational Nurse 1 (LVN 1). During a concurrent observation and interview on January 20, 2022, at 8:43 AM, LVN 1 was preparing Resident 3's medications which are as follows: 1. One tablet of Abilify (antipsychotic) 20 mg (milligrams - a unit of measurement for dose) and one tablet of Abilify 5 mg for a total dose of Abilify 25 mg 2. One tablet of chewable aspirin (drug to prevent heart attack and stroke) 81 mg 3. One tablet of Buspirone (drug to treat anxiety) 5 mg 4. One tablet of Calcium (mineral supplement) 600 mg combined with Vitamin D 3 10 micrograms (mcg- a unit of measurement for dose) (400 International Units- IU- a unit of measurement for dose) 5. One tablet of docusate sodium (stool softener) 100 mg 6. One tablet of magnesium oxide (mineral supplement) 400 mg 7. Two tablets of sennosides (drug to treat constipation) 8.6 mg 8. One tablet of lorazepam (drug to treat anxiety) 1 mg. During a concurrent observation and interview on January 20, 2022, at 8:53 AM with LVN 1, ten pills were observed. LVN 1 stated she counted ten pills. The multivitamin/mineral tablet was not observed during the count. During an observation on January 20, 2022, at 8:54 AM, LVN 1 was observed administering 10 pills to Resident 3. During an observation on January 20, 2022, at 8:56 AM, LVN 1 stated she was done administering all the scheduled medications for Resident 3. During a concurrent observation, interview, and record review on January 20, 2022, at 9:42 AM, LVN 1 inspected the bottle of Calcium 600 mg/Vitamin D 3 10 mcg (400 IU) and compared it to the prescriber's order for Calcium-Vitamin D Tablet 600-200 MG-UNIT Give 1 tablet by mouth one time a day for supplement. LVN 1 acknowledged the prescriber's order for Resident 3, and stated she administered a 555025 Page 8 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0759 different dose of Vitamin D than what was ordered. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on January 20, 2022, at 9:43 AM, LVN 1 reviewed the prescriber's order for Multi Vitamins/Mineral Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement. LVN 1 acknowledged the prescriber's order for Resident 3. Residents Affected - Few During a review of the facility's Medication Administration Schedule, the document indicated the medication administration time for Once a Day (OD) - 0900. During a concurrent interview and record review on January 21, 2022, at 8:45 AM, the policy was reviewed with the Director of Nursing (DON). The policy titled Policy and Procedures for Med Pass -VII. PREPARATION FOR MEDICATION ADMINISTRATION . MEDICATION ADMINISTRATION - GENERAL GUIDELINES reviewed October 1, 2021, indicated Medications are administered in accordance with the written orders of the attending physician. The DON acknowledged the policy. 555025 Page 9 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen, when there where dead insects and cobwebs under the shelves in the dry storage and behind the stove. Residents Affected - Many This had the potential to contaminate the food and food contact surfaces in a highly susceptible population of 43 residents. Findings: During an observation and interview on January 18, 2022, at 8:05 AM, under the shelf in the dry storage room on the east wall, there was cobwebs. Under the shelf on the west wall, there were dead insects on the floor under the shelf. The Dietary Supervisor stated the floors should be clean. During an observation on January 18, 2022, at 8:16 AM, there were cobwebs behind the stove and some debris on the floor under the stove. During a review of the FDA Federal Food Code 2017, 6-501.111 Controlling Pests, states: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. And 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests, states Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. 555025 Page 10 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe infection control program when outdated supplies were available for resident use in the Medication/Supply Room. Residents Affected - Few This failure had the potential for a universe of 43 residents to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact wound healing. Findings: During an observation and concurrent interview on [DATE], at 9:50 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). 1. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the First Aid Kit in the Medication/Supply Room were expired. a. Three (3) Roller Gauze Bandages (used to secure wound dressings) supplies were observed expired: 2017 11 01 [supply expired [DATE]], 2018 01 03 [supply expired [DATE]], and 2018 01 03 [supply expired [DATE]]. The supplies were approximately 48 months outdated. b. Four (4) Sterile (germ-free) Non-Woven Sponges (used for wound cleaning) supplies were observed expired: 2018 03 15 [supply expired [DATE]], 2018 03 15 [supply expired [DATE]], 2017 12 10 [supply expired [DATE]], and 2017 12 10 [supply expired [DATE]]. The supplies were approximately 48 months outdated. c. One (1) Combine Pad (used to absorb heavy draining wounds) was observed expired 2018 03 01 [supply expired [DATE]]. The supplies were approximately 46 months outdated. d. One (1) Eye Pad (used to cover and protect the eye wound) was observed expired 2017 12 [supply expired [DATE]]. The supplies were approximately 48 months outdated. 2. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the Medication/Supply Room were expired: multiple individual packets in the five (5) cartons of Universal Removal Wipes (used to clean and prepare the resident's skin) indicated an imprint of [DATE] [supply expired [DATE]. The supplies were approximately 17 months outdated. During an interview with the Director of Nursing (DON) on [DATE], at 3:10 PM, the DON stated the facility had no policies regarding outdated supplies when facility see expired supplies the staff removes it from stock. During an interview with the Infection Preventionist (IP) on [DATE], at 8:08 AM, the IP acknowledged the Infection Preventionist is involved in training staff. The IP stated that if licensed nurses found outdated medical supplies, such as sterile bandages or sponges, she would tell them to discard the supply because don't know the effectiveness or if safe to use. 555025 Page 11 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for 19 of 21 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of these residents in their rooms. Findings: During an entrance conference interview with the Director of Nursing (DON), on January 18, 2022 at 8:19 AM, the DON stated the facility had resident rooms which had less than the required square footage (80 sq. ft. of livable space). During an environmental tour with the Maintenance Supervisor (MS), on January 19, 2022 at 9:57 AM, 19 of the 21 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: room [ROOM NUMBER] (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (4 beds) measured: 292.8 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 146.4 sq. ft. (73.2 sq. ft. per resident) room [ROOM NUMBER] (3 beds) measured: 282 sq. ft. (94 sq. ft. per resident) room [ROOM NUMBER] (3 beds) measured: 258 sq. ft. (86 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 150 sq. ft. (75 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 150 sq. ft. (75 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) 555025 Page 12 of 13 555025 01/24/2022 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0912 room [ROOM NUMBER] (2 beds) measured: 151.28 sq. ft. (75.64 sq. ft. per resident) Level of Harm - Potential for minimal harm room [ROOM NUMBER] (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) Residents Affected - Some room [ROOM NUMBER] (2 beds) measured: 152.4 sq. ft. (76.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 155 sq. ft. (77.5 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 152.4 sq. ft. (76.2 sq. ft. per resident) room [ROOM NUMBER] (2 beds) measured: 139.7 sq. ft. (69.85 sq. ft. per resident) These rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. During an interview with the Administrator, on January 20, 2022 at 9:15 AM, he confirmed the measurements for 21 of the 21 residents' rooms and 19 of these did not meet the required 80 square feet per resident requirement. The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency. 555025 Page 13 of 13