Health inspection·January 30, 2020

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 observation, interview, and record review, the facility failed to develop a care plan for one of three residents (78), reviewed for hearing needs. As a result, there was a potential for Resident 78 to experience decreased socialization and isolation. Findings: On 1/27/20 at 11:16 A.M., an observation was conducted with Resident 78, in her room. Resident 78 did not communicate when asked questions and repeatedly pointed to her left ear. On 1/29/20 at 7:52 A.M., an interview was conducted with CNA 14. CNA 14 stated Resident 78 spoke some English and pointed at things in order to make her needs known. CNA 14 stated he was unaware if Resident 78 had any hearing issues and he had not noticed any hearing assistive devices in her room. On 1/29/20 at 8:02 A.M., an interview and record review was conducted with LN 13, regarding Resident 78. LN 13 stated Resident 78 could not hear very well and she did not have hearing aids. LN 13 could not locate a plan of care for Resident 78's impaired hearing. LN 13 stated there should have been a hearing care plan, so staff would know how to better communicate with Resident 78. On 1/29/20 at 8:49 A.M., an interview was conducted with the AD. The AD stated Resident 78 did not attend group activities, because she spoke limited English and could not hear very well. The AD stated Resident 78's family provided her with an ear amplifier to assist with hearing, which Resident 78 used often. On 1/29/20 at 9:06 A.M., an interview and record review was conducted with the MDSN. The MDSN stated Resident 78's last annual MDS (an assessment tool), dated 11/30/19, indicated the resident had moderate hearing impairment and used an amplifier as an assistive device. On 1/29/20 at 9:33 A.M., an interview and record review was conducted with SSW 1. SSW 1 stated Resident 78 was able to express her basic needs in English. SSW 1 stated Resident 78 was hard of hearing and used no hearing aids, because her family declined those auxiliary services. SSW 1 reviewed Resident 78's last care conference meeting held on 12/12/19. The care conference meeting did not address Resident 78's hearing needs. SSW 1 could not locate a hearing impaired care plan for Resident 78. SSW 1 stated if Resident 78's hearing issues had been discussed in the care conference meeting, a care plan for hearing impairment would have been developed, so staff could be informed of the resident's needs. SSW 1 reviewed Resident 78's last quarterly social service assessment dated [DATE]. The assessment indicated Resident 78's hearing needs were discussed with the family and they declined exploring any hearing assistive devices. SSW 1 stated this information should have been shared with other staff members and a care plan developed, so everyone was informed of the resident's needs and deficits. On 1/29/20 at 11:03 A.M., an interview was conducted with the NS. The NS stated Resident 78 should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete have a care plan for hearing impairment and her amplifier should have been listed on the care plan interventions. The NS stated care plans were important for staff communication, and in order to provide consistency of care. According to the facility's policy, titled Care Planning and Assessment, dated October 2018, . D. The care plan is reviewed and updated regularly by members of the IDT or when a conflict of change occurs involving care delivery . F. The plan of care will be kept current during the patients stay . Event ID: Facility ID: 555301 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 57 was admitted to the facility on [DATE] per the facility's Patient Information sheet. Per the IDT meeting notes dated 1/17/20, Resident 57 was diagnosed with multisystem organ failure which included respiratory failure with ventilator dependence. Per Resident 57's Physician Order sheet, dated 1/9/20, the NP ordered, Ativan .25 mg q 6 hrs prn, pulling at life sustaining tubes, indefinitely. On 1/29/20 at 8:45 A.M., the NP was interviewed. The NP stated, she was told by the PC if she wrote an order for Ativan indefinitely, it was adequate and no review was required. The NP stated she was unaware there was a 14 day review, or evaluation necessary to continue Ativan. During a concurrent review of the MAR with the DON on 1/29/20 at 11 A.M., there were 19 doses of Ativan administered during the month of January 2020 for Resident 57. On 1/29/20 at 11:20 A.M., the PC was interviewed in person with the DON. The PC manager joined the interview on speaker phone. The Ativan order and administration was reviewed, for Resident 57. The Ativan was administered to Resident 57 past the 14 day limit without a provider evaluation or any documentation in regards to the need for continued use. The PC stated, The 14 day rule fits with Psychotropic use, normally the initial dose should be 14 days. If the resident was able to go to a routine dose we follow the provider order. In some cases, such as Resident 57, routine may be too much. The PC manager stated, It is a lot to evaluate residents every 14 days, however routine might compromise quality of life. The PC manager further stated, If the condition (diagnosis) does not change, a patient/resident should be on the medication indefinitely, the subacute residents have a chronic illness. If there is a chronic condition, nothing is going to change. The PC manager also stated, the regulation was not meant to include all patients/residents and they (residents) should not need to be evaluated every 14 days. During the QAPI review on 1/30/20 at 9:35 A.M., MD 17 discussed Ativan use. MD 17 stated, they (the facility) tried to reduce medication by GDR (Gradual Dose Reduction), but he wanted to continue to allow residents to improve to their optimal level. MD 17 stated the providers were expected to document the use of Ativan every 14 days, but had not been documenting the need consistently. Per the facility's policy and procedure titled, Medication Monitoring Medication Management, dated, 11/17, .Based on a comprehensive assessment of a resident, the facility must insure: .PRN orders for psychotropic drugs are limited to 14 days. Exception: if the attending physician or prescribing practioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record. Based on interview and record review, the facility failed to review, evaluate and document Ativan (a medication to treat anxiety) prn (as needed) in the 14 day time frame for continued usage for three of 13 residents reviewed for psychotropic (mind altering) medications (37,54,57). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 This failure had the potential for residents to receive unnecessary medication. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Resident 37 was admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage caused by multiple strokes) and depressive disorder (depressed mood) per the facility's Patient Information sheet. A review of Resident 37's medical record indicated a physician's order, dated 12/5/19, . Ativan 0.5 mg PO (by mouth) q (every) 6 hours prn for anxiety x 2 months until 2/5/20 . An interview and record review was conducted with LN 6 on 1/30/20 at 10:01 A.M. LN 6 stated that Resident 37 had episodes of anxiety and had received Ativan 0.5 mg 8 times between 12/5/19 and 1/30/20 per the eMar. An interview was conducted on 1/30/20, at 10:12 A.M. with MD 17. MD 17 stated, The medical staff are aware of the 14 day review, we need to do 14 day reviews and document rationale, indication and duration for the PRN medications in the medical record. An interview was conducted via telephone on 1/30/20, at 12:52 P.M., with the PC. The PC stated, The use of prn medication orders with the timeframe limit of 14 day review will need to be done. A review of the facility's policy, dated 11/2017, titled, Medication Monitoring Medication Management, indicated, . based on a comprehensive assessment of a resident, the facility must insure: PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . 2. Resident 54 was admitted to the facility on [DATE], with diagnoses which included Amyotrophic Lateral Sclerosis (ALS a deteriorating neuro-muscular disease that causes muscle weakness, paralysis, respiratory failure) per the facility's History & Physical. Resident 54 was observed on 1/28/20 at 9:24 A.M., sitting up in bed awake, with eyes open and tracking movement with his eyes. CNA 16 entered Resident 54's room and Resident 54 communicated with CNA 16 by blinking while using an alphabet and picture board. CNA16 stated that Resident 54 was very alert and was able to make his needs known via the alphabet and picture board. On 1/29/20 a record review, was conducted for Resident 54; The Physician Order dated 11/28/18, indicated, Ativan 1mg tablet via G-tube as needed every four (4) hours for anxiety as evidenced by shortness of breath. The order failed to include a time-frame limit of 14 days. Resident 54's MAR was reviewed from 1/1/20 to 1/29/20. The MAR indicated Resident 54 received 40 doses of Ativan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview and record review was conducted on 1/30/20, at 12:39 P.M., with the DON. The Ativan order was jointly reviewed and the DON stated, Ativan did not have a timeframe limit documented. An interview was conducted on 1/30/20, at 10:12 A.M., with MD 17. MD 17 stated, the medical staff were aware of the 14 day Ativan review. MD 17 stated all reviews should have a documented rational for indication and duration of PRN Ativan use in the medical records. Per the facility's policy titled, Medication Monitoring Medication Management, dated 11/17, .Based on a comprehensive assessment of a resident, the facility must insure: PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor one of two residents meal preferences for a cola beverage (70). This failure had the potential to decrease fluid intake by not honoring resident's preferences. Findings: Resident 70 was admitted to the facility on [DATE] with diagnoses that included abdominal pain per the facility's Patient Information sheet. An observation was conducted in the facility's dining room on 1/27/20 at 12 P.M. Resident 70's tray had an 8 ounce can of Sprite ( a citrus-flavored soda). Resident 70's meal ticket indicated a request for Coke (a cola-flavored beverage). A concurrent interview and review of Resident 70's lunch ticket was conducted on 1/28/20 at 1:36 P.M. with the DOO/FSN and the FSN Manager. The DOO/FSN stated, He (Resident 70) requested coke, but was served Sprite yesterday (1/27/20). We ran out of coke, because our stock levels were short, and gave Sprite, we should have told the resident; it was a preference issue. A review of the facility's policy, dated 12/11/19, titled, Menu Selections-Food Preference indicated, .E. Villa Pom 1 .preferred food items will be honored with regard to individual preferences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the menu related to Tuscan vegetables and 2% milk. Residents Affected - Few This failure had the potential to not meet the nutritional needs of residents. Findings: During a dining observations in the facility's dining room on 1/27/20 at 12 P.M., and 1/28/20 at 8:20 A.M., the following were noted: 1. Resident 7 received green beans instead of the Tuscan vegetables that were selected on the luncheon menu; 2. All residents who were supposed to receive 2% milk for breakfast received 1% milk. 1. An interview was conducted with Resident 7 on 1/27/20 at 12:15 P.M. Resident 70 stated, Hey, where are the Tuscan vegetables? Everyone else has them! A review of Resident 7's meal ticket indicated that Tuscan vegetables were selected by Resident 7. An interview and menu review was conducted on 1/28/20 at 1:36 P.M., with the DOO/FNS and the FNS Manager. Resident 7's lunch ticket indicated that he was on a dysphagia chopped diet and that Tuscan vegetables were a choice on the select menu. A review of the facility's dysphagia chopped menu indicated that chopped green beans were the vegetable to be served for dysphagia diets. The DOO/FNS stated, The menu ticket had been printed wrong and the resident was not informed of this, he should have been. 2. Residents who were supposed to receive 2% milk received 1% milk instead. On their breakfast trays, there was a card indicating that 1% milk was substituted for 2% milk because the facility ran out of 2% milk. An interview and menu review was conducted on 1/28/20 at 1:36 P.M., with the DOO/FNS and the FNS Manager. The DOO/FNS and the FNS Manager stated that the stock level for 2% milk was too low and the substitution of 1% milk was not appropriate. A review of the facility's policy, dated 12/11/19, titled, Menu Selections-Food Preferences, indicated, .III. Standard of Practice .to review for accuracy resident menu selections .to ensure that the nutritional needs are meet and/or menu substitutions are appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villas at Poway 15615 Pomerado Rd Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 remove expired food from one of three refrigerators, and there was no process in place to determine freshness of produce. Residents Affected - Few This failure had the potential to expose residents to foodborne illness. Findings: A tour of the facility's kitchen was conducted on 1/27/20 at 8 A.M., with the FNS Manager. In one refrigerator, there were 1/2 gallons of 2% milk (x 2) that had expiration dates of 1/26/20. The FNS Manager stated, Those are expired, they should not be in here. In addition, there were 4 boxes of portobello mushrooms, five pounds each, in the refrigerator. There was no use by date on the boxes. The mushrooms were inspected and found to be either dried out or covered with a wet, opaque substance. The FNS Manager stated that the mushrooms did not look fresh. The FNS Manager stated, Fresh produce doesn't have a use by date, we look at it to see if it is fresh. An interview was conducted with the DHR on 1/29/20 at 9:47 A.M. The DHR stated, Just looking at produce to see if it is fresh is subjective; a more specific policy is needed. A group interview was conducted on 1/30/20 at 10:40 A.M., with the DON, RD, DHR, FNS Manager, and the FNS supervisor. The RD and DON stated, expired food should not be in the refrigerator. The DHR stated, Just looking at produce is subjective and not reliable. A review of the facility's policy, dated 12/17/19, titled, Food Storage, indicated, .IV Steps of the Procedure: A. most foods contain an expiration date . I. discard food past the use-by date . A review of the facility's document, dated 3/14/14, titled Produce Shelf Life, indicated, . 4-6 days mushrooms . discard when spoiled . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 9 of 9