Health inspection·March 23, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm On 3/22/23 at 8:49 A.M., an observation and interview was conducted with LN 12. LN 12 observed Resident 39's urine catheter drainage bag attached to the left side of the bed, with urine visible in the drainage bag. LN 12 stated Resident 39 did not have a dignity bag and there should be one for the residents' dignity and privacy. LN 12 stated CNA 11 should have put one on yesterday, when it was pointed out to him. Residents Affected - Some 5. Resident 94 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, per the facility's Patient Information record. On 3/20/23 at 10:18 A.M., an observation was conducted of Resident 94 as she sat in a wheelchair in her room, with a family member standing beside her. A urinary catheter bag was attached to the side of the wheelchair. The urinary catheter drainage bag contained yellow urine and no dignity bag present. On 3/20/23, Resident 94's clinical record was reviewed: According to the physician's order, dated 3/8/23, .Foley catheter care every shift . According to the quarterly MDS, dated [DATE], the cognitive assessment, section C1000, was listed as moderately impaired cognition. Section H0100, indicated the resident had an indwelling urinary catheter. Per the care plan, titled Indwelling urinary device, dated 2/10/23, an intervention was listed, .Maintain Dignity . On 3/21/23 at 8:17 A.M., an observation was conducted of Resident 94 as she sat up in bed. A urinary drainage bag was attached to the bed frame and urine was visible in the drainage bag. No dignity bag was present. On 3/21/23 at 3 P.M., an interview was conducted with CNA 12. CNA 12 stated all residents with urinary catheter bags, should have dignity bags to provide privacy and dignity, no matter if they got out of bed or not. On 3/21/23 at 3:46 P.M., an interview was conducted with LN 11. LN 11 stated every resident with a urinary catheter needed to have a dignity bag, and it did not matter if they got out of bed or not. LN 11 stated dignity bags were important to protect the resident's privacy and dignity from others seeing what was in the collection bag. On 3/21/23 at 3:55 P.M., an observation was conducted of Resident 94 as she sat up in bed. A family member was standing next to the bed, visiting. Resident 94's urinary catheter drainage bag with yellow urine was attached to the bed frame and visible from the hallway. No dignity bag was present. On 3/22/23 at 2:50 P.M., an interview was conducted with the DSD. The DSD stated urinary drainage bags should only be covered if the resident was out of the room. The DSD stated it was possible for visitor to see the uncovered drainage bags from the hallway or when they entered a room. The DSD stated since other non-staff persons could see the urinary drainage bags, they should be covered with a dignity bag. The DSD stated the dignity bags were important to protect resident's privacy and dignity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 2 of 40 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 03/23/2023 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 0557 Level of Harm - Minimal harm or potential for actual harm On 3/23/23 at 8:43 A.M., an interview was conducted with the I-DON. The I-DON stated urinary drainage collection bags should be covered with a dignity bag, since they had visitors and other non-staff persons in the building. The I-DON stated if a resident did not have a dignity bag covering the urine drainage bag, there was a potential for the residents' dignity to be affected. Residents Affected - Some According to the I-DON, the facility did not have a policy for urinary catheters. According to the policy titled Patient Rights, dated November 2019, .B. It is the standard of practice at Villa Pomerado to protect and promote the rights of each resident, in particular, the right to a dignified existence . According to the facility's Resident [NAME] of Rights, dated December 2012, .12. To be treated with consideration, respect and full recognition of dignity, and individuality, including privacy in treatment and in care of personal needs . Based on observation, interview, and record review the facility failed to provide dignity and privacy to six of seven (Residents 2, 39, 85, 86, 71, and 94) , reviewed for Dignity. As a result, there was the potential for residents to experience a decline in self-esteem. Findings: 1. Resident 2 was admitted to the facility on [DATE], with diagnoses that include paraplegia (an inability to voluntarily move the lower parts of the body), per the facility's Patient Information record. On 3/20/23, a review of Resident 2's MDS (a clinical assessment tool), dated 2/10/23, indicated a BIMS (test for cognitive function) was 14 out of 15, indicating cognition was intact. On 3/21/23 at 10:08 A.M., a concurrent observation and interview was conducted with CNA 21. Resident 2 was observed sitting up in bed, a Foley catheter bag was hanging off the right side of the bed draining yellow colored urine into a catheter bag. CNA 21 stated, the resident urine bag did not have a cover on it and was visible from the hallway. CNA 21 further stated, the urine bag should have a cover bag over it to provide the resident with dignity, and it did not. 2. Resident 71 was admitted to the facility on [DATE], with diagnoses that include prostate cancer (a disease affecting the male reproductive gland), per the facility's Patient Information record. On 3/21/23, a review of Resident 71's MDS, dated [DATE], indicated a BIMS score of 15 out of 15, indicating cognition was intact. On 3/21/23 at 10:38 A.M., a concurrent observation and interview was conducted with CNA 22. Resident 71 was observed sitting up in bed with a Foley catheter to the right side of the bed with yellow colored urine was draining into the urine bag. CNA 22 stated, the resident urine bag did not have a cover on it and that the bag was visible to all. CNA 22 stated, he knew that the facility had cover bags for the urine bags but was not sure where they were kept. CNA 22 further stated, the urine bag should have a cover bag over it to provide the resident with dignity and privacy. 3. Resident 86 was admitted to the facility on [DATE], with diagnoses that include asthma (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 3 of 40 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 03/23/2023 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 0557 condition affecting breathing patterns), per the facility's Patient Information record. Level of Harm - Minimal harm or potential for actual harm On 3/21/23, a review of Resident 86's MDS, dated [DATE], indicated a BIMS score of 13 out of 15, indicating cognition was intact. Residents Affected - Some On 3/21/23 at 11:27 A.M., a concurrent interview and observation was conducted with the CNA 21. Resident 86 was observed sitting up in bed with a Foley catheter bag on the left side of the bed draining yellow colored urine into the drainage bag. CNA 21 stated, the resident's urine bag did not have a cover on it and was visible from the hallway. CNA 21 further stated, the urine bag should have a cover bag over it to provide the resident with dignity, and it did not. On 3/23/23 at 1:17 P.M., an interview was conducted with the ICN. The ICN stated, the catheter drainage bags should have had dignity cover bags over them to provide the resident's with dignity and privacy. The ICN further stated, it was an expectation that all residents were to be treated with dignity. On 3/23/23 at 2:37 P.M., an interview was conducted with the I-DON. The I-DON stated, it is the expectation that all residents are treated with dignity. The I-DON further stated, the resident catheter drainage bags should have had dignity cover bags over them to provide the residents with dignity and privacy. 6. Resident 85 was admitted on [DATE], with diagnoses of Acute Hypoxemic (a low level of oxygen in the blood), Respiratory Failure (inadequate gas exchange by the respiratory system), per the facility's Patient Information record. During an observation on 3/21/23, at 9:18 A.M., Resident was awake, seated upright in bed. CNA 1 was observed feeding Resident 85 with breakfast. CNA 1 was standing while assisting with feeding. An interview was conducted with CNA 1 on 3/21/23, at 10:16 A.M. CNA1 stated she was standing while feeding Resident 85, because it was easier for her. CNA 1 stated she was taught to either stand or sit while assisting residents with meals. During an interview with LN 1 on 3/22/23, at 8:00 A.M., LN 1 stated staff should not stand while feeding residents. LN 1 stated staff should be at eye level, not higher than residents. LN 1 stated being at eye level made residents more comfortable, relaxed and provided staff the opportunity to communicate with residents. During an interview with the I-DON on 3/23/23, at 8:15 A.M., the I-DON stated her expectation was for staff to sit with the resident while feeding. The I-DON stated sitting, rather than standing while feeding provided a comfortable environment for the resident and promoted dignity. The facility did not provide a Policy and Procedure (P&P) regarding feeding residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 4 of 40 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 03/23/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 sensitive (touch pad) call light was available for one of one resident, (Resident 13) reviewed for accommodation of needs. Residents Affected - Few This failure resulted in Resident 13 not getting his needs met. Findings: Resident 13 was admitted to the facility on [DATE], with diagnoses that included Quadriplegia (paralysis of arms, legs, and body from the neck down), per facility's Patient Information record. During an observation and interview on 3/20/23, at 11:09 A.M., with Resident 13, Resident 13 was in bed sitting upright. Resident 13 stated, he had to yell out for help, because he could not use the push button call light. Resident13 was observed with upper & lower extremity contractures (a stiffening of the muscles). A push button call light was clipped on Resident 13's bed and the resident could not reach for it. During a review of Resident 13's MDS (a assessment tool), dated 2/21/23, the MDS indicated, a cognitive score of 15, indicating he was cognitively intact. An interview was conducted on 3/21/23, at 3:15 P.M., with CNA 2. CNA 2 stated Resident 13 would yell out for coffee and for food. CNA 2 stated Resident 13 was totally dependent and could not use a standard call light, so he would yell out for help. During an interview on 3/22/23, at 7:50 A.M., with CNA 3, CNA 3 stated stated residents who were not able to speak or could not move their hands were provided a sensitive call light. CNA 3 stated the sensitive call light was important staff to provide for resident needs. An interview was conducted with LN 1 on 3/22/23 8 A.M., LN 1 stated Resident 13 yelled for everything, even for small requests. LN 1 stated Resident 13 yelled out for assistance. LN 1 stated Resident 13 had a sensitive call light in a previous room. LN 1 stated when Resident 13 was moved to his current room, the sensitive call light was not transferred with him. During an interview on 3/22/23, at 9:55 A.M., with LN 2, LN 2 stated Resident 13 had a sensitive call light when he was in a different room. LN 2 stated she was not aware Resident 13 did not currently have a sensitive call light. LN 2 stated Resident 13 should have the sensitive call light to prevent from yelling out. An interview was conducted on 3/23/23, at 8:15 A.M., with the I-DON. The I-DON stated if a resident was not able to press a call light for assistance, the resident should have a head touch/sensitive call light. The I-DON stated a resident should be able to call for assistance without yelling out for staff. The I-DON stated a sensitive call light gave more independence and control for the resident. The I-DON stated without access to a call light, the resident may feel scared or out of control. The facility could not provide a policy regarding call lights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 5 of 40 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 03/23/2023 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 conduct a quarterly (every three months) MDS assessment (a clinical tool which is submitted to Centers for Medicare & Medicaid Services [CMS]) and submit it to CMS in a timely manner for one of four residents (Resident 74) reviewed for Resident Assessments. Residents Affected - Few As a result, the facility and CMS were delayed in knowing Resident 74's current health status. Findings: Resident 74 was admitted to the facility on [DATE], per the facility's Patient Information record. On 3/22/23 at 7:57 A.M., an interview and record review was conducted with the MDSN. The MDSN stated Resident 74 was originally admitted to the sub-acute unit (medically fragile residents who require special services, such as inhalation therapy), and then transferred to Station C on 12/29/21, where she has remained since. The MDSN reviewed Resident 74's MDS assessments and CMS submissions. Resident 74 had a quarterly assessment completed on 10/6/22, and another quarterly assessment should have been completed in 1/8/23, but it was missed. The MDSN stated the computer system should have generated a notice, indicating the quarterly MDS was due, but it did not generate. The MDSN stated she caught the error on 2/6/23 and immediately completed an assessment and submitted it to CMS, after the due date. The MDSN stated quarterly MDS assessments were mandatory because it was important for CMS to know how the resident was doing, and if any decline in the resident's health had occurred. On 3/23/23 at 11:10 A.M., an interview was conducted with the I-DON. The I-DON stated she expected all residents' quarterly MDS assessments to be completed and submitted in a timely manner. According to the Resident Assessment Instrument, Version 3.0 [NAME], dated October 2019, .5. Quarterly Assessment (A0310A = 02): The Quarterly assessment is a .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored .must be not more than 92 days after the most recent .assessment of any type . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 6 of 40 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 03/23/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written summary of the baseline care plans for three of five residents and/or their representatives (Resident 58, 85 and 402), reviewed for comprehensive care plans. This failure had the potential for residents and/or their representatives of not being informed of the resident's initial plan of care and services. Findings: 1. Resident 58 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/6/23, the admitting diagnoses included pelvic (hip bone) fracture (a break in the bone). During a review of Resident 58's MDS (a clinical assessment tool), dated 3/11/23, the MDS indicated, a cognitive score of 13, indicating cognition was intact. During observation and interview on 3/20/23, at 9:55 A.M., Resident 58 was lying in bed with oxygen being administered. Resident 58 stated she had a fall and was receiving therapy at the facility. Resident 58 stated she did not require oxygen before the fall. An alarm monitoring device was on top of the bedside table (a device that alarms, to alert staff if pressure is remove from the bed) and was connected to a pad under Resident 58's bed sheet. Resident 58 stated she did not know why she had an alarm and was not informed of why she required an alarm. There was no documented evidence a written copy of the baseline care plans and summary of service were provided to the resident or the resident representatives. 2. Resident 85 was admitted to the facility on [DATE], with diagnoses according to the face sheet with diagnosis of hypoxemia (a low level of oxygen in the blood) and respiratory failure (inadequate gas exchange by the respiratory system)., per the facility's Patient Information record. During an observation on 3/20/23, at 9:09 a.m., Resident 85 was in bed, eating breakfast. There was no documented evidence a written copy of the baseline care plans and summary of service were provided to the resident or the resident representatives. 3. Resident 402 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/17/23, the admitting diagnoses included right hip pain and neuropathy (nerve disorder). During observation and interview on 3/20/23, at 11 A.M., Resident 402 stated she was admitted to the facility because of extreme pain to the right hip. Resident 402 stated the pain medications were not working and the nurses could not give her anything stronger. Resident 402 stated she had not had a care conference meeting, regarding her care. During an interview and concurrent record review of Resident 402's pain levels on 3/21/23, at 1:15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 7 of 40 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 03/23/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some p.m., with LN 1, LN 1 stated Resident 402's pain levels indicated pain level ranged 6 to 8, with 10 being the worst pain and zero being no pain at all. During an interview with Resident 402 on 3/22/23, at 10:30 A.M., Resident 402 stated after an increase with the pain medication, her pain level did not go down to a 6. Resident 402 stated after three hours, the pain was up, high again. During interview on 3/22/23, at 8:23 a.m., with the SS 1, the SS 1 stated she and SS 2 visited newly admitted residents within 48 hours of admission. SS 1 stated the charting was completed MDSN scheduled the care conferences. An interview was conducted on 3/22/23, at 9:01 A.M., with the MDSN nurse. The MDS nurse stated she scheduled the comprehensive Interdisciplinary team (IDT- team members from different disciplines) meetings within 2-3 weeks of resident's admission to the facility. The MDSN stated Social Services were responsible for initiating the baseline care plans. There was no documented evidence a written copy of the baseline care plans and summary of service were provided to the resident or the resident representatives. During an interview on 3/22/23, at 10:50 A.M., with SS 1 and SS 2, SS 1 stated Social Services completed the baseline care plans electronically. SS1 stated a copy of baseline care plans were not provided to residents or their representatives and they were unaware they should be. During an interview on 3/23/23, at 8:15 A.M., with the I-DON, the I-DON stated the baseline care plan helped with continuity of care and communication between staff and residents, or the resident representatives. The I-DON stated it was important to provide a copy of baseline care plan to residents or family for them to be involved with care. During a review of the facility's policy, titled Procedure: Care Planning and Assessment, dated 10/24/18, indicated, .IV. A. Upon completion of the baseline care plan, the patient or representative will be given a copy of the plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 8 of 40 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 03/23/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 comprehensive care plans were revised and/or updated for three of five residents (Resident 58, 87 and Resident 402), reviewed for comprehensive care plans when: 1. Resident 58's care plan was not developed for the use of oxygen. 2. Resident 87's care plan for skin integrity did not indicate the current pressure ulcer status, and the use of Negative Wound Pressure Therapy (NWPT- wound vac-suction tubing, and wound dressing to remove excess fluid and any infectious material present in the wound), and Resident 87's wound center follow up appointments. 3. Resident 402's care plan was not updated when Resident 402's current pain medication was ineffective. Failure to revised and/or update the care plans had the potential for delayed care, miscommunication among caregivers, and decreased physical well-being. Findings: 1. Resident 58 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/2/23, diagnoses included pelvic (the basin-shaped bone connecting the trunk and legs) fracture (a break in a bone). During observation and interview on 3/20/23, at 9:55 A.M., Resident 58 was in bed with oxygen being administered. Resident 58 stated she had a fall and started receiving oxygen while at the facility. A review of Resident 58's Physician's Orders, dated 3/6/23, indicated, oxygen at 2 liters per minute via nasal cannula (oxygen delivers through the nostrils)as needed for shortness of breath. During an interview on 3/21/23, at 4 P.M., with CNA 2, CNA 2 stated Resident 58's oxygen was continuous, but it was just discontinued today, (3/21/23). During interview and concurrent record review with LN 2 on 3/22/23, 10 A.M., LN 2 stated Resident 58 started receiving oxygen on 3/6/23. LN 2 could not locate a care plan for oxygen administration. LN 2 stated it was important to have a care plan, so staff knew what intervention were in place, so consistent care could be provided. 2. Resident 87 was admitted to the facility on [DATE]. According to the physician's History and Physical, dated 3/8/23, diagnoses included unstageable sacral (bottom of the spine) region pressure ulcer. During an interview on 3/20/23, at 11:57 A.M., with Resident 87, Resident 87 stated she was admitted in November 2022 with a pressure ulcer and then the wound vac was started after admission. The wound vac was observed to be inside a black bag hanging at side to bed and the clear tubing had light (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 9 of 40 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 03/23/2023 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 0657 red fluid draining inside of it. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 87's physician's orders, dated 2/19/23 indicated, Vashe (brand name) Wound Therapy External Solution (Wound Cleansers). Apply to sacral/coccyx topically every day shift every Tue, Thu, Sun for Wound. Cleanse open area on sacrum/coccyx with Vashe. Apply NPWT with black foam continuous negative pressure of 125 mm Hg (millimeters of mercury.) Residents Affected - Some During a wound treatment observation on 3/21/23, at 2:43 P.M., with LN 3, LN 3 stated Resident 87's wound was unstageable upon admission and was currently at a stage 4 (a deep wound reaching the muscles, ligaments, or bones) wound. LN 3 stated the wound treatment would be continue according to physician's orders, and she was unsure how long the wound would take to heal. During an interview and joint record review or the wound center appointments. LN 2 stated the care plan should have been updated to list these things, because it was important to know the plan of care and what was being done for the resident. should be listed and updated regularly. During a review of the facility's policy, titled Procedure: Care Planning and Assessment, revised on 10/24/18, .D. The care plan is reviewed and updated regularly by members of the IDT or when a conflict or change occurs involving care deliver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 10 of 40 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 03/23/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the manufacture's guidelines for low air loss (LAL- a special mattress that provides alternating airflow within the mattress, to relieve pressure), to maintain skin integrity for three of five residents, (Resident 64, 80, 83) reviewed for pressure ulcers. Residents Affected - Few As a result, Residents 64, 80 and 83, had the potential to develop pressure ulcers from incorrect mattress settings. Findings: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, per the facility's Patient Information record. On 3/20/23 at 2:09 P.M., an observation was conducted of Resident 64 as she laid in bed. Resident 64's LAL mattress was set for a weight of 175-200, with 15-minute intervals of inflation/deflation. Resident 64's weight appeared under 175 pounds. On 3/21/23 at 3:23 P.M., an interview was conducted with CNA 11. CNA 11 stated only the LNs or NP changed the settings on the LAL mattresses, and CNAs did not touch them. CNA 11 stated if something was wrong with the LAL mattress, like an alarm going off, he would notify the charge nurse. On 3/22/23 at 8:32 A.M., an observation of Resident 64's LAL mattress was conducted as she laid in bed. The LAL mattress was set for a weight of 175-200 with 15-minute intervals of pressure. On 3/22/23 at 8:42 A.M., an interview was conducted with LN 12. LN 12 stated if a LAL mattress was needed, she would call the company to come and set it up. LN 12 stated all LNs were trained by the mattress company, in case the mattresses needed to be adjusted or there was a problem. LN 12 stated the LAL mattresses were set according to the resident's weight, which was indicated on the box at the foot of the bed. LN 12 said an example would be if the resident weight 150 pounds, the LAL mattress would be set for the 150 range. On 3/22/23 at 8:55 A.M., an observation and interview was conducted with LN 15, of Resident 64 as she laid in bed. LN 15 stated LAL beds were used for residents who did not get out of bed, in order to prevent skin breakdown. LN 15 stated the LAL mattresses needed to be set according to the resident's weight, because if too firm or too soft, it could be irritating to the skin. LN 15 stated the intervals were set by the company and the LNs had nothing to do with that. LN 15 stated Resident 64's LAL mattress was set for a weight of 175 to 200. On 3/22/23 at 9:04 A.M., a record review was conducted with LN 15 of Resident 64's weight. LN 15 stated Resident 64 had a recorded weight of 152 pounds on 3/14/23. Resident 64's previous weight on 2/28/23 was 154 pounds. LN 15 stated since the LAL mattress was set for 175-20, it was set too high for the resident's weight. 2. Resident 80 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, per the facility's Patient Information record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 11 of 40 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 03/23/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/20/23 at 2:04 P.M., an observation was conducted of Resident 80, as she laid in bed. Resident 80's LAL mattress was set for a weight of 145-175 with intervals at 5-minutes. Resident 80's weight appeared under 145 pounds. On 3/22/23 at 9:02 A.M., an observation and interview was conducted with LN 15 of Resident 80 as she laid in bed. Resident 80's LAL mattress was set for a weight of 145-175 at 5-minute intervals On 3/22/23 at 9:09 A.M., a record review was conducted with LN 15 of Resident 80's weight. LN 15 stated Resident 80 weighed 139.6 on 3/14/23. LN stated she needed to adjust Resident 80's LAL bed, because it was set too firm. On 3/22/23 at 11:35 A.M., an interview was conducted with NP of the sub-acute unit (residents who require a higher level of care) where Resident 64 and 80 resided. The NP stated residents in this unit do not get up, out of bed, so most resident had LAL mattresses. The NP stated LAL mattresses should be set according to the resident's weight. The NP stated the facility currently had no process for monitoring the LAL mattress settings. On 3/22/23 at 3:26 P.M., an interview was conducted with the DSD. The DSD stated LAL mattresses were important to to prevent pressure ulcers. The DSD stated if a LAL mattress was too firm, it could cause increased pressure to a bony prominence resulting injury and if too soft, the resident would sink down into the bed frame from no support. The DSD stated LAL mattresses needed to be set according to the resident's weight and adjusted as needed. On 3/23/23 at 8:43 A.M., an interview was conducted with the I-DON. The I-DON stated LAL mattresses were put on as a preventative measure for skin issues. The I-DON stated she expected the LAL mattresses to be set according to the resident's weight. 3. Resident 83 was admitted to the facility on [DATE] with diagnoses which included right hip fracture, with surgical repair, per the facility's Patient On 3/20/23 at 10:21 A.M., an observation was conducted of Resident 83 as she laid in bed. Resident 83's LAL mattress was set for a weight of 120-145. Resident 83's weight appeared under 100 pounds. On 3/22/23 at 4:01 P.M., a record review was conducted for Resident 83. Resident 83's weigh was recorded as 33.8 kilograms equal to 75 pounds on 3/15/23. On 3/22/23 at 4:33 P.M., an observation and interview was conducted with LN 14, after a dressing change on Resident 83's heels. LN 14 viewed the setting for Resident 83's LAL mattresses, which read 120-145 at 15-minute intervals. LN 14 stated Resident 83 appeared to be around 100 pounds and the mattress was set too high for her. LN 14 was informed of Resident 83's most recent weight of 75 pounds. LN 14 programmed Resident 83's mattress to setting of 75-100 pounds. According to the manufacturers quideline, Blue Chip, undated, Table 1 Weight and Comfort Level Reference, listed a graph indicating mattress level setting related to resident weight. According to the facility's policy, titled Procedure: Pressure Injury Prevention, dated August 2018,1. Propose: To prevent occurrence of pressure injury .identify individuals at risk .A .assess risk .1. Impaired ability to transfer. 2. Impaired for bed mobility .6. Friction and shearing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 12 of 40 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 03/23/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with very low body weight and severe malnutrition risk was assessed according to the facility policy and standards of practice. Residents Affected - Few This failure had the potential to cause additional weight loss and further compromise the one of 22 sampled residents (Resident 85) nutrition and health status. Cross reference F803, F804, F867 Findings: Per a review of Resident 85's admission Record dated 3/22/23, Resident 85 was admitted on [DATE] with diagnoses of Acute hypoxemic respiratory failure (impaired air exchange between the lungs and blood), and prior medical history of high blood pressure and chronic obstructive pulmonary disease (COPD-diseases of the lung that block airflow and makes it difficult to breathe). A review of Resident 85's LTC Nutritional Status document dated 2/3/23 completed by RD 3, indicated .Nutrition Risk Symptoms LTC: Diagnosed Malnutrition .Nutritional Intake Meets Needs (GOAL)= Not Met .decreased appetite; Weight Gain (Range) 1-2#(pounds) per month to approach 170 pounds (GOAL) . A review of Resident 85's Nutrition assessment dated [DATE] completed by RD 3, indicated, .Ideal body weight: 91.8 kg (202 pounds) .usual weight: 77.2 kg(169.8 pounds) .Appetite: Poor .Nutrition Plans: Encourage adequate intake .Clinical nutrition assessment to follow . A review of Resident 85's Nutrition assessment dated [DATE] completed by RD 3, indicated .Diet tolerance: Good, Recent oral intake: 46% average/week, Abnormal lab: 2/27/23-BUN (blood urea nitrogen): 31 (high) .Body Mass Index (BMI): 17.2 (underweight) .Adequacy of Intake: Not meeting needs .Nutritional Goals: .PO Intake 50-75% . A review of Resident 85's meal intake report dated 3/23/23 from 3/16/23-3/22/23, indicated daily average breakfast intake was 32.14%, lunch was 35.71%, and dinner was 34.52%. During an observation and interview on 3/22/23 at 11:44 A.M. with Resident 85, the resident was lying in bed awake with an oxygen tank next to the bed. Resident 85 had visible difficulty and labored breathing. Resident 85 stated that he was tired and unable to eat much. There was a pink sheet posted on the wall with the words in bold Diet, chopped, honeythick, puree 1:1 supervisor. Resident 85 stated he ate mixed fruit, French toast, and a milkshake supplement for breakfast this morning. The resident further stated he eats about 1/3 of the food he gets because of my stomach. Resident 85 stated he Liked the Milkshakes. On 3/23/23 at 9:10 A.M., a joint observation and interview was conducted with Resident 85. Resident 85 was alone in his room, lying slightly lower in the bed than the prior day, and trying to feed himself breakfast. His meal tray had scrambled eggs, chopped potatoes, a bowl of oatmeal, a cup of mixed fruit, and supplement milkshake. Resident 85 stated he won't eat everything he has on his plate. The resident was observed trying to feed himself and struggled bringing the spoon to his mouth with each time he scooped food from his plate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 13 of 40 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 03/23/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's Resident Diet Order list dated 3/21/23, indicated Resident 85 was on a Regular, Honeythick liquids, Ice chips, and no fluid milk. A review of the facility's Nourishment Delivery Report dated 3/22/23, indicated Resident 85 was to receive one 8oz. milkshake supplement at Breakfast, one 11 oz. milkshake supplement at Lunch, and one 4 oz. supplement milkshake at Dinner. A review of Resident 85's weight history as of 3/22/23 indicated the admit weight on 2/4/23 was 153.7 pounds and on 3/4/23 was 156.6 pounds. On 3/23/23 at 9:37 A.M., an interview was conducted with RD 2. RD 2 stated the process for conducting an initial nutrition assessment is to check for new admits from the census, then schedule to complete the nutrition screening is completed within 3 days of admission. The screening included determining the resident's food allergens, weight history, food preferences, feeding abilities (assistance or self), medical history, diet orders, and supplements. The nutrition assessment is completed within 7 days of resident's admission, which included a review of the resident's blood labs values, medications, meal intake percentages for breakfast, lunch, and dinner, and oral supplement intake. RD 2 further stated the facility did not have a different screening or completing nutrition assessments process for residents with severe malnutrition or not eating well. RD 2 stated Resident 85 should have been re-evaluated more frequently to assess his poor meal intake in order to modify the interventions. During an interview and record review of Resident 85's medical records, RD 3 stated Resident 85 was screened as malnourished, and assessed as having moderate-severe nutrition risk. RD 3 stated Resident 85 looked malnourished, had lost weight, and had decreased albumin lab value (protein in the blood). RD 3 stated because the Resident complained of abdominal pain, was not eating much food, was underweight and assessed as Severe nutrition risk, then he should have been seen again for a follow up assessment on 2/13/23. But the next nutrition assessment was on 3/6/23. During an interview and record review on 3/23/23 at 1:40 P.M., the CNM stated her expectation for taking residents' weekly weights was it should be taken monthly if the weights were stable for the first 4 weeks. The CNM stated the follow up process for Resident 85's could have been improved by reassessing the resident's weight and meal intake weekly or more frequently, in order to modify interventions to improve his nutrition status. According to authors [NAME] and [NAME] (2009) of the Journal of Healthy Aging .25% of residents experienced weight loss when research staff conducted standardized weighing procedures over time. The Academy of Nutrition and Dietetics (AND) reported that under-nutrition from low food intake adversely affects the quality and length of life, and therefore, has aroused the concern of geriatric health professionals . A review of the facility procedure document dated 9/20/19, titled Weighing Residents, indicated .Residents are weighed to determine nutritional status and evaluation of overall health .C. Residents are weighed monthly, may be weighed more frequently by physician or by dietary staff for residents determined to be at significant nutritional risk . A review of the facility procedure document dated 1/9/22, titled Nutritional Screening/Assessment/Documentation- Long term Care and Sub Acute, indicated .4.A patient with significant nutritional change may be reassessed by the Registered Dietitian (RD) at any time.The Dietitian will be monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 14 of 40 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 03/23/2023 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 0692 .b. Monitoring Weight status: Residents will be weighed upon admission, then weekly times four weeks .as deemed necessary by the IDT (interdisciplinary team) . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 15 of 40 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 03/23/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of five residents (Resident 46 and 92) were monitored for side effects of unnecessary drugs. Residents Affected - Few These failures had the potential for Resident 46 and 92 to have side effects that went undetected by staff. Findings: 1. Resident 46's admitted to the facility on [DATE]. According to the physician's history and physical, dated 5/30/22, Resident 46 diagnoses included traumatic brain injury (TBI) and neurocognitive impairment (decreased mental ability) with behavioral problems. A review of Resident 46's initial psychiatric consultation, dated 1/8/20, indicated Resident 46, .has been resistant, easily agitated, and aggressive. He strikes out at caregivers and is refusing all care. A review of physician medication orders for Resident 46, indicated Seroquel (an antipsychotic; class of psychotropic medication used to treat mental/mood disorders), 50 mg (milligram) tablet once a day at bedtime (HS) was started on 12/27/22. The orders indicated Ativan (an antianxiety; class of psychotropic medication used to treat anxiety), 1mg tablet as needed (PRN) every 4 hours (q4) was started on 12/26/22. A record review of physician progress note, titled psychoactive med review, dated 1/20/23, The progress note indicated the continuation of the prescribed psychotropic medications (a group of medications that affect mental function, behavior and mood) was needed because Resident 46 continued to be combative, refuse treatment and pose a danger to self and others. The progress note indicated side effects for both psychotropic medications were to be monitored. A review of Resident 46's MDS assessment, dated 1/11/23, indicated the facility was unable to conduct a BIMS, (a test that assesses mental function) on Resident 46 because the resident was rarely/never understood. On 3/22/23 at 4:06 P.M., an interview and concurrent record review of Resident 46's electronic health record (EHR) was conducted with LN 11. LN 11 stated Resident 46 was prescribed and had been receiving Seroquel 50mg, nightly at 9:00 P.M., since 12/27/22 . LN 11 reviewed Resident 46's physician orders and stated there was no order to monitor Resident 46 for side effects of the prescribed antipsychotic, Seroquel, or the prescribed antianxiety, Ativan. LN 11 stated there should be a task ordered in point click care (PCC-software used to document medication and treatment administration) and to monitor for side effects when a resident was on psychotropic medications. LN 11 reviewed PCC and stated there was no indication Resident 46 had been monitored for side effects Seroquel or Ativan since they had been prescribed. On 3/23/23 at 9:26 A.M., an interview and concurrent record review of Resident 46's TAR record was conducted with LN 32. LN 32 stated no monitoring of side effects for Seroquel and Ativan had been documented in the medical record for Resident 46. LN 32 stated Resident 46 should have been monitored for side effects of prescribed psychotropic medications to ensure safe care is being provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 16 of 40 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 03/23/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/23/23 at 1:39 P.M., a telephone interview was conducted with the PC. The PC stated nurses were expected to monitor for side effects and adverse reactions of antipsychotic and antianxiety medications every shift. The PC stated nurses were to document monitoring of these medications every shift. On 3/23/23 at 2 P.M., an interview was conducted with the I-DON. The I-DON stated nurses were expected to document the monitoring of side effects and findings every shift in PCC for all psychotropic medications. A review of the facility policy, titled Antipsychotic Review Guidelines, dated 1/4/20, indicated Purpose: to ensure psychotropic medications are monitored for effectiveness and signs of side effects .IV. Steps of Procedure: A. Performed by: The Interdisciplinary Team (IDT) who will review .5. Any evidence of side effects. A review of the facility policy, titled Documentation Schedule, dated 9/20/19, indicated, Purpose: To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .IV. Steps of Procedure .J. Medications and treatments are documented in the EZ-MAR according to the established practice. 2. A review of Resident 92's record of admission, indicated Resident 92 was admitted to the facility on [DATE]. per the facility's Patient Information record. According to the physician's history and physical, dated 1/10/23, Resident 92 was diagnosed with incomplete quadriplegia (loss of ability to move from the neck down) and a history of arrhythmia (when the heart beats with an abnormal rhythm). A review of Resident 92's MDS assessment for hearing, speech, and vision; and cognitive patterns, dated 2/19/23, indicated Resident 92 was unable to speak and had severely impaired cognitive status. A review of physician's orders and the MAR indicated Resident 92 was started on Eliquis (an anticoagulant; medication used to prevent blood clots), 2.5 mg two times a day, on 2/20/23, for atrial fibrillation (an arrythmia; an irregular rapid heartbeat). On 3/23/23 at 11:15 A.M., a interview and concurrent record review of Resident 92's EHR was conducted with LN 32. LN 32 stated there was no order to monitor for side effects of Eliquis for Resident 92. LN 32 stated residents on anticoagulants are at risk of bleeding and should be monitored for bleeding gums, hematuria, and bruising. LN 32 stated it was standard practice to document side effects of an anticoagulant in the MAR every shift. LN 32 reviewed the MAR and stated there was no documentation that monitoring occurred for side effects of the prescribed Eliquis for Resident 92 since it was started on 2/20/23. On 3/23/23 at 11:22 A.M., an interview and concurrent record of review of Resident 92's physician orders was conducted with NP. NP stated there was no order to monitor Resident 92 for side effects of Eliquis. On 3/23/23 at 1:39 P.M., a telephone interview was conducted with the PC. The PC stated nurses administering anticoagulants were expected to monitor for side effects, such as bruising or bleeding. The PC stated monitoring of side effects for administered medications were expected to be documented in the MAR every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 17 of 40 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 03/23/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/23/23 at 2:00 P.M., an interview was conducted with the I-DON. The I-DON stated nurses were expected to observe all precautions regarding the use of anticoagulants for residents; including documenting the monitoring of side effects and findings every shift. The facility was unable to provide a policy & procedure for monitoring side effects for anticoagulants upon request. A review of the facility policy, titled Documentation Schedule, dated 9/20/19, indicated, Purpose: To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .IV. Steps of Procedure .J. Medications and treatments are documented in the EZ-MAR according to the established practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 18 of 40 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 03/23/2023 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 observations, interviews, and document reviews, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. Residents Affected - Many This failure led to twelve (12) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status. Cross reference F804 Findings: During a review of the facility's undated therapeutic menu spreadsheet titled Week 2, Tuesday, 3/21/23, the Regular Diet lunch meal was 3 ounces (oz.) oven fried chicken breast, ½ cup mashed potatoes, ½ cup sauteed green beans and cherry tomatoes, 8 ounces (oz.) 1% milk, 6 oz. creamy lentil soup, 2 saltine crackers, and 1 iced brownie. The Dysphagia Pureed Diet lunch meal included a 3 oz. turkey puree with 1 oz. chicken gravy, 3 oz. corn puree, 3 oz. green beans puree, 8 oz. 1% milk, and 1 orange jello gelatin cup. During an observation and interview on 3/21/23 at 10:03 A.M. of the lunch meal food production in the main kitchen, the A.M. [NAME] (CK) 1 prepared 15 pre-packaged pureed food items, entrées, and side item each, and placed them in the steamer oven. CK 1 was asked did he prepare any pureed meals, and CK 1 stated No because we use prepacked pureed foods for the pureed diets. CK 1 further stated he did not prepare soup for the pureed diets. The FSM acknowledged CK 1 did not prepare soup for the pureed diets and stated, the pureed don't get soups according to therapeutic menu spreadsheet. During a review of the facility's undated therapeutic menu spreadsheet titled Week 2 Wednesday, 3/22/23, the Regular Diet indicated the lunch meal was 3 ounces (oz.) braised pork loin with 1 oz. brown sauce, ½ cup mashed potatoes, ½ cup steamed broccoli, 1 bread roll, 1 slice butter, 8 ounces (oz.) 1% milk, 6 oz. cream of mushroom soup, 2 saltine crackers, and 1 blondie bar. The Dysphagia Pureed Diet lunch meal included 4 oz. pork puree mold with 1 oz. brown sauce, 3 oz. mashed sweet potatoes puree, 3 oz. broccoli puree, 8 oz. 1% milk, and 1 tapioca pudding cup. During an interview on 3/22/23 at 4:15 P.M. with the FSM, the FSM stated the pureed diet included prepackaged foods because it was easier preparation for the Cooks because they are pre- portioned with adequate nutrition. The FSM acknowledged the therapeutic menu for Dysphagia Puree did not include pureed soups and bread rolls. The FSM stated the pureed diet should get soups and bread if it is tolerable for the puree diet. During an interview on 3/23/23 at 10:56 A.M. with the FSM, the FSM stated her expectation was for the puree diets to meet the same nutritional standards as the regular diet. The FSM acknowledged the weekly average nutrient analysis of the pureed diet had less calories and protein than the regular diet but stated they should be closer to equal because fewer nutrients could impair the resident's nutrition and health status. The FSM further stated the weekly menu should have been posted in the dining room and provided to the residents so they know what meals will be served. Review of facility undated document titled Nutritional Analysis: Average for Week 2 Cycle, indicated the Regular diet provided 2810 calories, 123 grams of protein, and 28 grams of fiber. The Pureed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 19 of 40 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 03/23/2023 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 diet provided 2415 calories, 122 grams of protein, and 17 grams of fiber. Level of Harm - Minimal harm or potential for actual harm Review of facility's Diet Manual document titled Pureed Diet page A-39 indicated .Soups .FOODS ALLOWED .All smooth cream soups or broth type soups with pureed . ingredients . Residents Affected - Many Review of the facility's procedure dated 1/11/23 titled Menu Planning and Nutritional Standards indicated, .A. 90% of RDAs and DRIs will be provided daily .2. The 7 day .menu cycle is submitted for nutritional analysis. 3. Based on the results of the nutritional analysis, recipes, or products are adjusted or substituted to ensure nutrients meet standards . Review of the facility's policy dated 7/14/21, titled Food and Nutrition Services (FANS) indicated, .B. All patient meals are produced according to standardized recipes and are analyzed to the meet RDAs of the base population and approved by a Registered Dietitian .C. The primary goals of the Food and Nutrition Services .necessary to: 1. Prepare and serve attractive, satisfying .meals under high standards .2. Contribute significantly .by planning menus that meet the nutritional and therapeutic needs of patients in accordance with physicians' orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 20 of 40 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 03/23/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and review of facility documents, the facility failed to ensure that residents meals were served at a palatable and appetizing temperature. Residents Affected - Few This finding had the potential to cause reduced food intake and affect nutrition status among medically vulnerable residents on therapeutic diets. The facility census was 109. Cross reference F803 Finding: During a concurrent interview and document review of the lunch menu on 3/21/23 at 10:03 A.M., the [NAME] 1, (CK1) stated lunch menu for that day consisted of oven fried chicken, mashed potato with gravy, and green beans. CK1 further stated the puree menu consisted of roast turkey with green beans, and corn; the puree were bought pre made frozen in individual molds. On 3/21/23 at 11:50 A.M., an interview with Resident 403 was conducted. Resident 403 stated that, .the veggies were not cooked well enough .and the oatmeal is always cold . Resident 403 further stated his food was not chopped like it was at his previous facility. On 3/21/23, an observation of the lunch meal tray distribution from tray line to Unit D was conducted. The observation was between 12:50 P.M. to 1:15 P.M., timer started as the last tray, (the test tray) went on cart, until last tray was passed out on Unit D, and all residents were set up to eat. During a concurrent observation of the test tray and interview with FSM on 3/21/23 at 1:15 P.M., the FSM took the temperatures of each meal item for the regular and pureed diet with the facility's thermometer and compared them with the surveyor's thermometer. The FSM also tasted each food item with the surveyors. The Regular diet meal temperatures included: Mashed Potatoes: 129.4 degrees Fahrenheit (F); Breaded Chicken: 125.0 degrees F; [NAME] Beans: 107. 0 degrees F; Milk: 54.6 degrees F; and Creamy lentil Soup: 105.3 degrees F. The puree diet temperatures were as follows: Corn: 126.0 degrees F; Turkey: 122.0 degrees F; and [NAME] Beans: 119.0 degrees F. The FSM stated that all the food was lukewarm and could use additional seasoning to improve flavor. The FSM further stated the breadcrumb chicken tasted rubbery, not crisp and the pureed turkey tasted like stuffing or dressing and not like turkey. On 3/23/23 at 9:13 A.M., a follow up interview with Resident 403 was conducted. Patient 403 stated the breakfast .was terrible .his eggs tasted like gravel .and were cold. During an interview with the FSM on 3/23/23 at 10:56 A.M., the FSM stated the expectation for residents' food was that they should get food they want to eat, and it should be at a palatable temperature, texture, and taste. The FSM stated it was important for residents to have palatable food because it could affect their food intake. The FSM further stated, and if residents do not eat the food, they will not get the nutrition they need for better health outcomes. According to the 2022 Food and Drug Administration (FDA) Food Code, Section 3-501.16, titled Time/Temperature Control for Safety Food, Hot and Cold Holding, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) .135 degrees F or above .or .may be held at a temperature of .130 degrees F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 21 of 40 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 03/23/2023 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 0804 or above; .(2) At .41ºF or less. Level of Harm - Minimal harm or potential for actual harm According to the 2022 FDA Food Code, Section 3-403.11, titled Reheating for Hot Holding, .If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated . Residents Affected - Few A review of facility procedure dated 1/11/23 titled Transportation of the [NAME] at Poway Food - FANS, indicated .Meals will be produced at [NAME] Health Poway kitchen, transported to the [NAME] at Poway to ensure that food is maintained at safe temperatures and in a sanitary manner .; C. The temperature of food .will be monitored on a regular basis through the use of test trays . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 22 of 40 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 03/23/2023 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation protocols were maintained in the kitchen according to standards of practice and facility policy when: 1. Loading dock area, dumpster cart, and area in front of the dumpster were not free of kitchen waste. 2. Ten (10) kitchen floor sink drains were dirty and filled with food waste. 3. An Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 4. An expired supplement was found in a nourishment room refrigerator in the facility nursing station. These failures exposed residents to unsanitary practices in the kitchen, which had the potential to contaminate the food and place residents at risk of developing a foodborne illness. Cross reference F814, F908, and F925 Findings: 1. During a concurrent observation and interview on 03/20/23 at 2:34 P.M. with Food Service Worker 1 (FSW1), FSW 1 demonstrated how he removed trash from the kitchen. There were several foul soiled kitchen wastes observed at base of the dumpster lift area where the trash from the large trash cart was dumped. FSW1 stated he was not sure who was responsible for cleaning up the area. Dumpster cart was observed to have residual wastes inside it. The Foodservice Manager (FSM) and Foodservice Director (FSD) acknowledged the wastes outside the garbage disposal area and stated it should be cleaner. According to the 2022 FDA Federal Food Code, section 4-601.11, It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2022). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13). A review of facility procedure dated 11/28/19 titled FANS Environmental Sanitation, indicated, the purpose of the procedure is to .maintain a clean environment, which is essential for food safety .a. Daily: i. Clean and sanitize waste bins .d. Three times weekly: .ix. Clean and sanitize main entrance door and surrounding wall . 2. During the initial kitchen tour, an observation of three (3) of the kitchen's floor sink drains was conducted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 23 of 40 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 03/23/2023 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 On 3/21/23 at 9:10 A.M., an observation of seven (7) kitchen sink drains was conducted. Food and kitchen waste was observed in 6 of 7 drains. Some items observed in drains included: used tea bags, small individual ice cream containers, and pasta. Mold and food debris were observed in the 7 sink drains. The Cook's food prep sink labeled Food Prep Only in the center of the main kitchen had a mound of rotted food scraps collected on top of the drain. Residents Affected - Many On 3/21/23 at 10:14 A.M., an interview with [NAME] 3 (CK3) was conducted. CK3 stated his cleaning process in the cooking area was to first use soap and water to clean area, then sanitize with sanitizer after every time they were done cooking in the areas, and this included mopping floor area. CK3 stated he also cleaned food prep sink basin but did not clean floor sink drains. On 3/21/23 at 4:07 P.M., an interview with FSW2 was conducted. FSW2 stated she was designated to clean area 41 which was the area around tray line. She stated her daily cleaning process was to sweeps floors, mop the area, then clean the steam table with soap then sanitize it. FSW2 stated she does clean food prep sink basins but does not clean the floor sink drains. On 3/21/23 at 4:15 P.M., an interview was conducted with Executive Chef (EXC). EXC stated in regard to cleaning the kitchen .Each person is responsible for their area. On 3/22/23 at 10:53 P.M., a concurrent interview with the FSM, FSD, and Environmental Services Director (EVD), observation of kitchen floor sink drains, and record review of pest control invoices was conducted. EVD stated that his staff doesn't clean the kitchen except for the restroom in the kitchen. The FSM, FSD, and EVD stated they were unaware of the dirty condition the floor sink drains were in inside the kitchen. The FSD and FSM stated the drains were unacceptably dirty. The FSD, FSM, and EVD stated their expectation was for the kitchen and SNF to have clean drains on a regular basis in the kitchen to prevent contamination of food and possible pest infestation. According to the 2022 FDA Federal Food Code, section 4-602.13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A review of the facility's policy titled Procedure: FANS Environmental Sanitation dated 12/05/22, indicated .2. Cleaning responsibilities .a. Daily .i. Clean and sanitize trash and waste bins .xi. High power spray and dry large and small trash bins/lids .xiii. Clean and sanitize hand sinks throughout kitchen . 3. On 3/20/23 at 10:48 A.M., an interview with Maintenance Director (MND) was conducted. The MND stated that skilled nursing facility (SNF) ice machine was cleaned 3 times a year by vendor and he and his staff performed weekly and monthly cleanings. MND stated that his staff emptied the ice bin out and cleaned the interior and exterior of machine with half to half household bleach and water diluted solution. On 3/20/23 at 11:50 A.M., a concurrent observation of the SNF Ice machine and interview with FSD, FSM, and MND was conducted. The MND opened ice machine and removed door to access the ice chute. A surveyor wiped a white paper towel along the interior areas of the bin door and along the bottom of the ice chute. The white paper towel was soiled with brown grainy dirt substances. MND was not familiar with how to remove the ice curtain of the machine. The MND, FSM, and FSD acknowledged the soiled white paper towel with the dark brown grainy substances on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 24 of 40 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 03/23/2023 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 Residents Affected - Many During a concurrent observation, interview, and record review with the MND on 3/21/23 at 9:32 A.M., the MND showed the surveyors the cleaning chemicals his staff used to clean the SNF ice machine. The cleaning chemicals were Super Sani Cloth, Zep Stainless Steel Cleaner, and household Clorox Bleach. A review of the Super Sani Cloth directions indicated, .May be harmful if swallowed .; the Zep Stainless Steel Cleaner directions indicated, .Do not take internally . and the Clorox Bleach bottle stated, .Harmful if swallowed . On 3/22/23 at 8:15 A.M., a concurrent observation of SNF Ice Machine and interview with the ice machine cleaning vendor Technician (VT), FSM, FSD, and MND were conducted. VT described his cleaning process as follows: 1. Open ice machine cover, 2. Remove top of machine, 3. Remove the curtain in front of ice grid, 4. Turn ice evaporator off, 5. Put descaler into reservoir, 6. Circulate the descaler, 7. Clean the internal pipes and tubes individually, disconnecting them and submerging them in separate buckets of descaler, water, and sanitizer and scrubbing them with pipe cleaners. VT stated he used CLR Descaler every 4 months, and Scotsman brand cleaner to clean internal components. VT removed the curtain covering the ice grid, and a brownish gray substance resembling mold was observed on the interior of the curtain. A Surveyor took a white paper towel and wiped the inside area of the ice chute and tray attached to the ice grid. The paper towel had dark brown crusty, semi-grimy pink substances on it resembling mold. The MND stated the ice machine cleaning done by his staff did not entail cleaning the ice machine curtain. The VT, FSM, FSD, and MND acknowledged the dirt and grime substances on the paper towel. VT, FSM, FSD, and MND stated it should not be there and the machine should be visibly clean. The MND stated the staff should use cleaning chemicals recommended by the manufacturer's guidelines in the future. During an interview with the FSM on 3/23/23 at 10:56 A.M., the FSM stated that the expectation for the facility's ice machines was that they should be operational and cleaned on a regular schedule using cleaning chemicals that follow the manufacturer's guidelines. The FSM further stated ice is food and should not be contaminated with mold or harmful chemicals because it could affect the health of the facility residents. According to the 2022 US FDA Food Code, Section 4-501.17, titled Warewashing Equipment, Cleaning Agents; Failure to use detergents or cleaners in accordance with the manufacturer's label instructions could create safety concerns for the employee and consumer .chemical residues could find their way into food if detergents or cleaners are used carelessly. Equipment .may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used. According to the 2022 US FDA Food Code, Section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with un-sanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. A review of the facility's undated policy titled Palomar Hospital-Poway Ice Machine Operations and Maintenance Program indicated, .Scotsman Weekly Ice maker Cleaning and Sanitation, the cleaning and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 25 of 40 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 03/23/2023 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 sanitizing solution to be used per this policy is '200 ppm chlorine solution' and 'Cleaning solution A' . Level of Harm - Minimal harm or potential for actual harm A review of the ice machine's manufacturer's guidelines, dated March 2021, located on the inside door of the ice machine in the SNF, indicated .sanitizer to be used for this machine is Nucalgon IMS and Scotsman Clear One for cleaning internal parts . Residents Affected - Many A review of facility policy 11/28/19, titled Procedure: FANS Environmental Sanitation indicated, .G. All sanitizing agents used in accordance with the manufacturer's recommendation. 4. On 3/20/23 at 3:15 P.M. an observation of Nourishment room [ROOM NUMBER] was conducted. One container of Med Pass 2.0 was passed the expiration date 2/13/23. The FSM, FSD, and Clinical Nutrition Manager (CNM) were present and acknowledged the expired supplement on the shelf. The FSM and FSD stated there should not be any expired supplements in the nourishment rooms because it could be given to residents, and this may increase their chance of getting a foodborne illness. According to the 2022 Federal FDA Food Code, section 3-602.11, titled Food Labels .(A) Food packaged .shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Review of facility policy entitled Procedure: Patient Nourishment Rooms indicates, .I. Discarding of expired items is the responsibility of Nutrition Services and is done according to established guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 26 of 40 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 03/23/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure: 1. Loading dock, dumpster cart, and area in front of the dumpster were free of kitchen waste. Residents Affected - Many 2. Food and Nutrition department floor sink drains were free from food waste. These failures provided an unsanitary environment in the kitchen that harbored pests and had the potential to contaminate resident food. The nursing home census was 109 residents. Cross reference F812, F925 Findings: 1. During a kitchen observation of the garbage disposal and concurrent interview on 03/20/23 at 2:34 P.M., Food Service Worker 1 (FSW1) demonstrated the trash removal process from the kitchen. FSW1 brought trash bags in garbage can to dock. FSW1 went down service lift to get dumpster cart. Food debris and garbage from kitchen was observed between lift and dock. FSW1 put the trash bags in the trash cart from the dock. FSW1 then climbed down from the loading dock and then he pushed trash cart to dumpster lift, which put the cart contents into dumpster and compressed contents. Foul smelling kitchen waste was observed at base of the lift where the cart was dumped. FSW1 stated he was not sure who was responsible for cleaning up the area. Dumpster cart was observed to have waste residue inside it. FSW1 returned the cart to storage area on the dock and walked to back kitchen door entrance. On the wall next to the back kitchen door entrance, there was a large electronic bug zapper neon light with dozens of dead flies, spider webs, and other insects. There were noticeable flies and gnats that flew inside the kitchen after FSW 1 entered the back door. The Food Service Director (FSD) and Food Service Manager (FSM) acknowledged the bug zapper light device was dirty with dead insects and spider webs and both stated it should be clean. 2. During the initial kitchen tour on 3/20/23 8:32 A.M., an observation of three floor sink drains was conducted. The one under a hand wash sink had pasta noodles and other debris inside, and the other two drains had visible food debris in them. On 3/21/23 at 9:10 A.M., during a kitchen observation there were seven (7) additional floor sink drains found with large amounts of kitchen waste inside them including food scraps, mildew, trash, and other debris. Some drains contained used tea bags, smashed individual ice cream containers, and substances that resembled mold. One floor sink drain in the cooking area under a food prep sink sign that read Food Prep Only had a mound of indistinguishable rotting food scraps filled to the top of the drain. On 3/21/23 at 10:14 A.M., an interview with [NAME] 3 (CK3) was conducted. CK3 stated his process for cleaning cooking area after cooking was complete was as follows: use soap and water to clean area first, sanitize with sanitizer after every time they were done cooking in the areas, including mopping the floor of that area. CK3 stated that he cleaned under the cook's prep counter table every day. CK3 further stated he cleaned the food prep sink basin but did not clean sink the floor sink drains. On 3/21/23 at 4:07 P.M., an interview with Food Service Worker 2 (FSW2) was conducted. The FSW2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 27 of 40 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 03/23/2023 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated she was designated to clean area 41 which was the area around tray line. FSW2 stated her cleaning process was to first sweep the floors, then mop, next clean the steam table with soap first, then sanitizes it with sanitizer. FSW2 stated she does clean food prep sink basins but not the floor sink drains. On 3/21/23 at 4:15 P.M., an interview was conducted with Executive Chef (EXC). EXC stated that with regards to cleaning the kitchen Each person is responsible for their area. On 3/22/23 at 10:53 A.M., a concurrent interview with the FSM, FSD, and Environmental Services Director (EVD), observation of the sink drains, and record review of facility's pest control maintenance invoices, was conducted. The EVD stated that his staff doesn't clean the kitchen floor sink drains, they only clean the kitchen restroom. EVD stated his team is responsible for overseeing the pest control in the facility. FSM, FSD, and EVD stated they were unaware of how dirty the floor sink drains were in the kitchen. The FSD and FSM acknowledged the kitchen floor sink drains were unacceptably dirty. During a review of the pest control invoices on 3/23/23 from January 2023- March 7, 2023, the invoice dated March 7, 2023, indicated, 5/19/2019 .Accumulated debris in floor drain .Clean and remove debris in or around drains to prevent possible pest infestation The FSD, FSM, and EVD all stated their expectation was for the kitchen and nursing home to be pest free and to have the kitchen floor sink drains cleaned regularly to prevent a potential pest infestation, and contamination of the food. According to the 2022 FDA Federal Food Code, section 4-601.11, It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2022). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13). According to the 2022 FDA Federal Food Code, section 4-602.13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A review of the facility's policy titled Procedure: FANS Environmental Sanitation dated 12/05/22, indicated .2. Cleaning responsibilities .a. Daily .i. Clean and sanitize trash and waste bins .xi. High power spray and dry large and small trash bins/lids .xiii. Clean and sanitize hand sinks throughout kitchen . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 28 of 40 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 03/23/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review, the Quality Assessment and Improvement Plan (QAPI-a plan to improve the overall quality of life and quality of care and services delivered to nursing home residents), failed to identify areas of improvement related to: 1. Weight loss (F-692) 2. Kitchen (F-803, F-812, F-814, F-908, F-925 3. Infection control (F-880) As a result, there was the potential to affect the safety and quality of care for residents. Findings: 1. On 3/23/23 at 2:43 P.M., an interview was conducted with the ADM, I-DON, RD 1 and RD 2. The department heads were informed the Centers for Medicare and Medicaid Services (CMS) had not reported any weight loss, according to the last MDS submission. The facility also reported to the survey team via their current Matrix Rooster (a list of residents used by the facility to identify pertinent care areas), dated 3/20/23, there were no residents reported with weight lost. The survey team later identified a resident with significant weight loss. According to RD 2, there was no current QAPI plan identifying issues with weight loss. RD 2 stated the RDs used a system called Care Tracker for reviewing residents' weight, and the facility used a program called Cerner. RD 2 stated the two different computer system did not interface with each other. RD 2 stated admission weights were the only weights entered into Cerner. The facility did not say how the MDSNs were capturing any resident with weight loss for reporting to CMS and for listing on the Matrix Rooster. RD 2 stated resident with weight loss were identified and discuss in their weekly meeting, she they were being identified, just not reported to CMS or the MDSN. The RDs stated they could access both Care Tracker and Cerner, but LNs only had access to Cerner. 2. During an interview with the CNM and FSM on 3/23/23 at 2:30 P.M., the CNM stated the facility did not have a QAPI plan to track residents' weight loss or follow up nutrition assessments. The CNM stated the facility used two computer data tracking systems for monitoring weight loss but they do not interface, so that's where things fell off for monitoring the residents' weight loss. The CNM and FSM stated there should be a clearer system to monitor the resident's weight loss using one or both computer systems. On 3/23/23 at 2:43 P.M., an interview was conducted with the ADM, I-DON, RD 1 and RD 2. The ADM and I-DON stated they have no authority or kitchen oversight, which was located in the hospital, adjacent to the skilled nursing facility. 3. On 3/23/23 at 2:43 P.M., an interview was conducted with the ADM and I-DON. The ADM stated the only infection control issue they currently had in their QAPI was antibiotic stewardship (the effort to improve how antibiotics are prescribed by clinicians and used by residents). The ADM and I-DON were unaware syringes were being reused in the sub-acute unit (a unit which provides a higher level of care) for liquid medication administration. The ADM stated she was unaware they needed a fulltime (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 29 of 40 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 03/23/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete credentialed ICN or two part time ICN with Infection Control credentials and stated the DSD did not have infection control credentials. The ADM stated she was unaware there was a requirement for annual review of the infection control policy. According to the facility's Policy, titled Procedure: Quality Assessment and Improvement Plan, dated November 2020, .Quality Assurance (QA) is the process of meeting and maintaining established quality standards such as CMS quality indicators .C. The QAPI committee will review the information provided by various sources and assist with prioritization of problem prone areas . Event ID: Facility ID: 555301 If continuation sheet Page 30 of 40 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 03/23/2023 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 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** 2a. Resident 83 was admitted to the facility on [DATE], with diagnoses which included right hip fracture with surgical repair, per the facility's Patient Information record. Residents Affected - Some On 3/20/23 at 10:20 A.M., and on 3/21/23 at 8:11 A.M., an observation was conducted of Resident 83 as she laid in bed. Resident 83 was receiving oxygen at 2 liters (Al) via nasal annular, (NC-a flexible plastic tube that delivers oxygen via the nasal cavities). The oxygen tubing had a handwritten label, dated 3/5/23. On 3/20/23, Resident 83's clinical record was reviewed: According to the physician orders, dated 3/4/23, .O 2 at 2 LP (liters per minute) via NC . There was no physician's order of when to change the oxygen tubing and there was documented evidence on Resident 83's MAR or TAR that oxygen tubing had been changed. On 3/21/23 at 12:03 P.M., an interview was conducted with the ICN. The ICN stated oxygen tubing was changed every Sunday night on the P.M. shift (3 P.M. - 11:30 P.M.), for every resident receiving oxygen therapy. The ICN stated if oxygen tubing was not changed routinely, bacteria could accumulate in tubing and cause harm to the resident. The ICN stated moisture and condensation could also be in the tubing, which would enhance bacteria growth. On 3/21/23 at 12:13 P.M., an observation and interview was conducted with LN 13 of Resident 83 as she laid in bed. LN 13 observed Resident 83's oxygen tubing dated 3/5/23. LN 13 stated the oxygen tubing should have been changed on 3/19/23, according to the facility's policy, and this was not okay. LN 13 stated the resident was at risk of respiratory infection from possible bacteria build up in the oxygen tubing. 2. Resident 206 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalon (a brain disfunction caused from, impaired metabolism), per the facility's Patient Information record. On 3/20/23 at 9:32 A.M., and at 2:47 P.M., an observation was conducted of Resident 206 as she laid in bed. Resident 206 was receiving 2 liters of oxygen via nasal cannula. The oxygen tubing was not dated. The humidifier had 1/8 clear fluid remaining in the plastic bottle and the bottle was undated. On 3/20/23, Resident 206's clinical record was reviewed. According to the physician's order, dated 3/17/23, .admin O2 at 2 LMP (liter per minute) via NC .Change .tubing weekly every evening shift every Sunday, start 3/19/23 . According to the TAR, the oxygen tubing was changed on the evening of 3/19/23, but the tubing was never dated, indicating it had not been changed. On 3/21/23 at 11:44 A.M., an interview was conducted with LN 14. LN 14 stated LNs change all oxygen tubing and humidifiers every Sunday night on the P.M., shift. LN 14 stated it was important to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 31 of 40 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 03/23/2023 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 0880 change the oxygen devices weekly to prevent infection from occurring within then oxygen set up. Level of Harm - Minimal harm or potential for actual harm On 03/21/23 12:06 P.M., an observation and interview was conducted with the ICN of Resident 206 as she laid in bed. The ICN stated Resident 206 should have her oxygen tubing dated, along with humidifier and they were not. The ICN stated it was important to consistently change the tubing and humidifier to prevent bacteria from growing, which would result in an infection. Residents Affected - Some On 3/22/23 at 2:50 P.M., an interview was conducted with the DSD. The DSD stated all tubing and humidifiers should be dated of when they were changed. The DSD stated it was important to routinely change oxygen equipment to prevent infection from occurring. On 3/23/23 at 8:43 A.M., an interview was conducted with the I-DON. The I-DON stated oxygen tubing and humidifiers were changed every Sunday evening by then LNs on the P.M. shift. The I-DON stated LNs should request an order from the physician to change all oxygen equipment once a week, and then the order would appear on the TAR. The I-DON stated if oxygen equipment was not routinely changed, bacteria could grow and residents would be at risk of infection. The I-DON stated all oxygen equipment should be changed at the same time, not just the tubing. On 3/23/23 at 9 A.M., the I-DON reviewed the facility's policy, titled Procedure: Supply-Equipment changes for Infection Control, dated November 2019, .IV. Steps of Procedure: A. Change items according to the following schedule: .3. Nebulizer circuit: weekly, 4. Oxygen tubing: monthly . The I-DON stated she believed all oxygen set-up equipment should be changed weekly, which included the oxygen tubing, to prevent infection. Based on observation, interview, and record review the facility failed to ensure infection control practice where followed when: 1. Staff were reusing the one-time-use syringes in the sub-acute (a specialized unit with higher acuity resident) unit; on two of four medication (Cart 1 and Cart 2) carts. 2. Oxygen equipment was not being dated or changed routinely, for two of five residents (Resident 83 and 206). 3. The infection prevention and control policy was not reviewed annually As a result, residents had the potential to be exposed to infections. Findings: 1. On 3/22/23, at 9:11 A.M., a concurrent observation and interview with LN 21 of unit B station. LN 21 stated she was responsible for checking the medication cart. The following were observed: Medication Cart #1 Fourth Drawer: *Levocarnitine Solution (medication to prevent low carnitine in dialysis patients) 200mls bottle with a 10ml syringe in a plastic wrap taped to the bottle. *Levetiracetam Solution (medication to prevent seizures) 300mls bottle with a 10ml syringe in a plastic wrap taped to the bottle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 32 of 40 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 03/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LN 21 validated above listed items found on Cart 1. LN 21 stated, these syringes were in the cart when she started her shift and was not sure how long they had been in use. LN 21 further state, she did not know the facility policy. On 3/22/23, at 10:38 A.M., a concurrent observation and interview with LN 22 of the second of four medication carts, Cart 2. LN 22 stated, she was responsible for checking the medication cart at the start of her shift. The following were observed: Medication Cart #2 Third Drawer: *Felbatol Suspension (Medication to prevent seizures) 200mls with a 10ml syringe in a plastic wrap taped to the bottle. *Levocarnitine Solution (medication to prevent low carnitine in dialysis patients) 200mls bottle with a 10ml syringe in a plastic wrap taped to the bottle. LN 22 validated above listed items. LN 22 stated these syringes were in the cart when she started her shift and was not sure how long they had been in use. LN 22 stated that the nurses use the syringe to get the medications out of the bottles and did not know the syringe could not be reused. LN 22 further stated, she was not sure of the facility policy. ON 3/22/23 at 11:22 A.M., an observation a of a 10ml syringe in a plastic wrap taped to a medication bottle in Medication Cart #2 was noted to have visible residual medication debris on it. On 3/23/23 at 1:01 P.M., a telephone interview with the PC was conducted. The PC stated, medication soluble's sent to the facility do not come with a syringe. The PC further stated it is the expectation for the LN staff to use designated measured medication cups for all soluble medications. On 3/23/23, at 1:33 P.M., an interview with the ICN nurse was conducted. The ICN nurse stated, the expectation is for the staff to utilize good infection control practices. The ICN nurse stated, the syringes were a one-time use item and should not have been reused. The ICN nurse further stated, the staff need to observe good infection control practices to infections to residents. On 3/23/23, at 2:03 P.M., an interview with the I-DON was conducted. The I-DON stated the expectation is for the LN staff to perform good infection control practices. The I-DON further stated, the LN staff should have thrown out the syringe after each use. A review of the manufacturers' packaging stated, their syringes were a single use item. 3. On 3/23/23 the facility's policy, titled Procedure: Enhanced Standard Precautions-Infection Control, dated 10/11/13, was reviewed and had not been updated for the past 10 years. According to Code of Federal Regulations, 483.80 Infection Control . F-880 .section 483.80(f) Annual review: The facility will conduct an annual review of its IPCP and update their program. An interview and concurrent record review were conducted on 3/22/23, at 3:40 p.m., with the ICN. The ICN stated she performed duties of the infection control nurse for 4 hours, and the DSD also performed the duties for four hours a day. The ICN reviewed the infection control policy and stated the policy was not currently updated and the hospital committee was the one who approved policies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 33 of 40 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 03/23/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/23/23, at 8:15 a.m., with the I-DON, the I-DON stated the Infection Control policy had not been reviewed annually. The ICN stated it was important to have an updated policy because infection control issues change constantly and they needed to stay know the latest information available. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 34 of 40 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 03/23/2023 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to ensure to have a full-time, certified infection control nurse (ICN-a professional who ensures healthcare workers and patients are doing all the things they should be doing to prevent infections and the spread of infections), who provides assessment, monitoring, development, implementation and management of the facility's infection prevention and control program. This failure had the potential of negatively affecting the quality of care provided to all residents. Findings: On 3/22/23 at 3:40 P.M., an interview was conducted with the facility's ICN. The ICN stated she worked as the ICN for four hours a day and was fully certified as a ICN. The ICN stated she shared the infection prevention duties with the DSD, who provided education, monitoring, and teaching to residents and staff members. On 3/22/23, at 3:40 p.m., an interview was conducted with the DSD. The DSD stated she was currently in training for certification as an ICN, an was not yet certified. The DSD stated she assisted with infection control training to staff members. During an interview on 3/23/23, at 8:15 a.m., with the I-DON, the I-DON stated a full time ICN was needed. The I-DON stated it was important to clearly delineate the role on an ICN. The I-DON stated since the start of COVID, there were many things impacted with infection control. The I-DON stated their resident population had important pieces of care provided to prevent infections. A review of the All Facilities letter (AFL 21-51), dated December 13, 2021, titled Assembly [NAME] (AB) 1585 - Expansion of SNF (skilled nursing facility) Infection Preventionist (IP) Minimum Qualifications, indicated, SNFs continue to be required to employ a full-time, dedicated IP . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 35 of 40 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 03/23/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and document reviews the facility failed to ensure: 1. One ice machine in the main kitchen was maintained in a safe operating condition. Residents Affected - Many 2. One ice machine in the skilled nursing facility (SNF) was maintained and cleaned according to manufacturer's guidelines and standards of practice. This failure created the potential for residents to receive and consume ice from machines that were contaminated with substances resembling mold and other hazardous chemicals, that could lead to foodborne illness and impair health status. The facility census was 109. Cross reference F812 Findings: 1. On 3/20/23 at 8:40 A.M., during the initial kitchen tour, a concurrent observation and interview was conducted with the Patient Service Supervisor (PSS). Ice machine #15 was observed to be empty, no ice in bin. Machine log read machine was cleaned on 3/19/23. No signs indicating the ice machine was out of service were present on the machine. PSS stated she believed the Ice machine #15 in the main kitchen, stopped working on 3/19/23 during the night shift. The ice bin was empty, and the front panel red light was blinking. On 3/20/23 at 8:58 A.M., a concurrent interview and observation of the ice machine was done with Food Service Manager (FSM). FSM stated a vendor comes in to clean and maintain Ice Machine #15, but she was unaware how long it was not working or out of service. On 3/20/23 at 10:30 A.M., during an interview with the Food Service Director (FSD) in the kitchen, the FSD stated the facility maintenance departments takes care of cleaning and maintaining ice machine #15 and a vendor maintains the ice machine in the SNF. The FSD stated she believed the ice machine #15 recently went out of service but did not know when it occurred. On 3/21/23 at 9:00 A.M. an observation of ice machine # 15 was conducted. An Out of service sign was placed on the front of the machine. FSM stated there was no functional ice machine in the main kitchen, to use, and only in the SNF ice machine worked. 2. On 3/20/23 at 10:48 A.M., an interview with Maintenance Director (MND) was conducted. MND stated the SNF ice machine cleaning was done 3 times a year by a vendor, and the maintenance department staff conducted weekly and monthly cleanings. The MND stated when his staff cleaned the ice machine monthly, they would empty the ice bin out and clean the interior and exterior of machine with a half to half diluted solution of household bleach and water. On 3/20/23 at 11:50 A.M., a concurrent observation of the SNF Ice machine and interview with the MND, FSD and FSM was conducted. MND opened the ice machine and removed the access door to the chute area. A surveyor wiped a clean paper towel along the interior areas of bin doorway, and along the bottom of the ice chute. The white paper towel was soiled with brown grainy residue substances. MND was not familiar with how to remove the ice machine curtain inside the machine. The MND, FSM, and FSD all acknowledged the soiled residue on the paper towel from the ice machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 36 of 40 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 03/23/2023 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 3/21/23 at 9:32 A.M., a concurrent interview with MS, observation of ice machine cleaning chemicals, and record review of ICE MACHINE OPERATIONS AND MAINTENANCE MANAGEMENT was conducted. MND stated cleaning chemicals he used for cleaning Villa's ice machine were the following: 1. Super Sani Cloth, 2. Zep Stainless Steel Cleaner, 3. Clorox Bleach. MND brought samples of the chemicals that were used. Record review of Super Sani Cloth directions on container states, .May be harmful if swallowed . Record review of Zep Stainless Steel Cleaner directions on bottle states, .Do not take internally . Record review of directions on Clorox Bleach bottle states, .Harmful if swallowed . On 3/22/23 at 8:15 A.M., a concurrent observation of the ice machine and interview with the vendor technician (VT), FSM, FSD, and MND was conducted. The VT described his cleaning process as follows: 1. Open ice machine cover, 2. Remove top of machine, 3. Remove the curtain in front of ice grid, 4. Turn ice evaporator off, 5. Put descaler into reservoir, 6. Circulate the descaler, 7. Clean the internal pipes and tubes individually, disconnecting them and submerging them in separate buckets of descaler, water, and sanitizer and scrubbing them with pipe cleaners. VT stated he used CLR Descaler every 4 months, and Scotsman brand cleaner to clean internal components. VT removed the curtain covering the ice grid, mold was observed on interior of the curtain. MND stated his staff did not remove or clean the ice machine curtain when they did their cleaning. A Surveyor took a white paper towel and wiped the inside area of the ice chute and ice tray attached to the ice grid. The paper towel had dark brown crusty, semi-grimy particles and a pink substance resembling mold on it. The VT, FSM, FSD, and MND all acknowledged the brown and pink grime substances on the paper towel. The VT, FSM, FSD, and MND stated it should not be there and the machine should be visibly clean. The MND stated the staff should use the cleaning chemicals recommended by the manufacturer's guidelines to clean the ice machine in the SNF. On 3/23/23 at 10:56 A.M., an interview was conducted with FSM. The FSM stated the expectation for the ice machine cleaning was that they should be operational and cleaned on a regular schedule with chemical solutions that follow manufacturer's guidelines. The FSM stated ice is food and should not be contaminated with mold or harmful chemicals because it could affect the health of the SNF residents. A review of facility's undated policy, titled Palomar Hospital-Poway Ice Machine Operations and Maintenance Program, indicated .Scotsman Weekly Ice maker Cleaning and Sanitation, the cleaning and sanitizing solution to be used per this policy is '200 ppm chlorine solution and Cleaning solution A' . A review of the manufacturer's guidelines, dated March 2021, found inside the SNF Ice machine cover door panel indicated .sanitizer to be used for this machine is Nucalgon IMS and Scotsman Clear One for cleaning internal parts . According to the 2022 US FDA Food Code, Section 4-501.17, titled Warewashing Equipment, Cleaning Agents; Failure to use detergents or cleaners in accordance with the manufacturer's label instructions could create safety concerns for the employee and consumer .chemical residues could find their way into food if detergents or cleaners are used carelessly. Equipment or utensils may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used. According to the 2022 US FDA Food Code, Section 4-501.11, titled Good Repair and Proper Adjustment. (Equipment) Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 37 of 40 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 03/23/2023 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to the 2022 US FDA Food Code, Section 3-303.11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with un-sanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. A review of facility policy dated 12/05/22, titled Procedure: FANS Environmental Sanitation was conducted. Policy states, .G. All sanitizing agents used in accordance with the manufacturer's recommendation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 38 of 40 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 03/23/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the main kitchen area and the skilled nursing home (SNF) were free of pests. Residents Affected - Many This failure had the potential to contaminate food prepared, stored and served to facility residents, which could lead to widespread foodborne illness. The facility census was 109. Cross reference F812, F814 Findings: During the initial kitchen tour on 3/20/23 at 8:45 A.M., multiple fruit flies were observed flying around hand washing sinks and food prep sinks. On 3/20/23 at 2:35 P.M., an observation of exterior loading dock was conducted enroute to trash disposal area. A large electronic bug zapper light was on the outside wall at the back exit door entrance exit to kitchen with dozens of dead flies, other insects, and spider webs. The Foodservice Manager (FSM) and Foodservice Director (FSD) acknowledged the dirty electronic bug light with dead insect carcasses and spider webs and stated it should be clean. During an observation on 3/21/23 at 8:05 A.M. of the SNF's Education Room there were multiple dead pest carcasses including cockroaches, crickets, and rodents found on the floors on glue sticky insect pads and mouse traps. Specifically, there were four (4) metal box mouse traps and 6 glue rodent/pest traps in the main room and around room the kitchenette. The glue sticky traps had dead roach and cricket carcasses stuck to it. A one-inch gap under the sliding door leading to the outside courtyard was identified while the survey team occupied the room during the recertification survey period from 3/20/23-3/23/23. On 3/22/23 at 10:53 A.M., an observation, interview with the Environmental Services Director (EVD), and record review of the facility's pest control vendor's Service Inspection Reports was conducted. The EVD stated he and his team were responsible for overseeing the pest control in the hospital and SNF. The EVD was shown the mousetraps and glue traps in the SNF's Education Room. He stated he was unaware of the mousetraps and insect filled glue traps in the Education room and they should have been changed out because the pest control vendor was recently at the facility. A review of the Service Inspection Report invoices from January 2023 through March 7, 2023, indicated the pest control company had not documented any activity under Conditions/Observations since 12/7/21. Review of the entry from 4/13/21 indicated .Sliding door entry has gaps on bottom which creates a possible entry point . The EVD stated the Education room had a problem earlier in the year with pests, but he thought it was resolved. The EVD stated his expectation was that the facility would be pest free. On 3/22/23 at 3:04 P.M. a concurrent interview with Environmental Services Supervisor (EVS) and observation of pest traps was conducted. The EVS supervisor stated she oversaw the pest control vendor visits in the SNF. The EVS stated that pest control company comes weekly, and on-call as needed. The EVS stated she goes with the vendor when they do their service and reviews what they did afterwards. EVS stated the vendor was here Tuesday 3/21/23 in the evening but was told to not come to this room. The EVS stated each time the vendor changes the rodent trap or glue sticker, they are supposed to replace with new ones and date the back of the trap. The EVS did not know the Education room traps and sticky pads were filled with insects and had not been changed. The EVS also stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 39 of 40 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 03/23/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many know the vendor was not documenting on invoices what services were performed at the visits. The EVS stated her expectation was the facility would be free of pests and the vendor would document the services performed during visits. During an interview with the FSM on 3/23/23 at 10:56 A.M. the FSM stated her expectation was for the kitchen and SNF to be pest free. The FSM stated the importance of having a pest free kitchen and facility was to prevent contamination of the food, so residents don't get sick. On 3/23/23 at 1:30 P.M. an observation and interview with Resident 213 was conducted. Review of MDS section C assessed Resident 213's BIMs to be 14, meaning patient has intact cognition. Resident 213 was observed sitting up in the wheelchair with the bedside table in front of her and lunch meal tray on the table. A banana was on her plate. Resident 213 stated, I don't want to eat this banana, there's flies all over it, see there's one right there . Resident 213 then stated, Can I get another banana that's not bruised and doesn't have flies on it? Two gnats were observed flying near lunch tray. The tray was removed by staff. The ADM was present during the observation and interview and stated the flies should not be on the resident's food, so she requested another banana from the kitchen. According to the 2017 Federal Food Code, section 6-501.111, stated .Controlling Pests .The premises shall be maintained free of insects, rodents, and other pests .by .routinely inspecting the premises for evidence of pests . A review of facility policy dated 8/23/16, titled Procedure: Pest Elimination Contracted Services indicated, .1. Observance to ensure a pest free facility is the joint responsibility of all hospital employees and the Environmental services personnel assigned to perform cleaning services in a particular department FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 40 of 40