Health inspection·May 22, 2025

F 0550 Pick-Up, dated 2/5/24, indicated .4. Trays are delivered within the scheduled meal times for each unit . 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 2 of 23 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 05/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Advance Directive information was provided to a resident (Resident 10). This failure had the result for Resident 10 to not have the opportunity to express wishes for care if capacity for decision making was lost. Findings: On 5/19/25 Resident 10's clinical record was reviewed. Resident 10 was re-admitted to the facility on [DATE] per the facility's Patient Information. A document titled Advance Directive Acknowledgment dated 2/19/19, 4/19/19, and 2/13/24 indicated, I do not have an Advance Directive, however, I am interested in receiving an Advance Directive Brochure . which was initialed by Resident 10 and Resident 10's family member. There was no notation on either of the forms of whether the brochure was given to the resident or family member. On 05/21/25 at 08:29 A.M., a joint review of Resident 10's record was conducted with the Patient Financial Advocate (PFA). The PFA stated there was no documentation of whether Resident 10 received the Advance Directive brochure. The PFA stated Business Office staff should have documented on the Advance Directive Acknowledgment form if the brochure was provided. On 05/21/25 at 10:28 A.M., Resident 10 was interviewed in her room. Resident 10 stated she had been at facility for six years. Resident 10 stated she did not know what an Advance Directive was and did not receive a brochure or information from the facility about it. On 05/21/25 at 02:21 P.M., a joint review of Resident 10's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 10 did not have an Advance Directive on the chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/21/25 at 2:32 P.M., a joint review of Resident 10's record was conducted with the Administrator (ADM). The ADM stated if there was an Advance Directive, it should have been on the physical paper chart. On 05/22/25 at 08:48 A.M., a joint review of Resident 10's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advance Directive, the HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 10. On 05/22/25 at 09:05 A.M., the ADM was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated there was no Advanced Directive available for Resident 10. Per facility procedure Advance Directives, revised 5/13/24, .Inquiry and documentation regarding advance directive should occur as soon as reasonably possible during the admission process on all patients. At the time of admission, the patient .should be asked about and provided with, if requested, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 3 of 23 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 05/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm written information about the advance health care directive .the patient .who does not have an advance directive should be offered Your Right to Make Decisions about Medical Care .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 4 of 23 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 05/22/2025 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 0583 Keep residents' personal and medical records private and confidential. 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 protect confidential information for one unsampled resident (Resident 15). Residents Affected - Few This failure had the potential for Resident 15's confidential health information to be accessed by unauthorized individuals. Findings: On 5/19/25 Resident 15's clinical record was reviewed. Resident 15 was admitted to the facility on [DATE] per the facility's Patient Information with a diagnosis of Respiratory Failure (when the lungs cant properly exchange oxygen). On 5/21/25 at 8:37 A.M., an observation and interview was conducted with LN 1 during preparation for medication administration for Resident 15. LN 1 was observed putting the packaging for Prosource no carb 102 (a supplement used to increase protein intake) into the medication cart trash. The identification label attached to the Prosource packaging had Resident 15's first and last name on it. LN 1 stated she should have put Resident 15's identification label into the confidential bin. On 5/21/25 at 3:38 P.M., an interview was conducted with Unit Manager (UM) 11. UM 11 stated labels with a resident name on it should have been put in the confidential bin and not into the trash. On 5/22/25 at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated any resident identification label would need to go in the confidential shred machine and should not be present on packaging placed in the trash can. A review of the facility's policy titled Procedure: Privacy- Confidentiality and Access to Patient Information revised 12/31/2021, indicated .1. Protected Health Information or PHI is any individually identifiable health information .Individually identifiable means that the health or medical information includes or contains any element of personal identifying information sufficient to allow identification of the individual such as a patient's name .10. All hospital personnel are responsible for controlling and enforcing the principle of confidentiality, .Each department is responsible for providing a secure location for patient identifiable information, and will take reasonable measures to ensure the security of the information against unauthorized access FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 5 of 23 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 05/22/2025 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 interview and record review, the facility failed to obtain residents' weight upon admission for seven of 18 sampled residents (36, 280, 282, 430, 19, 9, 3). In addition, the facility did not ensure input and outputs (I & Os) were documented accurately for one sampled resident (Resident 73) on intravenous (IV - giving medications, fluids, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medications. Residents Affected - Some These failures had the potential to delay identification of risk factors related to nutrition and hydration for Resident 2, 36, 280, 282, 430, 19, 9, 3, and 73. Findings: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), per the facility's Patient Information. 2. Resident 280 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), per the facility's Patient Information. 3. Resident 282 was admitted to the facility on [DATE] with diagnoses which included hypertension, per the facility's Patient Information. 4. Resident 430 was admitted to the facility on [DATE] with diagnoses which included pneumonia (an infection/inflammation in the lungs), per the facility's Patient Information. On 5/21/25 at 9:41 A.M., a joint review of Resident 36, Resident 280, and Resident 282's clinical record and an interview was conducted with Licensed Nurse (LN) 11. Clinical record review as follows: Resident 36 was admitted on [DATE]. Resident 36's weight was taken/ documented on 5/11/25. Resident 280 was admitted on [DATE]. Resident 280's weight was taken/ documented on 5/18/25. Resident 282 was admitted on [DATE]. Resident 282's weight was taken/ documented on 5/11/25. LN 11 stated residents' weights should have been taken upon admission for a baseline to ensure the residents were not losing weight or developing edema (swelling). On 5/21/25 at 10:19 A.M., an interview was conducted with Restorative Nursing Assistant (RNA) 11. RNA 11 stated the RNAs were responsible for weighing the residents on Saturdays and Sundays. RNA 11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 6 of 23 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 05/22/2025 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 - Some stated when residents were admitted to the facility on weekdays, the Certified Nursing Assistants (CNAs) were responsible to weigh the residents upon admission. RNA 11 stated when the staff were not able to obtain the residents weights on the day of admission, the staff were supposed to weigh the residents the following day within a 24-hour period. On 5/21/25 at 3:58 P.M., a joint review of Resident 36, Resident 280, Resident 282 and Resident 430's clinical record and an interview was conducted with the Unit Manager (UM) 11. Clinical record review as follows: - Resident 36 was admitted on [DATE]. Resident 36's weight was taken/ documented on 5/11/25. - Resident 280 was admitted on [DATE]. Resident 280's weight was taken/ documented on 5/18/25. - Resident 282 was admitted on [DATE]. Resident 282's weight was taken/ documented on 5/11/25. - Resident 430 was admitted on [DATE]. Resident 430's weight was taken/ documented on 5/7/25. UM 11 stated residents' weights should have been taken upon admission and readmission unless contraindicated like orthopedic procedures. UM 11 stated the residents' weights as zero indicated, Someone was trying to bypass the assessment. UM 11 stated the resident's weight should have been accurate. UM 11 stated the residents should have been weighed within 24 hours upon admission for baseline to check if a resident was gaining or losing weight. UM 11 stated per the regulation the residents should be weighed upon admission or within 24 hours. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility's policy was to weigh the residents within 72 hours on admission. The DON stated, Even so with our policy, we are not abiding with our policy. A review of the facility's policy titled, Weighing Residents, revised 8/29/23, indicated, Residents are weighed to determine nutritional status and evaluation of overall health . A review of the facility's policy titled, Documentation Schedule, revised 9/20/19, indicated, .To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .C. admission documentation is completed within 24 hours of the admission . 5. Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's, Patient Information. On 5/22/25 at 10:19 A.M., a joint record review and an interview were conducted with LN 23. LN 23 described the facility's process on weighing residents. LN 23 stated the residents would be weigh upon admission, then every week for 4 weeks and then every month or if there was an order that weighing was contraindicated. Resident 19's Weight Detail Report indicated Resident 19 admission weight was taken on 3/14/24. LN 23 stated that Resident 19 should have been weighed on 3/4/24 and not 10 days later. 6. Resident 9 was re- admitted to the facility on [DATE], with diagnoses which included pyelonephritis (kidney infection), per the facility's, Patient Information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 7 of 23 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 05/22/2025 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 - Some On 5/22/25 at 10:20 A.M., a joint record review and an interview were conducted with LN 23. A review of Resident 9's Weights Detailed Entry Report indicated Resident 9's admission weight was taken on 1/5/25. LN 23 stated Resident 9 should have been weighed on 12/24/25 upon admission and should not have waited 12 days later. 7. Resident 3 was admitted to the facility on [DATE], with diagnoses which included Liver abscess (pus filled pocket caused by infection), per the facility's, Patient Information. On 5/22/25 at 10:22 A.M., a joint record review and an interview were conducted with LN 23. A review of Resident 3's Weights Detailed Entry Report indicated Resident 3's admission weight was taken on 1/28/24. LN 23 stated Resident 3 should have been weighed on 1/11/24 upon admission and should not have waited 17 days later. On 5/22/25 at 11:37 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff should have followed the policy and procedure for weighing residents. The DON stated she expected staff to weigh residents on admission. A review of the facility's policy titled, Weighing Residents, revised 8/29/23, indicated, Residents are weighed to determine nutritional status and evaluation of overall health . A review of the facility's policy titled, Documentation Schedule, revised 9/20/19, indicated, .To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .C. admission documentation is completed within 24 hours of the admission . 8. According to the facility's Patient Information record, Resident 73 was admitted on [DATE] with diagnoses that included congestive heart failure (CHF - condition when the heart isn't pumping blood as efficiently as it should, leading to fluid buildup in the body, especially the lungs). A record review of Resident 73's physician's orders indicated on 5/7/25, Resident 73 was started on Zosyn (antibiotic) 3.375 grams IV every 6 hours x 10 days for pneumonia (PNA - lung infection). A record review of Resident 73's I&Os for the month of May 2025 indicated that recorded input did not include the IV fluid amount Resident 73 received from the IV antibiotics. On 5/20/25, at 3:30 P.M., an interview was conducted with the licensed nurse (LN 1). LN 1 stated IV fluids and IV medication amounts are not recorded or documented. LN 1 stated they stopped recording IV intake amounts when the electronic medical records (EMR) system was changed. On 5/21/25, at 3:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that all fluids, including IV medications, need to be recorded in the residents' I&Os. A review of the facility policy titled Procedure: Intake and Output, dated 1/31/04, indicated .3. Licensed nurse records fluids administered by intravenous lines as intake . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 8 of 23 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 05/22/2025 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of one resident reviewed for dialysis (Resident 19). Residents Affected - Few This deficient practice had the potential for Resident 19's dialysis access to clot. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's Patient Information. On 5/19/25 at 11:03 A.M., an interview was conducted with Resident 19 in her room. Resident 19 stated she was a dialysis resident and scheduled for dialysis on Tuesday, Thursday, and Saturday. Resident 19 showed her right arm dialysis access site. On 5/20/25 at 4 P.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was up in her wheelchair. Resident 19 stated she came back from her dialysis at 1 P.M. and showed a dressing on her right upper arm dialysis access site. Resident 19 stated the facility nurse will remove the dressing after 24 hours. On 5/21/25 at 8:07 A.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was seated in bed for breakfast. Dressing noted in her right arm dialysis access site. On 5/21/25 at 8:25 A.M., an interview was conducted with Licensed Nurse (LN) 21. LN 21 stated, Resident 19 went to dialysis yesterday and came back with a dressing on her dialysis access site. LN 21 stated she did not know when to remove the dressing in Resident 19 dialysis access site. On 5/21/25 at 11:30 A.M., a concurrent record review and an interview were conducted with LN 23. Resident 19 dialysis communication record was reviewed. There was no documentation indicated when to remove the dressing. LN 23 stated dressing on Resident 19's access site would be removed 24 hours after dialysis. On 5/21/25 at 4:20 P.M., an interview and an observation were conducted with Resident 19 in her room. Resident 19 was seated in her wheelchair and noted that there was no dressing on her right upper arm. Resident 19 stated the dressing was removed by the staff around 12 noon. On 5/22/25 at 4:32 P.M., an interview was conducted with LN 22. LN 22 stated Resident 19 access site dressing should be removed 24 hours after dialysis. On 5/22/25 at 8:06 A.M., a phone interview was conducted with the Hemo Dialysis Nurse (HDN). The HDN stated she was one of Resident 19's dialysis nurses and very familiar with her care. The HDN stated Resident 19 went to dialysis on Tuesday, Thursday, and Saturday. The HDN stated dressing on Resident 19's access site should be removed at the end of the day or between 4 - 6 hours after dialysis. The HDN stated the dressing should not be left on for 24 hours due to increased risk of clotting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 9 of 23 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 05/22/2025 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 0698 On 5/22/25 at 8:42 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the dressing for the dialysis access site should be removed 24 hours after the dialysis. Level of Harm - Minimal harm or potential for actual harm The facility did not have a Dialysis Care policy and procedure upon request. Residents Affected - Few - FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 10 of 23 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 05/22/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four license nurses were knowledgeable in assessing the thrill and bruit (thrills are palpable, vibratory sensations felt on the skin, while bruits are abnormal, audible sounds heard through a stethoscope) related to dialysis (the process of cleaning the blood through a machine) access. This failure had the potential for dialysis access to develop complications that may not be identified timely and addressed. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's, Patient Information. On 5/19/25 at 11:03 A.M., an interview was conducted with Resident 19 in her room. Resident 19 stated she was a dialysis resident and scheduled for dialysis on Tuesday, Thursday, and Saturday. Resident 19 showed her right arm dialysis access site. On 5/20/25 at 4 P.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was up in her wheelchair. Resident 19 stated she came back from her dialysis at 1 P.M. and showed the dressing on her right upper arm dialysis access site. Resident 19 stated the facility nurse will remove the dressing after 24 hours. On 5/21/25 at 4:32 P.M., an interview was conducted with LN 22. LN 22 was unable to described how to check Resident 19's dialysis access site's bruit and thrill. On 5/22/25 at 7:25 A.M., an interview was conducted with Resident 19 in her room. Resident 19 was seated in her wheelchair. She stated that she was waiting for her transportation for dialysis. Resident 19 stated staff checked her dialysis access site every shift. Resident 19 described how the LNs checked if her dialysis access was working. Resident 19 stated the LNs placed their hands on the dialysis access and felt it. Resident 19 stated the LNs did not use a stethoscope in checking her dialysis access. On 5/22/25 at 7:36 A.M., an interview was conducted with LN 25. LN 25 stated she checked Resident 19's bruits and thrills by placing her hand over the dialysis access. LN 25 stated she did not receive training on how to take care of dialysis residents. On 5/22/25 at 9:32 A.M., an interview was conducted with LN 23. LN 23 stated she placed her hand over Resident 19's dialysis access to check the bruit and thrill. On 5/22/25 at 2:07 P.M., an interview was conducted with LN 11. LN 11 described how she checked the bruit and thrill of the dialysis access. She stated she placed her hand over the dialysis access and felt it. On 5/22/25 at 2:12 P.M., an interview was conducted with Unit Manager (UM) 11. UM 11 stated she did not receive educational training on how to take care of dialysis residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 11 of 23 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 05/22/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm On 5/22/25 at 2:29 P.M., an interview was conducted with LN 27. LN 27 stated she did not receive educational training on how to take care of dialysis residents. On 5/22/25 at 1:41 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she was not able to find evidence of training provided to staff related to dialysis care. Residents Affected - Few On 5/22/25 at 1:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she expected her staff to know how to properly check the bruit and thrill for a dialysis resident by using their stethoscope in listening to the bruit and palpating to feel the thrill. The DON further stated that she was not able to find evidence that staff were provided training on how to take care of dialysis residents. A review of the facility's Policy and Procedure(P&P) titled, Competency Evaluation, revision date 7/30/21, indicated .to identify the processes by which individual competence is evaluated and documented initially and on an ongoing basis to ensure employees at [name of the organization] can provide safe and effective quality care, treatment, and services .III .2. Competency evaluation focuses on key safety content such as specific processes and procedures related to the provision of care; conditions or diseases treated; services provided; the environment of care; infection control and equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 12 of 23 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 05/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the controlled drug record (CDR- an accounting of controlled medications, drugs with a high abuse potential) reconciled with the medication administration record (MAR- documentation that a resident received a medication) for one of three residents (Resident 3 ). As a result, this failure had the potential for the facility to be unable to readily identify drug diversion (illegal distribution or abuse of prescription drugs) of controlled medications. Findings: Resident 3 was admitted to the facility on [DATE] per the facility's Patient Information sheet. A record review of Resident 3's physician's order, CDR, and MAR was performed. Resident 3's physician's order dated 3/19/24, indicated the Resident was to receive oxycodone 5 milligrams (medication used to relieve pain) one tab every six hours as needed for moderate to severe pain. A review of Resident 3's CDR indicated 3 doses of the resident's oxycodone 5 milligrams was removed from the locked supply on 3/10/2025, 3/12/25, and 3/18/25. Resident 3's MAR for oxycodone 5 milligrams had blank entries on 3/10/2025, 3/12/25, and 3/18/25 and it could not be determined if the medication had been given to the resident. During an interview on 5/22/25 at 10:53 A.M., Unit Manager (UM)11 stated the Licensed Nurse (LN) had to sign controlled medications out on the CDR and document on the MAR when the medication was given to the resident. UM 11 stated that it was important to keep track of controlled medications so that other LNs knew when the medication was given. During a concurrent interview and record review on 5/22/25 at 11:07 A.M., the Director of Staff Development (DSD) reviewed the resident's CDR and MAR. The DSD stated Resident 3's oxycodone 5 milligrams tablet was removed and was not documented as administered on Resident 3's MAR on 3/10/25, 3/12/25, and 3/18/25. The DSD stated her expectation was for the LN to sign the CDR when controlled medications were removed from the locked drawer and then for the LN to document on the resident's MAR once the medication was given to the resident. During an interview on 5/22/25 at 2:15 P.M., the Director of Nursing (DON) stated Resident 3's oxycodone 5 milligram tablet was removed on 3/10/25, 3/12/25 and 3/18/25 but was not documented as given to the resident on the MAR. The DON stated there was currently no audit of controlled medications being done. The DON stated that the significance of doing an audit was to make sure there was no diversion. A review of the facility's policy and procedure titled Procedure: Controlled Drugs revised 9/12/2019, did not provide guidance related to reconciling and accounting for controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 13 of 23 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 05/22/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications in carts were properly stored and labeled when the following was found in two of twenty medication carts: 1. An expired insulin pen. 2. A use by sticker on a medication bottle was illegible. 3. There was a white pill in an unlabeled medication cup. As a result, medications had the potential to be improperly administered. Findings: On [DATE] at 3:39 P.M., an observation and interview was conducted with Licensed Nurse (LN) 2 during a review of a medication cart. Lantus 100 units/mL (milliliter) pen (a medication given to lower blood sugar), was found in the top drawer of the medication cart labeled with an orange sticker: do not use after [DATE]. LN 2 stated when insulin was opened the nurse put an orange sticker with the use by date on the insulin pen. LN 2 stated insulin once opened was good for 28 days. LN 2 stated nurses were supposed to check the date and double check the time to discard since the insulin is not potent after expiration. In the bottom drawer of the medication cart, a bottle of Constulose 10 g/15 mL (a medication to treat constipation) had an illegible date written on the use by sticker. LN 2 stated labeling should be legible to make sure it was not expired. On [DATE] at 11:36 A.M., an observation and interview was conducted with LN 3. One white pill in an unlabeled medication cup was found in the top drawer of a medication cart. LN 3 stated it should have had the resident's name and name of medication written on the cup. On [DATE] at 3:38 P.M., an interview was conducted with the Unit Manager (UM) 1. UM 1 stated open insulin should have been discarded within 28 days per their pharmacy's guidance. UM 1 stated use by labels on medications should be legible. On [DATE] at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the orange use by label lets the facility know when the medication would expire. The DON stated open Lantus with a use by date of [DATE] should not have been stored and ready for use in the medication cart. The DON stated labeling on medications should be legible. DON stated all medications needed to be dated and labeled with the resident name. A review of the facility's policy titled Medications and Medication Labels dated 5/16, indicated, .1. Each prescription medication will be labeled to include: .f. Date medication is dispensed .h. Expiration or end-of-use date, if not dispensed in original manufacturer packaging .End-of-use dating, which only includes the month and year (01/2017), falls to the last day of that month (expires [DATE]) 8. Medication containers having soiled, damaged, incomplete, illegible or makeshift labels are returned to pharmacy for re-labeling or destroyed in accordance with the medication destruction policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 14 of 23 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 05/22/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm A review of the facility's undated document provided by their pharmacy titled Abridged List of Medications with Shortened Expiration Dates indicated, .Insulins .Long Acting . Brand name Lantus . Beyond Use Date (BUD) Notes After Accessing Insulin for First Use .pen - 28 days . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 15 of 23 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 05/22/2025 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. Based on interview and record review the facility failed to ensure the Medical Director (MD) participated in the development and implementation of written policies and procedures, related to the care of residents receiving dialysis services. This had the potential to affect the effectiveness and quality of care delivered to residents on dialysis. (Cross reference to F698 and F726) Findings: On 5/22/25 at 4:15 P.M., a telephone interview was conducted with the MD. The MD stated part of his role was to participate and attend the QAPI (Quality Assessment and Improvement Plan) meeting. Participate in the development and implementation of written policies governing the medical, nursing and related health care services provided in the facility, and oversight with the physician provider. The MD stated he was not aware there was no written policy and procedure for nursing care of dialysis residents and no inservice training provided to the licensed nurses (LN) in assessing dialysis access. The MD stated that there should have been a policy and procedure for nursing to follow standard care practice for dialysis residents. The MD stated LNs should have been educated and trained on how to take care of dialysis residents including the assessment of bruit and thrill (thrills are palpable, vibratory sensations felt on the skin, while bruits are abnormal, audible sounds heard through a stethoscope). On 5/22/25 at 4:40 P.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM and the DON stated that in coordination with the MD, the facility would develop and implement policy and procedures for resident receiving dialysis services. A review of the facility's assessment, dated 9/18/17, indicated the facility provided dialysis services to residents. A review of a procedure for the Medical Director dated 2/16/11, indicated, .the standard of practice performed by the Medical Director included .plays a pivotal role in provision of clinical leadership regarding application of current standards of practice for resident care, new or proposed treatments, practices and resident outcomes. Knowledgeable regarding regulatory issues and the manner in which they may affect care practices. Provides input and approval for resident care policies and practices . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 16 of 23 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation related to: Residents Affected - Few 1. Advance Directives for two residents (10, 131). 2. A documentation for a resident's capacity to understand and make decisions was missing for one resident (40) 3. Resident's consent for treatment was incomplete (40). This failure resulted in conflicting records regarding the presence of Advance Directives (10, 31) and did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers (40). Findings: 1a. On 5/19/25 Resident 10's clinical record was reviewed. Resident 10 was admitted to the facility on [DATE] per the facility's Patient Information. A document titled Advance Directive Acknowledgment dated 2/19/19, 4/19/19, and 2/13/24 indicated, I do not have an Advance Directive, however, I am interested in receiving an Advance Directive Brochure . and was initialed by Resident 10 and Resident 10's family member. On 05/21/25 at 10:57 A.M., a joint review of Resident 10's record was conducted with Social Services (SS). The SS stated when residents were admitted Social Services assessed and documented the status of Advance Directives. Resident 10's Social Services Evaluation dated 11/20/19 indicated, Advance Directive: Yes/copy obtained and on chart. The SS stated the Advance Directive should have been on the chart. On 05/21/25 at 02:21 P.M., a joint review of Resident 10's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 10 did not have an Advance Directive the on chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/21/25 at 2:32 P.M., a joint review of Resident 10's record was conducted with the Administrator (ADM). The ADM stated if there was an Advanced Directive, it should have been on the physical paper chart. The ADM acknowledged the documentation discrepancy regarding the presence of an Advanced Directive. On 05/22/25 at 08:48 A.M., a joint review of Resident 10's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advanced Directive, HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 10. On 05/22/25 at 09:05 A.M., the Administrator (ADM) was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated the documentation had a discrepancy regarding if Resident 10 had an Advanced Directive. The ADM stated there was no Advanced Directive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 17 of 23 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 05/22/2025 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 0842 available for Resident 10. Level of Harm - Minimal harm or potential for actual harm Per facility procedure Advance Directives, revised 5/13/24, .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record . Residents Affected - Few 1b. On 5/19/25 Resident 131's clinical record was reviewed. Resident 131 was admitted to the facility on [DATE] per the facility's Resident Information. A document titled Advance Directive Acknowledgment dated 5/3/25 indicated; I do not have an Advanced Directive, however, I am interested in receiving an Advanced Directive Brochure. was initialed by Resident 131. On 05/21/25 at 10:59 A.M., a joint review of Resident 131's clinical record was conducted with Social Services (SS). The SS stated upon admission Social Services did an assessment which included Advanced Directive status. Resident 131's assessment indicated, Reg Adv Dir Info: Yes/copy requested. The SS stated the Advance Directive should have been on the chart. On 05/21/25 at 02:21 P.M., a joint review of Resident 131's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 131 did not have an Advance Directive the on chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/22/25 at 08:48 A.M., a joint review of Resident 131's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advance Directive, HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 131. On 05/22/25 at 09:05 A.M., the Administrator (ADM) was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated the documentation had a discrepancy regarding if Resident 131 had an Advance Directive. The ADM stated there was no Advanced Directive available for Resident 131. Per facility procedure Advance Directives, revised 5/13/24, .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record . 2. Resident 40 was re-admitted to the facility on [DATE] at 1:41 P.M. according to the facility's Patient Information. A review of Resident 40's physician progress notes dated 11/7/24 at 1:27 P.M., indicated diagnoses which included cognitive developmental delay with left cerebral hydrocephalus (fluid buildup causing increase pressure in the brain) and dependence on a ventilator (a medical device that helps a patient breathe by delivering oxygen). On 5/22/25 at 8:35 A.M., an interview and record review were conducted with licensed nurse (LN) 41. LN 41 stated residents' capacity to understand and make decisions were documented in the physician orders during each admission and re-admission. LN 41 stated re-admission on [DATE] documentation indicated Resident 40 did not have capacity to understand and make decisions. LN 41 stated Resident 40 was re-admitted to the facility on [DATE] but Resident 40's capacity to understand and make decision was not documented. On 5/22/2025 at 9:37 A.M., an interview was conducted with the Director of Staff Development (DSD). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 18 of 23 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DSD stated the physician determined resident's capacity to understand and make decisions and should have been documented in the history and physical examination (H&P). The DSD stated a physician determination of resident's capacity to understand and make decision should have been completed upon admission and on readmission. On 5/22/2025 at 10:22 A.M., an interview and record review were conducted with the Director of Nursing (DON). The DON stated physician the H&P did not mention Resident 40's capacity. The DON stated the physician determines a resident's capacity to understand and make decisions. The DON stated during readmission, LNs would ask the physician to resume a physician order including a resident's capacity to understand and make decisions. The DON stated physician should resume all orders including the resident's capacity to understand and make decisions. According to the facility policy entitled Policy: Capacity to Make Health Care Decisions, revised date 1/8/2025, indicated .III .B. Determination of Capacity .1. The primary physician is responsible for determining the patient's capacity to make health care decisions. 2. If there are indications that the patient lacks the capacity to make health care decisions, the primary physician should evaluate the patient .C. Documentation and Communication .1. The determination that a patient lacks or has a recovered capacity should promptly recorded in the patient's medical record . According to the facility policy entitled Procedure: Documentation Schedule, revised date 9/20/2019, indicated .IV. STEPS OF PROCEDURE: C. admission documentation is completed within 24 hours of the admission . 3. A review of Resident 40's facility [name of facility] Consent to Treatment did not indicate two witnesses for Resident 40's responsible party's (RP) verbal consent on 11/7/24 and was incomplete. On 5/22/25 at 9:03 A.M., an interview and record review were conducted with LN 41. LN 41 stated two licensed nurses should witness a verbal or telephone consent. LN 41 stated Resident 40's Consent to Treatment did not indicate two witnesses and was incomplete. On 5/22/25 at 10:40 A.M., an interview was conducted with the DON. The DON stated two licensed nurses should have witnessed verbal consent. On 5/22/25 at 10:56 A.M., an interview and record review were conducted with the administrator (ADM) and the DON. The DON stated the facility should complete Resident 40's Consent to Treatment because the facility was not authorized to do anything for her. The ADM stated the licensed nurses should complete the Consent to Treatment. The ADM stated two witnesses were required to verify verbal consent. According to the facility policy entitled Procedure: Documentation Schedule, revised date 9/20/2019, indicated .IV. STEPS OF PROCEDURE: C. admission documentation is completed within 24 hours of the admission . According to the facility policy entitled Policy: Conditions of Admission, revised date 2/14/25, indicated .5. If the patient or legal representative verbally consents to the CoA, two hospital employees should witness the verbal consent . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 19 of 23 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 05/22/2025 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** Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: Residents Affected - Some A. Resident 36 and Resident 282 were not identified and placed on enhanced barrier precautions (EBP involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), and licensed staff did not wear a gown when providing care to Resident 36 and Resident 282. B. Licensed Nurses (LN) did not perform hand hygiene (a process of washing hands or using a hand sanitizer) while dispensing medications, when changing gloves in a contact precaution room, and did not sanitize stethoscope and pulse oximeter after resident use. C. A bottle of body spray was found in the drawer of respiratory cart. These failures had the potential for cross contamination and spread of infection between residents, visitors and staff. Findings: A 1.Resident 36's Information Record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA - a type of organism that was resistant to several antibiotics [anti-infective] medications) and had a peripherally inserted central catheter (PICC, is a medical device with a tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for antibiotics. On 5/19/25 at 9:02 A.M., an observation and an interview of Resident 36 was conducted in her room. Resident 36 laid in bed, with PICC line on her right upper arm. Resident 36 stated she was receiving antibiotics through the PICC line due to an infection to her knee. Resident 36 stated she had the PICC line inserted prior to facility admission. There was no EBP sign noted prior to coming to Resident 36's room. On 5/20/25 at 3:37 P.M., a follow up observation and an interview of Resident 36 was conducted in her room. Resident 36 laid in bed, with PICC line on her right upper arm. There was no EBP sign noted prior to coming to Resident 36's room. On 5/20/25 at 3:52 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 12. CNA 12 stated Resident 36 was incontinent on her bowel and bladder and needed assistance. CNA 12 stated Resident 36 was not on isolation and no reported isolation precautions for the resident. CNA 12 stated the CNAs did not have to wear a gown when providing care to Resident 36 since she was not on isolation. On 5/21/25 at 8:29 A.M., an interview was conducted with CNA 14. CNA 14 stated Resident 36 was not on isolation and PPE were not needed when providing care to the resident. On 5/21/25 at 11:40 A.M., an observation and an interview was conducted with CNA 14. CNA 14 changed Resident 36's incontinence brief. CNA 14 was not wearing a gown while providing care to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 20 of 23 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 05/22/2025 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 36. CNA 14 stated Resident 36 was not on isolation and no gown was required when changing her incontinence brief. On 5/21/25 at 11:50 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 36 was not on isolation precautions and did not require PPE when providing care to Resident 36. LN 11 stated there was no sign which indicated the staff had to wear PPE when providing care to Resident 36. On 5/21/25 at 3:23 P.M., a joint review of Resident 36's clinical record and an interview was conducted with Infection Preventionist (IP). The IP stated Resident 36 had history of MRSA and had a PICC line. The IP stated residents with history of MRSA and with medical devices, the expectation was for the staff to wear PPE which consisted of mask, gown and gloves when providing care to residents with medical devices. The IP stated it was important for the staff to wear PPE when they were in contact with the residents like providing care, accessing the resident's medical device, and transferring the resident when they had long contact time with the resident. The IP further stated this was to prevent increase of acquiring organisms and infection and transmitting them to other residents. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow EBP protocol. The DON stated it was important since the residents were vulnerable and were high risk of developing an infection. A review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/20/24, indicated, In conjunction with other infection control measures, Enhanced barrier precautions (EBP) will be used to maintain a safe, sanitary and comfortable environment. The targeted use of proper personal protective equipment (PPE) along with the use of standard precautions during high-contact resident care activities will help prevent the transmission of communicable diseases and infections . A2. Resident 282's Information Record indicated Resident 282 was admitted to the facility on [DATE], with diagnoses which included bacteremia (presence of bacteria in the blood stream), had a peripherally inserted central catheter (PICC, is a medical device with a tube that's inserted through a vein in your arm and passed through to the larger veins near the heart) for antibiotics and a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings and medications to be administered directly to the stomach). On 5/19/25 at 9:23 A.M., an observation and an interview were conducted with Resident 282 in her room. Resident 282 had a right upper arm PICC line, and a g-tube. Resident 282 laid in bed and stated she received antibiotics in her PICC line and received nutrition via her g-tube. There was no EBP sign noted prior to coming to Resident 282's room. On 5/20/25 at 4:03 P.M., an interview was conducted with CNA 12. CNA 12 stated Resident 282 had a g-tube and was not on isolation. CNA 12 stated the staff only have to wear PPE when providing care to resident with a sign that indicated the resident was on isolation. CNA 12 stated she did not have to wear a gown when providing care to Resident 282. On 5/21/25 at 8:35 A.M., an interview was conducted with CNA 15. CNA 15 stated Resident 282 had a g-tube. CNA 15 stated since Resident 282 was not on isolation, staff were not to wear a gown. On 5/21/25 at 11:50 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 282 was not on isolation precautions and did not require PPE when providing care to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 21 of 23 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 05/22/2025 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 282. LN 11 stated there was no sign which indicated the staff had to wear PPE when providing care to Resident 282. On 5/21/25 at 3:23 P.M., a joint review of Resident 282's clinical record and an interview was conducted with Infection Preventionist (IP). The IP stated Resident 282 had bacteremia, a g-tube and a PICC line. The IP stated residents with medical devices, the expectation was for the staff to wear PPE which consisted of mask, gown and gloves when providing care to residents with medical devices. The IP stated it was important for the staff to wear PPE when they were in contact with the residents like providing care, accessing the resident's medical device, and transferring the resident when they had long contact time with the resident. The IP further stated this was to prevent increase of acquiring organisms and infection and transmitting them to other residents. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow EBP protocol. The DON stated it was important since the residents were vulnerable and were high risk of developing an infection. A review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/20/24, indicated, In conjunction with other infection control measures, Enhanced barrier precautions (EBP) will be used to maintain a safe, sanitary and comfortable environment. The targeted use of proper personal protective equipment (PPE) along with the use of standard precautions during high-contact resident care activities will help prevent the transmission of communicable diseases and infections . B. On 5/21/25 at 8:49 A.M., an observation and interview was conducted with LN 1 during Resident 15's medication administration. LN 1 had administered medications via feeding tube (a tube inserted into the stomach to give nutrition) to Resident 15. Resident 15 was in a contact precaution room (a room with a resident who has an infectious disease). LN 1 took off used gloves and applied a new pair of gloves without performing hand hygiene. LN 1 used a stethoscope (a medical device used to listen to the heart and lungs) and pulse oximeter (a medical device used to monitor heart rate and oxygen levels) on Resident 15. LN 1 then put the pulse oximeter into her pocket and placed the stethoscope around her neck without disinfecting them. LN 1 stated she removed her gloves in Resident 15's room and did not perform hand hygiene and she should have done so in a contact precaution room. LN 1 stated she also had not disinfected the stethoscope and pulse oximeter before exiting Resident 15's room and she should have. On 5/21/25 at 9:36 A.M., an observation and interview was conducted with LN 4 during Resident 20's medication administration. Resident 20 was on enhanced barrier precautions (use of PPE to prevent spreading infection to vulnerable residents during care). LN 4 was observed touching his face mask several times. LN 4 was observed dispensing medications and did not perform hand hygiene. LN 4 then applied a pair of gloves, carried Resident 20's medication tray, and set it down on a cabinet. LN 4 applied a PPE gown and then doubled gloved (applying another pair of gloves over the first pair of gloves). LN 4 entered Resident 20's room. LN 4 gave Resident 20 his oral medications and then removed the outer pair of gloves. LN 4 administered eye drops to Resident 20. LN 4 stated he did not perform hand hygiene after touching his mask and prior to dispensing Resident 20's medications. LN 4 stated he should not have been wearing double gloves during medication administration. C. On 5/21/25 at 11:14 A.M., an observation and interview was conducted with Respiratory Therapist (RT) 1. A bottle of (brand name) body spray gingham love was found in the right upper drawer of a respiratory medication cart. RT 1 stated he was not sure who it belonged to and it May be a co-worker's. RT 1 stated the body spray should not have been stored in the respiratory medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 22 of 23 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 05/22/2025 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 On 5/21/25 at 3:38 P.M., an interview was conducted with Infection Preventionist (IP). The IP stated hand hygiene was to be performed before changing gloves. The IP stated staff should have disinfected the stethoscope and pulse oximeter prior to exiting a contact precaution room to decrease the spread of infections. The IP also stated alcohol-based rub or handwashing should have been performed before dispensing or administering medications to residents. The IP further stated body spray should not have been in a respiratory medication cart, and it was an infection control risk. On 5/22/25 at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff would need to change gloves and perform hand hygiene within a patient room when changing care tasks, or if soiled. The DON further stated items like a stethoscope and pulse oximeter should not leave a contact precaution room without being disinfected. The DON stated LNs should perform hand hygiene prior to dispensing and administering medications and LNs should not be double gloving. The DON stated, Perfume should be not allowed in any medication cart. The DON further stated this was a potential for contamination and an infection control issue and Residents could be put at risk. A review of the facility's policy titled Procedure: Standard Precautions revised 11/01/2024, indicated, .3. Hand Hygiene .c. If hands are not visibly soiled, use alcohol gel routinely for decontaminating hands: .ii. before donning sterile gloves .vii. after removing gloves .d. Remove gloves promptly after use and immediately perform hand hygiene 7. Cleaning and Disinfecting Patient Care Equipment a. Shared equipment must be cleaned and disinfected before use on another patient by the immediate user . A review of the facility's policy titled Procedure: Cleaning and Disinfection of Equipment revised 06/10/2024, indicated, .10. Cleaning and disinfection of movable medical equipment will be done regularly and after equipment is taken into an isolation room . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555301 If continuation sheet Page 23 of 23