Health inspection·November 30, 2023

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 observation, interview and record review, the facility failed to administer an unexpired medication to one of 4 residents (Resident 3). This failure had the potential for Resident 3 to receive a less potent medication resulting in diminished effectiveness. Findings: During a review of Resident 3's admission Record, dated 10/29/23, Resident 3 was re-admitted to the facility on [DATE], with diagnoses which included but was not limited to right hand fracture (break), vitamin deficiency, and osteoporosis (weakening of the bones) with fracture of right ankle and foot. On observation, interview and record review , on 11/28/23 at 8:45 A.M., Licensed Nurse (LN) 1 was observed taking Centrum (multi vitamin) from Medication Cart 1. LN 1 poured and administered one oral tablet of Centrum to Resident 3. Label on Centrum designated it was opened by staff on 8/2/23 and expired per manufacturer on 7/23. After Centrum given, LN 1 reviewed label with surveyor. LN 1 confirmed Centrum was opened on 8/2/23 and expired 7/23. LN 1 stated policy was for unexpired medications to be given to residents. LN 1 stated expired medications could be less potent and less effective. During medical record review on 11/28/23 , the physician orders dated 10/29/23 indicate Centrum Woman one tablet was to be given orally once a day. Per Resident 3's medical administration record, Centrum Woman one tablet daily was recorded as given from 9/1/23 to 11/28/23. During an interview with the pharmacist (PH), on 11/30/23 at 10:48 A.M., the PH stated medications are reviewed monthly and the nurse consultant was responsible for confirming expired medications were discarded. The PH further stated she performed spot checks to review the facility pharmacy medication and it was unfortunate the medication had expired. The PH stated expired medications were not to be given to residents, as they could be less potent and less effective. The PH stated expired medications should be discarded. During an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 A.M., the DON stated the facility policy is to give unexpired medications to the residents. The DON further stated the expired Centrum Woman should not have been given and could be less effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 2 of 7 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Potential for minimal harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure non-pharmacological interventions (actions or treatments that do not include the use of medicine) were implemented for three of five sampled residents (Residents 1, 2 and 6) that had been given psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 6 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 2. Resident 1 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 3. Resident 2 was administered Ativan (a medication to treat anxiety) without documented evidence for the implementation of non-pharmacological resident-centered behavioral interventions. These failures had the potential to result in unnecessary psychotropic medications for Resident 1, 2, and 6, thus increasing the risk of breathing difficulties, sedation (severe sleepiness), anxiety (extreme uneasiness), agitation (extreme emotional disturbance) and memory loss. Findings: 1. During a review of Resident 6's admission Record, Resident 6 was re-admitted under Hospice Care to the facility on 4/4/22, with diagnoses that included but was not limited to stroke, severe vascular dementia (decline in brain function) with agitation, restlessness, and insomnia . Per Resident 6's Minimum Data Sheet Section C, dated 4/6/23, Resident 6 had a Brief Interview Mental Score (method of evaluating mental status) of 00, indicating severe mental impairment. Per Resident 6's physician order, on 10/26/23, Resident 6 was to receive Seroquel 25 mg amt 1/2 tab orally once an evening, for agitation with diagnosis: restlessness and agitation. During an interview, on 11/29/23 at 11:02 A.M., Licensed Nurse (LN) 3 stated Resident 6 was receiving Seroquel 12.5 mg for agitation. LN 3 further stated Resident 6's agitated behavior included refusing all care including any skin care or cleaning, striking at staff during care and becoming very upset while reaching for invisible objects. LN 3 stated if nurses attempted redirection this should be documented in Resident 6's medical record. During a concurrent interview and record review with LN 2, on 11/29/23 at 12:12 P.M., LN 2 stated Resident 6 had occasional episodes of confusion and agitation. LN 2 stated Resident 6 had been prescribed Seroquel for the agitation. LN 2 acknowledged it was important to ensure non-pharmacological interventions were documented to help prevent unnecessary use of psychotropic medications and their potentially dangerous side effects. On review of resident 6's medical record, LN 2 was unable to locate documentation of what non-pharmacological interventions had been done since Resident 6's admission. During a review of Resident 6's medical record, on 11/30/23, no documentation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 3 of 7 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 non-pharmacological staff interventions related to the Seroquel administration was located. Level of Harm - Potential for minimal harm During a phone interview with the pharmacist (PH) on 11/30/23 at 10:38 A.M., PH reported she monitored Resident 6's physician order for Seroquel since this medication had potentially dangerous side effects. Residents Affected - Some During an interview and record review on 11/30/23 at 10:00 A.M., the Director of Nursing (DON), confirmed non-pharmacological interventions for psychotropic medications should be documented in Resident 1, 2 and 6's medical record. She further acknowledged prior to 11/29/23 there was no documentation of these interventions being done. The DON agreed it is important to include non-pharmacological interventions to help decrease the use of unnecessary psychotropic medications . 2. A review of Resident 1's face sheet indicated Resident 1 was admitted from the memory care facility on 6/8/2021 with diagnoses that included dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental disorder characterized by feelings of worry, anxiety or fear) and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a joint observation and interview in the dining room on 11/28/2023, at 8:00 A.M., Resident 1 was sitting up in the wheelchair, assisted by Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 usually ate 50% of meals and was dependent with his care. CNA 1 stated Resident 1 liked to touch and grab things, and clapped his hands when awake. CNA 1 further stated she tried to keep Resident 1's hands occupied by giving Resident 1 something to hold on to. CNA 1 stated Resident 1 had episodes of agitation and struck out during care. During a joint interview and record review on 11/29/2023, at 11:24 A.M., with the Licensed nurse (LN) 3, LN 3 stated there was no documneted evidence of non-pharmacological interventions. 3. A review of Resident 2's face sheet indicated Resident 2 was admitted from home on 3/26/2021 with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning). During an observation on 11/28/23, at 8:30 A.M., Resident 2 was sitting in the wheelchair in the dining room being assisted by Certified Nursing Assistant (CNA) 2. During a joint interview and record review on 11/29/2023, at 11:24 A.M., with the Licensed nurse (LN) 3, LN 3 stated the Medication Administration Record (MAR) and care plan did not have non-pharmacological interventions prior to use of Ativan (a medication used to treat anxiety). LN 3 stated non-pharmacological interventions should have been documnted as implemented prior to administration of Ativan. An interview with the Director of Nursing (DON) on 11/30/2023, at 9:42 A.M., the DON confirmed non-pharmacological interventions were not documented as implemented prior to administration of Ativan. A review of the facility policy and procedure titled Psychotropic Medication, dated 9/30/2015 was conducted. The policy indicated the facility was responsible to ensure the .Documentation of the specific type and frequency of medication, will be completed in the resident's care plan, nursing progress notes and added to the medication record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 4 of 7 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 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. Based on observation, interview and record review, the facility failed to store a medication according to manufacturer instructions. This failure had the potential for the facility residents to receive a less potent medication resulting in diminished effectiveness in an emergent situation. Findings: During an inspection of the facility medication storage room, on 11/28/2023 at 12:05 P.M. a review was done of the medication room refrigerator with Licensed nurse (LN) 1. During an inspection of the emergency medication kit (a case containing medication used in an emergency) which was a clear/translucent kit, an unopened vial of Ativan (a medication used for anxiety) was noted to be stored in a clear vial, within a clear plastic bag, in the kit The manufacturer's instruction printed on the label of the vial indicated protect from light. LN 1 confirmed facility's policy is for medications to be stored according to manufacturer instructions. During an interview on 11/29/2023 at 9:18 A.M., LN 3 viewed a photograph of the manufacturer's instruction on the Ativan vial. LN 3 stated the medication was to be stored according to manufacturer instructions. She further stated the Ativan vial indicated the Medication needed to be protected from light, which while the refrigerator offered some protection, the clear vial, bag, and container would not be considered enough protection from light. LN 3 stated it was important to follow the manufacturer instructions for storage of the medication to ensure its effectiveness. During a telephone interview with the Pharmacist (PH), on 11/30/2023 at 10A.M., the PH stated she was unaware Ativan needed to be protected from light. She further stated this medication should have been placed in a light protected bag according to manufacturer instructions. The PH acknowledged it was important to follow the manufacturer instructions to protect the potency of the medication. During an interview with the Director of Nursing (DON), on 11/30/23 at 10:00 A.M., the DON stated facility policy was for medications to be stored according to the manufacturer instructions. She acknowledged the Ativan was not protected adequately from light, and this could diminish the potency of the medication. On review of facility policy titled, Medication Labeling & Proper Storage, revised 10/2018, manufacturer storage instructions for medications not located. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 5 of 7 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation interview and record review, the facility did not ensure confidentiality of the medical records for 12 of 12 sample residents (1, 2, 3,4, 6,7, 9, 10, 11,12, 116, 166). This failure had the potential to result in unauthorized access to confidential and protected health information. Findings: During a concurrent observation and interview on 11/28/2023 at 10:25 A.M., the narcotic administration logbook was noted to be sitting on top of medication cart 1. Licensed nurse (LN) 2 stated the narcotic administration logbook was allowed to be placed on the medication cart 1 shelf, if it was closed. She further stated it was a crazy hectic morning. During an observation on, 11/29/2023 at 8:40 A.M., the computer screen was noted to be open with a resident's medication record visible. During an observation and interview with LN 3, on 11/29/2023 at 10:30 A.M., LN 3 was shown a photograph of medication cart 2 with the computer screen on, showing the facility medication record. LN 3 stated the computer screen was not left open on purpose, she had been distracted, and facility policy was to have computer screens locked when not in use. LN 3 also reported medication cart 1 had a shelf where the closed narcotic administration logbook could be kept. LN 3 agreed that an unauthorized person could look at the logbook when the cart was unattended. During an interview with the director of nursing (DON), on 11/30/23 at 10:48 A.M., the DON's stated the narcotic administration logbook was to be kept in the bottom drawer of the medication cart unless the licensed nurse was currently passing medication. The narcotic administration logbook was not to be left unattended on top of the medication cart and it was important to secure it to maintain resident confidentiality. The DON confirmed facility policy was to protect resident confidentiality, with locked computer screens when not in use. On review of the facility policy, titled Electronic Medical Records, revised 3/2014, the facility will . make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 6 of 7 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 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 Based on interview and record reviews, the facility failed to implement a water system that included Legionella testing for thirteen out of thirteen residents affected. Residents Affected - Many This failure had the potential of affecting the health and safety of residents in the facility. Findings: During an interview on 11/29/2023 at 2:46 P.M., with the Maintenance Supervisor (MS), MS stated that the facility used solar water heating. The MS stated water was heated up to 140 degrees Fahrenheit. The MS further stated he did not know of any policies and procedures on Legionella prevention, and it should be the Director of Nursing (DON) handling it under the infection control program. During an interview on 11/29/2023 at 4:00 P.M., with the DON, the DON stated the facility did not have a policy on water management in accordance with Legionella testing. As of this date 11/29/2023, the facility has no documented policy on Water management regarding Legionella. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555906 If continuation sheet Page 7 of 7