Health inspection·August 8, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On July 18, 2024, a review of Resident A's medical record was conducted. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included a cerebral infarct (stroke-lack of blood flow in the brain) and asthma (a disease in which the airway narrows and swells, making it difficult to breathe). A review of Resident A's previous hospital records, dated May 30, 2024 (prior to admission to the facility), indicated, .Allergies .Aspirin .Guaifenesin .Acute stroke .Aspirin once safe .Clarifies that aspirin caused a rash in the past . A review of Resident A's Admit/Readmit Assessment, dated June 2, 2024, indicated, .Allergies .Aspirin, guaiFENesin . A review of Resident A's history and physical, dated June 3, 2024, indicated the resident was allergic to aspirin and guaifenesin. A review of Resident A's care plans indicated, .Allergic to guaifenesin, penicillin .Interventions: Flag chart, medication and treatment sheets with allergy information .Inform MD (Medical Director - physician) of all allergy information when receiving new orders .Inform pharmacy of allergy information .Monitor for signs and symptoms of allergic reaction such as rash, itching. Notify MD . A review of Resident A's Order Summary Report, indicated Resident A's allergies documented were guaifenesin, penicillin, and Cipro (ciprofloxacin - antibiotic to treat infections). The document included a physician's order, dated June 2, 2024, which indicated, Aspirin 81 Oral Tablet Delayed Release 81 MG (milligram - unit of measurement) Give 1 tablet .one time a day . A review of Resident A's Medications Administration Record (MAR), for June 2024, indicated allergies to guaifenesin. The MAR indicated aspirin was administered to Resident A from June 3 to 17, 2024, and June 19 to 22, 2024 (total of 19 days). Further review of Resident A's record (progress notes, MAR, physician's order, and admission record) did not include aspirin in the allergy list since admission to the facility. A review of Resident A's Progress Notes, indicated the following: - June 6, 2024, at 6:33 p.m., indicated, .The system has identified a possible drug allergy for the following order. Aspirin 81 oral tablet delayed release 81MG Give 1 tablet by mouth one time a day . - June 3, 2024, at 1:27 p.m., indicated, .The system has identified a possible drug allergy for the following order: Aspirin 81 Oral tablet delayed release 81MG (Aspirin) . A review of Resident A's Order Summary Report, included a physician's order, dated June 18, 2024, which indicated, .Rivaroxaban (Xarelto - blood thinner) Oral Tablet Give 1 tablet by mouth two times a day for PE (pulmonary embolism - blood clot in the lungs) for 21 days . A review of Resident A's Medication Administration Record, for June 2024, indicated Xarelto was administered to Resident A on June 19 to 23, 2024 (total of 10 doses). A review of Resident A's Order Summary Report, included a physician's order, dated June 21, 2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555915 If continuation sheet Page 2 of 6 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 555915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563 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 0684 Level of Harm - Minimal harm or potential for actual harm which indicated, .Ciprofloxacin (antibiotic medication to treat UTI (Urinary Tract Infection) tablet 500mg, one tab two times a day, for UTI for five days . A review of Resident A's Medication Administration Record, for June 2024, indicated ciprofloxacin was administered to Resident A on June 21 to 22, 2024 (three doses). Residents Affected - Few A review of Resident A's Progress Notes, dated June 22, 2024, at 1:26 p.m., indicated .per son and resident she feels like her lips are burning and her tongue is red, per son she had this before 20 yrs (years) ago when she takes aspirin, also noted with generalized body rash, warm to touch .per other son she had an allergic reaction with ATB (antibiotic) for UTI (urinary tract infection) long time ago but they do not remember the name of medication, MD made aware, per MD [name of MD] continue Cipro .son and resident requested to discontinue aspirin .assessed resident, noted with red tongue and generalized rash, MD made aware .no new skin problems noted at this time .no changes in condition noted at this time .Per Dr. [name], he thinks it's the ASA (aspirin) not the Cipro caused the allergic reaction .D/C (discontinue) ASA (Aspirin) start Plavix (medication to thin the blood). Continue Cipro . A review of Resident A's Assessment Summary, dated June 22, 2024, at 3:53 p.m., indicated, .Communication for Changes in Condition .generalized body rash .red tongue, burning feeling around lips . A review of Resident A's Order Summary Report, indicated the following physician's orders to address the generalized rashes: - .Monitor skin rashes for increased spread or signs of allergy reaction to antibiotics for 14 days, ordered June 22, 2024; and - .Hydrocortisone (medicine to treat skin conditions) Cream 2.5% (percent), apply to scattered rash topically (to skin) every day shift for rashes for 14 days, cleanse with NS (normal saline-used in the medical field to clean wounds), pat dry, leave open to air . A review of Resident A's Progress Notes, indicated the following: - June 23, 2024, at 12:13 p.m., indicated, .body rash is getting worse, her tongue still red and still feeling burning around lips .son is requesting to change order for ABT (antibiotic) for UTI .No new skin problems noted at this time . - June 23, 2024, at 10:52 p.m., indicated, .Communication for Changes in Condition .tachycardia (fast heart rate), hypoxia (not enough oxygen) .BP (blood pressure-the pressure of circulating blood against the heart) 150/75 (normal range less than 120/80) .P (pulse) 118 (normal range 60 - 100) .R (respiration) 35 (normal range 12 - 18) .O2 (oxygen) 85% .room air .RN (Registered Nurse) aware pt's (patient's) son [name] visited pt and was concerned about her condition, alerted charge nurse and CNA (certified Nursing Assistant) to room to assess pt (patient) .pt noted with tachycardia 118-119 bpm (beats per minute), tachypnea (fast breathing) 35 rpm (respirations per minute) .hypoxia 85% on RA (room air) .pt put on 5L (liters-a type of measurement)/min (minute) O2 (oxygen) via nasal cannula (tubing goes into the nose and delivers oxygen), O2 sat (saturation in blood level) increased to 95-96%. Son mostly concerned about O2 sat, RR (respiratory rate), and HR (heart rate) .Dr. [name] made aware .pt has poor PO (oral) intake for several days and ATB (antibiotic) changed from Cipro to Macrobid (antibiotic to treat infection) d/t (due to) allergic rxn (reaction), MD ordered 500cc (cubic centimeter-a unit of measurement) bolus (a single dose of fluid through a vein) NS (normal saline) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555915 If continuation sheet Page 3 of 6 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 555915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then NS 75cc/hr (hour) x 2 days, CBC (complete blood count-a laboratory test of blood cells in the body)/CMP (comprehensive metabolic panel-a test of blood for fluid balance and electrolytes) in AM (morning), and CXR (chest x-ray) in AM. Noted and carried out .RN started IV (intravenous - through the vein) and gave bolus, effective and symptoms relieved . - June 24, 2024, at 10:24 a.m., indicated, .MD (physician) see and assessed resident received new order to transfer to [name of hospital] for further evaluation due to allergic reaction to ATB (antibiotic) . - June 24, 2024, at 10:50 a.m., indicated, .Dr. [name] does not want to send resident via 911, MD wants a regular transport, MD explained to family . A review of Resident A's LTC (Long Term Care) Routine SNF (Skilled Nursing Facility) Visit, dated June 24, 2024, indicated, .Resident A .was treated for urinary tract infection in the [name] hospital with rocephin (antibiotic medication to treat infection) but there were no clear orders for PO (by mouth) antibiotics .repeat UA (urinalysis-a urine test) and urine culture (a lab test to check for bacteria or other germs in a urine sample) were ordered .UA was positive for urine tested .started on cipro(Ciprofloxacin) (received dose on 6/21 [June 21] am and pm, 6/22 [June 22] am) .Nursing called yesterday for rash with cipro. Generalized rash, no itching, tongue was red and some burning/cracking around the lips. Cipro was stopped. Changed to Macrobid (an antibiotic to treat infection). Received one dose last night 6/22 (June 22). Macrobid discontinued today as Urine culture showing candida (fungal infection - infection caused by yeast or molds) .patient was on Aspirin since stroke. Aspirin was stopped over the weekend and changed to Plavix by on call physician .family mentioned she had red tongue with Aspirin in the past .rash started 21st morning. It was generalized redness and no itching. Within the last 12 hours the rash is blistering and peeling. It is very painful. She is now having difficulty swallowing due to pain. She was started on IV fluids yesterday .Adverse Drug Reaction .rash worsened very rapidly. Concern of mucus membrane (lining inside organs and body) involvement along with skin blistering and peeling .urine culture showing candida. She had not been treated for it yet .send patient to [name] Emergency Department . Further review of Resident A's record (progress notes, MAR, and physician's order) did not indicate a medication was prescribed and administered to treat the resident's allergic reaction. On July 19, 2024, at 8:45 a.m., an interview was conducted with the Director of Nurses (DON). The DON stated Resident A was admitted with allergies to aspirin and guaifenesin, the admission nurse's report indicated the two medications were allergies, only the guaifenesin was put into the electronic medical record for the resident. The DON stated she did not know why the allergy for aspirin was not included in the allergy list. The DON stated the allergy list should have been reviewed closer and aspirin should have been added. The DON stated Resident A was admitted to the facility on [DATE], and was prescribed aspirin 81mg daily. The DON stated Redsident A was prescribed Cipro for five days after she returned from the hospital on June 21, 2024. The DON stated the cipro and aspirin were discontinued on June 22, 2024, after Resident A developed a body rash. On July 19, 2024, at 11:30 a.m., an interview was conducted with the Registered Nurse (RN). The RN stated a resident's medication list, on admission to the facility, should always be compared to their allergy list. The RN stated it was important to verify with the resident, if you are able to, if the resident is allergic to certain medications, what is their past reaction to the medications, and determine if it is a medication side effect or a true allergy. The RN stated the physician would need to be contacted to verify the medication list and allergies, discuss the resident's reaction to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555915 If continuation sheet Page 4 of 6 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 555915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563 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 0684 Level of Harm - Minimal harm or potential for actual harm medications in the past, and determined if it is a true allergy. The RN stated it was important to educate the resident and family on medication reactions and other medications in the same class of drugs, which may result in similar symptoms. The RN stated when a resident does have an allergic reaction, stop the medication, notify the doctor, order some type of antihistamine (medication used to treat allergies) or cream to treat symptoms (rash/hives). Residents Affected - Few On July 24, 2024, at 3:30 p.m., an interview was conducted with the Medical Doctor (MD). The MD stated Resident A did have aspirin listed as an allergy, when she was admitted to the facility, and upon review of her records from the hospital, it was determined the discharging provider from the hospital had prescribed her aspirin, for Resident A's stroke. The MD stated it was decided the benefits outweighed the risks, and the aspirin was continued to be given. The MD stated allergies can be more of an intolerance, and not a true allergy, when she spoke with Resident A, she was told Resident A had tingling on the tongue, and that is considered an intolerance. The MD stated Resident A had a UTI and was placed on multiple antibiotics for treatment. The MD stated she was aware Resident A had developed a rash, had tingling to her lips, and a reddened tongue, another provider was covering for her that weekend. The MD stated she was aware of the change in medication recommendations, and when the resident developed symptoms of tachycardia (a fast heart rate) and hypoxia (not enough oxygen in the body), IV (intravenous- giving a medicine or other substance through a tube inserted into a vein) fluids and oxygen were ordered. The MD stated Resident A could have been prescribed an antihistamine (medication given for allergies) to help with the allergic reaction symptoms, the on-call provider wanted to send the resident to the emergency room, however the family felt she was dehydrated and wanted the resident to receive the fluids, at the facility. The MD stated she came to see Resident A, Resident A was having an allergic reaction and the rash had advanced rapidly, the rash began to blister and open up, and Resident A was sent to the hospital. The MD stated it was protocol for staff to call the physician about allergies versus the medication orders to clarify before having medications filled from the pharmacy, she does not remember if the staff at the facility had called her about Resident A's order for aspirin. The MD concluded Resident A did develop an allergic reaction to the medications given, she is not sure if it was the aspirin or the antibiotics, which caused Stevens-Johnson Syndrome to develop. On July 29, 2024, Resident A's hospital medical records were reviewed. Resident A's ED (emergency department) to Hospital Admission, dated June 25, 2024, indicated, .Reason for visit w/ (with) Dx (diagnoses) .chief complaint: Rash .TENS (toxic epidermal necrolysis-a severe skin reaction, a life-threatening condition, causes peeling and blistering over the body, including the mouth, eyes and genitals - it is the most severe form of [NAME]-[NAME] syndrome-caused by a reaction to medications) .drug reaction .Reason for admission to the Hospital .Pt (patient) was transferred from (name of hospital) for TENS from possibly Cipro or Xarelto .Patient previously was on ASA (aspirin) but due to history of red tongue with ASA, pt. switched to Plavix (blood thinner) on 6/23 (June 23) .On 6/21 (June 21) pt began to develop a rash around her mouth as well as intra oral lesions (lesions inside the mouth), which spread to trunk and extremities. Pt also experience with burning sensation to eyes and while urinating .Hospital Course by Problem .Toxic epidermal necrolysis .patient was transferred to (name of hospital) from (name of hospital) on 6/25/2024 (June 25, 2024) for whole-body rash suspected secondary to TEN .Dermatology (branch of medicine concerned with the diagnosis and treatment of skin disorders) suspecting patient is toxic epidermal necrolysis possibly precipitated (cause to happen suddenly, unexpectedly) by aspirin versus Augmentin (antibiotic to treat infection) .poor PO (oral) intake .due to oral pain from her toxic epidermal necrolysis .aspirin discontinued due to concerns of it precipitating her toxic epidermal necrolysis .acute skin lesions progressing to epiderml necrolysis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555915 If continuation sheet Page 5 of 6 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 555915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Health and Rehabilitation Center 25924 Jackson Ave Murrieta, CA 92563 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is secondary to medications. After review of recent medications, possible culprits include antibiotics (Ceftriaxone, Cipro, Macrobid, or Amoxicillin [antibiotic used to treat infection]), ASA, XArelto .Avoided aspirin and Xarelto as they may have been culprits behind TEN/SJS . A review of Resident A's Discharge Summary, dated June 29, 2024, indicated, .Principal diagnosis: Toxic epidermal necrolysis (TEN) .please avoid aspirin, xarelto (a blood thinner), amoxicillin, ceftriaxone (medication to treat infection), macrobid, and ciprofloxacin as these may have contributed to development of your TEN .please discuss with neurology (study of the brain and nervous system) regarding alternative treatment besides aspirin .follow up with dermatology (study of the skin) for continued management of your wounds .follow up with urogynecology (study of the urinary system, bladder/kidneys, and female reproductive parts) regarding vulvovaginal (female genitals) involvement of your TEN . A review of Resident A's 'Discharge Summary, dated July 11,2024, indicated, .Hospital course by problem .Severe epidermal (layer of skin) necrolysis (destruction of dead tissue, blood cells) consistent with TEN .acute skin lesions progressing to epidermal necrolysis is secondary to medications .possible culprits include antibiotics (Ceftriaxone, Cipro, Macrobid, or Amoxicillin), ASA, Xarelto . A review of the facility's policy titled Provider Pharmacy Requirements, dated October 2012, indicated, .The provider pharmacy is responsible for rendering the required services in accordance with local, state, and federal laws and regulations .professional standard of practices .The provider pharmacy agrees to perform the following pharmaceutical (relating to medicinal drugs, or their preparation, use, or sale of drugs) services .maintain a medication profile on each resident that includes all medication dispensed and facility provided information such as resident's age, diagnoses, weight, condition, medication allergies, diet and other pertinent information .reviewing the resident's profile prior to dispensing any medication . A review of the facility's policy and procedure titled Adverse Drug Reactions, dated July 2015, indicated, .to monitor the resident's reaction to prescribed medications .this includes any allergic reaction or side effect to the medication as described in the manufacturer's information or current literature .If an adverse reaction is suspected, the first observed occurrence will be reported to the attending physician immediately .documentation of the observed reaction .monitoring of the resident during the episode will be done in accordance with physician's instruction, with all appropriate documentation done in the resident's medical record .Signs and symptoms of an allergic reaction may include .skin: irritation, redness, itching, swelling, blistering .rash .Lungs .tightness .shortness of breath .swelling or bumps on the face .lips, tongue .eyes: red, itchy, swollen, watery .pain, nausea .fatigue .upon determination of an adverse reaction, the name of the drug and the type of adverse reaction experienced will be documented on the physician's order sheet. The name of the drug will be documented on the Medication Administration Record (MAR) in the section titled 'allergies' . A review of the Lexicomp (medication reference) on July 30, 2024, for the medication aspirin, indicated adverse reactions included: Tachycardia (fast heart rate) .tachypnea (abnormally rapid breathing) .urticaria (hives) .anaphylaxis (life threatening allergic reaction) .Contraindication (a reason for a person not to receive a treatment or medication because it might be harmful) for aspirin include a known hypersensitivity (an abnormal physiological condition in which there is an undesirable and adverse immune response to an antigen [toxin]), a history of asthma, and urticaria . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555915 If continuation sheet Page 6 of 6