Other·February 7, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint: Complaint # CA00664722 Representing the California Department of Public Health: Surveyor 41422, HFEN The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility. This Department was able to substantiate three violations of the regulations for complaint number CA00664722.

F726 SS=D Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 03/04/2020 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 1 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure licensed nursing staff had the competency to safely administer chemotherapy drugs for one (Resident 1) of two sampled residents when nursing staff crushed Alunbrig, (used to treat people with non-small cell lung cancer (NSCLC) who have a certain abnormal gene that has caused the cancer to spread to other parts of their body). This failure had the potential to expose employees to hazardous drugs when they crushed the medication, which according to the manufacturer and the FDA should not be crushed. Findings: On December 10, 2019 an announced visit was conducted at the facility for an investigation of a complaint involving a medication error. A review of the medical record indicated Resident 1 was a 51-year-old male admitted to the facility on November 1, 2019 with diagnoses which included malignant neoplasm, (cancer) of the lung, secondary malignant neoplasm, (cancer that has spread from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 2 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE original site to other organs) of the brain, pneumonia, (a lung infection), drug or chemical induced diabetes with hyperglycemia, (drugs that cause blood sugar to be high), open wound left lower leg, compression fracture of T 11-T 12 vertebra, (broken bones in the thoracic spine), low back pain, and muscle wasting. Resident 1's facility physician orders dated November 5, 2019, were reviewed and indicated "...Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via J-Tube, (jejunostomy tube - a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food, hydration, and medication into the body) one time a day for CA (cancer) May crush medication per MD (doctor name)..." On December 10, 2019, at 2:50 p.m. an interview and concurrent record review of Resident 1's "Medication Administration Record" (MAR) dated November 2, 6, 7, 8, 9, 11, 12, 13, 14, 15, 2019, was conducted with Licensed Vocational Nurse 1 (LVN 1). She stated she gave the morning dose (9 a.m.) of brigatinib (generic drug name for Alunbrig), 90 MG via J-Tube, and stated that she crushed the medication for administration. The LVN said did not give the medication on November 3, 2019, and it was documented as a "9" on November 4 and 5, 2019, which indicated it was not given. She had no explanation as to why it was not given. On December 10, 2019, at 3:45 p.m., a telephone interview with Licensed Vocational Nurse 2 (LVN 2) was conducted. He stated when he prepared Resident 1's medications for administration on November 16, 2019. The order on the electronic medication administration record (eMAR) indicated an order for brigatinib 90 mg. The medication was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 3 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in a bottle instead of a bubble pack (the usual method the facility pharmacy packages medications). The label on the prescription bottle read brigatinib 180 mg. Since the medication was not scored, He said he asked other staff how the brigatinib was administered, and confirmed others were administering a whole tablet of brigatinib (180 mg) to Resident 1. He further stated the medication error should have been caught when medications were prepared for the resident and said that the order was a duplicate and should have been discontinued. On December 10, 2019, at 4:15 p.m. the facility's pharmacy consultant (PC) was interviewed. The PC stated he was not familiar with the medication Alunbrig, and did not know if Alunbrig could be crushed, however, he would follow manufacturer specifications, as most chemotherapeutic drugs are taken with or without food and not crushed. On January 8, 2020, at 2:15 p.m., an interview was conducted with LVN 3. She stated on November 5, 2019, at 2 p.m. she notified the oncologist and verified the prescription order provided by Resident 1's wife, for Alunbrig 180 mg. daily to be given through Resident 1's Jtube. She said the prescription indicated it was okay to crush. LVN 3 stated the facility policy and procedure for when medication changes are ordered, the original order would be discontinued. She stated she was not aware of the previous order for brigatinib 90 mg. The Director of Nursing, (DON) was interviewed on January 8, 2020, at 2:20 p.m., and stated the facility did not have a policy and procedure on competency training for chemotherapeutic drug administration for the licensed staff. She stated the nurses used a Lexicomp, (a reference that provides clear, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 4 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concise, point-of-care drug information) if they needed to look up any medications. On January 22, 2020, at 10:59 a.m., a second interview was conducted with LVN 1. She stated the MAR indicated to give brigatinib 90 MG via J-tube, therefore, the medication needed to be crushed, and the MAR did not need to specify to crush. LVN 1 stated she "googled" brigatinib, and read that the medication was for cancer but did not review the side effects, dosages, and did not know that it should not be crushed. She stated when she administered the brigatinib on November 2, 6, 7, 8, 9, 11, 12, 13, 14, and 15, 2019, she compared the pharmacy label on the medication bottle with the eMAR and identified a discrepancy with the dosage on the pharmacy label indicating 180 mg and the eMAR indicating 90 mg. She stated she should have followed through and resolved the discrepancy prior to administering the medication to Resident 1. She further stated on November 4 and 5, 2019 the eMAR indicated a code 9, which usually meant the medication was held, but could not recall if there was a reason. LVN 1 stated on November 9, 2019 she administered the Alunbrig 180 MG at 9 a.m. and again at 5 p.m., and said she was just following the order on the eMAR and did not compare with the original orders. On January 22, 2020, at 1:06 p.m., a second interview was conducted with the DON. She stated Resident 1's wife had Alunbrig medication delivered to her home, and brought the medication to the facility in a sealed bottle. The DON stated the prescription bottle label had no warning that it was a hazardous drug, so no extra precautions were taken. On January 23, 2020, at 12:10 p.m. a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 5 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE telephone interview was conducted with Resident 1's Oncologist's Nurse, (ON). The ON stated Resident 1's Oncologist was notified of the medication error by Resident 1's wife. The ON stated Resident 1's Oncologist had written a prescription order for the Alunbrig to be crushed, and would not be a risk to Resident 1, but could not confirm if it was a risk to licensed staff preparing and administering the crushed Alunbrig. A review of the manufacturer specifications for Alunbrig revised December, 2018, indicated " ...Swallow ALUNBRIG tablets whole. Do not crush or chew tablets...Embryo-Fetal Toxicity: Can cause fetal harm...may cause reduced fertility in males..." A review of the facility policy and procedure "Medication - Administration" revised July 1, 2016 indicated "...Safe handling of Oral Hazardous Drugs - A hazardous drug is any medication possessing at least one of the following characteristics...teratogenicity, (Any agent that can disturb the development of an embryo or fetus), reproductive toxicity, (adverse effects of a chemical substance on sexual function and fertility in adult males and females)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 6 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F755 Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/04/2020 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based upon interview, and record review, the facility failed to collaborate with its pharmacy services to assure effective policies and procedures were established and implemented related to administration of chemotherapeutic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 7 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications for one (Resident 1) of two sampled residents, and failed to ensure that medications brought in from home were sent to the pharmacy to verify the order with the resident's physician and added to the resident profile. Findings: On December 10, 2019 an announced visit was conducted at the facility for an investigation of a complaint involving a medication error. Resident 1's medical record was reviewed on December 10,2019, and indicated the resident was a 51-year-old male admitted to the facility on November 1, 2019, with diagnoses which included malignant neoplasm, (cancer) of the lung, secondary malignant neoplasm, (cancer that has spread from the original site to other organs) of the brain, pneumonia, (a lung infection), drug or chemical induced diabetes with hyperglycemia, (drugs that cause blood sugar to be high), open wound left lower leg, compression fracture of T 11-T 12 vertebra, (broken bones in the thoracic spine), low back pain, and muscle wasting. On December 10, 2019, at 2:26 p.m., an interview with the Director of Nursing (DON) was conducted. She stated she was notified on November 16, 2019 that Resident 1 received Alunbrig 360 mg (milligram) a day instead of 180 mg a day for 10 days. She stated the medication was put into the facility's system incorrectly. One order was for brigatinib (generic name) 180 mg once a day, and the other order was for Alunbrig (brand name for brigatinib) 180 mg in the afternoon. On December 10, 2019, at 3:45 p.m., an interview with Licensed Vocational Nurse 2 (LVN 2) was conducted. He stated when he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 8 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prepared Resident 1's medications for administration, the electronic Medication Administration Record (eMAR) indicated an order for brigatinib 90 mg. The label on the prescription bottle read brigatinib 180 mg, and since the medication was not scored, he asked other staff how the brigatinib was administered, and he confirmed others were administering a whole tablet of brigatinib 180 mg to the resident. He further stated that the order was duplicated, and should have been discontinued. He said the medication error should have been caught when staff first prepared the medication for Resident 1. LVN 1 was interviewed on January 22, 2020, at 10:59 a.m., and stated when she administered the brigatinib on November 2, 6, 7, 8, 9, 11, 12, 13, 14, and 15, 2019, she compared the pharmacy label on the medication bottle with the eMAR and identified a discrepancy with the dosage on the pharmacy label indicating 180 mg and the eMAR order, indicating 90 mg. She stated she should have followed through and resolved the discrepancy prior to administering the medication to Resident 1. LVN 1 stated on November 4 and 5, 2019, the eMAR indicated a code 9, which usually meant the medication was held, but could not recall the reason. LVN 1 stated on November 9, 2019, she administered the Alunbrig 180 MG at 9 a.m. and again at 5 p.m., and said she was just following the order on the eMAR. She said did not compare it with the original orders. Review of Resident 1's physician admission orders on November 1, 2019, indicated "...Brigatinib Tablet 90 mg Give (sic) 1 tablet via J-Tube (jejunostomy tube - a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medication into the body) one time a day for Lung CA (cancer)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 9 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's "Medication Administration Record" dated November 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 2019 indicated he received brigatinib 90 mg via J-Tube one time a day at 9 a.m. A review of Resident 1's orders dated November 5, 2019, and written at 2:09 p.m. indicated, "...Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via J-Tube one time a day for CA May crush medication per MD (doctor name)..." A review of Resident 1's orders dated November 5, 2019, and written at 8:36 p.m., indicated "...Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via J-Tube in the afternoon for CA May crush medication per MD (doctor name)...DISCONTINUE...Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via JTube one time a day..." Resident 1's "Medication Administration Record" dated November 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 2019 indicated "...Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via JTube in the afternoon for CA May crush medication per MD..." was given at 5 p.m. A review of Resident 1's "Assessment Summary" dated November 16, 2019, at 3:42 p.m., indicated "...The change in condition I (LVN 2) am calling about is/are: Medication error...There was an order for brigatinib 90 MG, Give 1 tablet via J-Tube one time a day for Lung CA and there was also an order for same medication, Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via J-Tube in the afternoon for CA. Original doctor's order was to give 180 mg a day. Patient was receiving 360 mg/day d/t (due to) duplicate order x 10 days...I (LVN 2) was working am (sic) shift on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 10 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cart 2...when I came to the patients Alunbrig Tablet 180 mg medication. The eMAR read Brigatinib Tablet 90 MG. So I stopped what I was doing went to the nursing station to verify the order..." A review of the facility policy and procedure "Medication Administration" with a revision date of July 1, 2016, indicated "...The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR)...any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication..." The facility's pharmacist consultant (PC) was interviewed by phone on December 10, 2019, at 4:15 p.m. The PC stated he was not familiar with the resident, and stated he did monthly medication checks around the eleventh of the month. He stated he did not recall if the medication could be crushed or not, but the facility should go by manufacturer's instructions. The PC further stated most chemo drugs were to be taken with or without food and were not to be crushed. A review of the manufacturer specifications for Alunbrig revised December, 2018, indicated "...Swallow ALUNBRIG tablets whole. Do not crush or chew tablets...Embryo-Fetal Toxicity: Can cause fetal harm...may cause reduced fertility in males..." A review of the facility policy and procedure "Medication - Administration" revised July 1, 2016 indicated "Safe handling of Oral Hazardous Drugs - A hazardous drug is any medication possessing at least one of the following characteristics...teratogenicity, (Any agent that can disturb the development of an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 11 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE embryo or fetus), reproductive toxicity, (adverse effects of a chemical substance on sexual function and fertility in adult males and females)..." In a second interview conducted with the PC on January 31, 2020 at 3:36 p.m., he stated he had completed the facility's Medication Regimen Review (MRR) on November 11, 2019. A review of the MRR revealed a recommendation to identify specific behaviors Resident 1 exhibited with escitalopram (Lexapro) for depression. He did say that there was a policy and procedure for medications brought into the facility from home or an outside pharmacy, but the facility informed him that the facility had its own policy. The PC stated medications that are brought in from home are sent to the pharmacy to verify the order, and add the medication to the resident profile. He said the facility policy stated that the doctor can check in the medications, and that was probably why the error occurred. The brigatinib was not sent to the pharmacy.

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 03/04/2020 The facility must ensure that itsFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 12 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one (Resident 1), of two residents reviewed, was free of significant medication errors when Resident 1 was administered a double dose of a chemotherapeutic medication used to treat the resident's lung cancer for ten days, and the medication was crushed for administration which was against manufacturer's specifications. This failure had resulted in significant medication errors. Subsequently, this failure had the potential to result in further suffering and serious adverse medication reactions for the resident. Findings: On December 10, 2019, an unannounced visit was conducted at the facility for an investigation of a complaint related to a medication error. Resident 1's medical record was reviewed and indicated the resident was admitted to the facility on November 1, 2019, with diagnoses which included malignant neoplasm, (cancer) of the lung, secondary malignant neoplasm, (cancer that has spread from the original site to other organs) of the brain, pneumonia, (a lung infection), drug or chemical induced diabetes with hyperglycemia, (drugs that cause blood sugar to be high), open wound left lower leg, compression fracture of T11 and T 12 vertebra, (broken bones in the thoracic spine), low back pain, and muscle wasting. The Director of Nursing (DON) was interviewed on December 10, 2019, at 2:26 p.m. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 13 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she was notified on November 16, 2019, that Resident 1 received Alunbrig 360 mg a day instead of 180 mg a day for 10 days. The DON stated the medication was entered into the facility's system incorrectly. One order was for brigatinib 180 mg once a day, and the other order was for Alunbrig (brand name for brigatinib) 180 mg in the afternoon. A record review of Resident 1's physician admission orders on November 1, 2019, indicated "...Brigatinib Tablet 90 MG Give 1 tablet via J-Tube (jejunostomy tube - a soft plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medication into the body) one time a day for Lung CA (cancer)..." Resident 1's Medication Administration Record (MAR) dated November 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 2019, was reviewed and revealed brigatinib 90 mg was given via J-Tube at 9 a.m. November 4 and 5, 2019, indicated "...9...other..." A review of Resident 1's physician orders dated November 5, 2019, and written at 2:09 p.m., indicated "...Alunbrig Tablet 180 MG (brigatinib) Give 1 tablet via J-Tube one time a day for CA May crush medication per MD (doctor name)..." A review of Resident 1's physician orders dated November 5, 2019, written at 8:36 p.m., indicated the order was changed to "Alunbrig Tablet 180 MG (Brigatinib) Give 1 tablet via JTube in the afternoon for CA May crush medication per MD (doctor name)..." The order indicated to discontinue the order for Alunbrig Tablet 180 mg (brigatinib) one time a day. A review of Resident 1's MAR dated November 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 2019, revealed "...Alunbrig Tablet 180 mg (brigatinib) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 14 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was given at 5 p.m. A review of Resident 1's "Assessment Summary" dated November 16, 2019, written at 3:42 p.m., indicated, "...The change in condition I (LVN 2) am calling about is/are: Medication error...There was an order for brigatinib 90 MG, Give 1 tablet via J-Tube one time a day for Lung CA and there was also an order for same medication, Alunbrig Tablet 180 MG (brigatinib) Give 1 tablet via J-Tube in the afternoon for CA. The original doctor's order was to give 180 mg a day. Patient was receiving 360 mg/day d/t (due to) duplicate order x 10 days ...I (LVN 2) was working am (sic) shift on cart 2 ...when I came to the patients Alunbrig Tablet 180 mg medication. The eMAR (electronic medication administration record) read Brigatinib Tablet 90 MG. So I stopped what I was doing went to the nursing station to verify the order ..." On December 10, 2019, at 3:45 p.m., a telephone interview with Licensed Vocational Nurse 2 (LVN 2) was conducted. LVN 2 stated he prepared Resident 1's medications for administration on November 16, 2019. He said the order on the eMAR revealed an order for brigatinib 90 mg. The medication was in a bottle instead of a bubble pack (the usual method the facility pharmacy packages medications), and the label on the prescription bottle read brigatinib 180 mg. Since the medication was not scored, he asked other staff how the brigatinib was administered, and confirmed others were administering a whole tablet of brigatinib (180 mg) to the resident. He further stated the medication error should have been caught when medication was first prepared for the resident. LVN 2 stated that the order was a duplicate and should have been discontinued. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 15 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On January 22, 2020, at 10:59 a.m., an interview was conducted with LVN 1. She stated when she administered the brigatinib on November 2, 6, 7, 8, 9, 11, 12, 13, 14, and 15, 2019, she compared the pharmacy label on the medication bottle with the eMAR and identified a discrepancy with the dosage. The pharmacy label indicated 180 mg and the eMAR indicated 90 mg. LVN 1 stated she should have followed through and resolved the discrepancy prior to administering the medication to Resident 1. LVN 1 stated on November 4, and 5, 2019 the eMAR indicated a code 9, which usually meant the medication was held, but she could not recall why. She stated on November 9, 2019, she administered the Alunbrig 180 mg at 9 a.m. and again at 5 p.m. and said she was just following the order on the eMAR but did not compare it with the original orders. She stated she had "googled" brigatinib, and read that the medication was for cancer. LVN 1 stated she did not review the side effects, or adverse reactions to the medication. On January 31, 2020 at 3:36 p.m. a telephone interview was conducted with the Pharmacy Consultant (PC). The PC stated according to the policy and procedure, medications that are brought in from home or an outside pharmacy are sent to the (facility's) pharmacy to verify the order, dosage, contraindications, and add the medication to the resident profile. He stated the facility did not follow this process. He further stated that the facility informed him that they had their own policy which stated the doctor can check in the medications, and that was "probably" where the error occurred. The brigatinib was not sent to the pharmacy. A review of Lexicomp Reference for Alunbrig, last updated December 31, 2019, indicated "...Dosing: Adult...Oral: 90 mg once daily for 7 days; if tolerated, increase dose to 180 mg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 16 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE once daily; continue (180 mg) until disease progression or unacceptable toxicity...' A review of the Manufacturer Specifications for Alunbrig, revised December, 2018, indicated the following adverse effects: "...Hyperglycemia...Grade 3 (blood sugar greater than 250)...If adequate hyperglycemic (high blood sugar) control cannot be achieved with optimal medical management, withhold ALUNBRIG until adequate hyperglycemic control is achieved...Adverse Reactions...Rash...Muscle Spasms...Back pain...Includes musculoskeletal pain and myalgia (muscle pain)..." Patient 1's eMAR for the month of November 2019, was reviewed and indicated the patient's blood sugars (BS) were tested every six hours starting November 2, 2019. His physician ordered NovoLOG (an insulin) to be given as determined by a sliding scale from November 2, 2019, through November 14, 2019. The results showed the patient's BS were variable and trending upwards from a low of 167 to a high of 318. On November 14, 2019, the patient's physician increased the sliding scale dosage due to the BS results. After the change in NovaLOG dosage, the patient's BS continued to be variable and trending upwards from a low of 309 to a high of 339 on November 20, 2019. The order was discontinued on November 21, 2019. According to the American Diabetes Association normal blood sugar levels should be less than 180 milligrams per deciliter (mg/dL) after meals. A review of Resident 1's physician's Progress Notes dated November 16, 2019, at 1 p.m. indicated Resident 1 exhibited an onset of severe back pain (adverse reaction of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 17 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Alunbrig). A review of Resident 1's eMAR indicated at the time of admission he was receiving nonpharmacological interventions for pain; and after November 7, 2019 Resident 1 was taking transdermal Salon Pas patches for lower back pain; Tylenol 650 mg, Norco 5-325 mg, Tylenol with codeine #4, Percocet, morphine sulfate solution, transdermal Bultrans patch, transdermal Fentanyl patch, and transdermal lidocaine patches to lower back, right shoulder, and spine for pain relief. A review of Resident 1's Assessment Summary dated November 21, 2019, at 10:37 a.m. indicated, "...change of condition...rash inner thighs (an adverse reaction to Alunbrig) and "...decreased O2 (oxygen) sat (saturation) 88% RA (room air)..." Normal oxygen saturation range on RA per the Mayo Clinic is 95-100% . Values under 90% is considered low. A review of the facility policy and procedure "Medication Administration" with a revision date of July 1, 2016, indicated "...The licensed nurse must know the following information about any medication they are administering...The drug's usual dosage...The drug's side effects and adverse reactions...The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR)...any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DBM011 Facility ID: 630017935 If continuation sheet 18 of 19 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555915 (X3) DATE SURVEY COMPLETED 02/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE SPRINGS HEALTH AND REHABILITATION CENTER 25924 Jackson Ave Murrieta, CA 92563 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: DBM011 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: 630017935 (X5) COMPLETE DATE If continuation sheet 19 of 19