Menifee Lakes Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide a resident representative with a copy of the resident's medical records within the required timeframe following a written request for one of three residents reviewed for resident's rights (Resident 1). This failure had the potential to cause unnecessary delay, frustrations, and anxiety for the resident's representative in obtaining the resident's medical information.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and homelike environment for one of four residents reviewed (Resident 1), when the resident's dentures and clothing were not maintained, safeguarded, and accounted for. This failure resulted in Resident 1's dentures and clothing not being available upon transfer to the hospital and had the potential to result in unmet nutritional needs, weight loss, and psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure post fall 72-hour monitoring (consistent monitoring of residents, each shift, for any changes from their baseline condition) was completed and documented for three of three residents reviewed for falls. This failure had the potential to delay identification of post-fall complications, changes in neurological status, pain, injury or decline in condition, resulting in delayed physician notification and implementation of necessary interventions.

Inspectors wroteBased on interview and record review, the facility failed to maintain current personnel records for three of three personnel files reviewed (CNAs 1, 2, and 3) when annual performance evaluations were not completed. This failure resulted in not inability to assess staff performance, identify areas needing improvement, and ensure competency in providing resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition for one of two residents reviewed (Resident 1), when staff did not notify the physician after the resident alleged that staff handled her roughly. This failure had the potential to result in a delay in medical and psychosocial evaluation and to place the resident at risk for unmet medical and psychosocial needs.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours after the allegation was made for one of two residents reviewed for abuse (Resident 1) when the Registered Nurse Supervisor (RNS) did not report an allegation after becoming aware of the incident. This failure resulted in a delay initiating an investigation and implementing protective measures, placing Resident 1 at risk for potential ongoing abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a timely assessment and monitoring of a resident following an allegation of abuse for one of two residents reviewed for abuse (Resident 1), when Resident 1 was not assessed for pain and emotional distress after the resident reported that a staff member slammed her arm during care. This failure resulted in a delay in identifying potential injury and unmet needs, placing Resident 1 at risk for untreated pain and undetected physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to provide a written summary of the baseline care plan for one of one resident reviewed (Resident C). This failure had the potential for Resident C not to be aware of the facility's plan of care for Resident C.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light is within reach for one of three residents reviewed (Resident B). Resident B is at risk of falling. This failure had the potential for Resident B not to be able to call for assistance, which could lead to unassisted attempts to stand and increase the risk of falls.

Inspectors wroteBased on observation, interviews and record review, the facility failed to reassess a resident for the use of grab bars (Bedrails to provide support and secure handhold) after being readmitted to the facility, for one out of four residents (Resident 1) reviewed for bed rail use. This failure resulted in the Resident 1's inability to use grab bars for repositioning assistance and bed mobility.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate and maintain infection prevention precautions (measures intended to prevent transmission of infectious microorganisms) for a resident with repeated Urinary Tract Infections (UTIs) with the presence of the microorganism Pseudomonas aeruginosa (Pseudomonas - a Multi Drug Resistant Organism [MDRO]) in their urine for one out of three residents reviewed for infection control precautions (Resident 2). This failure had the potential to spread infection to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of four residents reviewed (Resident 1), to monitor blood sugar level, assess meal intake percentage, or ensure proper communication among staff for a resident admitted with diabetes (abnormal blood sugar level). This failure had the potential to cause adverse health effects.

Inspectors wrote5. Resident 58's record was reviewed. Resident 58 was admitted to the facility on [DATE]. A review of Resident 58's MDS, dated January 18, 2025, indicated Resident 58 had BIMS score of 14 - cognitively intact. A review of Resident 58's POLST, dated March 22, 2024, indicated, .No Advance Directive .discussed with legally recognized decision maker (daughter) . A further review of Resident 58's medical records indicated the resident was not provided information or education about formulating an AD. On March 13, 2025, at 1:02 p.m. a concurrent interview and record review were conducted with Social Service Assistant (SSA) 1. SSA 1 stated, a social services assessment was conducted for all residents upon admission and that the assessment should include notations indicating whether an AD was discussed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when Residents 54 and 182 were missing documentation for the administration of controlled substance (CS, those with high potential for abuse and addiction) medications. The CS medications were signed out of the Antibiotic or Controlled Drug Record Medication (count sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 54. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when administered a combination of psychotropic medications with sedating effects, sustained a fall, continued to receive additional sedating psychotropic medications without consideration of the potential additive sedative effects, and sustained a second fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a recommended diet for Resident 51 after a change in health status. This failure had the potential for Resident 51 to have uncontrolled blood sugar levels and complications from type 2 diabetes mellitus (abnormal high sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Residents 36 and 57, nursing staff failed to properly clean and disinfect shared blood pressure (BP-pressure of blood in blood vessels) cuffs, stethoscopes, and glucometers (blood glucose meter to measure and display the amount of sugar (glucose) in your blood) according to the disposable Sani-Cloth Prime disposable wipe manufacturer's specified contact time (the time the resident equipment was to be in contact with the disposable wipes to kill micro-organisms). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was conducted for one of two residents reviewed for respiratory issue (Resident 30) when resident developed shortness of breath. This failure had the potential to negatively impact Resident 30's physical, mental, psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure post- (after) hemodialysis (removal of toxins and fluids from the blood through the use of a machine) assessment was completed on January 10, 2025, and January 27, 2025, for one of two residents reviewed for hemodialysis (Resident 20). This failure had the potential for delayed detection and/or management of complications arising from hemodialysis treatments for Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medically-related social service referrals were obtained for two of 21 sampled residents (Residents 26 and 30) when: 1. A referral for CT scan (computerized tomography - procedure that uses a combinations of X-rays and computer technology to create detailed cross-sectional images of the body) of the abdomen for gross hematuria (bloody urination) was not obtained for Resident 26. This failure had the potential to delay the identification of underlying causes of gross hematuria for Resident 26; and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of five sampled residents (Resident 1). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage when one refrigerated injectable medication vial was identified stored unrefrigerated not according to manufacturer's specifications. This failure had a potential for residents to receive medications that were inadequately monitored with unsafe and reduced effectiveness, which could lead to unsafe and ineffective medications for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within two hours to the California Department of Public Health (CDPH), for one of four residents, (Resident 1). This failure had the potential to place Resident 1 at risk for further abuse or harm.

Inspectors wroteBased on interview and record review, the facility failed to implement their Respiratory Protection Plan to ensure N-95 filtering facepiece respirator, (FFR - filtering facepiece respirator - a disposable half-mask that covers the user's airway [nose and mouth] and offers protection from particulate materials) fit testing (to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace) was conducted annually for one of four staff members. This failure had the potential to contribute to the spread of COVID-19 among residents and staff, potentially causing serious harm to the health and well-being of vulnerable residents with compromised health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate needs for two of three sampled residents reviewed (Residents A and B), when: 1. Resident A was not provided bedrails for repositioning as requested. This failure had the potential for Resident A to have unmet needs. 2. Resident B's call light was found not within her reach. This failure had the potential for Resident B not to be able to call for assistance from the staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 2), had a comfortable homelike environment when the curtain blinds, covering the resident's sliding door, were missing four slats and were not documented as needing repair in the maintenance repair log. This failure had the potential for Resident 2 to not feel like she was at home and has the potential to affect the efficiency of the blinds to block the sun's rays to keep the room cooler.

Inspectors wroteBased on interview and record review the facility failed to ensure access to personal and Medical Records (MR) was provided within two working days for one of two sample residents (Resident 3). This failure has the potential to result in a delay of care and treatment for Resident 3 affecting the resident's physical wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2 ' s surgical incision staples to his right below knee Amputation (R-BKA) were removed timley as ordered for one of three residents, (Resident 2). Resident 2 ' s wound staples were removed on January 22, 2024, two months after his R-BKA amputation on November 22, 2023. This failure has the potential to result in delayed tissue healing and placed the resident at risk for wound infection.

Inspectors wroteBased on interview and record review, the facility failed to treat residents with dignity when staff stated residents who were continent of urine, (the ability to hold back urine), and unable to get out of bed would be placed in a brief and instructed to use the call light when the brief needed to be changed. This failure had the potential to result in a resident feeling humiliated and embarrassed. On November 21, 2023, at 9:19 a.m., a telephone interview was conducted with a family member, (FM). The FM stated that Resident 1 had a hip fracture and was discharged to the facility for rehabilitation. The FM stated that Resident 1 was continent of urine and feces, but was placed in a brief, and instructed to use the call light when her brief was wet and needed to be changed. The FM stated that Resident 1 was so distraught and cried for the first couple of days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure bilateral floor mats for one of the three sampled residents (Resident C) was in placed in accordance with the physician order. This failure increased Resident C ' s risk for injury and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure the alarm was functioning and audible, allowing the resident to leave the facility without the staff's awareness for two of three sampled residents (Residents 1 and 2). This failure had the potential to compromise the resident's safety and increased the potential for accidents to occur.

Inspectors wroteBased on interview, and record review, the facility failed, for two of four residents reviewed (Resident 1 and 4), to maintain accurate medical records in accordance with accepted professional standards and practice when the staff failed to accurately document weekly skin assessments of wounds. This failure could increase the potential for confusion to occur in the provision of care for Resident 1 and 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) call light was within reach, when he had a history of fall. This failure had the potential for Resident 4 getting out of bed without assistance, which would increase his risk for fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) call light was within reach. This failure had the potential for Resident 4 to have unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the need to watch the television with volume within the confines of the resident's room. This failure had the potential to affect resident ' s mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for five of sixteen residents reviewed for Advance Directive (AD-written statement of a person's wishes regarding medical treatment) (Residents 21, 38, 63, 120, and 168): 1. A copy of the Advance Directive was in the resident's record; and 2. The facility offered assistance to the resident or responsible party in formulating the AD. These failures had the potential for Residents 21, 38, 63, 120, and 168 's advance directives not to be readily retrievable and available for the staff and physician and not know the residents' wishes regarding medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to incorporate the Preadmission Screening and Resident Review (PASARR - screening for individuals with a mental disorder and individuals with intellectual disability) Level II determination into the resident's care planning such as as psychotherapy and counseling, for one of one resident reviewed for PASARR (Resident 25). This failure had the potential to result in Resident 25 not receiving the appropriate care and services the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the resident with a copy of the summary of the baseline care plan, for one of 16 residents reviewed for baseline care plan (Resident 168). This failure had the potential to result in the resident not being aware of the care and services she would receive while at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop the comprehensive care plans for two of 26 residents reviewed (Residents 66 and 35) when: 1. For Resident 66, there was no care plan for hyponatremia (chemical imbalance of sodium in the body) and; 2. For Resident 35, there was no care plan for her left arm and hand edema. These failures had the potential for the residents not to be able to maintain a normal state of heath and receive necessary care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice for two (Residents 30 and 42) of 16 residents reviewed, when: 1. For Resident 30, one opened bottle and one unopened bottle of Systane (eyedrops to prevent dry eyes) were observed on the resident's nightstand; and 2. For Resident 42, one opened tube of Orajel cream (medication to treat toothache) was observed on the resident's nightstand. These failures had the potential for Residents 30 and 42 to receive medications without a physician's order.

Inspectors wroteBased on observation, interview and record review, for three of 26 residents reviewed (Resident 38, 62, and 158), the facility failed: 1. For Resident 62, to document the pacemaker information in the resident's record; and 2. For Resident 38, to notify the physician when the resident complained of dizziness. These failures had the potential to place these vulnerable residents at high risks for complications due to the delay of provision of care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide Methadone (offers rapid onset of long acting pain relief) the pain medication of choice for one of one resident reviewed for pain (Resident 168). This specific pain medication was from the resident's pain management physician. This failure had the potential for the resident's pain not effectively managed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that non-pharmacological interventions were offered before administering psychotropic (medication that affects behavior and mood) medication Lurasidone (treatment for bipolar disorder [severe mood swings]), for one of five residents reviewed for unnecessary medications. This failure had the potential to delay reducing the dose of resident's medication and prolong the duration of the resident's use of psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified timely, for one of one resident reviewed (Resident 66), when the resident had a low sodium (electrolyte that help control the amount of fluid and the balance of acids and bases [pH balance] in your body) level. This failure resulted in Resident 66 not to receive appropriate treatment and evaluation to address the resident's low sodium level and placed the resident at risk for further health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage was in accordance with professional standards for food service safety when: 1. One plastic bag containing 13 slices of bread was unlabeled and readily available for use; and 2. One cartoon of pasteurized liquid egg was found on the floor underneath the rack. This failure had the potential to result in cross contamination and expose medically vulnerable residents to foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice when: 1. For Resident 29, there was no physician notification of the constant potassium supplement refusals. In addition, there was no plan of care formulated to address the resident's constant refusal of medications. 2. For Resident 24, there was no assessment conducted when Resident 24 had multiple episodes of hypotension (low blood pressure). In addition, the physician was not notified of Resident 24's multiple episodes of hypotension. These failures had the potential to cause a delay in treatment and care for Resident 29's low potassium levels and Resident 24's low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when the kitchen ice machine was noted to have a soft gray and light brownish substance on the edge of the ice chute (inclined channel) located in the inner upper portion of the ice bin. In addition, the ice machine was not sanitized according to the manufacturer's instructions. This failure had the potential to result in cross contamination and food borne illness in a highly susceptible resident population of 68 residents on oral diets out of a universe of 73 facility census.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was in the resident's record for one of nine residents reviewed for AD (Resident 44). This failure had the potential for Resident 44's advance directive to not be readily retrievable by the staff and by the physician and not knowing the wishes of the resident regarding medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate lighting was provided in room [ROOM NUMBER]. This failure had the potential to affect residents' comfort and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse involving Residents 19 and 27 was reported to the California Department of Public Health (CDPH) immediately, but not later than two hours after the allegation was made. This failure had the potential to delay the identification and implementation of appropriate action and placed the residents at risk for further abuse.

Inspectors wroteBased on interview, and record review the facility failed, for two of 19 residents reviewed for baseline care plan (Residents 55 and 108), the following: 1) For Resident 108, the baseline care plan did not include instructions to address the resident's dietary and nutritional need. This failure placed Resident 108 at risk for not receiving an effective and person centered care to maintain optimal physical and mental well-being; and 2) For Resident 55, the facility failed to provide a written summary of the baseline care plan to the resident and/or the resident's responsible party. This failure had the potential to result in the resident not being aware of the care and services he would receive while at the facility.

Inspectors wroteBased on observation, interview, and record reivew, the facility failed to provide the preferred activity for one of one resident reviewed for activity care issues (Resident 18). This failure had the potential to affect Resident 18's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled properly when unlabeled tablets were observed in a Loratadine (medication for allergy symptoms) box. This failure had the potential to result for the licensed staff to administer the wrong medications to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures for one of two residents reviewed for infection (Resident 409) when one staff member was observed entering and exiting an isolation room without following the proper infection control precautions. This failure had the potential to result in spreading infection to a vulnerable resident population.