Menifee Lakes Post Acute

In the surveyor’s words

From the most serious findings on record at Menifee Lakes Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 14, 2022

  Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with the professional standards of practice for two of three sampled residents (Residents 1 and 2) when: 1. Resident 1 was not provided assistance during mealtimes based on the resident's comprehensive assessment. Resident 1 needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or non-weight bearing assistance) during meals. This failure resulted for Resident 1 to choke on his food and subsequently died while at the facility. 2. […]

• No harm, potential for more than minimal, patternF730Mar 13, 2026

  Based 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. Findings:On March 13, 2026, a review of personnel files for the following CNAs revealed no documented evidence of annual performance evaluations: -CNA 1 was hired on August 16, 2022 -CNA 2 was hired on August 30, 2023 -CNA 3 was hired on February 28, 2024 On March 13, 2026, at 2:55 p.m., a concurrent interview and record review were conducted with the Director of Staff Development (DSD). […]

• No harm, potential for more than minimal, patternF578Mar 13, 2025

  Based on interview and record review, the facility failed to ensure, six of nine residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 9, 29, 46, 50, 51, 58) had the following: 1. A copy of the AD available in the resident's record for Resident 9; and 2. The resident or their resident representative had been provided information regarding the formulation of an AD for Residents 29, 46, 50, 51, and 58. These failures had the potential to result in the ADs for Residents 9, 29, 46, 50, 51, and 58 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. Resident 50's record was reviewed. […]

• No harm, potential for more than minimal, patternF755Mar 13, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF758Mar 13, 2025

  Based 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. […]