Inspection·June 27, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one (Resident D) of four residents reviewed for pressure ulcers/injuries (PU/PI-localized damage to the skin and underlying soft tissue usually over a bony prominence resulting from intense or prolonged pressure), received care and services consistent with professional standards of practice, when the status of the pressure injuries, which included measurements, were not consistently documented. In addition, the facility failed to ensure provision of wound treatment was coordinated with the wound care team. Residents Affected - Few These failures have the potential to result in inconsistent provision of wound treatment which could contribute to the delayed healing of the resident's pressure injuries. Findings: On May 24, 2024, at 10:30 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to quality of care. On May 24, 2024, Resident D's medical record was reviewed. Resident D was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm (cancer) of the thyroid gland (a gland at the base of the neck) and dementia (a group of thinking and social symptoms that can interfere with daily function). A review of Resident D's Medication Review Report indicated, on May 14, 2024, Bactrim DS (double strength-an antibiotic used to treat an infection) one tablet twice a day for 10 days for a wound infection was ordered and on May 23, 2024, an order for Mupirocin (medication used to treat skin infections) external ointment 2% apply to sacrum topically (to the skin) for wound infection was placed. A review of Resident D's Skin and Wound Evaluation, dated April 29, 2023, indicated a pressure wound, Stage 2, in-house acquired to coccyx, length 1.0 cm (centimeters-a type of measurement), width 3.0 cm, and depth 0.2 cm, slough (dead cell accumulation, yellow to white in color) to wound bed, light exudate (drainage). A record review of Resident D's Comprehensive Skin Evaluation/Assessment indicated: -On May 2, 2024, a left thigh rear abrasion and left lower leg skin tear were noted, no documentation indicating the presence of a PU/PI to the sacrum/coccyx area (the bony structure at the back of the pelvis and the tail bone). - On May 7, 2024, three wound sites were noted: a left thigh abrasion, a left lower leg skin tear, and a right inner thigh abrasion, no documentation was found indicating the presence of a PU/PI to the sacrum/coccyx area. -On May 14, 2024, a left thigh rear abrasion, a left lower leg skin tear, and a right inner thigh abrasion were noted, no documentation was found indicating the presence of a sacrum/coccyx PU/PI. Additional Skin and Wound Evaluations for Resident D were reviewed. -On May 20, 2024, records indicated a pressure wound, located on the coccyx had .Obscured (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 2 of 4 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 055223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Jacinto Valley Post Acute 275 North San Jacinto Street Hemet, CA 92543 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few full-thickness skin and tissue loss .in-house acquired . the wound measurements were 5.3 cm in length, 5.7 cm in width, and not applicable for the depth, with a wound bed of 10% granulation (development of new tissue and blood vessels in a wound) and 90% slough, unstageable, with evidence of infection, redness/inflammation and warmth, moderate exudate, surrounding tissue discolored, erythema (skin redness caused by underlying disease), fragile skin, macerated (condition that occurs when a wound experiences excessive moisture, leading to softening and breaking down of the surrounding skin), the Periwound (area around the wound) is warm, dressing with calcium alginate (a substance used in wound repair) and foam; .slightly macerated to peri wound, redness and foul odor .purplish discoloration noted to surrounding area of the wound extending to rt (right) buttock, intact . A review of Resident D's Wound Report, dated May 20, 2024, indicated an assessment by a provider (physician, physician assistant or nurse practitioner) .continue Bactrim DS .sacral .pre-debridement (removal of damaged tissue from a wound) wound .L (length) 4.6 (cm) W (width) 5.1 (cm) D (depth) 0.2 (cm) .apply Mupirocin 2% cover with Calcium Alginate .Q 2 days . A review of Resident D's Wound Report, dated May 27, 2024, indicated .wounds appear to be regressing (worse state), ongoing infection .Sacral .stage 4 .pre-debridement wound .size L 5.2 (cm) W 8.6 (cm) D 0.7 (cm) .exudate moderate .erythema mild .odor foul .cleansed with Dakin's (solution used to clean infected wounds) .apply Mupirocin 2% .cover with Alginate . and Resident D's progress note indicated .sacral region .pressure ulcer stage 4, pre debridement measurement (L x W x D) 5.2 x 8.6 x 0.7 cm .post debridement measurement 5.3 x 8.7 x 0.8 cm .bone exposed . A review of Resident D's Hospice Skin Assessment notes: -On April 16, 2024, indicated .coccyx area .stage II (two) .size (L, W, D) .LVN (Licensed Vocational Nurse) at facility reported that pt (patient) has 2 new stage 2 wounds to coccyx measuring 0.8 x 0.8 x 0.1 cm and 0.9 x 0.7 x 0.1 cm .wound care to be performed by facility staff . -On April 30, 2024, indicated .Coccyx area .stage 2 .0.8, 0.8, 0.1 .coccyx area stage 2 .0.9, 0.7, 0.1 .pt continues to have 2 stage 2 to coccyx .wound care done by treatment nurse at facility .provided education to staff .Facility made aware to contact HH (hospice) with any questions or concerns . -On May 7, 2024, indicated .Buttock-right .pressure injury stage II .new .coccyx area .stage II .coccyx area .unstageable .wound is worsening. Pt now has 2 quarter sized wounds to coccyx and 1 nickel sized wound to right buttocks. Wound to mid- coccyx has 40% white slough and is unstageable .treatment nurse made aware of new wound orders . -On May 14, 2024, indicated .Coccyx area pressure injury unstageable new .worsening wound to coccyx measures 2.3 x 3.3 .80% slough, dark areas surrounding slough .The mid coccyx, R (right) coccyx, and R (right) buttocks wounds has increased in size and have become one large wound . -On May 22, 2024, indicated .Coccyx area pressure injury .unstageable .size 4.7, 5.2, 0.3 .wound nurse at facility stated NP (nurse practitioner) from [name] Wound visited pt earlier .wound care to be performed by facility staff. New wound measurements from [name] Wound for coccyx 4.7 cm x 5.2 cm x 0.3 cm . Resident D's Care plans were reviewed, dated January 17, 2024, indicated .Resident has impaired skin integrity as evidence by skin tear/abrasion .Interventions .Record location, size (length, width, depth) color of surrounding skin . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 3 of 4 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 055223 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Jacinto Valley Post Acute 275 North San Jacinto Street Hemet, CA 92543 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On May 24, 2024, at 1:20 p.m., and interview with concurrent record view was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated, Resident D was seen by the wound care treatment team and does not have a urinary catheter in place. LVN 1 stated the Comprehensive skin note for May 2, 2024 mentioned the skin tear and abrasion to Resident D's leg, there was no mention of the sacral/coccyx PU/PI, and the skin comprehensive evaluations dated May 7, 2024 and May 14, 2024 mentioned the skin tear and abrasions, and no mention of a sacral or coccyx pressure wound, the first note documenting the pressure injury to the sacrum/ coccyx was on May 20, 2024. LVN 1 stated the weekly comprehensive skin evaluation should have documentation for Resident D's sacral/coccyx wounds, with the measurements and description of the wound itself, LVN 1 could not find appropriate documentation. On May 24, 2024, at 2:35 p.m., an interview was conducted with the Hospice Nurse (HN). The HN stated he sees the Resident D about once a week, assess her, gets a set of vital signs, provides wound care, takes measurements, and reviews the current pressure injury with the hospice physician for additional orders. The HN stated Resident D's pressure ulcer has had rapid progression, Resident D is declining quickly, the pressure wound to her sacral area was small, a stage 1 or 2 and healed up, but reopened and is getting worse. On May 28, 2024, at 10:25 a.m. an interview and concurrent record review were conducted with LVN 2. LVN 2 stated comprehensive skin evaluations should be completed every week on each resident with any skin complications (skin tears, pressure injuries, rashes, abrasions), Resident D's pressure ulcer to her coccyx area would come and go. LVN 2 stated his comprehensive note from May 20, 2024, indicated the wound had re-opened and did not indicate a depth in his measurements, he did not think it needed to be measured because slough made it unstageable, a note from the HN on the same date stated it was a Stage 2, and he should have measured for a depth, and when slough is present it has to be considered a Stage 3 per wound care guidelines. LVN 2 could not find documentation of Resident D's pressure ulcer to her sacrum/coccyx after reviewing his notes on May 2, 2024, May 7, 2024, or May 14, 2024. LVN 2 stated he did not know a provider from the specialty wound care team, had treated Resident D's pressure injury on the same day he did, he did not make arrangements or collaborate with the wound team, and Resident D received two treatments on the same day, one from him and one from the wound care team. LVN 2 stated he forgot to include complete measurements and descriptions of Resident D's pressure injury in several of his notes, he overlooked the required documentation. A review of the facility's policy titled Hospice Program, dated July 2017, indicated .Hospice services are available to residents .certified as being terminally ill .it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related condition .it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs .coordinated care plans for residents receiving hospice services .in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including .skin integrity .mobility and repositioning . A review of the facility's protocol titled Pressure Ulcers/Skin Breakdown, dated April 2018, indicated .the nurse shall describe and document/report the following .full assessment of pressure sore including location, stage, length, width and depth, present of exudate or necrotic (dead) tissue .The physician will clarify the status of relevant medical issues .the impact of comorbid conditions on healing an existing wound .physician will order pertinent wound treatments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 4 of 4