Health inspection·April 14, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missing bank cards within the facility's surrounding area from March 26, 2025, through March 27, 2025. During her stay, FM 1 stated Resident 1 ' s bank cards and ID were in her wallet, which was placed inside her purse and at her bedside. FM 1 said Resident 1 did not know about these unauthorized bank transactions and her bank cards were missing until after her discharge in April 1, 2025. On April 14, 2025, at 2:31 p.m., an interview was conducted with the Director of Nursing (DON). the DON stated if a resident was admitted with valuables, such as jewelry, cash, bank cards, or ID Cards, the facility offers to keep them in a safe. The DON stated the resident will sign a waiver if they preferred to keep their valuable in their posession. The DON further stated they were made aware of the unauthorized transactions on Resident 1's bank cards after she was discharged on April 1, 2025. The DON stated these unauthorized transactions were made during Resident 1's stay in the facility and they were not able to identify the individual who conducted this unauthorized transactions. On April 16, 2025, at 2:41 p.m., and interview was conducted with SW 1. SW 1 stated Resident 1 had a signed a waiver indicating she preferred to keep her wallet in her possession at her bedside and not the facility safe. SW 1 stated she did not inspect the contents of Resident 1's wallet. SW 1 stated she was aware Resident 1 had bank cards and ID her card in her possessions and this was not documented in her personal belongings list. SW 1 further stated the staff was responsible for ensuring that residents ' items were kept safe. SW 1 stated that facility should safeguard the resident ' s possessions. SW 1 stated they knew Resident 1 had a wallet and that it was in her purse. SW 1 stated the facility should have had safeguards in place such as monitoring of personal belongings in a resident's posession. SW 1 stated the personal belongings inventory lists were used to keep track of resident's personal items. On April 17, 2025, at 1:43 p.m., a telephone interview was conducted with the DON. The DON stated the facility did not have specific monitoring system in place for residents who chose to keep their valuables. The DON stated Resident 1's personal belonging inventory lists should have been itemized and specific. The facility's policy and procedure titled, Personal Property, dated August 2022 was reviewed. The policy indictaed, .Resident belongings are treated with respect by facility staff, regardless of perceived value . The facility's undated policy and procedure titled, ' Safekeeping of Personal Funds and Valuables of Residents in the Facility, was reviewed. The policy indicated, .Personal funds or valuables may include: cash, checks, jewelries, ID Cards, wallet, credit/debit cards, etc . The facility shall have the responsibility to implement written procedures to prevent misappropriation of resident personal funds or valuables . The facility shall provide a resident a receipt for the personal funds or valuables, and retain a copy for its records . Upon admission, resident ' s belongings shall be itemized in the Inventory List . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 2 of 3 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 04/14/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Resident's personal funds or valuables itemized during admission or at any time during the resident's stay int he facility, shall be turned over to the family or responsible party, and shall be accounted for, signed out, and witnessed in the Inventory List accordingly . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 3 of 3