Health inspection·October 8, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's discharge to a 3rd party agency (not contracted with the facility) for assistance in finding appropriate/safe placement in the community; c. She would document when she requests assistance from a 3rd party agency, and all the correspondence with the 3rd party agency involving residents;d. Resident 1 approached her on August 11, 2025, and requested to be discharged from the facility, as he (Resident 1) wanted more of a private room;e. On August 26, 2025, she referred Resident 1 to a 3rd party agency to assist with finding community placement, and she informed the 3rd party agency that the resident was requesting a room downstairs that could accommodate his wheelchair; f. On August 27, 2025, the 3rd party agency came to the facility to assess resident for Compatibility (healthcare needs) for a specific room and board, and she provided the 3rd party agency with the resident's (Resident 1) medical records such as the history and physical and the IDT functional abilities collaboration documents; g. On September 17, 2025, the 3rd party agency informed the CM that the resident (Resident 1) was appropriate for placement at the room and board, and the room and board would provide caregiver services to meet the resident's daily mobility and ADL needs, and that resident would have a room downstairs;h. The 3rd party agency did not specify how many caregiver hours were available daily to assist the resident (Resident 1) at the room and board, and she did not know how many caregiver hours would be provided at the room and board, as she had not contacted or verified this information with the room and board;i. On September 18, 2025, the resident (Resident 1) was discharged to a room and board. The CM explained that this room and boards are for more independent residents, and PT notes confirmed the resident is independent with transfers;j. The CM verified she did not have any documentation reflecting Resident 1's referral to the 3rd party, and there was no documentation of correspondence she had with this 3rd party agency related to the resident's discharge.A review of Resident 1's progress notes did not indicate any documentation that an assessment was conducted by the facility to determine the appropriate placement for discharge. A review of Resident 1's, IDT (Interdisciplinary Team) Functional Abilities, assessment, with the effective date of August 7, 2025, at 5:11 p.m., indicated the following:a. Self-care .toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement .Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or support trunk or limbs, or holds trunk or limbs but provides less than half the effort) .Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear that is appropriate for safe mobility .Partial/moderate assistance .; and b. Mobility .Sit to Stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed .Supervision or touching assistance .Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) .supervision or touching assistance .Toilet Transfer: The ability to get on and off a toilet or commode .Supervision or touching assistance .Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space .Partial/moderate assistance .12 steps: The ability to go up and down 12 steps with or without rail .Not attempted due to medical condition or safety concerns . A review of Resident 1's IDT Functional Abilities assessment, dated September 18, 2025, at 9:01 a.m., indicated the same assessment on self-care and mobility as the assessment conducted on August 7, 2025.A review of Resident 1's, Discharge Summary and Post-Care Instruction, dated September 17, 2025, at 4:42 p.m., by Registered Nurse (RN) 1 indicated that the resident will be discharged from the facility on September 18, 2025, at approximately 11 a.m. to a room and board with home health services. Further review of the document indicated that the resident requires some assistance with activities of daily living, has functional limitations, is chairfast with slightly limited mobility and is a fall risk. On October 2, 2025, at 3:42 p.m., during an interview, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 2 of 5 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 10/08/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CM stated the discharge process also would include a follow-up call to the resident by the Social Worker (SW), the day after discharge to Make sure everything's O.K., with the resident.On October 6, 2025, at 11:56 a.m., during an interview with SW 1, she stated the following:a. She is not involved in discharge planning for a resident, but she is responsible for giving the resident the notice of proposed discharge;b. She follows-up with a phone call to the resident within 72 hours after their discharge, to find out how the resident is adjusting to their new living arrangements, and If they are doing ok.;c. If a resident is their own representative (Deemed able to make their own decisions), she would attempt to contact the resident by making 2-3 calls and leaving a voicemail if necessary. SW stated she will document her follow-up calls and attempts;d. After the resident (Resident 1) was discharged from the facility to the room and board, she did not document her attempted calls, but she believed attempting to call him 2 times on September 19, 2025, and believed she left two voice mails. However, SW 1 stated she could not remember if Resident 1 returned calls.On October 6, 2025, at 12:19 p.m., during an interview with Resident 1 via telephone call, the resident's speech was noticed to be slow and slurred, and stated the following: a. A CM at the facility, he was unsure of the name, and a 3rd party agency arranged his discharge (September 18, 2025) to the room and board;b. He wanted to be discharged to a room and board because he was told by the facility that he would have a room downstairs, and caregiver available to help him;c. When he arrived at the room and board, his room was upstairs, and he could not walk upstairs because he was wheelchair bound;d. He slept downstairs in the dining room with no privacy; e. A caregiver was not available to help him transfer to and from his wheelchair to the toilet, and the bathroom could not accommodate the size of his wheelchair, so he had to use the bathroom with the door open, which made him feel bad because there was no privacy; f. He had two falls during his stay at the room and board while he was trying to transfer himself from the bed to his wheelchair, he slid to the ground, and a maintenance person helped him up. He did not have any injuries from the fall;g. He was not happy and the situation at the room and board was upsetting; andh. He was unsure if the facility called to follow up with him while at the room and board where he stayed for approximately four and a half days, until the owner of the room and board drove him to the GACH and left him there for no reason. On October 6, 2025, at 12:54 p.m., during an interview with the Director of Nursing (DON), the DON stated the following: a. She does not have a direct role in the facilities discharge process, but pending resident discharges are discussed during a stand-up meeting with the department heads;b. The process to discharge a resident to a room and board would usually include a 3rd party agency assessing the resident's care needs to ensure the room and board would be able to provide appropriate care for the resident and would discuss with resident any concerns they may have;c. Prior to discharge, the facility has a responsibility to ensure the room and board can provide the caregiver services needed to care for the resident, and this should be done by the CM contacting the room and board to verify the required caregiver services would be provided;d. After a resident is discharged , the social worker (SW) is expected to follow up with the resident within 72 hours by making 2-3 calls to the resident, and if unable to contact the resident, a follow-up call should be made to the room and board to ensure the discharge was appropriate for the resident with no complaints or concerns; ande. Resident 1's discharge was discussed during a stand-up meeting prior to resident's discharge on [DATE], and it was stated resident was going to have caregiver services provided by the room and board.On October 6, 2025, at 2:49 p.m., an interview was conducted with the CM who stated when a 3rd party agency assesses a resident for discharge to a room and board the 3rd party agency does not provide the CM with a copy of their (3rd party agency) assessment. The CM stated she, Just takes their (the 3rd party agency) word for it, when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 3 of 5 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 10/08/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3rd party agency stated the resident is appropriate for a safe discharge to the room and board. The CM further stated, she did not speak to the owner of the room and board until the day the resident (Resident 1) was discharged from the facility, on September 18, 2025, at which time, she informed the owner that the resident was on his way to the room and board via transport van. On October 6, 2025, at 3:15 p.m., during an interview with the owner of the room and board, the owner stated the following:a. Residents who stayed in her room and board were required to be independent with the ability to walk;b. The 3rd party agency reported that the resident (Resident 1) was very independent and could walk with a walker (Assistive device);c. Resident 1 presented to the room and board in a wheelchair and could not walk;d. The minute the resident arrived at the room and board, she told the resident he was not going to be able to stay at the room and board because they did not have the caregiver services the resident would require, and the resident could only stay for a few days;e. She originally arranged for the resident (Resident 1) to have a bedroom upstairs because she was told by the 3rd party agency he could walk, but the resident could not walk up the stairs, so she had to make a space for resident to sleep in a common area of the house, by placing a twin bed in the living room; f. The resident (Resident 1) was unsteady on his feet and would fall every day. She did not believe the resident hurt himself during falls, as he was a light guy and she would have to pick the resident up and put him back in the wheelchair;g. She did not speak to anyone at the facility regarding the resident being inappropriate to live in the room and board, because she thought resident would need a referral to go back to the facility; andh. She took the resident (Resident 1) to hospital because she could not provide care for him. A review of Resident 1's GACH Emergency Department Record dated September 25, 2025, at 3:23 p.m., (8 days after the resident was discharged to the room and board from the skilled nursing facility), indicated, .male patient presents to the ER (Emergency Room) via EMS (Emergency Medical Services) for evaluation of weakness .Patient reports having frequent falls and is unable to walk .Patient came from a board and care facility but is not receiving any care or assistance from staff .A review of Resident 1's GACH History and Physical dated September 25, 2025, indicated .male patient presents to the ER (Emergency Room) via EMS (Emergency Medical Services) for evaluation of weakness .Patient reports having frequent falls and is unable to walk .Patient came from a board and care facility but is not receiving any care or assistance from staff .Patient admitted to the medical floor daily with recurrent TIA (Transient Ischemic Attack-mini-stroke) old CVA (Cerebrovascular Accident-stroke) generalized weakness and falls for evaluation treatment. A review of Resident 1's, GACH records, titled, CT (image of) Brain, dated, September 25, 2025, at 3:24 p.m., indicated . Detailed Symptoms: slurred speech (and) fall . Impressions: . likely . chronic infarcts (TIAs) .Further review of Resident 1's, GACH Discharge Instructions, dated, October 2, 2025, at 1:02 p.m., indicated resident was being discharged back to the facility (Skilled Nursing Facility) with education provided on TIAs, weakness and fall prevention.A review of Resident 1's Skilled Nursing facility Admission/readmission Summary Note, dated, October 2, 2025, at 11:17 p.m., by RN 2, indicated (Resident) admitted . from (GACH) . Primary diagnosis of Weakness, TIA . Needs assistance in all ADL(s) .On October 8, 2025, at 1:00 p.m., a concurrent observation and interview was conducted with Resident 1 in his bedroom at the skilled nursing facility, and the resident was observed lying in bed, neatly dressed and groomed. Resident 1's speech was slow and slurred. Resident 1 stated the living arrangements at the room and board made him feel terrible and confused because what he was told at the facility (Skilled Nursing Facility) about the room and board prior to his discharge (on September 18, 2025) was totally different than what was provided at the room & board. A review of the facility Policy and Procedure, titled, Discharge Summary and Plan, revised March 2025, indicated, . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055223 If continuation sheet Page 4 of 5 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 10/08/2025 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Discharge Planning 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan .3. The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g. care giver support and education, rehabilitation .) 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identified the discharge destination and ensures that it meets the resident's health and safety needs as well as preferences. 6. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. 7. A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place .Discharge to the Community . 2. If the resident indicates an interest in returning to the community, the facility determines if appropriate and adequate support is in place. This may include the capacity of the resident's caregivers at home .5. If a resident wishes to be discharge to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility treats this situation similarly to refusal of care, and will: a. discuss with the resident .and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b. document that other, more suitable locations equipped to meet the needs of the resident were presented and discussed . Event ID: Facility ID: 055223 If continuation sheet Page 5 of 5