Health inspection·April 1, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were received, for one of three residents reviewed (Resident 4), when transportation to the dialysis center was not arranged. Residents Affected - Few This failure resulted in Resident 4 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 4 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure. Findings: On March 27, 2025, at 9 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On March 27, 2025, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a severe condition where the kidneys have permanently lost most of their ability to function). A review of Resident 4's Order Summary, included a physician's order, dated February 14, 2025, which indicated, .Dialysis: Location: (Name of Center) Sun City [NAME] Dialysis .Days: Monday, Wednesday .Friday Time:1:15pm-5:15pm Transport via (Name of Company) Transportation . A review of Resident 4's Nurses Progress Note, dated February 14, 2025, indicated, .(Name of Company) did not come to pick up resident. (Name of Company) transport contacted and spoke with (name) who stated transportation was never finalized . A review of Resident 4's physicians order, dated February 14, 2025, indicated, .MAY SEND OUT TO THE ER DUE TO MISSED DIALYSIS . A review of Resident 4's Nurses Progress Note, dated February 15, 2025, indicated, .RESIDENT IS STATING HE DID NOT GET DIALYSIS YESTERDAY WHEN HE WENT TO THE HOSPITAL . In addition, Resident 4's Nurses Progress Note, dated March 9, 2025, indicated, .Wife of the patient called .stated that her husband already missed 4 days of hemodialysis due to transportation problem. Last HD (hemodialysis) is 3/5/2025 .Dr. (Name) was notified, gave new order to send the patient to ER (emergency room) for Hemodialysis . (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056095 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 056095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Devonshire Care Center 1350 East Devonshire Avenue Hemet, CA 92544 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)