Inspection·May 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the California Department of Health (CDPH - a state agency) was notified timely or within two hours after an abuse allegation against a Certified Nursing Assistant (CNA) was reported to the facility staff according to the facility's policy and procedure, for one of three residents reviewed (Resident A). This failure had the potential for a delay in the investigation and implementation of the abuse protocol and exposed the vulnerable residents to further abuse. Findings: On March 9, 2025, at 1:30 p.m., an unannounced visit was conducted at the facility to investigate an allegation of abuse. On March 9, 2025, at 3:22 p.m., during an interview with Resident A and Resident A's family member, Resident A stated CNA 1 kept on putting her cellphone in his pocket on April 27, 2025. Resident A stated she told her family members about it when they visited her on April 28, 2025. On March 9, 2025, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included end stage renal disease and diabetes mellitus (abnormal blood sugar). Resident A's Minimum Data Set (MDS - a resident assessment tool), dated May 1, 2025, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 15 (indicating cognitively intact). Review of Resident A's progress notes did not indicate the abuse allegation reported to the facility on April 28, 2025. Resident A's Interdisciplinary Care Conference, dated April 30, 2025, at 8:45 a.m., indicated, .SSD (Social Service Director) DSD (Director of Staff Development) interview the patient .Per the resident, she is stating that on Sunday (April 27, 2025), the male CNA she describe as medium height lighter skin tone than the DSD with his hair in braids, entered her oom provided no patient care at the time and picked up her cell phone and proceeded to walk out of the room per the resident. She stated she got his attention by saying hey, hey, hey myc cell phone and he said oh I'm sorry and placed it back on the table .There was nothing on it besides her water pitcher, and her cell phone she stated that the CNA placed her cell phone in his pocket twice the third time he placed it in his pocket on his shirt each time she asked him to give her cell phone back and he would state. Oh, I'm sorry. Per (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 05/21/2025 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)