Health inspection·July 2, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few auditing procedures regarding ensuring IV orders were carried out as ordered.On July 1, 2025, at 1:35 p.m., the IJ was removed in the presence of the ADM and the current Director of Nursing (CDON) during the onsite survey, upon verification of the implementation of the IJ removal plan. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings:On June 19, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care. On June 19, 2025, at 1:14 p.m., Resident 1 was observed sitting on a wheelchair in the smoking area, and was able to maneuver self throughout the facility. In a concurrent interview with Resident 1, she stated she was supposed to receive IV antibiotics and the orthopedic consultation notes from a follow up appointment on May 23, 2025 was concurrently reviewed with Resident 1 which indicated the following:Rocephin 1 (one) gram daily for 6 (six) weeks through IV midline (a type of peripheral IV catheter [PIVC] that is longer than a standard IV, inserted into a vein in the upper arm, and the tip of the catheter resides in a larger vein near the shoulder) with (name of home health agency); and-RTC (Return to clinic) in three (3) weeks.Resident 1 further stated she had not received the IV antibiotic order of Rocephin since the orthopedic appointment on May 23, 2025. Resident 1 stated she was sent to the general acute hospital (GACH) on June 11, 2025, for the IV line placement but the hospital was not able to start the IV line and did not know why it was not done. On June 19, 2025, at 1:50 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated when she received the orthopedic consult notes on May 23, 2025, after Resident 1 went to the follow up appointment on May 23, 2025, she placed the order for IV antibiotics in the system. RN 1 stated Resident 1 should have been sent to the hospital to have the IV antibiotic be administered since it was to be given through IV midline. RN 1 stated the following shift should have followed up as the order also indicated with home health agency to administer. RN 1 stated she thought Resident 1 would be getting too much antibiotic since the resident was on oral antibiotic as well. On June 19, 2025, at 2:49 p.m., during an interview with the Medical Assistant (MA) of the OS, the MA stated the IV antibiotic Rocephin should have started on May 23, 2025. The MA stated the previous Director of Nursing (PDON) had called the orthopedic clinic on June 11, 2025, and was told the Rocephin order for Resident 1 should have started on May 23, 2025. The MA stated the PDON told her she would send Resident 1 to the hospital on June 11, 2025.On June 20, 2025, at 11:20 a.m., during an interview with Resident 1, she stated she went to the GACH but nothing was done regarding her IV antibiotic. Resident 1 stated the OS told her there was something like a black spot in the x-ray (radiographic test) of her left knee. Resident 1's left knee was observed to have redness at the sides of the incision site. Resident 1 stated she gets pain medication routinely. Resident 1 stated she received physical therapy daily. Resident 1 was observed with the therapist walking slowly in the hallway with a walker. Resident 1 was observed to be unable to ambulate independently and continued to require wheelchair if not with the therapist. On June 20, 2025, at 3:50 p.m., during an interview with the ADM, the ADM stated he also has a current RN license. Resident 1's orthopedic consultation note, dated May 23, 2025, was concurrently reviewed with the ADM. The ADM stated the order should have been clarified with the orthopedic clinic as it was not clear when the IV antibiotic should be administered to Resident 1. A review of Resident 1's Orthopedic Operative Report, dated May 8, 2025, indicated, .POSTOPERATIVE (the period of time following a surgical operation) DIAGNOSES: Left knee large effusion (excess fluid accumulation within or around the knee joint), questionable septic arthritis (a painful joint infection, usually caused by bacteria, that can damage cartilage and bone) with lateral meniscus (cartilage - a strong connective tissue found in joints, ear, nose) and medial meniscus tear (a common knee injury involving damage to the cartilage that acts as a shock (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 2 of 13 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 07/02/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few absorber and stabilizer in the knee joint), popliteal cyst (a fluid-filled swelling that develops behind the knee).large 30 ml (milliliter - unit of measurement) of turbid (cloudy, opaque, or thick with suspended matter) viscous (thick, sticky consistency) fluid is evacuated and is sent for Gram stain (a laboratory technique used to differentiate bacteria into two main groups: Gram-positive and Gram-negative).explained to her regarding the operation findings and the need for several weeks of IV antibiotics as consulted to infectious disease.IV midline is recommended. IV Rocephin 1 g (gram) daily for 6 (six) weeks and IV Flagyl (antibiotic to treat infection) 500 mg (milligram - unit of measurement) every 6 (six) hours recommended.A review of Resident 1's admission Record, indicated Resident 1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses which included left elbow fracture (broken bone), left knee ORIF (open reduction with internal fixation - a surgical procedure used to treat fractures, particularly those that are severely displaced or unstable), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue which could lead to inflammation and damage in various parts of the body, including the skin, joints, kidneys, heart, lungs, and blood cells).A review of Resident 1's physician's orders, date ordered May 16, 2025, indicated, .RESIDENT HAS F/U (follow up) ORTHO APPOINTMENT ON 5/23 (May 23, 2025) AT 8:30 AM (a.m.) WITH (name of orthopedic surgeon) AT (address of orthopedic clinic). A review of Resident 1's orthopedic consult notes, dated May 23, 2025, indicated, .Pt (patient) doesn't (does not) have IV access.Left knee septic arthritis.Plan.IV midline.IV Rocephin 1 gm q (every) daily x 6 weeks.A review of the facility document titled Progress Record, documented by the OS, sent with Resident 1 when she came back from appointment, dated May 23, 2025, indicated, .ordering IV midline and IV Rocephin 1 (one) gram QD (daily) x 6 wks (weeks) w/ (with) (name of home health agency).RTC (return to clinic) in 3 (three) weeks (around June 13, 2025).A review of Resident 1's physician order, date ordered May 23, 2025, .ORDER FOR IV MIDLINE AND IV ROCEPHIN 1 (one) GRAM (unit of measurement) DAILY X (times) 6 (six) WEEKS WITH (name of home health agency)., A review of Resident 1's Progress Notes, dated May 23, 2025, at 10:51 a.m., documented by RN 1, indicated the order from the orthopedic appointment for IV Rocephin, IV midline, and return to clinic in 3 weeks.Further review of Resident 1's record indicated there was no documented evidence of the orthopedic orders for IV midline and IV Rocephin was clarified with the orthopedic surgeon when to start the IV antibiotic and indication for the IV antibiotic. There was no documented evidence the physician's order for IV midline and IV Rocephin were carried out as ordered and administered to Resident 1 since May 23, 2025. A review of Resident 1's physician order, date ordered June 11, 2025, indicated, .Send to ER (Emergency Room) for IV Midline insertion.A review of Resident 1's GACH records, dated June 11, 2025, at 1:28 p.m., indicated, .Chief Complaint: midline placement.pt (patient) sent to ER (Emergency Room) from (name of skilled nursing facility) for midline placement.A review of Resident 1's Progress Notes, dated June 13, 2025, at 8:35 p.m., documented by RN 2 indicated, .Patient arrived at 2035 (8:35 p.m.) from (name of GACH).MD made aware. The progress notes did not include presence of IV access on Resident 1 or IV orders.Further review of Resident 1's records from June 13, 2025, to June 27, 2025, indicated there was no documented evidence if the physician or orthopedic surgeon was consulted regarding the IV midline not done in GACH and if the IV Rocephin was still needed to be given to Resident 1. On June 26, 2025, at 4: 20 p.m., a follow up interview was conducted with RN 1. RN 1 stated she was the RN on duty when Resident 1 came back from orthopedic appointment on May 23, 2025, and the orthopedic surgeon ordered IV midline and IV Rocephin daily for six weeks. RN 1 stated IV midline were not being done at the facility and the resident would need to be scheduled at the hospital for IV midline placement. RN 1 stated she was not able to clarify with the orthopedic surgeon when the IV Rocephin should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 3 of 13 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 07/02/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few started as she got busy and did not endorse it to the next shift RN. RN 1 stated she did not start a peripheral line so the IV Rocephin could be started on May 23, 2025. RN 1 stated she was not aware Rocephin could also be given through intramuscular (IM - through the muscles) injection.On June 26, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated the RN should have clarified with the OS the order for IV midline and IV Rocephin when the IV antibiotic should be started, and if the IV antibiotic could be administered in a different route. The ADM stated he found out about the OS orders on June 13, 2025, when he did chart review with the Case Manager (CM), Social Services Director (SSD), and the Infection Preventionist (IP) and then discussed it with the PDON. The ADM stated he instructed the PDON to clarify the OS orders. The ADM stated the CM told him that the IV Rocephin should have started on May 23, 2025. The ADM stated Rocephin could be given through IM or IV peripheral line while waiting for an IV midline to be placed. On June 27, 2025, at 9:28 a.m., a concurrent observation and interview was conducted with Resident 1 inside the resident's room. Resident 1 was observed sitting at the edge of the bed wearing short sleeve shirt, was observed without IV access on her arms. In a concurrent interview with Resident 1, she stated she had surgery on her left knee for septic arthritis which she was treated with IV antibiotics while at the GACH and thought it would be continued in the facility. Resident 1 stated she had a follow up appointment with the OS on May 23, 2025, and was ordered for IV antibiotic but until this date, have not received any IV antibiotics. Resident 1 stated she had inquired with the licensed nurses about the IV antibiotic but did not get a clear response from anyone of them. Resident 1 stated she went to the GACH on June 11, 2025, to have an IV midline placed but did not know why it was not placed while she was at the GACH. Resident 1 stated she did not know if she had a follow up appointment with the OS.On June 27, 2025, at 10:15 a.m., an interview was conducted with the CM. The CM stated her responsibility was to oversee the care and services being provided to the residents who received skilled services, from admission to discharge planning. The CM stated she would also arrange necessary appointments and transport services, and would review consultant notes after appointments. Resident 1's record was concurrently reviewed with the CM. The CM stated the following about Resident 1:-admitted to the facility on [DATE], for rehabilitation after left knee surgery;-Had a follow up appointment with the OS on May 23, 2025, with an order for IV Rocephin daily for six (6) weeks via IV midline;-The CM was not aware of the IV orders from the OS appointment on May 23, 2025, not until the DON discussed it with her on June 11, 2025, and the OS was called by the PDON and clarified the order for IV Rocephin and was informed IV Rocephin should have started on May 23, 2025; - The CM stated there was no documentation the licensed nurses followed up with the OS to clarify the order for IV midline and IV Rocephin. The CM stated the RN should have clarified with the OS regarding the need for the IV Rocephin and when it should be administered. -RN 1 told CM that a peripheral line was attempted but unable to get one on May 23, 2025. The CM stated there was no documentation a peripheral line was attempted to be inserted on Resident 1 and was not successful; -The DON told the CM she would handle the issue on Resident 1's IV order and the resident was sent out to the GACH for IV midline placement on June 11, 2025;-Resident 1 returned to the facility on June 13, 2025, without IV access and no further recommendations for IV antibiotics;-There was no documentation the facility communicated to the OS that IV Rocephin was not administered to Resident 1 since the resident came back from GACH on June 13, 2025, and if the IV Rocephin would still be needed to be administered to the resident; -The CM stated the facility should have clarified with the OS regarding the IV Rocephin order if still needed even after coming back from the GACH on June 13, 2025; and-There was no follow up appointment scheduled with the OS after it was ordered on May 23, 2025, for a RTC in three (3) weeks (around June 13, 2025). The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 4 of 13 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 07/02/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CM stated a follow up appointment with the OS should have been scheduled according to the physician's order. On June 27, 2025, at 11:11 a.m., an interview was conducted with the OS MA. The MA stated the PDON called the orthopedic clinic on June 11, 2025, to clarify regarding the IV Rocephin ordered by the OS on May 23, 2025, and advised the PDON the IV Rocephin should have been started on May 23, 2025. The MA stated the IV Rocephin was ordered by the OS for septic arthritis. The MA stated there was no schedule made by the facility for a follow up appointment with the OS after May 23, 2025. On June 27, 2025, at 1:32 p.m., a concurrent interview and record review was conducted with the Infection Preventionist (IP). The IP stated she was not aware Resident 1 was ordered for IV Rocephin when the resident returned from the orthopedic follow up appointment on May 23, 2025. The IP stated she should have reviewed Resident 1's record to evaluate appropriateness of the antibiotic since the resident was also ordered for Levaquin (medication to treat infection). On June 27, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated he instructed the CM to clarify with the orthopedic clinic and the primary physician to inform them the IV Rocephin was not administered to Resident 1 since May 23, 2025. The ADM stated he thought the CM would follow through with his instructions to address the issue on Resident 1. The ADM stated he was not aware the CM did call the orthopedic clinic not until today to verify for return appointment after May 23, 2025. The ADM stated Resident 1 could develop complications such as infection, pain, discomfort, and joint stiffness. On July 2, 2025, at 11 a.m., an interview was conducted with the OS. The OS stated left knee surgery was done on Resident 1 on May 8, 2025, due to fluid build up on her left knee joint with differential diagnosis (a systematic process used by healthcare professionals to identify the most likely cause of a patient's symptoms by distinguishing between various conditions that share similar characteristics) of septic arthritis. The OS stated during surgery, there was turbid viscous fluid-like pus from the knee joint indicative of septic arthritis, and he recommended for Resident 1 to receive IV Rocephin for 6 weeks while at the skilled nursing facility. The OS stated Resident 1 had a follow up appointment with him on May 23, 2025, and he ordered Resident 1 to have IV Rocephin after the appointment on May 23, 2025, for septic arthritis. The OS stated he was not aware the IV Rocephin was not administered to Resident 1 since May 23, 2025. The OS stated the IV Rocephin could be given via IV midline or peripheral line whatever was available. The OS stated the facility should have clarified with his clinic if the order was not clear and he expected the facility to have administered the IV Rocephin as ordered. The OS stated he evaluated Resident 1 on June 30, 2025, and assessed the resident to still have stiffness and pain in the affected knee. The OS stated the standard care for septic arthritis is IV antibiotic for 6 weeks and order was not followed by the facility. The OS stated Resident 1 could develop possible complications such as worsening of septic arthritis, osteomyelitis (a bone infection that occurs when bacteria or other microorganisms invade and infect the bone), destruction on the joint, chronic limp, gangrene (the death of body tissue due to a lack of blood supply or a severe bacterial infection), loss of limb, amputation (surgical removal of a limb or other body part), and death. A review of the facility's policy and procedures titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders, including any required time frame.A review of the facility's policy and procedure titled, Change in Condition: Notification of, dated August 25, 2021, indicated, .To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition.A Facility must immediately.consult with the Resident's physician.and notify.when there is.A significant change in the Resident's physical, mental, or psychosocial status.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 5 of 13 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 07/02/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete commence a new form of treatment).A review of the facility's policy and procedure titled, Physician Orders, dated March 22, 2022, indicated, .Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed on the appropriate communication system for that discipline. A review of the facility's undated policy and procedure titled, Appointments, indicated, .This policy and procedure document outlines the support a facility provides to residents in accessing specialty healthcare services to enhance their health and wellbeing.Requests for appointments are documented in the electronic medical record.The licensed nurse or designee schedules appointments based on medical necessity and other factors like cognitive status and transportation needs.License Nurse to document resident's departure and clinical condition on the day of the appointment and when resident comes back.Any orders and follow up appointment are documented in the electronic record and to follow up availability of MD (doctor of medicine) progress notes to be included in the resident's medical record.A review of the facility's policy and procedure titled, General Policies for IV Therapy, dated March 2023, indicated, .IV medications may be administered by RNs Physician's orders are required for initiating intravenous therapy .All orders must include name, dose, frequency, duration of therapy, route of administration and diagnosis .Initial antibiotic dose is be given within 4 (four) hours from the time the physician's order is obtained at at the next scheduled dose .When IV therapy is questioned, a collaborative effort amongst the physician, pharmacy, and facility will determine the safety and appropriateness of the therapy . Event ID: Facility ID: 056095 If continuation sheet Page 6 of 13 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 07/02/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate nursing services were provided to carry out the physician and orthopedic surgeon (OS - a medical doctor specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) orders to administer IV antibiotic, for one of four residents reviewed (Resident 1), when:1.Registered Nurse (RN) 1 did not clarify with the physician or the OS regarding the IV orders after Resident 1's follow up appointment on May 23, 2025. In addition RN 1 did not endorse to the following RN the need to clarify the IV order, and there was no documentation other licensed nurses (RNs and Licensed Vocational Nurses), followed up or clarified the IV order with the OS from May 23, 2025, to June 11, 2025; 2. RN 1 was not knowledgeable regarding other routes of administration of Rocephin (a medication to treat infection);These failures resulted to Resident 1 to not receive the IV antibiotic as ordered by the physician and the OS and had the potential to experience pain or discomfort, infection, joint stiffness, and affect overall health condition.Cross Reference F684Findings:On June 19, 2025, at 10 a.m., an unannounced visit was conducted at the facility to investigate a complaint on quality of care.On June 19, 2025, at 1:14 p.m., Resident 1 was observed sitting on a wheelchair in the smoking area, and was able to maneuver self throughout the facility. In a concurrent interview with Resident 1, she stated she was supposed to receive IV antibiotics and the orthopedic consultation notes from a follow up appointment on May 23, 2025 was concurrently reviewed with Resident 1 which indicated the following:- Rocephin 1 (one) gram daily for 6 (six) weeks through IV midline (a type of peripheral IV catheter [PIVC] that is longer than a standard IV, inserted into a vein in the upper arm, and the tip of the catheter resides in a larger vein near the shoulder) with (name of home health agency); and-RTC (Return to clinic) in three (3) weeks.Resident 1 further stated she had not received the IV antibiotic order of Rocephin since the orthopedic appointment on May 23, 2025. Resident 1 stated she was sent to the general acute hospital (GACH) on June 11, 2025, for the IV line placement but the hospital was not able to start the IV line and did not know why it was not done. On June 19, 2025, at 1:50 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated when she received the orthopedic consult notes on May 23, 2025, after Resident 1 went to the follow up appointment on May 23, 2025, she placed the order for IV antibiotics in the system. RN 1 stated Resident 1 should have been sent to the hospital to have the IV antibiotic be administered since it was to be given through IV midline. RN 1 stated the following shift should have followed up as the order also indicated with home health agency to administer. RN 1 stated she thought Resident 1 would be getting too much antibiotic since the resident was on oral antibiotic as well. A review of Resident 1's admission Record, indicated Resident 1 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses which included left elbow fracture (broken bone), left knee ORIF (open reduction with internal fixation - a surgical procedure used to treat fractures, particularly those that are severely displaced or unstable), and lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue which could lead to inflammation and damage in various parts of the body, including the skin, joints, kidneys, heart, lungs, and blood cells).A review of Resident 1's physician's orders, date ordered May 16, 2025, indicated, .RESIDENT HAS F/U (follow up) ORTHO APPOINTMENT ON 5/23 (May 23, 2025) AT 8:30 AM (a.m.) WITH (name of orthopedic surgeon) AT (address of orthopedic clinic). A review of Resident 1's orthopedic consult notes, dated May 23, 2025, indicated, .Pt (patient) doesn't (does not) have IV access.Left knee septic arthritis.Plan.IV midline.IV Rocephin 1 gm q (every) daily x 6 weeks.A review of the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 7 of 13 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 07/02/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some document titled Progress Record, documented by the OS, sent with Resident 1 when she came back from appointment, dated May 23, 2025, indicated, .ordering IV midline and IV Rocephin 1 (one) gram QD (daily) x 6 wks (weeks) w/ (with) (name of home health agency).RTC (return to clinic) in 3 (three) weeks (around June 13, 2025).A review of Resident 1's physician order, date ordered May 23, 2025, .ORDER FOR IV MIDLINE AND IV ROCEPHIN 1 (one) GRAM (unit of measurement) DAILY X (times) 6 (six) WEEKS WITH (name of home health agency)., A review of Resident 1's Progress Notes, dated May 23, 2025, at 10:51 a.m., documented by RN 1, indicated the order from the orthopedic appointment for IV Rocephin, IV midline, and return to clinic in 3 weeks.Further review of Resident 1's record indicated there was no documented evidence of the OS orders for IV midline and IV Rocephin was clarified with the OS when to start the IV antibiotic and indication for the IV antibiotic. There was no documented evidence the physician's order for IV midline and IV Rocephin were carried out as ordered and administered to Resident 1 since May 23, 2025. On June 26, 2025, at 4: 20 p.m., a follow up interview was conducted with RN 1. RN 1 stated she was the RN on duty when Resident 1 came back from orthopedic appointment on May 23, 2025, and the orthopedic surgeon ordered IV midline and IV Rocephin daily for six weeks. RN 1 stated IV midline were not being done at the facility and the resident would need to be scheduled at the hospital for IV midline placement. RN 1 stated she was not able to clarify with the orthopedic surgeon when the IV Rocephin should be started as she got busy and did not endorse it to the next shift RN. RN 1 stated she did not start a peripheral line so the IV Rocephin could be started on May 23, 2025. RN 1 stated she was not aware Rocephin could also be given through intramuscular (IM - through the muscles) injection.On June 26, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated the RN should have clarified with the OS the order for IV midline and IV Rocephin when the IV antibiotic should be started, and if the IV antibiotic could be administered in a different route. The ADM stated he found out about the OS orders on June 13, 2025, when he did chart review with the Case Manager (CM), Social Services Director (SSD), and the Infection Preventionist (IP) and then discussed it with the previous DON (PDON). The ADM stated he instructed the PDON to clarify the OS orders. The ADM stated the CM told him that the IV Rocephin should have started on May 23, 2025. The ADM stated Rocephin could be given through IM or IV peripheral line while waiting for an IV midline to be placed. On June 27, 2025, at 10:15 a.m., an interview was conducted with the Case Manager (CM). The CM stated her responsibility was to oversee the care and services being provided to the residents who received skilled services, from admission to discharge planning. The CM stated she would also arrange necessary appointments and transport services, and would review consultant notes after appointments. The CM the PDON called the OS clinic on June 11, 2025, and clarified the IV order from May 23, 2025, and was told the IV ordered by the OS should have been started on May 23, 2025. The CM stated the PDON sent out Resident 1 to the hospital for IV midline placement on June 11, 2025, and thought the PDON handled Resident 1's IV issue even after the resident came back to the facility on June 13, 2025. The CM stated she was not aware Resident 1 did not get an IV access from the hospital and if Resident 1 still needed the IV antibiotic. On June 27, 2025, at 5:47 p.m., an interview was conducted with the ADM. The ADM stated he instructed the CM to clarify with the orthopedic clinic and the primary physician to inform them the IV Rocephin was not administered to Resident 1 since May 23, 2025. The ADM stated he thought the CM would follow through with his instructions to address the issue on Resident 1. The ADM stated he was not aware the CM did call the orthopedic clinic not until today to verify for return appointment after May 23, 2025. The ADM stated Resident 1 could develop complications such as infection, pain, discomfort, and joint stiffness. On July 2, 2025, at 11:30 a.m., a concurrent interview and review of training records of RN 1 with the Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 8 of 13 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 07/02/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete of Staff Development (DSD), the DSD stated RN 1 did not have training regarding notification of the Medical Director, and documentation. The DSD stated RN1 missed the skills lab scheduled as she was working at that time, and was not able to make up for it. The DSD stated RN 1 should have completed the training as scheduled. A review of the facility's job description for RNs, indicated, .The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state .Consult and coordinate with the interdisciplinary team (IDT - a group of healthcare professionals) and healthcare professionals to assess, plan, implement and evaluate individualized resident care plans .Provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of care .Maintain documentation of all nursing care and services provided to the residents; use nurses' notes, flow sheets and electronic medical records according to facility protocol .Administer medications according to practitioner orders .Attend continuing education and in-service training programs as required to provide person-centered and competent care .A review of the facility's policy and procedure titled, Competency of Nursing Staff, dated May 2019, indicated, .All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law .Competency in skills and techniques necessary to care for residents' needs includes .Basic nursing skills .Training and competency evaluations include elements of critical thinking and processes necessary to identify and report resident changes of condition .RNs are trained for and evaluated on managing and reporting pertinent findings to the provider . Event ID: Facility ID: 056095 If continuation sheet Page 9 of 13 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 07/02/2025 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)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility record review, the facility failed to have a written Quality Assurance Performance Improved (QAPI - a systematic, interdisciplinary, comprehensive, and data - driven approach to maintain and improve safety, quality of care, and quality of life of the residents) plan in place to address issue on carrying out physician's order for IV antibiotics, when the facility identified the resident did not receive the IV antibiotic the orthopedic surgeon (OS - a medical director specializing in the diagnosis, treatment, and prevention of musculoskeletal system injuries and diseases) ordered.This failure resulted to the resident not to receive the appropriate care and treatment after a surgical procedure and had the potential for the resident to develop complications such as pain or discomfort, infection, joint stiffness, and affect overall health condition. Findings:On June 27, 2025, at 6:07 p.m., the Administrator (ADM) was verbally notified of the Immediate Jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to administer the IV antibiotic to Resident 1 for 35 days. A substandard quality of care (SQC) was identified related to the facility's failure to administer IV antibiotic to Resident 1. See findings under F684. On July 1, 2025, at 2:33 p.m., an interview was conducted with the ADM to discuss regarding the facility's QAPI program. The ADM stated the facility did not proceed to conduct a QAPI program to address the issue on the IV medications order not carried out as ordered by the physician and the OS on May 23, 2025, after it was identified as a missed administration on June 11, 2025 (19 days after the IV medication was initially ordered). A review of the facility's QAPI program meeting information, indicated QAPI meetings were held on February 6, 2025, April 24, 2025, and June 19, 2025, which was attended by the Medical Director, ADM, Director of Nursing (DON), Director of Staff Development (DSD), Infection Preventionist, Activity Director, Dietary Director, Social Services Director, Medical Records Designee, Maintenance Supervisor, Pharmacy Consultant, and [NAME] President of Operations. On July 2, 2025, at 10:45 a.m., a follow up interview and concurrent review of QAPI meetings was conducted with the ADM. The ADM stated the facility had a QAPI meeting on June 19, 2025, but did not discuss the IV medication order not carried out since May 23, 2025. The ADM stated the facility should have included the issue on IV medication during their QAPI meeting on June 19, 2025. The ADM stated he thought the previous DON had taken cared of the issue. The ADM stated he was not aware the facility had an issue on IV medication order not carried out until it was brought to their attention on June 19, 2025, during the investigation of the complaint.A review of the facility's policy and procedure titled, Quality Assurance and Performance and Improvement (QAPI) Program - Governance and Leadership), dated March 2020, indicated, .The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee, which reports its findings, actions and results to the Administrator and governing body .The Administrator .is ultimately responsible for the QAPI program, and for interpreting the results and findings to the governing body .The governing body is responsible for ensuring that the QAPI program .Focused on problems and opportunities that reflect processess, functions and services provided to the residents . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 10 of 13 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 07/02/2025 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)

F 0881 Implement a program that monitors antibiotic use. 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 an effective antibiotic surveillance program (program to help monitor the effectiveness of antibiotics, identify emerging resistance patterns, and inform strategies for infection prevention and control) was conducted, for four of four residents (Residents 1, 2, 3, and 4) according to the facility's policy and procedure, when:1.For Resident 1, there was no appropriate indication for the use of Levaquin (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Levaquin;2.For Resident 2, the physician was not notified the use of Cipro (medication to treat infection) did not meet the criteria of the symptoms of urinary tract infection;3.For Resident3, there was no appropriate indication for the use of Macrobid (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Macrobid; and4.For Resident 4, there was no appropriate indication for the use of Cirpo (medication to treat infection). In addition, there was no antibiotic surveillance assessment completed for the use of Cipro and Doxycycline (medication to treat infection).These failures resulted to the residents' use of antibiotic not to be evaluated for the appropriateness of its use, which could lead to development of complications related to use of the antibiotics. Findings:On June 25, 2025, at 1:11 p.m., during an interview with the Infection Preventionist (IP), the IP stated the facility conducts antibiotic surveillance of the residents who were prescribed antibiotics on admission and during their stay in the facility to ensure the antibiotic is necessary for the resident to be administered. The IP stated she would run a report indicating a list of residents on antibiotic. The IP stated the facility form titled, Antibiotic Surveillance Data Collection, was to be completed by the licensed nurse who initiated the antibiotic order either during admission or during the resident stay in the facility. The IP stated the document utilizes McGeer's criteria (a standardized definitions of infection used primarily for surveillance in long-term care facilities) or Loeb's criteria (a set of minimum clinical guidelines used in long-term care facilities to help determine when antibiotic treatment is appropriate for residents) to determine if the antibiotic is appropriate for the resident. The IP stated if the antibiotic surveillance indicated the criteria was not met, they will proceed with a time out to call the physician if still needed for the antibiotic to be administered to the resident. The IP stated it was her responsibility to ensure the antibiotic surveillance form was completed accurately and implement the antibiotic surveillance program according to the guidelines.On June 25, 2025, at 1:32 p.m., a concurrent interview and review of Residents 1, 2, 3, and 4's records were conducted with the IP. The following indicated:1.Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare following joint replacement and fracture of right elbow.A review of Resident 1's physician order, dated May 23, 2025, indicated the following:- .Levaquin (antibiotic) Tablet 500 MG (milligram - unit of measurement).Give 1 (one) tablet by mouth one time day for R/O (rule out) FRACTURE for 20 days.; and- .Order for IV Midline and IV Rocephin 1 (one) gram (unit of measurement) daily x (times) 6 (six) weeks with (name of home health).A review of Resident 1's Progress Notes, indicated, .RESIDENT CAME BACK FROM APPOINTMENT WITH A STAFF MEMBER AND TRANSPORT COMPANY. SUTURE WAS REMOVED, STERISTRIPS APPLIED.ORDER FOR IV MIDLIN (sic) AND IV ROCEPHIN 1 GRAM DAILY X 6 WEEKS WITH (name of home health).LEVAQUIN 500MG PO DAILY X 20.In a concurrent interview with the IP, the IP she stated there was no antibiotic surveillance form completed for the use of Levaquin for Resident 1. The IP stated she thought the indication for the antibiotic was for prophylaxis (prevent disease) related to the fracture. The IP stated she did not review the orthopedic consult notes to check why the physician ordered Levaquin for Resident 1. The IP stated the indication for Levaquin use was Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 11 of 13 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 07/02/2025 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)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not appropriate and should have been clarified and reviewed. The IP stated she was not aware Resident 1 was ordered for IV Rocephin.2.Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung disease) and diabetes mellitus (abnormal blood sugar).A review of Resident 2's Progress Notes, dated June 15, 2025, at 5:49 a.m., indicated, .Pt (patient) had episode of delirious (an acutely disturbed state of mind resulting from illness or intoxication and characterized by restlessness, illusions, and incoherence of thought and speech). Pt was sitting on edge of bed stating she was going to jump off to start walking.A review of Resident 2's lab Results Report, dated June 16, 2025, indicated cloudy urine, and many bacteria.A review of Resident 2's Progress Notes, dated June 18, 2025, at 12:32 a.m., indicated, .(name of physician) reviewed urine test result and he ordered Cipro 500 mg tab (tablet) bid (twice a day) x 10 days.A review of Resident 2's physician order, dated June 18, 2025, indicated, .Cipro Oral Tablet 500 MG.Give 1 (one) tablet by mouth two times a day for UTI (urinary tract infection) for 10 days. A review of Resident 2's Antibiotic Surveillance Data Collection, dated June 18, 2025, indicated, .Type of Infection.Urinary Tract Infection.Without an Indwelling Catheter.Criteria 1 and 2 must be present (none clicked).Not a True Infection.In a concurrent interview with the IP, the IP stated Resident 2's symptoms did not meet the criteria of a urinary tract infection. The IP stated a time out should have been conducted and the physician should have been notified that Resident 2's symptoms did not meet the criteria of urinary tract infection.3.Resident 3 was admitted to the facility on [DATE], with diagnoses which indicated fracture (broken) of the right femur (thigh bone) and urinary retention.A review of Resident 3's physician order, dated June 18, 2025, indicated, .Macrobid Oral Capsule 100 MG.Give 1 (one) capsule by mouth two times a day for infection for 5 (five) days).In a concurrent interview with the IP, she stated the Nurse Practitioner (NP) would usually order urinalysis (urine test) upon admission regardless of if the resident had symptoms or not. The IP stated the NP ordered urinalysis for Resident 3 on June 15, 2025. The IP stated the urinalysis results came back on June 17, 2025, with the presence of mucus and bacteria. The IP stated Resident 3 did not manifest any signs and symptoms of urinary tract infection. The IP stated the NP ordered for Macrobid (medication to treat infection) twice a day for five days. The IP stated the order for Macrobid for Resident 3 should have been clarified with the NP of what infection was being treated for it. The IP stated there was no antibiotic surveillance assessment initiated for the use of the Macrobid for Resident 3. The IP stated the antibiotic surveillance assessment should have been completed to determine if criteria for a true infection was met or not and if the antibiotic medication was necessary for the resident.4.Resident 4 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness) and diabetes mellitus (abnormal blood sugar).A review of Resident 4's physician order, dated June 7, 2025, indicated, .Doxycycline Hyclate (medication to treat infection) Oral Tablet 100 MG .Give 1 (one) tablet by mouth two times a day for wound infection for 10 days.A review of Resident 4's physician order, dated June 23, 2025, indicated, .Cipro (medication to treat infection) Oral Tablet 500 MG.Give 1 (one) tablet by mouth two times a day for Infection for 10 days.In a concurrent interview with the IP, she stated there was no antibiotic surveillance assessment form completed for the use of the doxycycline. The IP stated there should be an antibiotic surveillance assessment each time a resident was ordered for antibiotic. The IP stated the order for Cipro should have been clarified with the physician to have a specific diagnosis. The IP stated there was no antibiotic surveillance assessment completed for the use of Cipro, and stated there should have been completed to determine if it met the criteria for a true infection.A review of the facility's policy and procedure titled, Antibiotic Stewardship, dated September 18, 2023, indicated, .Antibiotics will be prescribed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 12 of 13 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 07/02/2025 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)

F 0881 Level of Harm - Minimal harm or potential for actual harm administered to residents under the guidance of the facility's antibiotic stewardship program.The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.If an antibiotic is indicated, prescribers will provide complete antibiotic orders including.Indications for use.When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information.signs and symptoms. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056095 If continuation sheet Page 13 of 13