Other·August 23, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one Facility reported incident. Facility report incident number CA00628233 Representing the California Department of Public Health: Surveyor 39920 The inspection was limited to the specific Facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for Facility reported incident number CA00628233.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 08/08/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7WBU11 Facility ID: CA240000064 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056095 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEVONSHIRE CARE CENTER 1350 E Devonshire Ave Hemet, CA 92544 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse, when the facility nursing assistant students witnessed a facility staff member (Certified Nursing Assistant CNA 1) mocking and roughly handling a resident (Resident 1), during provision of care. This failure could negatively impact Resident 1's psychosocial, and mental well-being. Findings: On March 22, 2019, at 12:17 p.m., an unannounced visit was made to the facility to investigate an allegation of physical abuse. Resident 1's record was reviewed. Resident 1 was re-admitted to the facility on September 7, 2017, with diagnoses which included cognitive communication deficit (difficulty in thinking and communicating) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Resident 1's history and physical (H&P), indicated, "...neurological: confused, alert..." The document provided by the facility dated March 15, 2019, indicated the Director of Staff Development (DSD) and the Unit Manager (UM) interviewed CNA 1. In addition, the document indicated, "... (name of CNA 1) said that when the resident turned over, the resident started to try to hit her so she held (name of Resident 1's) arms so they can fasten her pullups..." On March 22, 2019, at 12:32 p.m., Resident 1 was observed in bed. Resident 1 was alert, confused, and carried very limited conversation. On March 22, 2019, at 12:50 p.m., the UM was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7WBU11 Facility ID: CA240000064 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056095 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEVONSHIRE CARE CENTER 1350 E Devonshire Ave Hemet, CA 92544 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE interviewed. The UM stated the incident involving a CNA (CNA 1) and Resident 1 was witnessed by the Nursing Assistant Students (NAS). The NAS witnessed CNA 1 handling Resident 1 more forcefully than necessary. The UM stated facility staff should not handle residents more forcefully than necessary. On March 22, 2019, at 1:20 p.m., the facility Administrator (ADM) was interviewed. The ADM stated staff should not treat residents forcefully, and CNA 1 should not be working as a CNA because of her action towards Resident 1. The ADM stated CNA 1 was terminated. On May 17, 2019, at 10:50 a.m., NAS 1 was interviewed. NAS 1 stated on the afternoon of March 11, 2019, she and the two other nursing assistant students were changing the briefs for Resident 1, when CNA 1 came to assist. NAS 1 described CNA 1's action towards Resident 1 as "forceful." She stated as CNA 1 was covering the resident (Resident 1), the resident refused. NAS 1 stated she saw CNA 1 grabbed both wrists of the resident (Resident 1), and shook the resident forcefully three times. She (NAS 1) stated she saw Resident 1 stuck her tongue out at the CNA (CNA 1), and CNA 1 stuck her tongue out at Resident 1, mockingly, as she was turning her back at the resident. On May 29, 2019, at 3:08 p.m., CNA 2 was interviewed. She stated the staff should give any resident with aggressive behavior time to calm down, explain the care to be given, listen to the resident, and get help from other staff. On June 20, 2019, at 1:21 p.m., NAS 2 was interviewed. NAS 2 stated she and the other two NAS were giving care to Resident 1, on March 11, 2019. NAS 2 stated they were changing the briefs for Resident 1, and she was a little difficult, because she could not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7WBU11 Facility ID: CA240000064 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056095 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEVONSHIRE CARE CENTER 1350 E Devonshire Ave Hemet, CA 92544 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE comprehend well. CNA 1 came over to assist. Resident 1 was slow in helping them (NAS and CNA 1) with care, and she became increasingly agitated. CNA 1 then grabbed the hands of Resident 1 close to the resident's chest and shook her. NAS 2 stated CNA 1 handled Resident 1 "roughly", and stuck her tongue out to the resident (Resident 1). NAS 2 stated she could tell from the facial expression of Resident 1 that she was upset and mad. Resident 1's nursing care plan for activities of daily living (ADL), dated June 12, 2018, indicated, "...When she gets upset, feisty during care; give her space and time to calm down; redirect behavior. Once calmed down, proceed with care..." Resident 1's nursing care plan for Alzheimer, indicated the following: a. July 11, 2017, "Approach the resident/patient in a calm, unhurried manner; reassure as necessary...Allow extra time after speaking for resident/patient to process thoughts and respond..."; and b. August 16, 2017, "...Approach the resident in a clam (sic) manner. Speak to her in soft tone of voice..." The facility policy and procedure titled, "Abuse Prohibition," revised July 1, 2018, was reviewed. The policy and procedure indicated, "...Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish...Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm...Physical abuse includes hitting, slapping, pinching, kicking, etc., as well as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7WBU11 Facility ID: CA240000064 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056095 (X3) DATE SURVEY COMPLETED 07/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DEVONSHIRE CARE CENTER 1350 E Devonshire Ave Hemet, CA 92544 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE controlling behavior through corporal punishment. Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation...(Facility) will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents...The Center will implement an abuse prohibition program through the following...prevention of occurrences...Purpose: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of resident property for all patients..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7WBU11 Facility ID: CA240000064 If continuation sheet 5 of 5