Other·August 29, 2018

F000 INITIAL COMMENTS

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 an abbreviated standard survey for the investigation of complaint. Complaint numbers CA00577642 and CA00581091 Representing the California Department of Public Health: Surveyor Federal/State ID# 34435/2829, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Deficiencies were issued for complaint numbers CA00577642 and CA00581091.

F660 SS=E Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 04/19/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the 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: TNSX11 Facility ID: CA240000284 If continuation sheet 1 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 2 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement an effective and safe discharge process for four (Resident 1, Resident 2, Resident 3 and, Resident 4) out of four sampled residents reviewed, in a universe of 70 discharged residents from October 1, 2017, through March 21, 2018. Resident 1, Resident 2, Resident 3 and, Resident 4, who were identified to required caregiver support, were discharged to an unlicensed room and board facility without available and capable caregivers. This deficient practice resulted in Resident 1, Resident 2, Resident 3 and, Resident 4's, unsafe transition to the community. Findings: On March 21, 2018, at 10:30 a.m., an unannounced complaint investigation was conducted at the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 3 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 1. Resident 1's record was reviewed. Resident 1 was admitted to the facility on September 9, 2014 and was discharged from the facility on November 17, 2017. The most recent history and physical dated, September 28, 2017, indicated 90 year old Resident 1's diagnoses included, chronic obstructive pulmonary disease (COPD - respiratory disease), psychosis (mental disorder characterized with impaired thought and emotion ) and dementia (memory loss). The history and physical dated, September 28, 2017, further indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. Resident 1's record further indicated the following: - The Minimum Data Set (MDS - an assessment tool) dated November 9, 2017, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 6 (a score of 0-7 means severely impaired). The MDS also indicated Resident 1 required supervision and cueing with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" weekly summary, from October 14, through November 11, 2017, indicated Resident 1 had long and short term memory problems. The nursing documents further indicated Resident 1 had impaired decision making skills and required supervision on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated November 17, 2017, indicated Resident 1 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. - The "DISCHARGE SUMMARY," dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 4 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 November 17, 2017, indicated, Resident 1 was discharged to (name) room and board. 2. Resident 2's record was reviewed. Resident 2 was admitted to the facility on November 29, 2017 and was discharged from the facility on December 18, 2017. The history and physical dated, December 4, 2017, indicated 74 year old Resident 2's diagnoses included, schizophrenia (mental disorder that affects thinking and behavior) and dementia. The history and physical dated, December 4, 2018, further indicated Resident 2 did not have the capacity to understand and make decisions due to dementia. Resident 2's record further indicated the following: - The MDS dated, December 18, 2017, indicated Resident 1 had a BIMS score of 3 (a score of 0-7 means severely impaired). The MDS also indicated Resident 2 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" daily progress record, from November 30, through December 2, 2017 and, weekly summary dated, December 4 and December 11, 2017, indicated Resident 2 had short term memory problems and periods of forgetfulness. The nursing documents further indicated Resident 2 had impaired decision making skills and required supervision and assistance on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated December 18, 2018, indicated Resident 1 required assistance with meal preparation, grooming, bathing, shopping, transportation to physician appointments, etc. The document further indicated Resident 2's discharge home FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 5 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 medications included Risperdone 0.5 mg twice a day for schizophrenia, and Mirtazipine 15 mg daily for depression. - The "DISCHARGE SUMMARY," dated December 18, 2017, indicated, Resident 1 was discharged to (name) room and board. 3. Resident 3's record was reviewed. Resident 3 was admitted to the facility on October 12, 2016 and was discharged from the facility on November 22, 2017. The history and physical dated, October 18, 2016, indicated 84 year old Resident 3's diagnoses included Alzheimer's dementia. Resident 2's record further indicated the following: - The MDS dated, October 25, 2017, indicated Resident 3 had a BIMS score of 9 (a score of 8 -12 means moderately impaired). The MDS also indicated Resident 3 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" weekly summary dated, October 4 through November 22, 2017, indicated Resident 3 had periods of forgetfulness. The nursing documents further indicated Resident 3 had fluctuating capacity to make decisions and required supervision and assistance on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated November 17, 2017, indicated Resident 3 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. - The "DISCHARGE SUMMARY," dated November 17, 2017, indicated, Resident 3 was discharged to (name) room and board. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 6 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 4. Resident 4's record was reviewed. Resident 4 was admitted to the facility on October 7, 2017 and was discharged from the facility on December 6, 2017. The history and physical dated, October 18, 2016, indicated 75 year old Resident 3's diagnoses included debility (weakness). Resident 4's record further indicated the following: - The MDS dated, December 6, 2017, indicated Resident 3 had a BIMS score of 15 (a score of 13-15 means cognitively intact). The MDS also indicated Resident 4 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" daily progress and weekly summary dated, November 30, through December 6, 2017, indicated Resident 4 had short term memory problems and periods of forgetfulness. The nursing documents further indicated Resident 4 had fluctuating capacity to make decisions and required supervision on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated December 6, 2017, indicated Resident 4 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. The document further indicated "Register sex offender appointment ...Please contact (name) officer of sex offender ..." - The "DISCHARGE SUMMARY," dated December 6, 2017, indicated, Resident 4 was discharged to (name) room and board. On March 21, 2018, at 11 a.m., the facility social worker (SW) was interviewed. The SW stated room and board facilities do not have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 7 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 caregivers. The SW stated Resident 1, Resident 2, Resident 3 and Resident 4 were discharged to a room and board facility that they recommended. The SW stated all four residents were discharged to the same room and board facility. On March 21, 2018, at 12:30 p.m., a phone interview was conducted with the owner of the room and board facility where Resident 1 was discharged to in the presence of the Administrator and Director of Nursing (DON). The owner of the room and board stated, "We only provide room and board ...no caregiver services ...we do not administer medications...do not assist in anyway..." The owner of the room and board further stated that her facility is not licensed and they only provide meals and laundry services for an extra fee. The owner of the room and board confirmed the other three residents were discharged from the facility to her room and board. On March 21, 2018, at at 12:45 p.m., the DON was interviewed. The DON stated only residents who are independent in their activities of daily living should be transferred to room and board facilities. The DON stated room and board facilities are like hotels or motels, no one is available to help or assist with activities of daily living since there are no caregivers. The DON further stated residents transferred to room and board facilities should have the cognitive capacity to identify and make needs known, especially with medications and appointments. On March 28, 2018, at 3:16 p.m., a telephone interview was conducted with a Police Department Deputy 1 (PD 1). PD 1 stated she accompanied Resident 1's responsible party when Resident 1 was picked up from the room and board facility she was discharged to. PD 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 8 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 stated the room and board facility did not provide 24 hour care and did not administer medications.. PD 1 stated Resident 1 appeared "confused". PD 1 stated Resident 1 "did not know I was a police officer...she kept on saying she would knit me a sweater."

F745 SS=E Provision of Medically Related Social Service CFR(s): 483.40(d)

F745 04/19/2018 §483.40(d) The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility social worker (SW) failed to ensure four (Resident 1, Resident 2, Resident 3 and, Resident 4) of four sampled residents reviewed, in a universe of 70 discharged residents from October 1, 2017, through March 21, 2018, were provided sufficient and appropriate transitions of care assistance when they were discharged from the facility. This deficient practice resulted in Resident 1, Resident 2, Resident 3 and, Resident 4's, unsafe transition to the community. Findings: On March 21, 2018, at 10:30 a.m., an unannounced complaint investigation was conducted at the facility. 1. Resident 1's record was reviewed. Resident 1 was admitted to the facility on September 9, 2014 and was discharged from the facility on November 17, 2017. The most recent history and physical dated, September 28, 2017, indicated 90 year old Resident 1's diagnoses included, chronic obstructive pulmonary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 9 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 disease (COPD - respiratory disease), psychosis (mental disorder characterized with impaired thought and emotion ) and dementia (memory loss). The history and physical dated, September 28, 2017, further indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. Resident 1's record further indicated the following: - The Minimum Data Set (MDS - an assessment tool) dated November 9, 2017, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 6 (a score of 0-7 means severely impaired). The MDS also indicated Resident 1 required supervision and cueing with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" weekly summary, from October 14, through November 11, 2017, indicated Resident 1 had long and short term memory problems. The nursing documents further indicated Resident 1 had impaired decision making skills and required supervision on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated November 17, 2017, indicated Resident 1 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. - The "DISCHARGE SUMMARY," dated November 17, 2017, indicated, Resident 1 was discharged to (name) room and board. 2. Resident 2's record was reviewed. Resident 2 was admitted to the facility on November 29, 2017 and was discharged from the facility on December 18, 2017. The history and physical dated, December 4, 2017, indicated 74 year old FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 10 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 Resident 2's diagnoses included, schizophrenia (mental disorder that affects thinking and behavior) and dementia. The history and physical dated, December 4, 2018, further indicated Resident 2 did not have the capacity to understand and make decisions due to dementia. Resident 2's record further indicated the following: - The MDS dated, December 18, 2017, indicated Resident 1 had a BIMS score of 3 (a score of 0-7 means severely impaired). The MDS also indicated Resident 2 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" daily progress record, from November 30, through December 2, 2017 and, weekly summary dated, December 4 and December 11, 2017, indicated Resident 2 had short term memory problems and periods of forgetfulness. The nursing documents further indicated Resident 2 had impaired decision making skills and required supervision and assistance on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated December 18, 2018, indicated Resident 1 required assistance with meal preparation, grooming, bathing, shopping, transportation to physician appointments, etc. The document further indicated Resident 2's discharge home medications included Risperdone 0.5 mg twice a day for schizophrenia, and Mirtazipine 15 mg daily for depression. - The "DISCHARGE SUMMARY," dated December 18, 2017, indicated, Resident 1 was discharged to (name) room and board. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 11 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 3. Resident 3's record was reviewed. Resident 3 was admitted to the facility on October 12, 2016 and was discharged from the facility on November 22, 2017. The history and physical dated, October 18, 2016, indicated 84 year old Resident 3's diagnoses included Alzheimer's dementia. Resident 2's record further indicated the following: - The MDS dated, October 25, 2017, indicated Resident 3 had a BIMS score of 9 (a score of 8 -12 means moderately impaired). The MDS also indicated Resident 3 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" weekly summary dated, October 4 through November 22, 2017, indicated Resident 3 had periods of forgetfulness. The nursing documents further indicated Resident 3 had fluctuating capacity to make decisions and required supervision and assistance on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated November 17, 2017, indicated Resident 3 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. - The "DISCHARGE SUMMARY," dated November 17, 2017, indicated, Resident 3 was discharged to (name) room and board. 4. Resident 4's record was reviewed. Resident 4 was admitted to the facility on October 7, 2017 and was discharged from the facility on December 6, 2017. The history and physical dated, October 18, 2016, indicated 75 year old Resident 3's diagnoses included debility (weakness). Resident 4's record further indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 12 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 - The MDS dated, December 6, 2017, indicated Resident 3 had a BIMS score of 15 (a score of 13-15 means cognitively intact). The MDS also indicated Resident 4 required supervision and physical assistance with activities of daily living (includes walking, dressing, personal hygiene, bathing and toileting). - The "LICENSE NURSE RECORD" daily progress and weekly summary dated, November 30, through December 6, 2017, indicated Resident 4 had short term memory problems and periods of forgetfulness. The nursing documents further indicated Resident 4 had fluctuating capacity to make decisions and required supervision on most functional activities. - The "POST DISCHARGE PLAN OF CARE," dated December 6, 2017, indicated Resident 4 required assistance with meal preparation, bathing, shopping, transportation to physician appointments, etc. The document further indicated "Register sex offender appointment ...Please contact (name) officer of sex offender ..." - The "DISCHARGE SUMMARY," dated December 6, 2017, indicated, Resident 4 was discharged to (name) room and board. On March 21, 2018, at 11 a.m., the facility SW was interviewed. The SW stated room and board facilities do not have caregivers. The SW stated Resident 1, Resident 2, Resident 3 and Resident 4 were discharged to a room and board facility that they recommended. The SW stated all four residents were discharged to the same room and board facility. On March 21, 2018, at 12:30 p.m., a phone interview was conducted with the owner of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 13 of 14 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: _______________ 555135 (X3) DATE SURVEY COMPLETED 04/19/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND SPRINGS CARE CENTER 1441 Michigan Ave Beaumont, CA 92223 (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 room and board facility where Resident 1 was discharged to in the presence of the Administrator and Director of Nursing (DON). The owner of the room and board stated, "We only provide room and board ...no caregiver services ...we do not administer medications...do not assist in anyway..." The owner of the room and board further stated that her facility is not licensed and they only provide meals and laundry services for an extra fee. The owner of the room and board confirmed the other three residents were discharged from the facility to her room and board. On March 21, 2018, at at 12:45 p.m., the DON was interviewed. The DON stated only residents who are independent in their activities of daily living should be transferred to room and board facilities. The DON stated room and board facilities are like hotels or motels, no one is available to help or assist with activities of daily living since there are no caregivers. The DON further stated residents transferred to room and board facilities should have the cognitive capacity to identify and make needs known, especially with medications and appointments. On March 28, 2018, at 3:16 p.m., a telephone interview was conducted with Police Department Deputy 1 (PD 1). PD 1 stated she accompanied Resident 1's responsible party when Resident 1 was picked up from the room and board facility she was discharged to. PD 1 stated the room and board facility did not provide 24 hour care and did not administer medications.. PD 1 stated Resident 1 appeared "confused". PD 1 stated Resident 1 "did not know I was a police officer...she kept on saying she would knit me a sweater." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TNSX11 Facility ID: CA240000284 If continuation sheet 14 of 14