Other·April 16, 2019

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 a re-certification survey conducted from August 20, 2018 to August 28, 2018. A Substandard Quality of Care was identified on August 23, 2018 and an extended survey was announced to the facility on August 27, 2018, at 9 a.m. Representing the California Department of Public Health: Surveyor 39503, HFEN; Surveyor 36684; HFEN; Surveyor 37537, HFEN; Surveyor 40227, HFEN; Surveyor 40036, HFEN; Surveyor 38479, HFEN; and Surveyor 25281, Pharmaceutical Consultant II The facility census was 80 residents. Resident sample size was 19. One facility Reported Incident CA005600945 was included during the recertification survey, it was unsubstantiated.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 09/07/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and 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: 00IJ11 Facility ID: CA240000284 If continuation sheet 1 of 131 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 08/28/2018 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 preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide accommodation of needs to three of 19 residents reviewed (Residents 232, 49 and 2), when the call light button was not within the residents' reach. This failure resulted for the residents not to have a means of directly contacting the staff for assistance. Findings: 1. On August 21, 2018, at 2:01 p.m., Resident 232 was observed lying down in bed, turned on his right side. Resident 232's call light was placed on his back closer to the left side of the bed. When the resident was asked if he could turn on his left side and try to reach for his call light, Resident 232 gave a blank stare. Subsequently, the Director of Staff Development (DSD) walked in to Resident 232's room. The DSD verified Resident 232 was turned on his right side and the call light was placed on the resident's back closer to the left side of the bed. The DSD stated Resident 232 needed assistance on turning. The DSD stated all staff should ensure call lights were within residents' reach at all times, including after repositioning the residents in bed. On August 22, 2018, at 10:15 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was the assigned CNA for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 2 of 131 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 08/28/2018 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 232 today. CNA 1 stated Resident 232 needed assistance for turning and repositioning. On August 22, 2018, Resident 232's record was reviewed. Resident 232 was admitted to the facility on August 8, 2018. Resident 232's Minimum Data Set (MDS - an assessment tool) dated August 20, 2018, indicated Resident 232 was "total dependence" on bed mobility and needed a one-person physical assist. Resident 232's care plan, last reviewed on August 20, 2018, indicated, "Focus: resident has self-care deficits...bed mobility: Total...Interventions...Call light within reach and attend needs promptly..." 2. On August 20, 2018, at 9:15 a.m., Resident 49 was observed lying down in bed. Resident 49's call light was neatly coiled and was hanging by the wall above the resident's bed. On August 20, 2018, at 9:18 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 verified Resident 49's call light was neatly coiled and hanging by the wall. LVN 1 stated Resident 49 was able to use the call light and it should be within the resident's reach and not hanging by the wall. LVN 1 stated all staff were responsible in ensuring that the call light button was within resident's reach at all times so the resident could call for help when needed. On August 21, 2018, Resident 49's record was reviewed. Resident 49 was admitted to the facility on March 28, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 3 of 131 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 08/28/2018 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 49's care plan, last reviewed on July 17, 2018, indicated, "Focus: resident has selfcare deficits and requires supervision with set up assistance with ADLs (activities of daily living) related to cognitive deficits...Interventions...Call light within reach and attend needs promptly..." 3. On August 20, 2018, at 9:17 a.m., Resident 2 was observed in bed, alert and conversant. Resident 2's head of bed was elevated and the call light button was observed hanging by the headboard and was not within resident's reach. In a concurrent interview, Resident 2 stated she needed a glass of water. Resident 2 was observed to be hard of hearing and was unable to answer appropriately when asked how did she call for assistance. On August 20, 2018, at 9:25 a.m., Certified Nursing Assistant (CNA) 2 was observed from the hallway, to have entered Resident 2's room and then left again after a few minutes. On August 20, 2018, at 9:27 a.m., a second observation was conducted with Resident 2. Resident 2's call light button was still observed to be in hanging by the headboard and was not within her reach. On August 20, 2018, at 9:31 a.m., an observation on Resident 2 and an interview with CNA 2 was conducted. CNA 2 stated she was the CNA assigned to Resident 2 today. CNA 2 stated she went in Resident 2's room earlier to prepare her for her ADLs (Activities of Daily Living). CNA 2 stated Resident 2 was able to use the call light button for assistance. In a concurrent observation, Resident 2's call light button was still observed to be hanging by Resident 2's headboard away from resident's reach. CNA 2 then took the call light button FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 4 of 131 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 08/28/2018 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 from the headboard and placed it by Resident 2's pillow. CNA 2 was asked if Resident 2 was able to reach the call light button if it was hanging by the headboard and CNA 2 stated "No." CNA 2 stated Resident 2's call light button had to be within her reach at all times. On August 21, 2018, Resident 2's record was reviewed. Resident 2 was admitted to the facility on February 7, 2018, with diagnoses that included muscle weakness and dementia (progressive memory loss that affect daily functioning). The care plan initiated on February 2, 2018 indicated, "Focus...Resident has self care deficit...related to: cognitive deficit, communication deficit, muscular weakness...poor safety awareness, visual deficit, weakness...Interventions...Call light within reach and attend needs promptly..." On August 27, 2018, at 2:05 p.m., the Director of Nursing (DON) was interviewed. The DON stated the call light button at bedside should be within the resident's reach at all times. The DON stated each time a staff entered a resident's room, the call light placement should be checked and made sure it was within the resident's reach. The facility's policy and procedure titled, "...Call Lights," dated August 17, 2018, was reviewed. The policy indicated, "...All staff should know how to place the call light for a resident...Insuring (sic.) that the call light is within the resident's reach when in his/her room..."

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v) FORM CMS-2567(02-99) Previous Versions Obsolete

F578 Event ID: 00IJ11 09/07/2018 Facility ID: CA240000284 If continuation sheet 5 of 131 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 08/28/2018 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 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 6 of 131 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 08/28/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, for 10 of 12 residents reviewed (Residents 21, 61, 48, 16, 8, 79, 26, 43, 2, and 41), the facility failed to provide documented evidence an Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) was discussed with the resident and/or Resident Representative (RR), nor residents and/or RR had been offered an opportunity to decline or accept assistance to formulate an AD. In addition, the facility failed to ensure a Physician Orders for Life-Sustaining Treatment (POLST - pre-arranged instructions related to life-sustaining treatments upon admission) was completed for Resident 79 and 61. This facility failure had the potential for residents not to be able to exercise their rights to make their choices followed related to lifesustaining treatment and services in case of emergency if they should become incapacitated. Findings: 1. On August 21, 2018, Resident 21's record was reviewed. Resident 21 was admitted to the facility on November 30, 2012, with diagnoses that included Alzheimer's Disease (progressive loss of ability to think, process thoughts, and make sound decisions). Resident 21's history and physical dated December 29, 2017, indicated, "does NOT have the capacity to understand and make decisions." The resident's son was named the RR and had a conservatorship pending application on file. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 7 of 131 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 08/28/2018 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 On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence an AD was discussed with the resident and RR, or was offered an opportunity to decline or accept assistance to formulate an AD. The SSD stated AD was usually discussed with the resident and with RR upon admission to the facility. The SSD further stated assistance should have been provided to the resident and RR, an opportunity provided to decline or accept assistance to formulate an AD, and document these discussions and any AD that the resident or RR made. 2. On August 21, 2018, Resident 61's record was reviewed. Resident 61 was admitted to the facility on July 16, 2018, with diagnoses that included schizophrenia (behavioral disorderdisturbance in thought, emotion, and behavior that causes faulty perception). Resident 61's history and physical dated August 5, 2018, indicated, "has the capacity to understand and make decisions." Resident is self-responsible. On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence the POLST was completed and AD was discussed with the resident, or was offered an opportunity to decline or accept assistance to formulate an AD. The SSD stated POLST and AD were usually discussed and completed with the resident upon admission to the facility. The SSD further stated, the POLST should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 8 of 131 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 08/28/2018 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 have been completed on admission and assistance should have been provided to Resident 61 to decline or accept assistance to formulate an AD, and have documented these discussions and any AD that the resident had made. 3. On August 21, 2018, Resident 48's record was reviewed. Resident 48 was admitted to the facility on July 15, 2010, with diagnoses that included Alzheimer's Disease (progressive loss of ability to think, process thoughts, and make sound decisions). Resident 48's history and physical indicated, "does NOT have the capacity to understand and make decisions." The resident's daughter was named the RR and guardian. On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide for documented evidence an AD was discussed with Resdient 48 and the RR, or was offered an opportunity to decline or accept assistance to formulate an AD. The SSD stated AD was usually discussed with the resident and with RR upon admission to the facility. The SSD further stated, assistance should have been provided to the resident and RR, an opportunity provided to decline or accept assistance to formulate AD, and document these discussions and any AD that the resident made. 4. On August 20, 2018, Resident 16's record was reviewed. Resident 16 was admitted to the facility on April 2, 2014. Resident 16 had her son as the resident representative (RR). Resident 16's record had no documented evidence of an AD nor a written information to formulate an AD including a written description FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 9 of 131 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 08/28/2018 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 of the facility's policies to implement an AD. On August 21, 2018, at 3:35 p.m., a concurrent interview and record review was conducted with the Social Services Director (SSD). The SSD verified Resident 16's record had no documented evidence of an AD nor a written information to formulate an AD including a written description of the facility's policies to implement an AD. The SSD stated she usually discuss the AD to the resident or RR upon admission. If there was no AD on the resident's record, it means it was not done. 5. On August 20, 2018, Resident 8's record was reviewed. Resident 8 was admitted to the facility on February 10, 2017. Resident 8 had a public guardian. Resident 8's record had no documented evidence of an AD nor a written information to formulate an AD including a written description of the facility's policies to implement an AD. On August 21, 2018, at 3:08 p.m., a concurrent interview and record review was conducted with the Social Services Director (SSD). The SSD verified Resident 8's record had no documented evidence of an AD nor a written information to formulate an AD including a written description of the facility's policies to implement an AD. 6. On August 21, 2018, Resident 79's record was reviewed. Resident 79 was admitted to the facility on August 1, 2018. Resident 79's history and physical dated August 2, 2018, indicated, "does not have the capacity to understand and make decisions." There was no RR on the record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 10 of 131 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 08/28/2018 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 There was no advance directive or POLST completed for Resident 79. On August 21, 2018, at 3:45 p.m., an interview and record review was conducted with Registered Nurse (RN) 1. RN 1 stated the POLST was not completed for Resident 79. On August 21, 2018, at 3:55 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence of an AD was discussed with a RR. The SSD stated Resident 79's AD and POLST were missed. 7. On August 21, 2018, Resident 26's record was reviewed. Resident 26 was admitted to the facility on March 10, 2018. The history and physical dated March 11, 2018, indicated Resident 26 does not have the capacity to understand and make decisions. Resident 26's brother, was the RR. Resident 26's record had no documented evidence an AD was formulated nor discussed with the resident. On August 21, 2018, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated AD was not necessary if the POLST form was completed and signed. The DON further stated a completed POLST form was sufficient to meet the requirements in the absence of an AD. On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence an AD was discussed with Resident 26 and/or RR. The SSD further stated assistance should have been provided to Resident 26 and/or RR and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 11 of 131 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 08/28/2018 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 should have been documented in the resident's medical record. On August 21, 2018, at 3:02 p.m., an interview was conducted with the Admission Coordinator (AC). The AC stated upon review on each admission, the presence of a POLST form was sufficient to meet the requirements in the absence of an AD. The facility's document titled, "Physician Orders for Life-Sustaining Treatment (POLST)," revised January 2016, was reviewed. The document indicated, "...POLST does not replace the Advance Directive..." 8. On August 21, 2018, Resident 43's record was reviewed. Resident 43 was admitted to the facility on March 15, 2018. The history and physical dated March 16, 2018, indicated Resident 43 does not have the capacity to understand and make decisions. Resident 43's sister was the RR. Resident 43's record had no documented evidence an AD was formulated nor discussed with the resident. On August 21, 2018, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated AD was not necessary if the POLST form was completed and signed. The DON further stated a completed POLST form was sufficient to meet the requirements in the absence of an AD. On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence an AD was discussed with Resident 43 and/or RR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 12 of 131 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 08/28/2018 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 SSD further stated assistance should have been provided to Resident 43 and/or RR and should have been documented in the resident's medical record. On August 21, 2018, at 3:02 p.m., an interview was conducted with the Admission Coordinator (AC). The AC stated upon review on each admission, the presence of a POLST form was sufficient to meet the requirements in the absence of an AD. The facility's document titled, "Physician Orders for Life-Sustaining Treatment (POLST)," revised January 2016, was reviewed. The document indicated, "...POLST does not replace the Advance Directive..." 9. On August 21, 2018, Resident 2's record was reviewed. Resident 2 was admitted to the facility on February 7, 2018. The history and physical dated February 14, 2018, indicated Resident 2 does not have the capacity to understand and make decisions. Resident 2's son was the RR. Resident 2's record had no documented evidence an AD was formulated nor discussed with the resident. On August 21, 2018, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated AD was not necessary if the POLST form was completed and signed. The DON further stated a completed POLST form was sufficient to meet the requirements in the absence of an AD. On August 21, 2018, at 2:44 p.m., an interview and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence an AD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 13 of 131 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 08/28/2018 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 was discussed with Resident 2 and/or RR. The SSD further stated assistance should have been provided to Resident 2 and/or RR and should have been documented in the resident's medical record. On August 21, 2018, at 3:02 p.m., an interview was conducted with the Admission Coordinator (AC). The AC stated upon review on each admission, the presence of a POLST form was sufficient to meet the requirements in the absence of an AD. The facility's document titled, "Physician Orders for Life-Sustaining Treatment (POLST)," revised January 2016, was reviewed. The document indicated, "...POLST does not replace the Advance Directive..." 10. On August 21, 2018, Resident 41's record was reviewed. Resident 41 was admitted to the facility on January 5, 2018. The history and physical dated January 6, 2018, indicated Resident 41 does not have the capacity to understand and make decisions. Resident 41 is under the conservatorship of a public guardian. Resident 41's record had no documented evidence an AD was formulated nor discussed with the resident. On August 21, 2018, at 2:23 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated AD was not necessary if the POLST form was completed and signed. The DON further stated a completed POLST form was sufficient to meet the requirements in the absence of an AD. On August 21, 2018, at 2:44 p.m., an interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 14 of 131 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 08/28/2018 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 and record review was conducted with the Social Services Director (SSD). The SSD was unable to provide documented evidence an AD was discussed with Resident 41 and/or RR. The SSD further stated assistance should have been provided to Resident 41 and/or RR and should have been documented in the resident's medical record. On August 21, 2018, at 3:02 p.m., an interview was conducted with the Admission Coordinator (AC). The AC stated upon review on each admission, the presence of a POLST form was sufficient to meet the requirements in the absence of an AD. The facility's document titled, "Physician Orders for Life-Sustaining Treatment (POLST)," revised January 2016, was reviewed. The document indicated, "...POLST does not replace the Advance Directive..." On August 28, 2018, the facility's policy and procedure titled, "RECORD CONTENT...ADVANCE DIRECTIVE, PREFERRED INTENSITY OF TREATMENT," dated August 17, 2018, was reviewed. The policy indicated, "...Provide written information to the resident at the time of admission...their right under the State Law to accept or refuse medical treatment and the right to formulate an advance directive... Include documentation in the resident's health record at the time of admission that the resident has been provided with written information regarding advance directive and whether the resident has executed such document..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 15 of 131 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 08/28/2018 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

F583 Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/07/2018 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one of six FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 16 of 131 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 08/28/2018 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 residents observed for medication administration (Resident 35), to ensure privacy and confidentiality of medical records was maintained, when a licensed nurse used her personal mobile phone to communicate Resident 35's protected health information with the physician. This failure placed Resident 35's protected health information at risk of being accessible to unauthorized individuals. Findings: On August 22, 2018, at 5:22 p.m., a medication administration observation with Licensed Vocational Nurse (LVN) 2 was conducted. LVN 2 was observed to check Resident 35's blood sugar. The glucometer (device used to check blood sugar level) indicated 493 (normal 80120 mg/dL {milligrams per deciliter}). LVN 2 stated she would notify the physician about the resident's high blood sugar. LVN 2 was then observed to use her personal mobile phone. LVN 2 stated licensed nurses at this facility were allowed to "text" (sending of messages using a mobile phone) the physicians. In addition, LVN 2 stated if the physicians reply with an order, the nurses would transcribe the order as a telephone order. On August 27, 2018, at 11:14 a.m., Registered Nurse (RN) 2 was interviewed. RN 2 stated physicians allowed licensed nurses at this facility to relay their referrals through "text." RN 2 stated the nurses use their personal mobile phones since the facility did not have mobile phones available for sending "text" messages to the physicians. On August 27, 2018, at 11:30 a.m., RN 3 was interviewed. RN 3 stated physicians should be called/informed of residents' medical concerns. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 17 of 131 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 08/28/2018 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 RN 3 further stated she would personally use the telephone but some physicians do not answer calls right away so licensed nurses have sent "text" messages to communicate with them. On August 27, 2018, at 11:45 a.m., the Director of Staff Development (DSD) was interviewed. The DSD stated she was not sure what the facility policy indicated about acceptable methods of communicating with physicians. In addition, the DSD stated, licensed nurses should not use their personal mobile phones to "text" residents' medical concerns to the physicians. On August 27, 2018, at 2:53 p.m., the Director of Nursing (DON) was interviewed. The DON stated nurses were not supposed to communicate residents' medical concerns with physicians through "text" but should call the physicians using the facility phones. The DON further stated fax messaging could be an alternative but should be followed up with a call. The facility's policy titled, "HIPAA (Health Insurance Portability and Accountability Act) Privacy," dated August 17, 2018, was reviewed. The policy indicated: "...The forms and/or formats in which this facility maintains PHI applies to information in whatever form (whether oral, written, or electronic) that relates to an individual's healthcare condition and identifies, or reasonably could be used to identify, the individual..."

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8) FORM CMS-2567(02-99) Previous Versions Obsolete

F623 Event ID: 00IJ11 09/07/2018 Facility ID: CA240000284 If continuation sheet 18 of 131 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 08/28/2018 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 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 19 of 131 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 08/28/2018 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 §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 20 of 131 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 08/28/2018 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 closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, for four of four residents reviewed for hospitalization (Resident 62, 42, 231, and 59), the facility failed to provide a documented evidence a notice before transfer was provided to the resident and/or resident representative (RR), and the reason for the move in writing, and in a language and manner they understand, that specifies: - The reason, effective date, and location for the transfer or discharge; - A statement of the resident's appeal rights; - Name, address, and telephone number of the ombudsman; and - Address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities and individuals with mental disorders. In addition, the facility failed to provide a copy of notice of transfer for Resident 59 to the Ombudsman. This facility failure may result to the resident and/or RR, not to be aware of their rights and privileges accorded to nursing facility residents, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 21 of 131 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 08/28/2018 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 who was transferred to the hospital for emergency purposes or for therapeutic leave of absence, and for the ombudsman to intervene on a timely manner on behalf of the residents, if they should need assistance after they are transferred or discharged. Findings: 1. On August 21, 2018, Resident 62's record was reviewed. Resident 62 was admitted on June 26, 2018, and was subsequently transferred to the hospital on August 14, 2018, for treatment and evaluation. There was no documented evidence that a written notice before transfer was provided to the resident or RR upon Resident 62's transfer to the hospital. On August 21, 2018, at 3:39 p.m., the Registered Nurse (RN) 3 was interviewed. The RN 3 stated she was not aware of a requirement regarding a written notice of transfer that was supposed to be provided to the resident or RR before the resident was transferred to the hospital. On August 21,2018, at 3:50 p.m., the Medical Record Director (MRD) was interviewed. The MRD stated the facility did not provide a written notification of transfer when the resident was transferred to the hospital. The MRD further stated there should be a written notification for notice of transfer provided to the resident and/or RR prior to resident's transfer to the hospital. 2. On August 20, 2018, Resident 42's record was reviewed. Resident 42 was admitted to the facility on September 13, 2015, with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other mental functions). Resident 42's spouse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 22 of 131 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 08/28/2018 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 was the RR. Resident 42's Physician's Order, dated August 16, 2018, indicated, "May transfer to (name of the hospital)...for further eval (evaluation) Dx (diagnoses) GEN (general) WEAKNESS..." There was no documented evidence a written notice of transfer was given to the RR when Resident 54 was transferred to the hospital on August 16, 2018. On August 28, 2018, at 9:47 a.m., the Social Services Director (SSD) was interviewed. The SSD stated she provides a copy of written transfer of notice to resident or RR for planned discharges only. The SSD stated she was not aware of the new regulation that it should be given to residents that were transferred out for hospitalization. The SSD stated a written notice of transfer was not given to the RR when Resident 42 was hospitalized on August 16, 2018. 3. On August 20, 2018, at 4:16 p.m., Resident 231's record was reviewed. Resident 231 was admitted to the facility on August 6, 2018, with diagnoses that included benign prostatic hyperplasia (BPH - prostate gland enlargement that can cause difficulty in urination). Resident 231's spouse was the RR. Resident 231's Physician's Order, dated August 8, 2018, indicated, "May send out to hospital for foley cath (a flexible tube which a clinician passes through the urethra and into the bladder to drain urine) re-insert..." Resident 231's Physician's Order, dated August 17, 2018, indicated, "Send to ER (emergency room)...reinsertion of catheter..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 23 of 131 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 08/28/2018 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 There was no documented evidence a written notice of transfer was given to the RR when Resident 231 was transferred to the hospital on August 8, 2018 and August 17, 2018. On August 28, 2018, at 9:47 a.m., the Social Services Director (SSD) was interviewed. The SSD stated she only provides copy of written transfer of notice to resident or RR for planned discharges only. The SSD stated she was not aware of the new regulation that it should be given to residents that were transferred out for hospitalization. The SSD stated a written notice of transfer was not given to the RR when Resident 231 was hospitalized on both dates: August 8, 2018 and August 17, 2018. 4. On August 21, 2018, Resident 59's record was reviewed. Resident 59 was admitted to the facility on May 17, 2018, with diagnoses that included: cellulitis (bacterial skin infection) of the left lower leg. Resident 59's spouse was the RR. Resident's 59's physician's order dated June 20, 2018, indicated, "send to ER (name of the Hospital) for Medical Evaluation." There was no documented evidence the Ombudsman's office was notified of the Resident 59's transfer to the hospital on June 20, 2018. On August 28, 2018, at 8:50 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated she notifiy the Ombudsman for transfer of the residents to the community. The SSD further stated she do not notify the Ombudsman for residents transferred out for hospitalization. The SSD stated she was not aware of the new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 24 of 131 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 08/28/2018 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 regulation that requires a written copy of transfer notification should be given to the Ombudsman's office when the resident transferred out to hospital.

F625 SS=E Notice of Bed Hold Policy Before/Upon Trnsfr CFR(s): 483.15(d)(1)(2)

F625 09/07/2018 §483.15(d) Notice of bed-hold policy and return§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bedhold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e) (1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 25 of 131 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 08/28/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, for four of four residents reviewed for hospitalization (Residents 62, 42, 231, and 59), the facility failed to ensure a written notice for bed-hold policy was provided to the resident and/or resident representative (RR) before transfer to the hospital with information about: - The duration of the state bed-hold policy; - The reserve bed payment policy in the state plan; - The nursing facility's policies regarding bedhold periods; and - The conditions permitting the resident to return to the facility. This facility failure may result to the resident losing an opportunity to have a secured bed to return to during period of absence from the facility. Findings: 1. On August 21, 2018, Resident 62's record was reviewed. Resident 62 was admitted on June 26, 2018, and was subsequently transferred to the hospital on August 14, 2018 for treatment and evaluation. There was no documented evidence that a written notice for bed-hold notice was provided to the resident and/or RR upon Resident 62's transfer to the hospital. On August 21, 2018, at 3:39 p.m., the Registered Nurse (RN) 3 was interviewed. The RN 3 stated she was not aware of a requirement regarding a written notice for bedFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 26 of 131 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 08/28/2018 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 hold that was supposed to be provided to the resident or RR before the resident was transferred to the hospital. On August 21, 2018, at 3:50 p.m., the Medical Record Director (MRD) was interviewed. The MRD stated the facility did not provide a written notification when the resident was transferred to the hospital. The MRD further stated they should have provided a written notification for bed-hold policy to the resident or RR prior to resident's transfer to the hospital. On August 23, 2018, Resident 62's record was reviewed. Resident 62's document titled, "NOTIFICATION OF BED HOLD," dated June 27, 2018, indicated, "...Bed Hold Notice Upon Transfer: At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice that specifies the duration of the Bed Hold Policy..." 2. On August 20, 2018, Resident 42's record was reviewed. Resident was admitted to the facility on September 13, 2015, with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Resident 42's spouse was the RR. Resident 42's Physician's Order, dated August 16, 2018, indicated, "May transfer to (name of the hospital)...for further eval (evaluation) Dx (diagnoses) GEN (general) WEAKNESS..." There was no documented evidence a written notice for bed-hold policy was given to the RR when Resident 42 was transferred out to the hospital on August 16, 2018. On August 28, 2018, at 9:40 a.m., the Minimum Data Set (MDS - an assessment tool) Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 27 of 131 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 08/28/2018 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 (MDSN) was interviewed. The MDSN stated a written notice for bed-hold policy was given to resident or RR upon admission to the facility. When the resident was transferred for hospitalization the licensed nurses would write a 7-day bed hold order. The MDSN stated the licensed nurses were not aware of the new regulation that a written notice for bed-hold policy should be given to resident or RR when the resident transfer out for hospitalization. The MDSN stated there was no documented evidence a written notice for bed-hold policy was given to the RR when Resident 42 was hospitalized on August 16, 2018. 3. On August 20, 2018, at 4:16 p.m., Resident 231's record was reviewed. Resident 231 was admitted to the facility on August 6, 2018, with the diagnoses that included benign prostatic hyperplasia (BPH - prostate gland enlargement that can cause difficulty in urination). Resident 231's spouse was the RR. Resident 231's Physician's Order, dated August 8, 2018, indicated, "May send out to hospital for foley cath (a flexible tube which a clinician passes through the urethra and into the bladder to drain urine) re-insert..." Resident 231's Physician's Order, dated August 17, 2018, indicated, "Send to ER (emergency room)...reinsertion of catheter..." There was no documented evidence a written notice for bed-hold policy was given to the RR when Resident 231 was transferred out to the hospital on August 8, 2018 and August 17, 2018. On August 28, 2018, at 10:10 a.m., the MDSN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 28 of 131 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 08/28/2018 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 was interviewed. The MDSN/LVN stated the licensed nurses were not aware of the new regulation that a written notice for bed-hold policy should be given to resident or RR when the resident transfer out for hospitalization. The MDSN stated there was no documented evidence a written notice for bed-hold policy was given to the RR when Resident 231 was hospitalized on both dates: August 8, 2018 and August 17, 2018. 4. On August 21, 2018, Resident 59's record was reviewed. Resident 59 was admitted to the facility on May 17, 2018, with diagnoses that included: cellulitis (bacterial skin infection) of the left lower leg. Resident 59's spouse was the RR. Resident's 59's physician's order dated June 20, 2018, indicated, "send to ER (name of the Hospital) for Medical Evaluation." There was no documented evidence a written notice for bed-hold was provided to the resident or RR upon transfer to the hospital on June 20, 2018. On August 21, 2018, at 4:03 p.m., a record review and interview was conducted with the Medical Records Director (MRD). The MRD stated a bed-hold notice was not provided to Resident 59 or the RR when the resident was sent to the hospital on June 20, 2018. The facility's policy and procedure titled, "Record Content...Bed Hold Notification," dated August 17, 2018, indicated, "The resident or resident's representative shall be informed, in writing, of their right to exercise the bed hold provision...This information shall be provided at the time of admission and transfer to a general acute care hospital or for a therapeutic leave..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 29 of 131 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 08/28/2018 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

F645 PASARR Screening for MD & ID CFR(s): 483.20(k)(1)-(3)

F645 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/07/2018 §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k) (3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 30 of 131 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 08/28/2018 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 §483.20(k)(2) Exceptions. For purposes of this section(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b) (3) or is a person with a related condition as described in 435.1010 of this chapter. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of 19 residents (Resident 20) reviewed, the facility failed to coordinate with State-Designated Authority (SDA) to conduct a Preadmission Screening and Resident Review (PASARR) Level II evaluation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 31 of 131 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 08/28/2018 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 This may result to the nursing facility's failure to incorporate in the resident's care plan, determinations made by the SDA for specialized services required to meet the resident's needs while residing in the facility. Findings: On August 21, 2018, Resident 20's records was reviewed. Resident 20 was admitted to the facility on November 19, 2015, with diagnoses that included schizophrenia (mental disorder that affects how a person thinks, feels, and behaves). Resident 20's record further indicated a PASARR Level I was conducted on November 1, 2015. The PASARR Level I screening indicated the need for a PASARR Level II evaluation to ensure that Nursing Facility (NF) placement was appropriate and to identify what specialized services and recommendations was required to better care for the resident. There was no documented evidence the facility followed up and coordinated with SDA for a Level II PASARR assessment and evaluation. On August 21, 2018, at 2:15 p.m., the Minimum Data Set (MDS- a resident assessment tool) Nurse (MDSN) was interviewed. The MDSN stated she was responsible for the completion of PASARR screening for the residents upon admissions. The MDSN was asked regarding Resident 20's PASARR Level I screening conducted on November 20, 2015 that indicated a Level II PASARR assessment and evaluation was needed. The MDSN was unable to provide documented evidence that Resident 20's PASARR Level II FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 32 of 131 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 08/28/2018 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 determination was completed by the SDA as required by the PASARR Level I screening conducted on November 20, 2015. The MDSN stated a PASARR Level II assessment and evaluation should have been done. MDSN further stated a PASARR Level II had to be completed by the SDA to determine if the nursing facility placement was appropriate for the resident. On August 28, 2018, the facility's policy and procedure titled "PASARR COMPLETION," dated August 17, 2018, was reviewed. The policy indicated, "...THIS FACILITY WILL COMPLETE A PASARR FOR ALL RESIDENTS ON ADMISSION AND REFER THOSE WITH MENTAL ILLNESS OR ID (INTELLECTUAL DISABILITY) TO THE STATE... All recommendations must be followed up with documentation in the clinical record and care planned as indicated/needed..."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 09/07/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 33 of 131 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 08/28/2018 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 well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one of 19 residents reviewed (Resident 31), to ensure a comprehensive care plan was initiated when a decline in the ADLs (Activities of Daily Living routine activities done everyday without assistance such as eating, bathing, getting dressed, toileting and transferring) was identified on March 1, 2018. This failure had the potential for Resident 31 not to receive the appropriate interventions needed to help prevent further decline in his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 34 of 131 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 08/28/2018 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 condition. Findings: On August 20, 2018, at 10:31 a.m., Resident 31 was observed in his wheelchair in the dining/activity room. Resident 31's wheelchair was reclined and was observed to have one foot rest on the right side. Resident 31 was awake but was not responsive to name when called. On August 20, 2018, at 3:07 p.m., Resident 31's record was reviewed with the Minimum Data Set (MDS- an assessment tool) Nurse (MDSN). Resident 31 was admitted to the facility on September 25, 2015, with diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other important mental functions). The Rehabilitation Screening form, completed by the physicial therapist, dated February 22, 2018, indicated, "...Patient reported with increase difficulty on ambulation during RNA (Restorative Nurse Assist) program..." The Interdisciplinary Team Conference Record dated March 1, 2018, indicated Resident 31 had a significant change in condition. The record further indicated, "...IDT (interdisciplinary team) MEETING CONDUCTED RELATING TO: SIGNIFICANT CHANGE OF CONDITION- DECLINE IN ADL FUNCTION/EXTENSIVE- TOTAL ASSIST AND NON-AMBULATORY STATUS...RESIDENT DECLINED SIGNIFICANTLY IN ADL FUNCTION REQUIRING EXTENSIVE TO TOTAL ASSISTANCE WITH ADLS...CONTINUE TO MONITOR AND ASSIST WITH ADLS..." Resident 31's active care plans, with a review FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 35 of 131 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 08/28/2018 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 date of June 31, 2018, did not indicate a care plan was initiated to address and prevent further complications on Resident 31's decline in ADLs, after the IDT team had identified it in March 1, 2018. in a concurrent interview, MDSN stated the IDT had identified Resident 31's significant decline in his ADL's and ambulation on March 1, 2018. The MDSN stated a care plan was not initiated to address the decline in ADLs. The MDSN stated a care plan should have been initiated by the facility after Resident 31's decline in ADL was identified in March 1, 2018. The facility's policy and procedure titled,"Policy: Decline," dated August 17, 2018, was reviewed. The policy indicated, "...A DECLINE IN RESIDENT'S CONDITION WILL RESULT IN RE-ASSESSMENT AS INDICATED...The discipline responsibility for the re-assessment will develop a plan of care that address the decline...Interdisciplinary Team Conference will be convened to review and implement plan of care..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 09/07/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 36 of 131 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 08/28/2018 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 by: Based on observation, interview, and record review, the facility failed to ensure, four of 19 residents reviewed (Residents 21, 16, 31, and 41), receive treatment and care in accordance with professional standards of practice when: 1. Resident 21, 16, and 31 were not provided a wheelchair foot rest to provide good body alignment and support. This facility failure may result to poor posture and development of potential contracture (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints); and 2. The facility failed to identify and address Resident 41's eye redness with discharge and pain. This facility failure may result to delay in treatment and may contribute to development of potential infection and complications. Findings: 1a. On August 20, 2018, at 9:54 a.m., Resident 21 was observed in the dining room sitting on a tilt-wheelchair. Resident 21's wheelchair was noted slightly tilted, head and neck without support; knees slightly bent and elevated; and legs dangling (no foot rest) on air. Resident 21 was alert but confused and unable to make her needs known. On August 20, 2018, at 12:00 noon, an observation and interview was conducted with the Restorative Nursing Assistant (RNA). The RNA acknowledged Resident 21 was in an awkward tilted position. The RNA stated Resident 21 should have a foot rest for leg support and wheelchair positioned upright for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 37 of 131 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 08/28/2018 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 good body alignment. On August 20, 2018, at 12:36 p.m., the Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she got Resident 21 up on her wheelchair and did not place the foot rest because the resident's legs did not stay put and she decided to leave the foot rest off. CNA 2 further stated she should have left the foot rest on but they were short and did not fit the resident's legs. On August 21, 2018, at 2:36 p.m., an observation and interview was conducted with the Minimum Data Set (MDS-a resident assessment tool) Nurse (MDSN). The MDSN inspected the tilt-wheelchair and stated the foot rest was permanently attached and pushed back under the wheelchair. The MDSN stated the foot rest was short and needed to be adjusted to accommodate Resident 21's leg length and body frame for comfort and support. The MDSN further stated the wheelchair should have been kept on an upright position every time Resident 21 was seated to maintain good body alignment. 1b. On August 20, 2018, at 12:10 p.m., Resident 16 was observed with the following: - Resident 16 was in her wheelchair in the dining/activity room. - Resident 16's wheelchair was reclined with no foot rest. - Resident 16's both lower extremities were dangling and both feet were pointed down on the floor. - Resident 16 was awake but was not able to appropriately respond to the interview FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 38 of 131 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 08/28/2018 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 questions. On August 20, 2018, at 12:53 p.m., a concurrent observation and interview was conducted with the Restorative Nurse Assistant (RNA). The RNA verified Resident 16 was in her wheelchair, reclined with no foot rest. Resident 16's both lower extremities were still observed to be dangling and both feet were pointed down on the floor. The RNA stated Resident 16's lower extremities should not be dangling from the wheelchair and a foot rest should be in place for the resident's use. The RNA stated a wheelchair foot rest was needed to support Resident 16's legs and feet for good body alignment. On August 22, 2018, at 8:51 a.m., the Registered Physical Therapist (RPT) was interviewed. The RPT stated residents who were wheelchair bound and unable to wheel themselves should have a foot rest at all times for leg support and for good body alignment. On August 22, 2018, Resident 16's record was reviewed. Resident 16 was admitted to the facility on April 2, 2014, with diagnoses that included hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body) and generalized muscle weakness. Resident 16's Minimum Data Set (MDS), dated August 22, 2018, indicated, Resident 16's function was "total dependence" and uses a wheelchair. 1c. On August 20, 2018, at 10:31 a.m., Resident 31 was in his wheelchair in the dining/activity room. Resident 31's wheelchair was reclined and had one foot rest on the right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 39 of 131 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 08/28/2018 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 side. Resident 31's both lower extremities were dangling and were not placed on the foot rest for support. Resident 31 was awake but was not responsive to name when called. On August 20, 2018, at 12:15 p.m., an observation and interview was conducted with the Restorative Nurse Assistant (RNA) . Resident 31 was observed in his wheelchair in the dining room. Resident 31's wheelchair was reclined and had one foot rest on the right side of the wheelchair. Resident 31's both lower extremities were still observed to be dangling from the wheelchair. In a concurrent interview, the RNA stated Resident 31's lower extremities should not be dangling and should have been positioned on two wheelchair foot rests for support. On August 20, 2018, Resident 31's record was reviewed. Resident 31 was admitted to the facility on September 25, 2015, with diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other important mental functions). The care plan initiated on December 19, 2016, indicated, "...Resident is at risk for having needs unmet related to non-verbal...Dx (diagnosis) Alzheimer's Disease...Intervention...Anticipate and meet all needs..." On August 27, 2018, at 4:23 p.m., the Registered Physical Therapist (RPT) was interviewed. The RPT stated Resident 31 needed foot rests for support when in wheelchair to keep the feet in neutral position and help prevent contracture (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) of the foot. The RPT further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 40 of 131 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 08/28/2018 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 he had communicated with the CNAs (Certified Nursing Assistants) that Resident 31 needed to have wheelchair foot rests when he is up in his wheelchair. The facility's policy and procedure titled, "Body Positioning and Alignment," dated August 17, 2018, was reviewed. The policy indicated, "...Residents are to be assessed upon admission for special positioning needs...Nursing shall document the resident's positioning needs in the Care Plan and coordinate interventions...The charge nurse shall supervise the positioning program to assure that the resident's needs are met..." 2. On August 20, 2018, at 11:49 a.m., an observation was conducted on Resident 41. Resident 41 was in bed, alert, and conversant. Resident 41's right lower eyelid was observed to be reddened and appeared to be inflammed. Resident 41's eyes were observed to be puffy and had light green mucousy discharges. In a concurrent interview, Resident 41 stated he felt pain in his eyes. On August 21, 2018, at 9 a.m., an observation on Resident 41 and an interview with Licensed Vocational Nurse (LVN) 3 was conducted. Resident 41 was in his wheelchair in the dining room seated in front of the television with the other residents. Resident 41's right lower eyelid was still observed to be reddened and appeared inflammed. Resdient 41's eyes appeared puffy and had light green mucousy discharges. LVN 3 assessed Resident 41. Resident 41 stated he felt pain in his eyes first thing in the morning and the pain was on a 5 out of 10 scale (pain scale 10 - worst pain) in both of his "eyeballs". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 41 of 131 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 08/28/2018 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 In a concurrent interview, LVN 3 stated he was the licensed nurse assigned to Resident 41 on August 20, 2018 and August 21, 2018. LVN 3 stated he did not receive any report about Resident 41's current eye condition. On August 21, 2018, at 2:34 p.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated he was the CNA assigned to Resident 41 on August 20, 2018, in the evening shift. CNA 3 stated he noticed Resident 41's eyes to be a little bit reddened and he figured it was only "tired eyes". CNA 3 stated he did not felt it was something that needed to be reported to the charge nurse. On August 21, 2018, at 3:30 pm, a record review was conducted with Minimum Data Set (MDS- an assessment tool) Nurse (MDSN). Resident 41 was admitted to the facility on August 24, 2017, with diagnoses that included disorder of the eyelid. An opthalmology (doctor who specializes in eye disease and disorders) progress notes dated April 6, 2018, indicated Resident 41 had blepharitis (eyelid inflammation) on both eyes and ectropion (lower eyelid turns or sags outward away from the eye exposing the surface of inner eyelid causing eye dryness, excessive tearing, and irritation) to both eyes. The care plan dated June 20, 2018, indicated, "...impaired visual functioning related to aging, diagnosis of Floppy Eye Syndrome (type of eyelid disorder)...Observe for eye pain, decrease in vision, blurring, redness, discharge, itchiness, puffiness, and report to MD (medical doctor)..." There was no documented evidence Resident 41's current eye condition was identified by the facility and was referred to the physician for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 42 of 131 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 08/28/2018 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 treatment. In a concurrent interview, MDSN stated Resident 41 did not have a current treatment order for the reddened eyelid with pain and eye drainage. MDSN stated the facility was not able to identify Resident 41's current eye condition until August 21, 2018. On August 28, 2018, at 2:05 p.m., the Director of Nursing (DON) was interviewed. The DON was made aware of Resident 41's current eye condition and the facility's failure to identify it and refer to the physician for treatment orders. The DON stated the licensed nurses should have identified Resident 41's current eye condition during their medication pass and the CNAs should have identified it when they rendered care to the resident.

F685 SS=D Treatment/Devices to Maintain Hearing/Vision CFR(s): 483.25(a)(1)(2)

F685 §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for one resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 43 of 131 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 08/28/2018 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), to address hearing deficit issues when a referral for audiology consult was not followed up. This resulted in Resident 2 not to receive an evaluation for her hearing loss. Findings: On August 20, 2018, at 9:17 a.m., an observation was conducted on Resident 2. Resident 2 was in bed, alert, and conversant. Resident 2 was observed to have a hard time hearing when the interview questions were repeated to her several times. During the interview Resident 2 stated to speak to her loudly, close to her ear because she was not able to hear very well. On August 20, 2018, at 2:08 p.m., Resident 2's record was reviewed with the Social Service Director (SSD). Resident 2 was admitted to the facility on February 7, 2018. The physician's order dated February 7, 2018, indicated, "Audiology Consult PRN (as needed) for hearing problems." The undated Social Service Assessment form, completed by the SSD on admission indicated, "...Hearing Patterns...Impaired (slightly)...Hearing Appliances...Not indicated...Hearing Consultation...Not indicated at this time...Comments...You have to speak a little louder to her..." The Quarterly Social Service Notes dated May 15, 2018, did not indicate if an audiology consult was conducted. The Ancillary Services Audiology section was left blank. In a concurrent interview, the SSD stated an audiology consult for Resident 2 was not done at the time of the admission because she was waiting for Resident 2's family member to notify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 44 of 131 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 08/28/2018 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 facility if she had hearing aids prior to admission. The SSD stated in the Quarterly Social Service meeting on May 15, 2018, Resident 2's family member had mentioned Resident 2's ears were blocked with ear wax. The SSD stated she was not able to follow up with the family if Resident 2 had hearing aids. The SSD stated she was not able to follow up in May 2018 if Resident 2 needed an audiology consult. The SSD stated Resident 2 did not have audiology consult since she was admitted on February 7, 2018. The SSD stated she should have followed up Resident 2's audiology consult. The facility's document titled, "Job Description...Social Service Department..." dated March 12, 2014, was reviewed. The document indicated, "...Essential Duties and Responsibilities...Assist in the provision of the medically-related social services to attain or maintain the highest practicable, mental and psychosocial well-being of each resident...Facilitates any identified problems, e.g. dental visual, communication, etc.."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 45 of 131 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 08/28/2018 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for one of 19 residents (Resident 6) observed during meal times, the facility failed to provide a safe accident-free environment when a confused and vulnerable resident was not supervised while eating in her room. This facility failure could put the resident at risk for choking and aspiration while eating alone in her room. Findings: On August 20, 2018, at 12:49 p.m., Resident 6 was observed in her bed, eating her meal with bare hands. Resident 6 just stared when spoken to and without provocation, threw a banana peel on the floor. On August 20, 2018, Resident 6's record was reviewed. Resident 6 was admitted to the facility on November 20, 2012, with diagnoses that included dementia (progressive loss of ability to think, process thoughts, and make sound decisions) and schizophrenia (mental disorder that affects how a person thinks, feels, and behaves). Further record review indicated: - Resident 6's history and physical dated December 29, 2017, indicated, resident was confused and did not have the capacity to understand and make decisions. - The Minimum Data Set (MDS - resident assessment tool) dated August 18, 2018, indicated, "...Functional Status...Eating...SelfPerformance: Supervision - oversight, encouragement or cueing...Support: Set up help only..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 46 of 131 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 08/28/2018 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 care plan titled, "Focus: Resident has self care deficits and requires assistance with ADLs (activity of daily living) related to...poor safety awareness...Goal Target Date: 11/15/2018...Intervention...Provide a safe environment..." On August 20, 2018, at 12:59 p.m., an observation and interview was conducted with the Certified Nursing Assistant (CNA) 4 at Resident 6's bedside. CNA 4 stated she delivered the resident's tray. CNA 4 stated the tray contained a banana, french fries, burger, and a salad. CNA 4 stated she set up the food tray and left the resident to eat. When CNA 4 was asked if there was any potential problem that may arise if resident was to be left to eat by herself, CNA 4 stated, "Yes," and further stated that the resident had to be supervised because she may choke on her food. On August 22, 2018, at 7:35 a.m., Resident 6 was observed eating breakfast by herself. CNA 5 went in and removed the breakfast tray and left the dry corn flakes with no utensils noted for the resident to use. In a concurrent interview, CNA 5 stated Resident 6 had been eating by herself since she started working for the facility October of last year. CNA 5 further stated the resident usually ate with her bare hands and had to be cued and reminded to use her utensils. When CNA 5 was asked if there was any potential problem that may arise if resident was to be left to eat by herself, CNA 5 stated, "Yes," and further stated that the resident had to be supervised because she may choke on her food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 47 of 131 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 08/28/2018 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 On August 27, 2018, at 11:00 a.m., the Director of Nursing (DON) was interviewed regarding the need for supervision during meal times for Resident 6. The DON stated Resident 6 had to be supervised during meal times. DON further stated Resident 6 had to be seated upright and food cut into bite sizes during meals to prevent choking. On August 27, 2018, the facility's policy and procedure, titled "Policy: Supervising Meals," dated August 17, 2018, was reviewed. The policy indicated, "...TO ENSURE THAT RESIDENTS ARE PROPERLY SUPERVISED DURING MEALS...residents who eat in room are to be monitored by nursing staff...Residents who require assistance in eating shall be provided appropriate assistance..."

F755 SS=F Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist whoFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 48 of 131 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 08/28/2018 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 §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for six of six residents (Residents 15, 61, 47, 3, 72, and 59), to provide evidence of accountability for narcotic (controlled drug that induces stupor, coma, or insensibility to pain) pain medications Norco and Tramadol (narcotic pain medications) when: 1. For Resident 15, the medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and was not documented on the Medication Administration Record (MAR) if administered to the resident from the period of June 2018 to August 2018; 2. For Resident 61, the medication Norco and Tramadol was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and was not documented on the MAR if administered to the resident from the period of July 2018 to August 2018; 3. For Resident 47, the medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 49 of 131 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 08/28/2018 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 and was not documented on the MAR if administered to the resident from the period of June 2018 to August 2018; 4. For Resident 3, the medication Tramadol was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and was not documented on the MAR if administered to the resident from the period of June 2018 to August 2018; 5. For Resident 72, the medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and was not documented on the MAR if administered to the resident from the period of June 2018 to August 2018; and 6. For Resident 59, the medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and was not documented on the MAR if administered to the resident from the period of June 2018 to August 2018. These failures resulted to the delay in the identification of drug discrepancies and possible medication diversion of controlled medications. Findings: 1. On August 22, 2018, at 10:58 a.m., a narcotic medication reconciliation for Resident 15 was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 stated the facility's process in giving PRN (as needed) narcotic pain medications was for the licensed nurse to sign out the medication from the narcotic count sheet, administer the medication to the resident, document in the resident's MAR the reason for giving the medication, document and sign the date and time the medication was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 50 of 131 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 08/28/2018 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 administered, and an evaluation on the effectiveness of the medication. Resident 15 had a physician's order dated August 30, 2016, for Norco 5/325 mg (milligrams) tablet to be given by mouth every six hours PRN for severe pain..." The narcotic count sheet reviewed with LVN 4 indicated Norco was signed out by the licensed nurses 15 times from the period of August 16 August 22, 2018. Resident 15's August 2018 MAR indicated Norco 5/325 mg was administered to Resident 15 three times from August 19 and 20, 2018. In a concurrent interview, LVN 4 stated, the licensed nurses who signed out the Norco from the narcotic count sheet from August 16 to 22, 2018, should have documented and signed in Resident 15's MAR, the date and time the medication was administered, the indication for giving the medication, and evaluation for the effectiveness of the medication. On August 23, 2018, Resident 15's record was reviewed. Resident 15 was admitted to the facility on August 8, 2014, with diagnoses that included ostoearthritis (degenerative joint disease). The narcotic count sheet for Norco from the period of June 6 to 30, 2018, indicated the licensed nurses signed out the Norco from the narcotic count sheet 14 times. The Norco PRN order in Resident 15's June 2018 MAR did not indicate Norco was administered to the resident when it was signed out by the licensed nurses on the following dates: - June 19, 2018, (time unclear); - June 20, 2018 at 6 p.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 51 of 131 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 08/28/2018 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 - June 21, 2018, at 7 p.m.; - June 24, 2018, at 6 p.m., - June 24, 2018, at 6 p.m.; and - June 3 (sic.) at 9 a.m. The narcotic count sheet for Norco from the period of July 1 to 31, indicated the licensed nurses signed out the Norco from the narcotic count sheet 36 times. The Norco PRN order in Resident 15's July 2018 MAR did not indicate Norco was administered to the resident when it was signed out by the licensed nurses on the following dates: - July 1, 2018, at 8 p.m.; - July 2, 2018, at 6:40 a.m., 1 p.m., and 7 p.m.; - July 11, 2018, at 9 a.m.; - July 20, 2018, at 1:45 p.m., the second entry for July 20, 2018 time was not clearly written; - July 24, 2018, at 6:45 a.m., 1 p.m.; and - July 28, 2018, at 9 a.m. The narcotic count sheet for Norco from the period of August 1 to 22, indicated the licensed nurses signed out the Norco from the narcotic count sheet 23 times. The Norco PRN order in Resident 15's August 2018 MAR did not indicate Norco was administered to the resident when it was signed out by the licensed nurses on the following dates: - August 3, 2018, at 6:50 a.m., and 1:45 p.m.; - August 7, 2018, at 6:40 a.m., and second FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 52 of 131 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 08/28/2018 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 entry for August 7, 2018 the time was not clearly written; - One entry after August 7, 2018 - the date and time was not clearly written; - August 9, 2018, at 6:35 am, 12 p.m., and 6 p.m., - August 16, 2018, at 9 a.m.; - August 17, 2018, at 10 a.m.; - Entry after August 17, 2018 - the date and time was not clearly written; - August 18, 2018, at 6:30 a.m. and 11:30 a.m.; - August 19, 2:30 p.m.; - Four entries after August 19, 2018 - the date, time, and initial of licensed nurse were not clearly written; - August 21, 2018 at 2 p.m., and - August 22, 2018 at 6:40 a.m. On August 23, 2018, at 11:03 a.m., an interview and record review was conducted with LVN 5. LVN 5 verified his initials on Resident 15's Norco count sheet on the following dates: - June 19 and 31, 2018; - July 1, 11, and 28, 2018; and - August 16, 17, and 19, 2018. In a concurrent interview, LVN 5 stated he signed out the Norco from the narcotic count FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 53 of 131 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 08/28/2018 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 sheet on those dates. LVN 5 stated he did not sign and document on the MAR the date and time the Norco was administered, the indication for use, and the evaluation for the effectiveness of the medication. LVN 5 stated he "missed signing," and he, "forgot at that time" to document in Resident 15's MAR. LVN 5 stated he should have documented in the MAR the date and time the Norco was administered, indication for use, and the evaluation for the effectiveness of the medication. On August 23, 2018, at 11:40 a.m., an interview was conducted with LVN 3. LVN 3 verified his initials on Resident 15's Norco narcotic count sheet. LVN 3 stated he did not sign and document on the MAR the date and time the Norco was administered, the indication for use, and the evaluation for the effectiveness of the medication. LVN 3 stated he should have signed and documented on the MAR. On August 23, 2018, at 11:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated he expected the licensed nurses to follow the facility's policy and procedure in dispensing the narcotic pain medications. On August 27, 2018, at 3:57 p.m., a record review was conducted with LVN 3. LVN 3 verified his iniitals of Resident 15's narcotic count sheet the dates Norco was signed out but was not documented in the MAR as administered to Resident 15. The dates were as follows: - July 2 (signed out twice), 12, 20 (signed out twice), and 24, 2018, (signed out three times); and - August 3 (signed out twice), 7 (signed out FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 54 of 131 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 08/28/2018 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 twice), 9 (signed out three times), and 16, 2018. 2. On August 22, 2018, at 5:45 p.m., Resident 61's record was reviewed. Resident 61 was admitted to the facility on August 2, 2018, with diagnoses that included cutaneous abscess (confined pocket of pus that collects in tissues, organs, or spaces in the body) of the body. The physician's order dated August 2, 2018, indicated, "Norco 5/325 mg 1 tab (tablet) PO (by mouth) Q 6H (every six hours) PRN for moderate pain," and "Tramadol 50 mg PO 1 tab Q6h PRN for moderate pain." The narcotic count sheet indicated Norco was signed out by the licensed nurses 14 times from the period of July 18- July 26, 2018. Resident 61's July MAR indicated Norco 5/325 mg was administered to the resident during that period 11 times. The following dates indicated Norco was signed out in the narcotic count sheet but not documented in the July 2018 MAR if administered to the resident: - July 20, 2018, at 1 p.m., and 10 p.m.; and - July 23, 2018, at 3 p.m. The narcotic count sheet for Norco was signed out by the licensed nurses eight times from the period of August 3 to 20, 2018. Resident 61's August MAR indicated Norco was administered to the resident during that period three times. The following dates indicated Norco was signed out in the narcotic count sheet but not documented in the August 2018 MAR if administered to the resident: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 55 of 131 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 08/28/2018 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 - August 6, 2018, at 10 a.m.; - August 7, 2018, at 9 a.m.; - August 9, 2018, 1 p.m., 4:30 p.m.; and - August 22, 2018, at 9 p.m. The narcotic count sheet for Tramadol was signed out by the licensed nurses eight times from the period of July 17 to 25, 2018. Resident 61's July MAR did not indicate Tramadol was administered to the resident during that period. The following dates indicated Tramadol was signed out in the narcotic count sheet but not documented in the July 2018 MAR if administered to the resident: - July 17, 2018, at 7:35 a.m., and 1:44 p.m.; and - July 25, 2018, at 9 p.m. The narcotic count sheet for Tramadol was signed out by the licensed nurses two times from the period of August 4 to 9, 2018. Resident 61's August MAR did not indicate Tramadol was administered to the resident during that period. The following dates indicated Tramadol was signed out in the narcotic count sheet but not documented in the August 2018 MAR if administered to the resident: - August 4, 2018, at 9 a.m.; and - August 9, 2018, at 2:45 p.m. On August 23, 2018, at 2:13 p.m., Resident 61's record was reviewed with LVN 5. LVN 5 verified his initials on Resident 61's narcotic count sheet for Norco and Tramadol. LVN 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 56 of 131 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 08/28/2018 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 he had signed out Norco and Tramadol from the narcotic count sheets for July and August but failed to document on the MAR if they were administered to the resident on the following dates: - Norco - August 6 at 10 a.m., August 7 at 9 a.m., and August 9 at 4:30 p.m.; and - Tramadol - July 17, 2018 at 7:35 a.m., and 1:44 p.m. In a concurrent interview, LVN 5 stated he signed out the Norco and Tramadol on those dates but he did not sign the MAR if administered to the resident. LVN 5 stated he made a bad habit of not signing due to his lack of time management. LVN 5 stated he should have signed the MAR, did his pain assessment on Resident 61, and documented at the back of the MAR narrative notes on why the PRN pain medication was given. 3. On August 22, 2018, at 3 p.m., Resident 47's record was reviewed with the Director of Staff Development (DSD). Resident 47 was admitted to the facility with an initial admission date of July 10, 2014, with the diagnoses that included osteoarthritis (type of arthritis that affects joints in the hand, knees, hip and spine). Resident 47 had a physician's order, dated April 28, 2018, for Norco 5/325, 1 tab (tablet) to be given every four hours as needed for pain. Subsequently, the following initials on Resident 47's Norco narcotic count sheet was reviewed and verified with the DSD: a. The 2018 narcotic count sheet for Resident 47's Norco indicated Licensed Vocational Nurse (LVN) 5 signed out the medication on: a1. For the month of June 2018: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 57 of 131 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 08/28/2018 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 - June 10 at 9 a.m.; - June 11 at 10 a.m.; - June 12 at 7 p.m.; - June 14 at 10 a.m.; - June 17 at 7 a.m.; - June 19 at 9 a.m., and 2:30 p.m.; - June 21 at 6:45 a.m., and 11 a.m.; - June 25 at 10 a.m.; and - June 26 at 7 a.m., and 11a.m. Resident 47's MAR, dated June 2018, did not indicate if LVN 5 had administered the Norco to Resident 34 on June 10, 11, 12, 14, 17, 19, 21, 25, and 26. a2. For the month of July 2018: - July 3 at 9 a.m.; - July 6 at 8 a.m.; - July 23 at 2:30 p.m.; - July 28 at 8 a.m., and 1 p.m.; and - July 29 at 10 a.m. Resident 47's MAR, dated July 2018, did not indicate if LVN 1 had administered the Norco to Resident 34 on July 3, 6, 23, 28, and 29. a3. For the month of August 2018: - August 17 at 1 p.m.; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 58 of 131 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 08/28/2018 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 - August 19 at 7 a.m., and 1:30 p.m. Resident 47's MAR, dated August 2018, did not indicate if LVN 1 had administered the Norco to Resident 34 on August 17 and 19. b. The 2018 narcotic count sheet for Resident 47's Norco indicated LVN 3 signed out the medication on: b1. For the month of June: - June 12 at 7 a.m., and 11:15 a.m.; - June 18 (unable to read the time); - June 27 at 6:50 a.m., and 11:30 a.m.; and - June 28 at 6:50 a.m., and 11 a.m.; Resident 47's MAR, dated June 2018, did not indicate if LVN 2 had administered the Norco to Resident 34 on June 12, 18, 27, and 28. b2. For the month of July 2018: - July 1 at 6:45 a.m., and 12 p.m.; - July 2 at 7:30 a.m., and 12:30 p.m.; - July 16 at 7:10 a.m.; - July 17 at 12 p.m.; - July 18 at 11:45 a.m.; - July 20 at 7:10 a.m., and 12:15 p.m.; and - July 27 at 7:30 a.m., and 1:45 p.m. Resident 47's MAR, dated July 2018, did not indicate if LVN 2 had administered the Norco to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 59 of 131 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 08/28/2018 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 34 on July 1, 2, 16, 17, 18, 20, and 27. b3. For the month of August 2018: - August 9 at 6:45 p.m., 5 p.m. and there was one documented entry that was unable to read the time; - August 18 at 3 p.m.; and - There were six documented entyries after August 19 that were unable to read the date and time. Resident 47's MAR, dated August 2018, did not indicate if LVN 2 had administered the Norco to Resident 34 on August 9 and 18. After August 18, there were two initials on August 20 and two initials on August 21 indicating Norco was administered to Resident 34. In a concurrent interview, the DSD stated LVN 5 and LVN 3 should have documented in Resident 47's MAR if Norco was administered to the resident. On August 23, 2018 at 2:12 p.m., a concurrent record review and interview was conducted with LVN 5. LVN 5 confirmed it was his signature on Resident 47's Norco count sheet for the month of June, July and August 2018. LVN 5 was made aware of his missing initials on Resident 47's MAR that would indicate the Norco signed out from the narcotic count sheet was administered to Resident 47. LVN 5 stated he knew the facility's process when giving pain medication from conducting pain assessment before medicating the resident, documenting in the narcotic count sheet and on the MAR after administering the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 60 of 131 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 08/28/2018 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 medication to the resident, and conducting pain assessment after medicating the resident to know if the medication was effective. LVN 5 stated he did not document on the MAR because of his poor time management. LVN 5 stated he was doing late entry signing of the PRN medication he administered to the residents as his way of catching up on his documentation. LVN 5 stated late entry was not appropriate but its better than not putting anything at all. On August 23, 2018, at 3:26 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 confirmed it was his signature on Resident 47's Norco count sheet for the month of June, July and August 2018. LVN 3 was not able to read the date and time on the last six entries on Resident 47's Norco count sheet for August 2018, however he verified it was his initials on it. LVN 3 was made aware of his missing initials on Resident 47's MAR that would indicate the Norco signed out from the narcotic count sheet was administered to Resident 47. LVN 3 stated he was not aware there were a lot of missing initials on the MAR. LVN 3 stated he knews the facility's process when giving pain medication from conducting pain assessment before medicating the resident, documenting in the narcotic count sheet and on the MAR after administering the medication to the resident, and conducting pain assessment after medicating the resident to know if the medication was effective. LVN 3 stated he did not document on the MAR after giving the narcotic to the resident because most of the time, he was pulled by other nurses asking for help or to do another task, and he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 61 of 131 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 08/28/2018 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 forgot to sign the narcotic medication he administered to the resident. LVN 3 stated he should document on the MAR after giving the pain medication to the resident. LVN 3 stated he made a mistake for not signing the MAR. On August 23, 2018, at 3:27 p.m., the Administrator was interviewed. The Administrator stated the facility was not doing narcotic medication reconciliation audit. The Administrator stated the Medical Records (MR) department checks on the MAR only and was not verifying the narcotic medications signed out on the narcotic count sheet. On August 27, 2018, at 11:51 a.m., the Director of Nursing (DON) was interviewed. The DON stated nurses should know and follow the facility's policy and procedure on the use of narcotics. The DON stated the Medical Records (MR) audit the MAR, the MR verified the medication orders were correct and the MAR have the licensed nurses signatures indicating medications were administered to the residents. The DON stated the licensed nurses ensure the narcotic medication had the correct count from the narcotic count sheet. The DON stated the facility did not have an audit process on narcotic medication reconciliation where the medication on the residents' narcotic count sheet reflects on the residents' MAR indicating the medication was administered to the residents. 4. On August 23, 2018, a medication reconciliation review was conducted for Resident 3. Resident 3 had a physician's order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 62 of 131 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 08/28/2018 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 dated December 12, 2017 for, "Tramadol (Ultram 50 mg [milligram] 1 tab [tablet] Q 4' [every 4 hours] PRN [as needed] for pain management). There was no documented evidence Tramadol 50 mg was signed as administered in the MAR of Resident 3 on multiple days, when Tramadol was signed out in the Narcotic Count Sheet during the months of June, July, and August 2018. On August 23, 2018, at 12:20 p.m., the Narcotic Count Sheet (NCS) and MAR was reviewed with the Director of Staff Development (DSD). The record indicated Tramadol 50 mg was signed out on multiple days and not documented as administered. The DSD verified and identified the licensed nurses who removed and signed out Tramadol 50 mg in the NCS, and did not document the medications as administered in Resident 3's MAR. The NCS for Tramadol PRN order in Resident 3's June 2018 MAR did not indicate Tramadol was administered to the resident when it was signed out by LVN 4 on the following dates: - June 27, 2018, at 7:15 a.m.; - June 28, 2018, at 6:45 a.m.; and - June 29, 2018, at 10:45 a.m. The NCS for Tramadol PRN order in Resident 3's July 2018 MAR did not indicate Tramadol was administered to the resident when it was signed out by LVN 4 on the following dates: - July 2, 2018, at 6:45 a.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 63 of 131 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 08/28/2018 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 - July 16, 2018, at 8:30 a.m.; - July 17, 2018, at 11:00 a.m.; - July 18, 2018, at 7:15 a.m.; - July 18, 2018, at 11:00 a.m.; - July 23, 2018, at 16:00 p.m.; - July 26, 2018, at 7:45 a.m.; - July 26, 2018, at 13:00 a.m.; - July 27, 2018, at 6:55 a.m.; - July 27, 2018, at 10:55 a.m.; - July 30, 2018, at 7:05 a.m.; and - July 31, 2018, at 7:00 a.m. The NCS for Tramadol PRN order in Resident 3's August 2018 MAR did not indicate Tramadol was administered to the resident when it was signed out by LVN 4 on the following dates: - August 2, 2018, at 10:30 a.m.; - August 3, 2018, at 6:40 a.m.; - August 9, 2018, at 11:30 a.m.; - August 12, 2018, at 14:00 p.m.; - August 15, 2018, at 8:00 a.m.; - August 20, 2018, at an undetermined time; - August 20, 2018, at 11:00 a.m.; - August 21, 2018, at an undetermined time; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 64 of 131 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 08/28/2018 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 - August 21, 2018, at 11:15 a.m.; and - August 22, 2018, at 7:05 a.m. On August 23, 2018, at 3:16 p.m., LVN 3 was interviewed. LVN 3 verified all his signatures that he removed the Tramadol 50 mg in the NCS, and did not document the Tramadol as administered in the MAR for Resident 3 for the month of June, July, and August 2018. LVN 3 stated he was aware that medications needed to be documented when administered. LVN 3 further stated he should have documented the Tramadol he signed out from Resident 3's NCS. 5. On August 22, 2018, resident 72's record was reviewed. Resident 72 was admitted to the facility on June 2, 2018, with diagnoses that included: fracture (broken bone) ot the right patella (knee cap). Resident 72's physician's order on June 6, 2018, indicated ,"Norco 5/325 Mg (milligrams) 1 PO (by mouth) q (every) 6 hours PRN (as needed) for moderate pain 4-6 hours apart not to exceed 3 Gm's (grams) a day." Resident 72's narcotic count sheet for Norco from the period of June 2 to 30, 2018, indicated licensed nurses signed out the Norco from the narcotic count sheet 6 times. The Norco PRN order in resident 72's MAR did not indicate Norco was administered to the resident when it was signed out of by licensed nurses on the following dates: June 10, 2018, at 6 p.m.; June 12, 2018, at 6 p.m.; June 18, 2018, at 9 a.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 65 of 131 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 08/28/2018 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 June 18, 2018, at 4 p.m.; June 27, 2018, at 6 p.m.; June 30, 2018, at 6 p.m.; Resident 72's narcotic count sheet for Norco from the period of July 1 to 31, 2018, indicated the licensed nurses signed out the Norco from the narcotic count sheet four times. The Norco PRN order in resident 72's MAR did not indicate Norco was administered to the resident when it was signed out of by licensed nurses on the following dates: July 7, 2018, at 7:15 a.m.; July 10, 2018, at 8 a.m.; July 17, 2018, at 9:30 a.m.; July 18, 2018, at 8:15 a.m.; Resident 72's narcotic count sheet for Norco from the period of August 1 to 22,2018, indicated the licensed nurses signed out Norco from the narcotic count sheet three times. The Norco PRN order in resident 72's MAR did not indicate Norco was administered to the resident when it was signed out of by licensed nurses on the following dates: August 6, 2018, at 9 a.m.; August 7, 2018, time not clearly written. August 10, 2018, time not clearly written. On August 27, 2018 at 3 p.m., LVN 5 recognized his initials on the narcotic count sheet for Resident 72. LVN 5 stated, because of time management issue he was not able to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 66 of 131 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 08/28/2018 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 document narcotic medications in the MAR. 6. On August 23, 2018, Resident 59's record was reviewed. Resident 59 was initially admitted to the facility on May 17, 2018, and was readmitted on June 23, 2018, with diagnoses including cellulitis (bacterial skin infection) on both lower limbs. Resident 59 had a physician's order dated June 23, 2018, for Norco 5/325 mg (milligrams) tablet to be given by mouth every four hours PRN (as needed) for pain 4-6 (pain scale 0-10, 10 being severe). The narcotic count sheet for Norco 5/325 mg from the period of June 6 to 30, 2018, indicated licensed nurses signed out Norco 28 times. Resident 59's June 2018 MAR had no indication of Norco being administered for 20 of those 28 from the narcotic count sheet on the following dates: - June 10, 2018, at 10 a.m.; - June 11, 2018, at 12 p.m.; - June 12, 2018, at 6:45 a.m., 10:45 a.m., and 7 p.m.; - June 13, 2018, at 9 a.m.; - June 14, 2018, at 10 a.m., and 11 p.m.; - June 15, 2018, at 1:22 a.m., 6:30 a.m., and 9 p.m.; - June 16, 2018, at 4 p.m.; - June 17, 2018, at 7 a.m., and (unable to identify written time); - June 18, 2018, at 11 a.m., and 5 p.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 67 of 131 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 08/28/2018 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 - June 19, 2018, at 9 a.m., and 5 p.m.; and - June 28, 2018, at 7 a.m., and 11:05 a.m. The narcotic count sheet for Norco 5/325 mg from the period of July 1 to 31, 2018, indicated licensed nurses signed out Norco 40 times. Resident 59's July 2018 MAR had no indication of Norco being administered for 16 of those 40 from the narcotic count sheet on the following dates: - July 1, 2018, at 6:35 a.m., 10:30 a.m., and 8 p.m.; - July 2, 2018, at 7 a.m., 11:05 a.m., and 9 p.m.; - July 16, 2018, at 8 a.m.; - July 17, 2018, at 11:05 a.m.; - July 18, 2018, at 10:45 a.m.; - July 20, 2018, at 11 a.m.; - July 23, 2018, at 7:30 p.m.; - July 24, 2018, at 7 p.m.; - July 28, 2018, at 8 a.m., and 1 p.m.; and - July 29, 2018, at 7:30 a.m., and 12:30 p.m. The narcotic count sheet for Norco 5/325 mg from the period of August 1 to 22, 2018, indicated licensed nurses signed out Norco 38 times. Resident 59's August 2018 MAR had no indication of Norco being administered for 19 of those 38 from the narcotic count sheet on the following dates: - August 3, 2018, at 3 p.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 68 of 131 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 08/28/2018 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 - August 9, 2018, at (unable to identify written time), 6:40 a.m., 10:40 a.m., 2:50 p.m., and (unable to identify written time); - August 11, 2018, at 1 p.m.; - August 12, 2018, at 11 a.m., and 3 p.m.; - August 15, 2018, at 6:40 a.m., and 11 a.m.; - August 16, 2018, at 9 a.m.; - August 17, 2018, at 12:30 p.m., and 2 p.m.; - August 19, 2018, at 1 p.m., and (unable to identify written time); - August 21, 2018, at (unable to identify written time), and 3 p.m.; and - August 22, 2018, at 6:45 a.m. On August 23, 2018, at 2:08 p.m., Resident 59's record was reviewed with Licensed Vocational Nurse (LVN) 5. LVN 5 verified his initials on Resident 59's narcotic count sheet for Norco. LVN 5 stated he had signed out Norco from the narcotic count sheets for June, July, and August 2018 but failed to document on the MARs if they were administered to the resident on the following dates: - June 10, 2018, at 10 a.m.; - June 11, 2018, at 12 p.m.; - June 12, 2018, at 7 p.m.; - June 14, 2018, at 1 a.m.; - June 17, 2018, at 7 a.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 69 of 131 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 08/28/2018 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 - June 19, 2018, at 9 a.m.; - July 1, 2018, at 6:35 a.m., and 8 p.m.; - July 17, 2018, at 11 a.m.; - July 28, 2018, at 8 a.m., and 1 p.m.; - July 29, 2018, at 7:30 a.m., and 12:30 p.m.; - August 16, 2018, at 9 a.m.; - August 19, 2018, at 1 p.m., and (unable to identify written time); In a subsequent interview, LVN 5 stated in the process of administering pain medications, he should perform a pain assessment, document on the narcotic count sheet and on the MAR, and perform another pain assessment after administering the pain medication. In addition, LVN 5 stated he failed to document on the MAR because of his poor time management. On August 23, 2018, at 3:09 p.m., Resident 59's record was reviewed with Licensed Vocational Nurse (LVN) 3. LVN 3 verified his initials on Resident 59's narcotic count sheet for Norco. LVN 3 stated he had signed out Norco from the narcotic count sheets for June, July, and August 2018 but failed to document on the MARs if they were administered to the resident on the following dates: - June 12, 2018, at 6:45 a.m., and 10:45 a.m.; - June 15, 2018, 6:30 a.m.; - June 28, 2018, at 7 a.m., and 11:05 a.m.; - July 2, 2018, at 7 a.m., and 11:05 a.m.; - July 20, 2018, at 11 a.m.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 70 of 131 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 08/28/2018 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 - July 23, 2018, at 7:30 p.m.; - August 9, 2018, at 10:40 a.m., 2:50 p.m., and (unable to identify written time); - August 12, 2018, at 11 a.m., and 3 p.m.; - August 15, 2018, at 6:40 a.m., and 11 a.m.; - August 21, 2018, at (unable to identify written time), and 3 p.m.; and - August 22, 2018, at 6:45 a.m. In a subsequent interview, LVN 3 stated he knew both narcotic count sheet and MAR should be signed, as well as assessments prior to and after administering pain medications should be done. LVN 3 further stated he should have signed the MARs after administering the pain medications but made the mistake of not signing them. The facility policy titled, "PREPARATION AND GENERAL GUIDELINES...MEDICATION ADMINISTRATION..." dated October 2017, was reviewed. The policy indicated: "...The individual who administers the medication...records...on the resident's MAR directly after the medication is given... ...When PRN medications are administered, the following documentation is provided...results achieved from giving the dose...signature or initials of person recording administration..."

F756 SS=F Drug Regimen Review, Report Irregular, Act On FORM CMS-2567(02-99) Previous Versions Obsolete

F756 Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 71 of 131 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 08/28/2018 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 CFR(s): 483.45(c)(1)(2)(4)(5) §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 72 of 131 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 08/28/2018 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the pharmaceutical consultant (PC) failed for: 1. Six of six residents (Residents 15, 61, 47, 3, 72, and 59), to identify drug irregularities when multiple licensed nurses were signing out narcotic medications (Norco and Tramadol narcotic pain medications) and were not documenting on the residents' Medication Administration Record (MAR) if the medications were administered. In addition, the PC failed to identify the unaccountability of narcotic medications. (Cross Reference F755); and 2. Two of five residents reviewed for unnecessary medications (Residents 60 and 80), to identify drug irregularities when the dose of the medications, Norco was administered without appropriate pain assessments, and Tramadol dose was increased and administered without appropriate pain assessments. These failures had the potential harm to the residents due to unnecessary use of narcotic pain medications and had the potential for drug irregularities that may result in the diversion of medications. Findings: 1. On August 23, 2018, Resident 15's record was reviewed. Resident 15's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 73 of 131 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 08/28/2018 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 Reference F755 Finding #1). There was no documented evidence the PC identified the drug irregularities and charting gaps for the PRN Norco medication when the Drug Regimen Review was conducted on Resident 15 from the period of June 2018 to August 2018. 2. On August 23, 2018, Resident 61's record was reviewed. Resident 61's count sheet for Norco from the period of July to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medications were administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755 Finding #2). There was no documented evidence the PC identified the drug irregularities and charting gaps for the PRN Norco and Tramadol medication when the Drug Regimen Review was conducted on Resident 61 from the period of July 2018 to August 2018. 3. On August 23, 2018, Resident 3's record was reviewed. Resident 3's count sheet for Tramadol from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755 Finding #4). There was no documented evidence the PC identified the drug irregularities and charting gaps for the PRN Tramadol medication when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 74 of 131 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 08/28/2018 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 Drug Regimen Review was conducted on Resident 3 from the period of June 2018 to August 2018. 4. On August 22, 2018, Resident 72's record was reviewed. Resident 72's count sheet for Norco from June 2018 to August 2018, indicated multiple licensed nurses were signing out of the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. (Cross Reference F755 Finding #5) There was no documented evidence the PC identified the drug irregularities and charting gaps for the PRN Norco medication when the Drug Regimen Review was conducted on Resident 3 from the period of June 2018 to August 2018. 5. On August 23, 2018, Resident 59's record was reviewed. Resident 59's narcotic count sheet for Norco 5/325 mg (milligrams) from the period of June 2018 to August 2018 indicated multiple licensed nurses signed out the narcotic pain medication but did not document on the MAR when the medications were administered. (Cross Reference F755 Finding #6). There was no documented evidence the PC had identified the drug irregularities and charting discrepancies for the PRN Norco medication when the Drug Regimen Review was conducted from the period of June 2018 to August 2018. 6. On August 23, 2018, Resident 47's record was reviewed. Resident 47's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 75 of 131 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 08/28/2018 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 effectiveness of the medication. (Cross Reference F755 Finding #3). There was no documented evidence the PC identified the drug irregularities and charting gaps for the PRN Norco medication when the Drug Regimen Review was conducted on Resident 47 from the period of June 2018 to August 2018. On August 23, 2018, at 4:41 p.m., the facility's PC was interviewed. The PC was made aware of the issues concerning the licensed nurses signing out PRN narcotic pain medications and not documenting in the MAR if the medications were administered to the residents. The PC stated he did not encounter issues regarding narcotic discrepancies for these residents. The PC stated he only looked at the MARs and charts of the residents. The PC stated he did not look into the narcotic count sheets and compared it with the residents MARs. The PC further stated he trusted the licensed nurses were documenting accurately. The PC further stated these medication irregularities could have been prevented. 7a. On August 27, 2018, at 10 a.m., Resident 80's record was reviewed. Resident 80 was admitted to the facility on June 13, 2018. Resident 80's "Order Summary Report," indicated, "Active Orders As Of: 08/01/2018...Pain Assessment (0= No Pain), (4 -6= Moderate Pain), (7-9= Severe Pain), (10= Very severe pain)...Norco Tablet 5/325 (narcotic pain medication) MG (milligram)...Give 1 tablet by mouth every four hours as needed for MODERATE PAIN...start date 6/13/2018...Tylenol Tablet (non-narcotic pain medication) 325 MG...Give 2 tablet by mouth every 4 hours as needed for Mild Pain...start date 6/13/2018..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 76 of 131 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 08/28/2018 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 80's MAR, dated July 2018, indicated the licensed nurses administered the Norco to Resident 80, 17 times (on July 1, 2, 6, 7, 8, 9, 14, 17, 21, 25, 30, and 31). Tylenol was not administered. Resident 80's pain assessments for the month of July 2018, indicated the pre-medication pain ratings were 0 except on July 9, 2018, and the post-medication ratings were blank except on July 9, 2018. Resident 80's MAR, dated August 2018, indicated the licensed nurses administered the Norco to Resident 80, 16 times (on July 1, 7, 9, 15, 16, 17, 18, 19, 20, 21, 22, 24, and 25). Tylenol was not administered. Resident 80's pain assessments for the month of August 2018, indicated the pre-medication pain ratings were 0 except on August 22, 2018, and the post-medication ratings were blank except on August 22, 2018. The facility's monthly drug regimen review (MDRR) for the month of June 2018, July 2018, and August 2018, had no documented evidence the PC had reported irregularities on the use of narcotic pain medication: Norco for Resident 80. On August 27, 2018, at 11:46 a.m., the PC was interviewed. The PC stated when he conduct his MDRR on the facility he check on the resident's MAR, physician's order and other pertinent information on the residents' record. The PC stated he conducted a MDRR to Resident 80 on the month of June 2018, July 2018, and August 2018. The PC stated he did not find irregularities on the resident's use of narcotic medication: Norco. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 77 of 131 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 08/28/2018 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 PC stated when licensed nurses administer pain medication when needed, they should conduct a pre-medication and postmedication pain assessment of the resident. After the PC was made aware of the premedication and post-medication pain assessment conducted for Resident 80 in the month of July 2018 and August 2018, the PC stated I should have reviewed the resident's use of narcotic pain medication: Norco. The PC stated the pain assessment does not indicate Resident 80 was in pain. The PC further stated irregularities should have been identified and recommendations should have been made to the resident's physician. 7b. On August 27, 2018, at 9:31 a.m., Resident 60's record was reviewed. Resident 60 was readmitted to the facility on February 14, 2017, with the diagnoses that included osteoarthritis (type of arthritis that affects joints in the hand, knees, hip and spine). Resident 60's "Order Summary Report", active orders as of June 1, 2018, indicated, "Tramadol HCl (narcotic pain medication) Tablet 50 mg Give 1 tablet by mouth one time a day for PAIN MANAGEMENT...order date 08/05/17...D/C 6/6/18..." Resident 60 had a physician's order, dated May 30, 2018, for Tramadol 50 mg PO (by mouth) Q8H (every 8 hours). Resident 60's MAR, dated May 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet one time a day for pain from May 1 to 31, 2018. Resident 60's pain assessments for the month FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 78 of 131 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 08/28/2018 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 of May 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated June 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet every 8 hours for pain. Resident 60's MAR indicated the resident refused Tramadol on June 3 at 6:30 a.m.; June 3 at 2 p.m.; June 4 at 6 a.m.; June 9 at 6 a.m.; June 10 at 6 a.m.; and June 16. Resident 60's pain assessments for the month of June 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated July 2018, indicated the licensed nurses administered the Tramadol 50 mg one tablet every eight hours for pain. Resident 60's pain assessments for the month of July 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated August 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet every 8 hours for pain from August 1 to August 26. Resident 60's pain assessments for the month of August 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. The facility's monthly drug regimen review (MDRR) for the month of May 2018, June 2018, July 2018, and August 2018, had no documented evidence the PC had reported irregularities on the use of narcotic pain medication: Tramadol for Resident 60. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 79 of 131 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 08/28/2018 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 On August 27, 2018 at 1:43 p.m., Registered Nurse (RN) 3 was interviewed. RN 3 stated there was no documented evidence there was a reason for increasing Resident 60's Tramadol from once a day to every eight hours. On August 27, 2018, at 11:46 a.m., the PC was interviewed. The PC stated when he conducts his MDRR on the facility he checks on the resident's MAR, physician's order and other pertinent information on the residents' record. The PC stated he conducted a MDRR for Resident 60 on the month of May 2018, June 2018, July 2018, and August 2018. The PC stated he did not find irregularities on the resident's use of narcotic medication: Tramadol. In addition, the PC stated he was aware Resident 60's Tramadol dose had been adjusted by the physician several times. The PC stated when licensed nurses administer pain medication including routine doses, when needed, they should conduct a pre-medication and post-medication pain assessment of the resident. After the PC was made aware of the premedication and post-medication pain assessment conducted for Resident 60 in the month of May 2018, June 2018, July 2018 and August 2018, the PC stated Tramadol dose should not have increased. The PC stated irregularities on the use of Tramadol should have been identified and recommendations should have been made to the resident's physician. The facility policy titled, "Organizational Aspects: Consultant Pharmacist Services Provider Requirements," dated August 17, 2018, was reviewed. The policy indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 80 of 131 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 08/28/2018 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 consultant pharmacist agrees to render the required service in accordance with...federal laws, regulations, and guidelines... ...Consultant pharmacist helps to identify...address, and resolve concerns and issues related to the provision of pharmaceutical services... ...Assisting the facility in evaluating the process of...controlling, reconciling...administering, monitoring responses to...medications... ...Reviewing the medication regimen...of each resident..."

F757 SS=F Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 81 of 131 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 08/28/2018 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 §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed for six of six residents (Residents 15, 61, 47, 72, 3, and 59) reviewed for narcotic pain medication (Norco and Tramadol - narcotic pain medications) and three of five sampled residents reviewed for unnecessary medication use (Residents 2, 60, and 80) when: 1. For Resident 15, the PRN (as needed) medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of a pain assessment conducted to justify the reason for use from the period of June 2018 to August 2018; 2. For Resident 61, the PRN medication Norco and Tramadol was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of an assessment conducted to justify the reason for use from the period of July 2018 to August 2018; 3. For Resident 2, there was no documented evidence of an assessment conducted to justify the continued use of the Debrox solution (ear drop used to loosen ear wax) medication; 4. For Resident 47, the PRN medication Norco was signed out from the narcotic count sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 82 of 131 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 08/28/2018 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 on multiple occasions by different licensed nurses and was there was no documented evidence of an assessment conducted to justify the reason for use from the period of June 2018 to August 2018; 5. For Resident 80, there was no documented evidence of pain assessment conducted prior to the administration of the PRN medication Norco, on multiple occasions by different licensed nurses; 6. For Resident 60, there was no documented evidence of a pain assessment conducted when a routine Tramadol (narcotic pain medication) medication dose was increased from once a day to three times a day; 7. For Resident 72, the PRN medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of a pain assessment conducted to justify the reason for use from the period of June 2018 to August 2018; 8. For Resident 3, the medication PRN Tramadol was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of a pain assessment conducted to justify the reason for use from the period of June 2018 to August 2018; 9. For Resident 59, the PRN medication Norco was signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of a pain assessment conducted to justify the reason for use from the period of June 2018 to August 2018. These failures had the potential for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 83 of 131 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 08/28/2018 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 residents to receive unnecessary medications. Findings: 1. On August 23, 2018, Resident 15's record was reviewed. Resident 15 was admitted to the facility on August 8, 2014, with diagnoses that included ostoearthritis (degenerative joint disease). Resident 15 had a physician's order dated August 30, 2016, for Norco 5/325 mg (milligrams) tablet to be given by mouth every six hours PRN for severe pain and Tylenol 325 mg two tablets every 4 hours for mild pain. The June 2018 MAR and the narcotic count sheet for Norco from the period of June 6 to 30, 2018, indicated the licensed nurses signed out the Norco from the narcotic count sheet 14 times. There was no documented evidence of a pain assessment conducted on Resident 15 when Norco was signed out and administered to the resident on the following dates: - June 19, 2018, (time unclear); - June 20, 2018, at 6 p.m.; - June 21, 2018, at 7 p.m.; - June 24, 2018, at 6 p.m., - June 24, 2018, at 6 p.m.; and - June 3 (sic.) at 9 a.m. The July 2018, MAR and the narcotic count sheet for Norco from the period of June 1 to 30, 2018, indicated the licensed nurses signed out the Norco from the narcotic count sheet 36 times. There was no documented evidence of a pain assessment conducted on Resident 15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 84 of 131 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 08/28/2018 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 when Norco was signed out and administered to the resident on the following dates: - July 1, 2018, at 8 p.m.; - July 2, 2018, at 6:40 a.m., 1 p.m., and 7 p.m.; - July 11, 2018, at 9 a.m.; - July 20, 2018, at 1:45 p.m., the second entry for July 20, 2018 time was not clearly written; - July 24, 2018, at 6:45 a.m., 1 p.m.; and - July 28, 2018, at 9 a.m. The August 2018, MAR and the narcotic count sheet for Norco from the period of August 1 to 22, 2018, indicated the licensed nurses signed out the Norco from the narcotic count sheet 23 times. There was no documented evidence of a pain assessment conducted on Resident 15 when Norco was signed out and administered to the resident on the following dates: - August 3, 2018, at 6:50 a.m., and 1:45 p.m.; - August 7, 2018, at 6:40 a.m., and second entry for August 7, 2018, the time was not clearly written; - One entry after August 7, 2018 - the date and time was not clearly written; - August 9, 2018, at 6:35 am, 12 p.m., and 6 p.m., - August 16, 2018, at 9 a.m.; - August 17, 2018, at 10 a.m.; - Entry after August 17, 2018 - the date and time was not clearly written; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 85 of 131 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 08/28/2018 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 - August 18, 2018, at 6:30 a.m. and 11:30 a.m.; - August 19, 2018, 2:30 p.m.; - Four entries after August 19, 2018 - the date, time, and initial of licensed nurse were not clearly written; - August 21, 2018, at 2 p.m., and - August 22, 2018, at 6:40 a.m. Resident 15's Pain Risk Assessment dated August 23, 2018, indicated a total score of six (0-10 score indicate Low Risk for pain; 11 and above High Risk for potential pain). On August 23, 2018, at 10:01 a.m., Certified Nursing Assistant (CNA) 10 was interviewed. CNA 10 stated she was assigned to Resident 15 and she was familiar with her care. CNA 10 stated Resident 16 was confused but was able to make her needs known. CNA 10 stated Resident 15 rarely complained of pain and only experienced occasional headaches. On August 23, 2018, at 11:03 a.m., an interview and record review was conducted with LVN 5. LVN 5 verified his initials on Resident 15's Norco count sheet on the following dates: - June 19 and 31, 2018; - July 1, 11, and 28, 2018; and - August 16, 17, and 19, 2018. In a concurrent interview, LVN 5 stated he signed out the Norco from the narcotic count sheet on those dates. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 86 of 131 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 08/28/2018 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 LVN 5 stated Resident 15 was not alert enough to verbalize her pain scale rate. LVN 5 stated he assessed Resident 15's severe pain through her facial grimacing and behavior of agitation. LVN 5 stated Resident 15 would call out for her pain medication and she preferred Norco instead of Tylenol so that was what he frequently gave her. LVN 5 did not have documented evidence of the pain assessments he had conducted on Resident 15 prior to administering PRN Norco, and evalauting the resident for the effectiveness of the medication on those dates. On August 27, 2018, at 3:57 p.m., Resident 15's record was reviewed with LVN 3. LVN 3 verified his initials on Resident 15's narcotic count sheet for Norco on the following dates: - July 2 (signed out twice), 12, 20 (signed out twice), and 24, 2018, (signed out three times); and - August 3 (signed out twice), 7 (signed out twice), 9 (signed out three times), and 16, 2018. In a concurrent interview, LVN 3 stated he administered the PRN Norco to Resident 15 on those dates. LVN 3 stated his parameter for severe pain on Resident 15 was when the resident yells out or she says, "Ow." LVN 3 stated Resident 15 had a PRN Tylenol; for mild pain but he usually gave the PRN Norco to Resident 15 because it was her "preference". LVN 3 further stated Resident 15 did not have a PRN medication for moderate pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 87 of 131 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 08/28/2018 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 LVN 3 did not have documented evidence of the pain assessments he had conducted on Resident 15 prior to administering PRN Norco, and evaluating the resident for the effectiveness of the medication on those dates. 2. On August 22, 2018, at 5:45 p.m., Resident 61's record was reviewed. Resident 61 was admitted to the facility on August 2, 2018. The physician's order dated August 2, 2018, indicated, "Norco 5/325 mg 1 tab (tablet) PO (by mouth) Q 6H (every six hours) PRN for moderate pain... Ibuprofen (non-narcotic pain medication) 800 mg Q 6H PRN for moderate pain... Tramadol 50 mg PO 1 tab Q6h PRN for moderate pain.." The medication Norco and Tramadol were signed out from the narcotic count sheet on multiple occasions by different licensed nurses and there was no documented evidence of a pain assessment conducted to indicate the reason for use, and an evaluation for the effectiveness of the medication, in the MAR from the period of July 2018 to August 2018. (Cross Reference F755 Finding #2). On August 23, 2018, at 2:13 p.m., Resident 61's record was reviewed with LVN 5. LVN 5 verified his initials on Resident 61's narcotic count sheet for Norco and Tramadol. LVN 5 did not have documented evidence of a pain assessment conducted prior to administering the PRN Norco and Tramadol to Resident 61. The dates were as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 88 of 131 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 08/28/2018 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 - Norco - August 6 at 10 a.m., August 7 at 9 a.m., and August 9 at 4:30 p.m.; and - Tramadol - July 17, 2018 at 7:35 a.m., and 1:44 p.m. In a concurrent interview, LVN 5 stated he assessed the resident's pain level depending on the resident's preference for pain medication which was the Norco and/or Tramadol. LVN 5 stated he usually gave the PRN narcotic pain medication right away and he does not offer the PRN Ibuprofen first. LVN 5 stated he considered the resident's facial grimacing as a factor in giving the pain medicaiton. In a concurrent interview, LVN 5 stated he should have signed the MAR, did his pain assessment on Resident 61, and documented at the back of the MAR narrative notes on why the PRN pain medication was given. LVN 5 further stated he did not have evidence of an evaluation conducted for the effectiveness of the pain medications administered. On August 23, 2018, at 11:40 a.m., the Director of Nursing (DON) was interviewed. The DON stated he expected the licensed nurses to follow the facility's policy and procedure in dispensing PRN narcotic pain medications to the residents. The DON stated prior to giving a narcotic pain medication, the licensed nurse should conduct an assessment to determine the appropriate pain medication needed, sign out the narcotic pain medication from the count sheet, give the medication to the resident, then document signature, date and time medication was given, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 89 of 131 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 08/28/2018 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 reason for giving the medication, and evaluation on the effectiveness of the medication. 3. On August 20, 2018, at 9:17 a.m., an observation was conducted on Resident 2. Resident 2 was in bed, alert, and conversant. Resident 2 was noted to have hard time hearing when the interview questions were repeated to her several times. During the interview Resident 2 stated to speak to her loudly, close to her ear because she was not able to hear very well. On August 20, 2018, Resident 2's record was reviewed. Resident 2 was admitted to the facility on February 7, 2018. The physician's order dated June 29, 2018, indicated, "Debrox Solution...Instill 1 drop in both ears at bedtime..." The nursing progress notes dated June 29, 2018, indicated the physician ordered the Debrox medication due to impacted cerumen (impacted earwax). Resident 2's August 2018 MAR indicated the licensed nurses had been administering the Debrox medication routinely at night since it was ordered in June 2018. On August 21, 2018, at 1:58 p.m., Registered Nurse (RN) 3 was interviewed. RN 3 stated the Debrox medication should have a stop date. RN 3 stated Resident 2's ears should have been irrigated after the Debrox treatment. RN 3 stated Resident 2's ears have not been irrigated for ear wax removal since she used the Debrox treatment in June 29, 2018. On August 21, 2018, at 2:06 p.m., Licensed Vocational Nurse (LVN) 6 was interviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 90 of 131 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 08/28/2018 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 LVN 6 stated she was the licensed nurse who obtained the order for Debrox solution from the physician. LVN 6 stated she did not clarify with the physician for a stop date order on the Debrox because she was not aware this medication needed it. LVN 6 stated she did not receive an order for an ear irrigation after the Debrox treatment nor did she clarify with the physician if an ear irrigation was needed after the treatment. On August 21, 2018, the facility's provider Pharmacy Manager (PM) was interviewed. The PM stated the Debrox medication was used for a short term treatment for impacted cerumen and the treatment should be repeated only if necessary. The PM stated the Debrox solution was a medication that softened the ear wax and the ear had to be irrigated after the treatment. The PC stated the resident had to be assessed and evaluated if the treatment needed to be repeated. The direction for use on the Debrox solution used on the resident indicated, "...Ear Wax Removal Drop...Adult and Children Over 12 years of age...place 5 to 10 drops into ear...Use 2x (two times) daily for up to 4 days... Any wax remaining after treatment may be removed by gently flushing the ear with warm water using a soft rubber bulb ear syringe..." 4. On August 22, 2018, at 3 p.m., Resident 47's record was reviewed. Resident 47's initial admission was on July 10, 2014, with diagnoses that included osteoarthritis (type of arthritis that affects joints in the hand, knees, hip and spine). Resident 47 had a physician's order, dated April 28, 2018, for Norco 5/325 (narcotic pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 91 of 131 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 08/28/2018 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 medication) 1 tab (tablet) to be given every four hours as needed for pain. Resident 47's MAR for the month of June 2018, July 2018, and August 2018, indicated, "Tylenol 325 MG (milligram)...Give 2 tablet by mouth every 4 hours as needed for Mild Pain...Order Date-08/12/2017..." Resident 47's MARs indicated Tylenol was not administered to Resident 47 except on July 3, 2018. The 2018 narcotic count sheet for Resident 47's Norco indicated: a. for the month of June 2018, Norco was signed out 23 times and was indicated as administered to the resident in the MAR for June 2018, four times; b. for the month of July 2018, Norco was signed out 36 times and was indicated as administered to the resident in the MAR for July 2018, 16 times; and c. for the month of August 2018, Norco was signed out 33 times and was indicated as administered to the resident in the MAR for August 2018, 21 times. (Cross Reference F755 Finding # 3) Resident 47's pain assessments indicated: a. for the month of June 2018, the premedication pain ratings were 0 except on June 17, 2018, the post-medication ratings were blank except on June 17, 2018, and the nonpharmacological interventions were blank. b. for the month of July 2018, the premedication pain ratings were 0 except on July 1, 16, 17, 24, and 26, 2018, the postmedication ratings were blank except on July 1, 16, 17, 24, and 26, 2018, and the nonFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 92 of 131 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 08/28/2018 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 pharmacological interventions were blank. c. for the month of August 2018, the premedication pain ratings were 0 except on August 10, 19, 20, and 21, 2018, the postmedication ratings were blank except on August 10, 19, 20, and 21, 2018, and non pharmacological interventions were blank except on August 11, 2018. On August 28, 2018, at 9:53 a.m., Resident 47 and Certified Nursing Assistant (CNA) 6 were interviewed. Resident 47 gave a blank stare when asked if she was in pain or had been experiencing pain. CNA 6 stated Resident 47 was non-interviewable. CNA 6 stated she could tell Resident 47 was in pain through facial grimacing. CNA 6 stated she was being assigned to different residents, however on most occasions that she had Resident 47, the resident does not appear to be in pain. CNA 6 stated she just finished helping Resident 47 with her Actrivities of Daily Living (ADL) today and Resident 47 was not in pain. On August 23, 2018 at 2:12 p.m., a concurrent record review and interview was conducted with LVN 5. LVN 5 confirmed it was his signature on Resident 47's Norco count sheet for the month of June, July and August 2018. LVN 5 was made aware of his missing initials on Resident 47's MAR that would indicate the Norco signed out from the narcotic count sheet was administered to Resident 47. LVN 5 stated he did not document on the MAR because of his poor time management. LVN 5 stated he based his assessment if the resident needed pain medication on resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 93 of 131 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 08/28/2018 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 facial grimacing or when resident was able to verbalized if in pain. LVN 1 stated he seldom use non-narcotic pain medication because the residents usually prefers to have narcotic medication for pain. On August 23, 2018, at 3:26 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 confirmed it was his signature on Resident 47's Norco count sheet for the month of June, July and August 2018. LVN 3 was not able to read the date and time on the last six entries on Resident 47's Norco count sheet for August 2018, however he verified it was his initials on it. LVN 3 was made aware of his missing initials on Resident 47's MAR that would indicate the Norco signed out from the narcotic count sheet was administered to Resident 47. LVN 3 stated he was not aware there were a lot of missing initials on the MAR. LVN 3 stated when he conducts his pain assessment to the resident, he based it on facial grimacing. LVN stated he tried to repositioned resident and if no relief, he will give Norco. LVN 3 stated he was familiar with the resident and he knows a non-narcotic medication would not be effective and so he decided to give the Norco for pain. On August 23, 2018, at 4:41 p.m., the Pharmacy Consultant (PC) was interviewed. The PC stated he rely on the licensed nurses documentation and he assumes licensed nurse assessment were accurate. The PC stated licensed nurses should start on non-pharmacological intervention or nonnarcotic medication for pain. In addition, the PC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 94 of 131 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 08/28/2018 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 narcotic medication should be use for residents having the severe pain. 5. On August 27, 2018, at 10 a.m., Resident 80's record was reviewed. Resident 80's was admitted to the facility on June 13, 2018. Resident 80's "Order Summary Report," indicated, "Active Orders As Of: 08/01/2018...Pain Assessment (0= No Pain), (4 -6= Moderate Pain), (7-9= Severe Pain), (10= Very severe pain)...Norco Tablet 5/325 (narcotic pain medication) MG (milligram)...Give 1 tablet by mouth every four hours as needed for MODERATE PAIN...start date 6/13/2018...Tylenol Tablet (non-narcotic pain medication) 325 MG...Give 2 tablet by mouth every 4 hours as needed for Mild Pain...start date 6/13/2018..." Resident 80's MAR, dated July 2018, indicated the licensed nurses administered the Norco to Resident 80, 17 times. Tylenol was not administered. Resident 80's pain assessments for the month of July 2018, indicated the pre-medication pain ratings were 0 except on July 9, 2018, the postmedication ratings were blank except on July 9, 2018, and the non-pharmacological interventions were blank except on July 9, 2018. Resident 80's MAR, dated August 2018, indicated the licensed nurses administered the Norco to Resident 80, 16 times. Tylenol was not administered. Resident 80's pain assessments for the month of August 2018, indicated the pre-medication pain ratings were 0 except on August 12, 2018, the post-medication ratings were blank except on August 12, 2018, and the nonFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 95 of 131 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 08/28/2018 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 pharmacological interventions were blank. On August 27, 2018, at 10:22 a.m., Certified Nursing Assistant (CNA) 7 was interviewed. CNA 7 stated she was assigned to Resident 80 for two days now. CNA 7 stated Resident 80 was able to verbalize if she was in pain. CNA 7 stated Resident 80 did not complaint of pain to her, for two days. On August 27, 2018, at 3:01 p.m., Resident 80 was interviewed. Resident 80 stated she had pain on both of her shoulders. Resident 80 stated she takes Tylenol or Norco for her shoulder pain. Resident 80 stated she does not ask for Norco all the time because it gives her "bad dreams" and Resident 80 stated "I don't want to be addicted to it." On August 27, 2018, at 1:43 p.m., Registered Nurse (RN) 3 was interviewed. RN 3 stated when giving pain medication, an assessment of pain should be conducted before and after administering the pain medication. RN 3 stated pain assessment was used as a tool to know the effectiveness of the pain medication. RN 3 acknowledge Resident 80's pain assessments did not indicate Resident 80 was in pain and needed a pain medication. On August 27, 2018, at 11:46 a.m., the Pharmacy Consultant (PC) was interviewed. The PC stated when licensed nurses administer pain medication, they should conduct a pre-medication and post-medication pain assessment of the resident. 6. On August 27, 2018, at 9:31 a.m., Resident 60's record was reviewed. Resident 60's was re-admitted to the facility on February 14, 2017 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 96 of 131 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 08/28/2018 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 with the diagnoses that included osteoarthritis (type of arthritis that affects joints in the hand, knees, hip and spine). Resident 60's "order summary report", active order as of June 1, 2018, indicated, "Tramadol (narcotic pain medication) 50 MG (milligram) Give 1 tablet by mouth once a day for PAIN MANAGEMENT...order date 08/05/17...DC 6/6/18..." Resident 60 had a physician's order, dated May 30, 2018, for Tramadol 50 mg PO (by mouth) Q8H (every 8 hours). Resident 60's MAR, dated May 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet one time a day for pain from May 1 to 31, 2018. Resident 60's pain assessments for the month of May 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated June 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet every 8 hours for pain. Resident 60's MAR indicated the resident refused Tramadol on June 3 at 6:30 a.m.; June 3 at 2 p.m.; June 4 at 6 a.m.; June 9 at 6 a.m.; June 10 at 6 a.m.; and June 16. Resident 60's pain assessments for the month of June 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated July 2018, indicated the licensed nurses administered the Tramadol 50 mg one tablet every eight hours for pain. Resident 60's pain assessments for the month FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 97 of 131 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 08/28/2018 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 of July 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. Resident 60's MAR, dated August 2018, indicated the licensed nurses administered the Tramadol 50 mg 1 tablet every 8 hours for pain from August 1 to August 26. Resident 60's pain assessments for the month of August 2018, indicated the pre-medication pain ratings were 0, and the post-medication ratings were blank. On August 27, 2018 at 1:43 p.m., Registered Nurse (RN) 3 was interviewed. RN 3 stated there was no documented evidence there was a reason for increasing Resident 60's Tramadol from once a day to every eight hours. RN 3 stated when giving pain medication, an assessment of pain should be conducted before and after administering the pain medication. RN 3 stated pain assessment was used as a tool to know the effectiveness of the pain medication. RN 3 acknowledge Resident 80's pain assessment does not indicate Resident 60 was in pain and needed a pain medication. On August 27, 2018, at 10:13 a.m., Resident 60 and the Certified Nursing Assistant (CNA) 8 were interviewed. CNA 8 stated Resident 60 speaks Spanish and that she could translate for her. When Resident 60 was asked if she was in pain the resident responded in Spanish that she needed to use the bathroom. CNA stated Resident 60 had periods of confusions. CNA 8 stated she is assigned to different FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 98 of 131 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 08/28/2018 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 residents. CNA 8 stated she was familiar with the care of Resident 60. CNA 8 stated Resident 60 had some pain but the resident does not appear to be in pain all the time. On August 27, 2018, at 11:46 a.m., the PC was interviewed. The PC stated when licensed nurses administer pain medication including routine doses, they should conduct a premedication and post-medication pain assessment of the resident. After the PC was made aware of the premedication and post-medication pain assessment conducted for Resident 60 in the month of May 2018, June 2018, July 2018 and August 2018, the PC stated Tramadol dose should not have increased. The PC stated irregularities on the use of Tramadol should have been identified and recommendations should have been made to the resident's physician. 7. On August 23, 2018, Resident 72's record was reviewed. Resident 72 was admitted to the facility on June 2, 2018, with diagnoses that included fracture of the right patella (knee cap). On August 23, 2018, a medication reconciliation was conducted for Resident 72. Resident 72 had a physician's order dated June 2, 2018, for Norco ( Hydrocodone) 5/325 mg (milligrams) give one tablet by mouth every six hours as needed for moderate pain NTE (not to exceed) 3 Gm (grams) in 24 HRS. Resident 72 had an order dated June 2, 2018, for Tylenol 325 Mg (non narcotic pain medication) Give two tablets by mouth every 4 hours as needed for mild pain (NTE), 3 GM'S in 24 hrs. Resident72's MAR dated June 2018, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 99 of 131 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 08/28/2018 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 licensed nurses administered Norco to Resident 72 one time (on June 29, 2018). Tylenol was administered one time (on June18, 2018). Resident 72's pain assessments for the month of June 2018 indicated the pre-medication pain raitings were zero, except on June 18, 2018, when he received Tylenol for pain rated three on a scale of pain from zero to ten. On June 29,2018, there's no record of pain assessment when Resident 72 received Norco. Resident 72's MAR dated July 2018, indicated the licensed nurses administered the Norco to Resident 72, two times (on July 9 and 17, 2018). Tylenol was not administered during the month of July, 2018. Resident 72's pain assessment for the month of July 2018, indicated the premedication pain ratings were zero except on July 7, 2018, when it showed a pain level of 7 (in a scale of 0 to 10). No Norco or Tylenol was administered according to the MAR record on July 7, 2018. Resident 72's MAR dated August 2018, indicated the licensed nurses administered the Norco to Resident 72, two times (on August 12 and 20 2018). Tylenol was not administered in the month of August 2018, according to the MAR. Resident 72's pain assessment for the month of August 2018, indicated the premedication ratings were zero, except for August 12, 2018 when Resident 72 received Norco for pain of in a scale of 0 to 10. On August 20, 2018 the pain assessment shows cero and Norco was dispensed that day according to the MAR. Tylenol was not administered to Resident 72 in the month of August according to the MAR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 100 of 131 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 08/28/2018 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 On August 27, 2018, at 11:46 a.m., the Pharmacy Consultant (PC) was interviewed. The PC stated: having inaccurate assessment for pain should have raised an issue to monitor the use of pain medication and check for the necessity of the use of pain medication. He stated he needs to include the narcotic count sheet in his monthly MMR ( monthly medication review) to better assess and make appropriate recommendations for the facility. The pain care plan for Resident 72, dated June 2, 2018, indicated the resident was able to verbalize pain levels. 8. On August 23, 2018, a medication reconciliation review was conducted for Resident 3. Resident 3 had a physician's order dated December 12, 2017 for: "Ultram (Tramadol- narcotic pain medication) 50 mg (milligram) 1 tab (tablet) Q 4' (every 4 hours) PRN (as needed) for pain management; and Tylenol tablet 325 mg (acetaminophen/nonnarcotic medication) give 2 tablet by mouth every 4 hours as needed for mild pain (NTE-not to exceed 3 gm (grams)/24 hours." On August 23, 2018, at 3:16 p.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 verified 22 Tramadol medications were removed from the Narcotic Count Sheet (NCS) during the months of June, July, and August 2018, and was not accounted for, nor signed in the MAR for Resident 3. (Cross-reference F755 Findings #4) LVN 3 was not able to provide documented evidence to justify the reason for the use of the Tramadol medications removed from the NCS for Resident 3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 101 of 131 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 08/28/2018 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 LVN 3 stated he had not offered Tylenol or used non-pharmacological interventions to address the resident's pain. On August 27, 2018, Resident 3's pain care plan dated August 16, 2018, was reviewed. The care plan indicated: "Focus: PAIN...I am cognitively intact and able to communicate needs...I am able to verbalize my pain levels... Goal: I will have less/reduced episodes of pain or discomfort through appropriate interventions... Interventions: Assess characteristics of pain...Monitor for s/s (signs and symptoms) of pain...Staff to provide non pharmacological intervention..." On August 27, 2018, the facility's "PAIN RISK ASSESSMENT" document dated August 23, 2018, was reviewed. The document indicated a "Pain Score" of 4 (Scoring system 0-10 Row Risk for potential pain). 9. On August 22, 2018, Resident 59's record was reviewed. Resident 59 was initially admitted to the facility on May 17, 2018, and was readmitted on June 23, 2018, with diagnoses including cellulitis (bacterial skin infection) on both lower limbs. Resident 59 had a physician's order dated June 23, 2018, for Norco 5/325 mg (milligrams) tablet to be given by mouth every four hours PRN pain 4-6 (pain scale 0-10, 10 being severe). On August 22, 2018, at 3:33 p.m., Resident 59 was interviewed. Resident 59 stated he was taking Tylenol, Ibuprofen (non-narcotic pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 102 of 131 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 08/28/2018 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), and Norco. Resident 59 stated he tried to avoid taking too much pain medications. The narcotic count sheet for Norco 5/325 mg from the period of July 1 to 31, 2018, indicated licensed nurses signed out Norco 40 times. Resident 59's July 2018 Pain Assessment Flowsheets indicated assessments were only documented on 12 out of 40 on the following dates: July 1, 2, 8, 9, 10, 12, 17, 18, 20, 22 (twice), and 29. There was no documented evidence pain assessments and evaluation for effectiveness were done for the months of June and August 2018. On August 22, 2018, at 4:35 p.m., the Medical Records Director (MRD) was interviewed. The MRD stated the June and August 2018 pain assessment flowsheets for Resident 59 were not available. On August 23, 2018, at 2:08 p.m., Resident 59's record was reviewed with Licensed Vocational Nurse (LVN) 5. LVN 5 verified his initials on Resident 59's Norco narcotic count sheets for June, July, and August 2018. In a concurrent interview, LVN 5 stated a pain assessment should be conducted prior to administering pain medications and an evaluation for effectiveness should be done after administering the pain medications. In addition, LVN 5 stated he failed to document pain assessments prior to medication administration and evaluation thereafter on Resident 59's MARs because of his poor time management. On August 23, 2018, at 3:09 p.m., Resident 59's record was reviewed with Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 103 of 131 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 08/28/2018 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 Vocational Nurse (LVN) 3. LVN 3 verified his initials on Resident 59's Norco narcotic count sheets for June, July, and August 2018. In a concurrent interview, LVN 3 stated a pain assessment should be conducted prior to administering pain medications and an evaluation for effectiveness should be done after administering the pain medications. LVN 3 further stated he should have documented pain assessments prior to medication administration and the evaluation for effectiveness thereafter on Resident 59's MARs but made the mistake of not signing them. In addition, LVN 3 stated he was aware Resident 59 had orders for Tylenol and Ibuprofen (non-narcotic pain medications). LVN 3 stated "many times they were not effective," so he administered Norco when Resident 59 would request for pain medication. Resident 59's MARs for June, July, and August 2018 were reviewed. There was no indication that Tylenol was administered at anytime within the period reviewed. The facility policy titled, "PREPARATION AND GENERAL GUIDELINES...MEDICATION ADMINISTRATION..." dated August 17, 2018, was reviewed. The policy indicated: "...When PRN medications are administered, the following documentation is provided: date and time of administration...complaints or symptoms for which the medication was given...results achieved from giving the dose and the time results were noted..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 104 of 131 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 08/28/2018 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

F759 Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent (5%) when two medication errors out of 27 opportunities observed for one of six sampled residents (Resident 3) . This failure resulted to a medication error rate of 7.4% and could result in the resident not receiving the full therapeutic effect of the medication. Findings: On August 22, 2018, at 9:01 a.m. a medication pass observation on Resident 3 was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed verifying medications with the physician's orders in the Medication Administration Record (MAR) as he poured the following medications in individual medications cups: - One tablet docusate sodium (DSS- stool softener); - One gel capsule of fish oil (supplement); FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 105 of 131 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 08/28/2018 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 - One tablet of multivitamin; - One table of Vitamin D3 supplement; - One tablet of finasteride (medication used to treat BPH (benign prostatic hyperplasiaprostate gland enlargement); - One tablet of propranolol (medication used to treat high blood pressure); and - Three capsules of Depakote (anti-seizure medication). On August 22, 2018, at 9:21 A.M., LVN 3 administered these medications to Resident 3 then signed the MAR after. On August 27, 2018, Resident 3's record was reviewed. Resident 3 was admitted to the facility on August 3, 2018, with diagnoses which included Parkinson's Disease (disorder of the nervous system that affects movement, often including tremors), BPH, seizures, and hypertension (high blood pressure). A review of Resident 3's physician's order indicated the following medications were to be given at 9 a.m.: - "Allopurinol Tablet (medication used to treat gout {form of arthitis characterized by severe pain, redness, and tenderness in joints}) 300 mg (milligrams) 1 tablet one time a day..." dated ordered April 12, 2018; - "Carbidopa-Levodopa Tablet (medications used for Parkinson's Disease) 10-100 mg by mouth three times a day..." date ordered August 3, 2018; - "Depakote Sprinkles Give 375 tablet by mouth two times a day..." date ordered August 3, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 106 of 131 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 08/28/2018 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 2017; - "Docusate Sodium Tablet 100 mg 1 tablet by mouth one time a day..." date ordered August 3, 2017; - "Finasteride Tablet 5 mg Give 1 tablet by mouth one time a day..." date ordered August 18, 2017; - "Fish Oil Capsule 1000 mg...give 1 capsule by mouth one time a day..."date ordered June 24, 2018; - "Multivitamins Tablet...Give 1 tablet by mouth one time a day for supplement..." and - Vitamin D3 tablet 1000 units...Give one tablet by mouth one time a day..." date ordered February 19, 2018. On August 27, 2018, at 9:44 a.m., Resident 3's MAR for August 2018 was reviewed with LVN 1. LVN 1 stated the MAR indicated the medications Allopurinol and Sinemet, were signed as administered by LVN 3 on August 22, 2018 at 9 a.m. LVN 3 was not observed to have poured and administered the medications , Allopurinol and Sinemet, during the medication pass observation conducted with LVN 3 for Resident 3 on August 22, 2018 at 9 a.m. On August 27, 2018, at 4:02 a.m., LVN 3 was interviewed. LVN 3 stated he did not recall if the medications Allopurinol and Sinemet were available or unavailable at the time of administration of medications for Resident 3 on August 22, 2018, at 9 a.m. LVN 3 further stated he did not recall if he gave the medications Allopurinol and Sinemet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 107 of 131 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 08/28/2018 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 before the 9 a.m. medication pass observation. LVN 3 stated he did not go back after 9 a.m. to give any medications to Resident 3 until the afternoon rounds. The facility's policy and procedure titled, "...MEDICATION ADMINISTRATIONGENERAL GUIDELINES," dated August 17, 2018, was reviewed. The policy indicated, "...Medications are administered as prescribed in accordance with good nursing principles and practices... Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label... Unless otherwise specified by the prescriber, routine medications are administered according to established medication administration schedule for the facility..."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 108 of 131 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 08/28/2018 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 §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Ensure internal medications (medications administered by mouth such as oral supplements and injectibles) and external medications (medications applied topically such as skin creams/ointments, skin disinfecting agents, and eye drops) were stored separately. This failure resulted in the facility to not to be in compliance with applicable state and federal laws, and; 2. Ensure expired medications were stored in the medication room and medication cart readily available for use. This failure had the potential for the residents to receive expired and ineffective medications. Findings: 1. On August 23, 2018 at 9:31 a.m., an inspection of the medication room was conducted with Registered Nurse (RN) 2. The following were observed: - Three 133 ml (milliliter) bottles of enema FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 109 of 131 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 08/28/2018 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 (liquid administered via rectum to promote bowel movement) were stored in a shelf with house supply medications such as Natural Fiber Therapy (fiber supplement), Vitamin C liquid supplements, Ferrous Sulfate liquid, and Sodium Bicarbonate tablets (supplement); and - Multiple vials of Ativan IM (anti-anxiety medication given via injection), stored on zip locks and labeled for individual resident's use, were stored next to an opened box of bisacodyl suppositories (laxative medication administered via rectum) in the medication refrigerator bottom drawer. In a concurrent interview, RN 2 stated it was not okay to store internal medications with external medications. 2. On August 23, 2018, at 9:31 a.m., an inspection of the medication room was conducted with RN 2. Three bottles of PRO STAT (liquid nutritional supplement) 887 ml (milliliter), with an expiration date of August 8, 2018, were stored in a shelf together with other house supply medications readily available for use. In a concurrent interview, RN 2 stated the expired PRO STAT should not have been stored in the shelf readily available for use. On August 23, 2018, at 10:32 a.m., an inspection of Medication Cart 3 was conducted with RN 2. The following were observed readily available for use: - One opened bottle of Vitamin B1 100 mg (milligram) tablets (supplement) with an expiration date of July 2018; - One opened bottle of Vitamin B complex (supplement) with an expiration date of March FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 110 of 131 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 08/28/2018 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 2018; - One opened bottle of Renavite tablets (supplement) with an expiration date of May 2018; - One opened box of Acephen Suppositories (medication used to reduce pain and fever administered via rectum) with an expiration date of June 2018; - One bottle of PRO STAT liquid with an expiration date of August 8, 2018; and - One bottle of Fiber Therapy Powder with an expiration date of July 2018. In a concurrent interview, RN 1 stated the expired house supply medications should have been removed and not stored in the medication cart. The facility's policy and procedure titled, "MEDICATION STORAGE IN THE FACILITY," dated August 17, 2018, was reviewed. The policy indicated, "...Orally administered medications are kept separately from externally used medications, such as suppositories, liquids and lotions... Refrigerated medications are kept closed in labeled containers, with internal and external medications separated... Outdated, contaminated, or deteriorated medications...are immediately removed from stock, disposed of according to procedures..."

F808 SS=D Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 §483.60(e) Therapeutic Diets FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 111 of 131 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 08/28/2018 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 §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow the therapeutic diet (diet ordered by a physician) for one of 19 residents reviewed (Resident 42), when a sandwich snack was not provided in between meals to the resident. This failure had the potential for Resident 42 not to receive the appropriate nutritive supplement as prescribed by the physician. Findings: 1. On August 20, 2018, at 11:03 a.m., the resident representative (RR) for Resident 42 was interviewed. The RR stated, Resident 42 may not be receiving the sandwich for snack and the resident was not able verbalized if he wanted a snack. The RR stated when she comes and visit Resident 42, she never saw the resident getting the sandwich for a snack. The RR stated the snack was ordered by Resident 42's physician because the resident had lost weight before. In addition, the RR stated the residnet's snack was part of Resident 42's care plan, it was discussed to her every time she attended the IDT (interdisciplinary team) meeting. On August 20, 2016, at 12:16 p.m., the Activity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 112 of 131 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 08/28/2018 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 Assistant (AA) was interviewed. The AA stated Resident 42 had been in the dining/activity room all morning. The AA stated coffee and crackers were offered to all the residents at 9:30 a.m. today in the activity/dining room. The AA stated Resident 42 would eat whatever was given to him. The AA stated Resident 42 was given crackers, there was no sandwich made for Resident 42 today. On August 21, 2018, at 2 p.m., Resident 42 was observed lying down in bed, awake. There was no sandwich snack at the bedside. Subsequently, Certified Nursing Assistant (CNA) 9 was observed pushing the nourishment cart on the hallway. In a concurrent interview, CNA 9 stated she was passing the prepared snack for the residents. CNA 9 stated there was no prepared sandwich or any snack for Resident 42 on the cart. On August 21, 2018, Resident 42's record was reviewed. Resident 42 was admitted to the facility on September 13, 2015, with the diagnoses that included aphasia (affect the ability to speak, and understand the language). Resident 42's spouse was the RR. Resident 42's "Order Summary Report." dated July 2018, indicated, "...SUPPLEMENT TID (three times a day) BETWEEN MEALS SANDWICH...start date 06/01/2016..." Facility record "Diet Type Report," dated August 19, 2018, indicated, "...(name of resident - Resident 42)...SUPPLEMENT SANDWICH..." Resident 42's "IDT Conference Record," dated June 19, 2018, had the dietary as one of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 113 of 131 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 08/28/2018 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 IDT members participated during the conference. The IDT conference record indicated, "weight/nutrition," was reviewed and the diet specified was "...sandwich TID between meals..." The IDT conference record indicated, "IDT reviewed with (name of the RR)...diet...current plan of care, will continue current plan of care..." Resident 42's care plan with a review date of March 25, 2018, indicated, "Focus: Resident has alteration in nutritional status ...Goal: minimized any unplanned weight changes daily...Interventions: diet as ordered...supplements as ordered..." On August 22, 2018, at 8:59 a.m., the Dietary Services Supervisor (DSS) was interviewed. The DSS stated when a diet was ordered; the medical record would give her a copy of the diet order, she will transcribed the order to the resident's dietary card and if there was a nourishment order she will input the order on her nourishment/snack list. The DSS verified Resident 42 had the supplement order for a sandwich between meals since June 1, 2016. The DSS stated it was not on her nourishment/snack list. The DSS stated there was no sandwich snack prepared for Resident 42 because it was not on her nourishment/snack list. The DSS stated Resident 42 should have receive a sandwich snack as ordered by the physician. Resident 42 did not received the sandwich for a snack since the order date of June 1, 2016.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary FORM CMS-2567(02-99) Previous Versions Obsolete

F812 Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 114 of 131 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 08/28/2018 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 CFR(s): 483.60(i)(1)(2) §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a "Critical Control Point Procedure," (a step in food preparation and serving to reduce/eliminate food safety hazard) was implemented when the facility did not check the salad and dessert's temperature prior to serving and distribution of lunch meal trays. In addition, the facility failed to provide documented evidence salad temperature was monitored every time salad was on the menu for the month of August 2018. This facility failure could result to vulnerable residents consuming food not properly cooled (cold food preserved at 41°F {degrees Fahrenheit} or lower) and may result to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 115 of 131 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 08/28/2018 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 foodborne illness. Findings: On August 22, 2018, at 11:48 a.m., during the tray line observation, the first few "Early diner" (list of residents who requested early meal trays) resident meal trays on a small roll-away cart were prepared for distribution right after the steam table "temping" (temperature food recording) was completed. Before the "Early Diner" meal trays were taken for distribution, the Dietary Services Supervisor (DSS) was requested to check the temperature of the salad and dessert. The DSS stated the salad and desert's temperature was already taken and logged. Random temperature check for salad and dessert were as follows: -Fiesta salad, 56°F; and -Tangy glazed fresh fruit, 51.1°F. In a concurrent interview, the DSS stated the fiesta salad was refrigerated and chilled at 9:00 a.m., and the tangy glazed fresh fruit at 10:30 a.m. The DSS stated there was not enough time left to cool down the salad and dessert. The DSS further stated the facility's cool down is 41°F or lower before serving salad and desserts. During the same interview with the DSS, the temperature log book was requested for inspection. The "Temperature Log Sheet," for August 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 116 of 131 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 08/28/2018 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 had no column allocated for salad temperatures to be recorded. The DSS was unable to provide documented evidence salad temperatures had been taken and recorded every time salad was on the menu for the month of August. The Cook overheard the exchanges and stated, they have not been taking the temperature for salad because the "Temperature Log Sheet" had no space to make the entry recording. On August 27, 2018, at 9:50 a.m., the DSS was interviewed about the importance of cool down period and food "temping." The DSS stated she should have made sure the salad temperature was taken and recorded every time salad was on the menu. On August 27, 2018, the facility's policy and procedure titled, "Daily Food Temperature Control," dated August 17, 2018, was reviewed. The policy indicated, "Temperatures of all hot and cold food shall be taken prior to meal service and recorded on the temperature log. This is done to ensure that food is safe and is served within the acceptable ranges... Any hot or cold food...meet minimum acceptable temperature...prior to service... Cold foods shall be less than 41 degrees F."

F842 SS=E Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 117 of 131 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 08/28/2018 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 accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained forFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 118 of 131 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 08/28/2018 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 (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed, for two of 19 residents reviewed (Residents 2 and 31), to maintain accurate medical records in accordance with accepted professional standards and practice when: 1. For Resident 2, two copies of the July 2018 Medication Administration Record (MAR) had an inconsistent physician's order entry for the Debrox solution (medication used to soften ear wax); and 2. For Resident 31, an order for PT (Physical Therapy) and OT (Occupational Therapy) evaluation and treatment order, dated July 27, 2018, was transcribed incorrectly in the resident's chart. These failures resulted to inaccuracy of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 119 of 131 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 08/28/2018 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 residents' record of treatment provided by the facility. Findings: 1. On August 20, 2018, at 3:18 p.m., Resident 2 was observed in her room, alert and conversant. Resident 2 was noted to have hearing difficulties when interview questions were repeated to her several times. In a concurrent interview, Resident 2 stated to speak loudly close to her ear because she cannot hear very well. On August 20, 2018, Resident 20's record was reviewed. Resident 20 was admitted to the facility on February 7, 2018. The physician's order dated June 29, 2018, indicated, "Debrox Solution...Instill one drop in both ears at bedtime for IMPAIRED (sic.) CERUMEN (impacted ear wax)." The following MARs were reviewed: - The June 2018 MAR indicated the medication Debrox solution was administered to the resident from June 29 to 31, 2018. - The July MAR 2018 did not have documented evidence the medication Debrox Solution was administered to the resident from July 1 to 31, 2018. There was no documented evidence the medication order for the Debrox Solution was transcribed in the July 2018 MAR. -The August 2018 MAR indicated the medication Debrox Solution was administered to Resident 2 from August 1 to 19, 2018. On August 20, 2018, copies of Resident 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 120 of 131 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 08/28/2018 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 health records including the MARs for June, July and August 2018 were requested and received from MDS Nurse (minimum date set an assessment tool). On August 20, 2018, at 4:26 p.m., a record review of Resident 2's record was conducted with Licensed Vocational Nurse (LVN) 4. LVN 4 reviewed the original copies of Resident 2's July 2018 MAR located in her chart. LVN 4 stated she did not find the order for the medication Debrox Solution transcribed in Resident 2's July 2018 MAR. Resident 2's July 2018 MAR included a page that indicated handwritten physician orders for Omeprazole (medication used for acid reflux {digestive disease in which stomach acid or bile irritates the food pipe lining}) dated June 27, 2018, and Remeron (medication used to to treat depression {type of mood disorder}) dated July 21, 2018. There was no entry following the order for Remeron in the July 2018 MAR. LVN 4 stated there was no documented evidence the medication Debrox was administered to Resident 2 in July 2018. On August 21, 2018, between 9 - 9:30 a.m., a second copy (a one paged MAR with hand written physician orders) of Resident 2's July 2018 MAR was received from the Medical Records Director (MRD). The second copy of the MAR received from the MRD indicated handwritten physician orders for Omeprazole dated June 27, 2018, Remeron, dated July 21, 2018, and the Debrox Solution, dated June 29, 2018. The second copy of the MAR indicated the order for Debrox Solution was handwritten after the Remeron medication entry. The second copy of the MAR also indicated Debrox FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 121 of 131 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 08/28/2018 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 Solution was administered to the resident from July 1- 31, 2018. Resident 2 had two duplicate copies of the handwritten page for the July 2018 MAR. The first copy, received on August 20, 2018, did not indicate a physician's order for the Debrox solution. The second copy, received on August 21, 2018, indicated a physician's order for the Debrox solution. On August 27, 2018, at 8:59 a.m., the MRD was interviewed. The MRD stated the second copy of Resident 2's July 2018 MAR, received on August 21, 2018, was from Resident 2's chart. The MRD was unable to explain why Resident 2 had two copies of the same handwritten page from Resident 2's July 2018 MAR, which had an inconsistent order entry for the Debrox solution. On August 27 2018, at 9:08 a.m., LVN 4 was interviewed. LVN 4 verified Resident 2's July 2018 MAR did not indicate an order for the Debrox Solution when the record review was conducted with her on August 20, 2018. LVN 4 was unable to explain why Resident 2 had two copies of the same handwritten page from Resident 2's July 2018 MAR, which had an inconsistent order entry for the Debrox solution. On August 27, 2018, at 9:10 a.m., the Director of Nursing (DON) was interviewed. The DON stated he was not able to tell when the handwritten order for Debrox solution was added in the second copy of Resident 2's July 2018 MAR. The DON stated he was not able to identify through penmanship, the licensed nurse who added the order entry for Debrox solution in the second copy of the July 2018 MAR. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 122 of 131 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 08/28/2018 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 DON stated he did not know why Resident 2 had two copies of the same page with handwritten physician orders from the July 2018 MAR indicating inconsistent physician order entry for the Debrox solution. The DON stated he was unable to explain because he did not know what happened. The DON stated it was not acceptable for Resident 2 to have two copies of the July 2018 MAR, with inconsistent physician orders for the Debrox solution. On August 27, 2018, at 10:12 a.m., the MRD was interviewed. The MRD stated the July 2018 MAR located in Resident 2's chart was already reviewed and audited by her. The MRD was not able to identify through penmanship the licensed nurse who added the handwritten physician's order for Debrox solution in the July 2018 MAR. The MRD stated she did not know when the order entry for Debrox solution was added in the July 2018 MAR. The MS was not able to provide the original copy of the page from the July 2018 MAR that did not have the entry for the Debrox solution. The MS stated basing it on the two copies of the same page of the MAR which had an inconsistent physician's order for Debrox solution, Resident 2 did not have an accurate medical record. On August 27, 2018, at 2:46 p.m., the second copy of Resident 2's July 2018 (MAR with handwritten physician's order for Debrox solution) was reviewed with LVN 7. LVN 7 stated she had signed her initials on the following dates, July 4, 5, 6, 7, 10, 11, 13, 15, 16, 18, 19, 24, 25, 28, 29, and 30, 2018. LVN 7 stated she had signed the MAR after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 123 of 131 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 08/28/2018 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 she administered to Debrox solution to Resident 2 in July 2018. LVN 7 stated she did not recall seeing two copies of the same handwritten MAR in Resident 2's July 2018 MAR. On August 27, 2018, at 3:05 p.m., the second copy of Resident 2's July 2018 MAR, was reviewed with LVN 2. LVN 2 stated the initials on the following dates, July 8, 9, 14, 17, 20, 21, 26, and 27, 2018, looked like her initials but it was not hers. LVN 2 stated she did not recall giving the Debrox medication to Resident 2 in July 2018. LVN 2 stated she did not recall signing an order for the Debrox solution Resident 2's July 2018 MAR. LVN 2 showed and verified her initials on the Remeron order entry (physician order entry handwritten before the Debrox solution order) for the dates July 21, 26, and 27, 2018. LVN 2 stated her initials written on the same dates for the Debrox solution order were different. LVN 2 stated, "I will not mess up my own initials." On August 28, 2018, at 9:30 a.m., the second copy of Resident 2's July 2018 MAR, was reviewed with Registered Nurse (RN) 2. RN 2 stated she worked the p.m. shift of July 31, 2018. RN 2 stated the initials in the entry for July 31 at 9 p.m. entry looked similar to her initials but she was not sure if it was hers. RN 2 stated she did not recall seeing two copies of the same handwritten MAR in Resident 2's July 2018 MAR 2. On August 20, 2018, at 10:31 a.m., Resident 31 was observed in the dining room. Resident 31 was in his wheelchair and did not respond FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 124 of 131 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 08/28/2018 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 when his name was called. The activity staff stated resident was confused and was nonverbal. On August 21, 2018, Resident 31's record was reviewed. Resident 31 was admitted to the facility on September 25, 2017, with diagnoses that included Alzheimer's disease (progressive memory loss that affects activities of daily living) The physician's order dated July 27, 2018, indicated, "PT/OT EVAL (evaluation) and TX (treatment) for functional decline." The nursing progress notes, dated July 27, 2018 at 8 a.m., indicated the physician had an order for PT and OT evaluation for the resident due to functional decline. There was no documented evidence of a PT and OT evaluation conducted on the resident. On August 21, 2018, at 10:44 a.m., Resident 31's record was reviewed with Registered Nurse (RN) 3. RN 3 stated she was the licensed nurse who carried out the order for PT and OT evaluation on Resident 31 on July 27, 2018. RN 3 verified her entry in the nursing progress notes dated July 27, 2018, for the PT and OT evaluation order. RN 3 stated Resident 31's physician's order for PT and OT evaluation on July 27, 2018, was meant for another resident. RN 3 stated she had written the order in error in Resident 31's chart. RN 1 stated she got confused with another resident whose last name sounded like Resident 31's. RN 3 acknowledged her error in transcribing the wrong physician orders in Resident 31's record. RN 3 stated this was not brought to her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 125 of 131 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 08/28/2018 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 attention until August 21, 2018, during the record review conducted with her. The facility's policy and procedure titled, "Record Content ...Documentation Principles," dated updated August 17, 2018, was reviewed. The policy indicated, "...Health records shall be kept for each resident and the content shall be in compliance with the licensing and certification governmental agency requirements and professional standards... Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident... All entries in the health record must be authenticated by the person making the entry with the date, signature and title... Late Entry- Include the date/time of the current entry, the date/shift or time the entry should have been made and proceed with the data entry... If an entire sheet must be recopied, this may be done with the approval of the Director of Nursing Services. The DNS and the Staff who is recopying the record shall both sign and date the recopied record, including the reason for recopying. The original is to be stapled to the copy..."

F867 SS=F QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 126 of 131 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 08/28/2018 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 (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement an appropraite plan of action to correct quality deficiencies related to Pharmaceutical Services when: 1. the facility failed to identify quality concerns regarding licensed nurses care practices that meets expected professional standards, when multiple licensed nurses failed to follow the facility's policy and procedure for narcotic medication administration (Cross Reference

F755); and 2. the facility failed to assess if contracted pharmaceutical consultants perform quality review to identify drug irregularities, when pain narcotic medications, Norco and Tramadol, were signed out in the narcotic count sheet by multiple licensed nurses on multiple occasions and was not documented in the Medication Administration Record (MAR) that it was administered to the residents. In addition, licensed nurses did not document the indication for use and the evaluation for the effectiveness of the medication (Cross Reference F755,

F756, and F757) . These failures had the potential for drug irregularities that may result in diversion of controlled medication and for the residents to recieved unnecassary medications. The above failures had resulted in a Substandard Quality of Care which was identified on August 23, 2018. An extended survey was announced to the facility on August FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 127 of 131 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 08/28/2018 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 27, 2018. Findings: On August 23, 2018, the following records were reviewed: - Resident 47's record was reviewed. Resident 47's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). - Resident 72's record was reviewed. Resident 72's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). - Resident 61's record was reviewed. Resident 61's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 128 of 131 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 08/28/2018 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 3's record was reviewed. Resident 3's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). - Resident 59's record was reviewed. Resident 59's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). - Resident 15's record was reviewed. Resident 15's count sheet for Norco from the period of June 2018 to August 2018, indicated multiple licensed nurses were signing out the narcotic pain medication, and were not documenting on the MAR if the medication was administered to the resident. In addition, the licensed nurses did not document the indication for use and evaluation for the effectiveness of the medication. (Cross Reference F755, F756, and

F757). On August 23, 2018, at 3:27 p.m., the Administrator was interviewed. The Administrator stated the facility was not doing narcotic medication reconciliation audit. The Administrator stated the Medical Records (MR) department check on the MAR only and was not verifying the narcotic medications signed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 129 of 131 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 08/28/2018 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 out on the narcotic count sheet. On August 27, 2018, at 11:51 a.m., the Director of Nursing (DON) was interviewed. The DON stated nurses should know and follow the facility's policy and procedure on the use of narcotics. The DON stated the Medical Records (MR) audit the MAR, the MR verified the medication orders were correct and the MAR have the licensed nurses signature indicating medications were administered to the residents. The DON stated the licensed nurses ensures the narcotic medications had the correct count from the narcotic count sheet. The DON stated the facility had no audit process on narcotic medication reconciliation where the medication on the residents' narcotic count sheet reflects on the residents' MAR indicating the medication was administered to the residents. The facility's policy and procedure titled, "Quality Assurance Improvement Plan," dated August 17, 2018, indicated "Our purpose is to take a proactive approach to continually provide the best service to all residents in accordance with the state and federal regulations...Our nursing home has a Performance Improvement Program, which systematically monitors, analyzes and improves its performance to improve resident/patient outcomes..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 Facility ID: CA240000284 If continuation sheet 130 of 131 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 08/28/2018 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) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 00IJ11 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000284 (X5) COMPLETE DATE If continuation sheet 131 of 131