Other·December 20, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one facility reported incident and one complaint. Facility Reported Incident # CA00588169 Complaint # CA00586935 Representing the California Department of Public Health: Surveyor Federal/State ID# 34435/2829, HFEN The inspection was limited to the specific entity reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. Deficiencies were issued for entity reported incident CA00588169 and complaint number CA00586935.

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

F600 09/24/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's 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: Q6MB11 Facility ID: CA240000567 If continuation sheet 1 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed ensure Resident A was free from daily verbal abuse from Licensenced Vocational Nurse 1 (LVN 1). This failure resulted in Resident A feeling uncomfortable, demeaned, intimidated, and afraid of retaliation. Findings: On May 21, 2018, at 1:55 p.m., Resident A's daughter was interviewed. Resident A's daughter stated on May 16, 2018, she telephoned the facility and spoke with the Unit Manager (UM). Resident A's daughter stated she told the UM that Resident A was verbally abused daily by LVN 1. Resident A's daughter stated she told the UM that Resident A had been crying because of LVN 1. Resident A's daughter stated the UM told her because she alleged "abuse", she (UM) would have to report it, and that LVN 1 would not be Resident A's nurse anymore. Resident A's daughter stated when she visited on May 19, and May 20, 2018, LVN 1 was still her mother's nurse. On May 23, 2018, at 11:45 a.m., an unannounced visit was conducted at the facility. Resident A's record was reviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 2 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 A was readmitted to the facility on April 9, 2018 with diagnoses that included COPD (chronic obstructive pulmonary disease - obstructive lung disease characterized by long term breathing problems), diabetes and bipolar disorder (mental disorder characterized with periods of depression and elevated mood). Resident A's history and physical dated April 12, 2018, indicated shortness of breath and anxiety as Resident A's chief complaint. The history and physical further stated Resident A was alert and oriented. The Minimum Data Set (MDS - an assessment tool) dated April 16, 2018, indicated Resident A had a BIMS score of 15 (Brief Interview Mental Status--determines a resident's cognitive status, a score of 13-15 indicates cognitively intact). The document indicated Resident A required limited to extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The document further indicated Resident A had not had a bath or shower the last seven days. Review of the staffing assignment for May 23, 2018, indicated LVN 1 was Resident A's nurse at the time of the visit. On May 23, 2018, at 11:50 a.m., Resident A was observed in her room. Resident A was sitting up in bed receiving a breathing treatment through a nebulizer (respiratory drug delivery device used to administer medication in the form of mist inhaled, to relieve shortness of breath and difficulty breathing). Resident A was also observed with a nasal cannula (device applied in the nostrils used to deliver supplemental oxygen) connected a portable oxygen tank at 3 liters per minute. Resident A was interviewed. Resident A stated she had COPD and diabetic neuropathy (nerve FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 3 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 damage caused by diabetes). Resident A stated because of shortness of breath from COPD, and pain from diabetic neuropathy, she was unable to perform her daily activities of living without extensive assistance. Resident A also stated she was dependent on her breathing treatments and pain medications to relieve her symptoms. Resident A stated LVN 1 told her she, "Takes too much medication." Resident A stated LVN 1 told her she (LVN 1) would call my doctor to stop giving me too much medications. Resident A stated LVN 1 would comment, "Oh yes it's that four hour thing."-- referring to her medication administration times, every time she had to come and administer her medications. Resident A stated she ended up crying every time. Resident A stated she had told the Social Worker (SW) and the UM that she did not want LVN 1 to be her nurse anymore but they told her they were short staffed. Resident A stated she felt "uncomfortable" with LVN 1. Resident A stated LVN 1 was "demeaning". She said she felt "intimidated" and "anxious" because of LVN 1's comments. Resident A stated, "I am afraid they will retaliate on me, I am scared of her (LVN 1) ...they're in control of my medications." Resident A was observed having difficulty breathing while talking, teary, and anxious during the interview. On May 23, 2018, at 12:30 p.m., the SW was interviewed with the Assistant Administrator (AA) in the room. The SW stated on May 8, 2018, Resident A was giving her "conflicting stories" regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 4 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 her medications. The SW stated she could not remember the all the details of her conversation with Resident A. The SW stated she offered Resident A "a room change" but Resident A refused. The SW stated she talked to the UM about it and they both talked to Resident A. The SW stated she documented the conversation she and the UM had with Resident A in the resident's record on May 8, 2018. Resident A's record was reviewed with the SW and the AA during the interview. Both confirmed Resident A's record contained only one note from the SW from May 1, through May 23, 2018. The note dated was dated, May 9, 2018, at 2:57 p.m.. The note indicated, "Social Services received phone call from daughter ...stated resident was in tears. Social services went to see resident and redirected and calm as resident was feeling down ..." The SW and the AA confirmed there was no documented evidence of the conversation the SW and UM had with Resident A, on May 8, 2018. The SW and the AA confirmed there was no other documented evidence detailing why Resident A "was in tears" and other interventions to address Resident A's mood on May 9, 2018. On May 23, 2018, at 1:15 p.m., the UM was interviewed with the AA in the room. The UM stated she remembers receiving a call from Resident A's daughter. The UM stated Resident A's daughter mentioned Resident A "did not like the nurse...she mentioned abuse". The UM stated she told Resident A's daughter that she would have to report it (abuse). The UM stated she was unable to remember the date and time of when she received the phone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 5 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 call from Resident A's daughter regarding the "abuse" allegation. The UM confirmed that when she received the call from Resident A's daughter she did tell her that LVN 1 would not be working with Resident A anymore. The UM stated she reported the allegation of "abuse" made by Resident A's daughter to the Administrator. The UM stated she talked to Resident A about the "abuse", but Resident A told her it was not true. The UM stated she did not document the interview with Resident A because, "The SW usually does it." The UM stated if an allegation of abuse was made the alleged perpetrator, "Should be removed right away" and the allegation investigated. The UM stated Resident A's case was an "exception" because Resident A told them it was not true. The UM stated she told Resident A, "The nurses do not do that (abuse)." The UM stated she did not do anything anymore after she interviewed Resident A. Resident A's record was reviewed with the UM and the AA during the interview. Both confirmed there was no documented evidence of the interview or investigation conducted by the UM with Resident A regarding the allegation of abuse communicated by Resident A's daughter on May 16, 2018 at the time of the visit. On May 23, 2018, at 2:15 p.m., the DON was interviewed. The DON stated the SW and UM should have documented their conversation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 6 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 Resident A. On May 23, 2018, at 2:30 p.m. the staffing assignment from May 1, through May 23, 2018 was reviewed with the AA. The AA confirmed that LVN 1 continued to be Resident A's nurse after the allegation of abuse was communicate to the UM by Resident A's daughter on May 16, 2018. The staffing assignment indicated, LVN 1 was Resident A's nurse on May 17, 19, 20, and 23, 2018 (total of four days after the allegation of abuse was made). On May 23, 2018, at 2:45 p.m., LVN 1 was interviewed. LVN 1 stated on May 16, or 17, 2018, the UM talked to her about "being rude and arguing" with Resident A. On May 29, 2018, at 10:30 a.m., a follow up visit was conducted at the facility. The Administrator was interviewed. The Administrator stated the UM never mentioned the allegation of "abuse" regarding Resident A to her. The Administrator stated if she knew Resident A's daughter had "alleged abuse," she would have reported it right away to the Department. The Administrator stated she would also have initiated an investigation immediately. The Administrator stated when the DON and the SW re-interviewed Resident A after the unannounced visit on May 23, 2018, Resident A denied the allegation of abuse. On May 29, 2018, at 12:25 p.m., Resident A was observed in her room. Resident A was interviewed. Resident A stated the DON and SW came and talked to her on May 23, 2018. Resident A stated she denied the allegation because she was "scared". Resident A stated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 7 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 "They have control over my medications...they hurt me mentally." On May 29, 2018, at 12:30 p.m., Resident A was re-interviewed with the Administrator. Resident A stated right after her interview with this surveyor on May 23, 2018, LVN 1 came into her room and asked what she had said to the surveyor. Resident A stated she felt "scared". Resident A stated she would be more comfortable if LVN 1 was not her nurse anymore. Resident A stated she felt "frightened". Resident A admitted that she lied to the DON and SW on May 23, 2018. Resident A apologized and stated she lied because she knew the SW was friends with LVN 1. Resident A was observed crying and anxious during the interview. After Resident A's interview, the Administrator stated the allegation made by Resident A was cause for concern. Review of the facility policy and procedure, "Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropiration Prevention," dated November 2018, indicated, "...detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse. The process should be available to patients, family members, advocates and staff to report abuse in a manner that elicits immediate attention without fear of retribution...Abuse against patients can be initiated by various people within the center. The center supports and protects patients, family members and staff from harm during an investigation of alleged abuse...Any allegation of abuse must be immediately reported to the supervisor and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 8 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 abuse prevention coordinator. The administrator follows the investigation process...in investigating the allegations of abuse a patient...Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation..."

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 09/24/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 9 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 Unit Manager (UM) failed to report to the administrator of the facility and to other officials, including the State Survey Agency, the allegation of daily verbal abuse by LVN 1 towards Resident A, after it was communicated on May 16, 2018. These failures resulted in the potential for continued abuse for Resident A and abuse for all the other facility residents. Findings: On May 21, 2018, at 1:55 p.m., Resident A's daughter was interviewed. Resident A's daughter stated on May 16, 2018, she telephoned the facility and spoke with the UM. Resident A's daughter stated she told the UM that Resident A was verbally abused daily by LVN 1. Resident A's daughter stated she told the UM that Resident A had been crying because of LVN 1. Resident A's daughter stated the UM told her because she alleged "abuse", she (UM) would have to report it, and that LVN 1 would not be Resident A's nurse anymore. Resident A's daughter stated when she visited on May 19, and May 20, 2018, LVN 1 was still her mother's nurse. On May 23, 2018, at 11:45 a.m., an unannounced visit was conducted at the facility. Resident A's record was reviewed. Resident A was readmitted to the facility on April 9, 2018 with diagnoses that included COPD (chronic obstructive pulmonary disease - obstructive lung disease characterized by long term breathing problems), diabetes and bipolar disorder (mental disorder characterized with periods of depression and elevated mood). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 10 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 A's history and physical dated April 12, 2018, indicated shortness of breath and anxiety as Resident A's chief complaint. The history and physical further stated Resident A was alert and oriented. The Minimum Data Set (MDS - an assessment tool) dated April 16, 2018, indicated Resident A had a BIMS score of 15 (Brief Interview Mental Status--determines a resident's cognitive status, a score of 13-15 indicates cognitively intact). The document indicated Resident A required limited to extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. Review of the staffing assignment for May 23, 2018, indicated LVN 1 was Resident A's nurse at the time of the visit. On May 23, 2018, at 11:50 a.m., Resident A was observed in her room. Resident A was sitting up in bed receiving a breathing treatment through a nebulizer (respiratory drug delivery device used to administer medication in the form of mist inhaled, to relieve shortness of breath and difficulty breathing). Resident A was also observed with a nasal cannula (device applied in the nostrils used to deliver supplemental oxygen) connected a portable oxygen tank at 3 liters per minute. Resident A was interviewed. Resident A stated she had COPD and diabetic neuropathy (nerve damage caused by diabetes). Resident A stated because of shortness of breath from COPD, and pain from diabetic neuropathy, she was unable to perform her daily activities of living without extensive assistance. Resident A also stated she was dependent on her breathing treatments and pain medications to relieve her symptoms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 11 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 A stated LVN 1 told her she, "Takes too much medication." Resident A stated LVN 1 told her she (LVN 1) would call my doctor to stop giving me too much medications. Resident A stated LVN 1 would comment, "Oh yes it's that four hour thing."-- referring to her medication administration times, every time she had to come and administer her medications. Resident A stated she ended up crying every time. Resident A stated she had told the Social Worker (SW) and the UM that she did not want LVN 1 to be her nurse anymore but they told her they were short staffed. Resident A stated she felt "uncomfortable" with LVN 1. Resident A stated LVN 1 was "demeaning". Resident A stated she felt "intimidated" and "anxious" because of LVN 1's comments. Resident A stated "I am afraid they will retaliate on me, I am scared of her (LVN 1) ...they're in control of my medications." Resident A was observed having difficulty breathing while talking, teary, and anxious during the interview. On May 23, 2018, at 1:15 p.m., the UM was interviewed with the Assistant Administrator (AA) in the room. The UM stated she remembers receiving a call from Resident A's daughter. The UM stated Resident A's daughter mentioned Resident A "did not like the nurse...she mentioned abuse". The UM stated she told Resident A's daughter that she would have to report it (abuse). The UM stated she was unable to remember the date and time of when she received the phone call from Resident A's daughter regarding the "abuse" allegation. The UM confirmed that when she received the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 12 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 call from Resident A's daughter she did tell her that LVN 1 would not be working with Resident A anymore. The UM stated she reported to the Administrator the allegation of "abuse" made by Resident A's daughter. The UM stated she talked to Resident A about the "abuse", but Resident A told her it was not true. The UM stated she did not document the interview with Resident A because, "The SW usually does it." The UM stated if an allegation of abuse was made the alleged perpetrator, "Should be removed right away" and the allegation investigated. The UM stated Resident A's case was an "exception" because Resident A told them it was not true. The UM stated she told Resident A "The nurses do not do that (abuse)." The UM stated she did not do anything anymore after she interviewed Resident A. Resident A's record was reviewed with the UM and the AA during the interview. Both confirmed there was no documented evidence of the interview or investigation conducted by the UM with Resident A regarding the allegation of abuse communicated by Resident A's daughter on May 16, 2018. On May 23, 2018, at 2:15 p.m., the (Director of Nursing) DON was interviewed. The DON stated she was not aware of the allegation of abuse communicated to the UM by Resident A's daughter on May 16, 2018. On May 23, 2018, at 2:30 p.m. the staffing assignment from May 1, through May 23, 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 13 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 reviewed with the AA. The AA confirmed that LVN 1 continued to be Resident A's nurse after the allegation of abuse was communicated by Resident A's daughter to the UM on May 16, 2018. The staffing assignment indicated, LVN 1 was Resident A's nurse on May 17, 19, 20, and 23, 2018 (total of four days after the allegation of abuses was made). On May 23, 2018, at 2:45 p.m., LVN 1 was interviewed. LVN 1 stated on May 16, or 17, 2018, the UM talked to her that she was "being rude and arguing" with Resident A. On May 29, 2018, at 10:30 a.m., a follow up visit was conducted at the facility. The Administrator was interviewed. The Administrator stated the UM never mentioned "abuse" regarding Resident A to her. The Administrator stated if she knew Resident A's daughter had "alleged abuse" she would have reported it right away to the Department. The Administrator stated she would also have initiated an investigation immediately. The Administrator stated the DON and the SW re-interviewed Resident A on May 23, 2018, after the unannounced visit. The Administrator stated Resident A denied the allegation of abuse. On May 29, 2018, at 12:25 p.m., Resident A was observed in her room. Resident A was interviewed. Resident A stated the DON and SW came and talked to her on May 23, 2018. Resident A stated she denied the allegation because she was "scared". Resident A stated, "They have control over my medications ...they hurt me mentally." On May 29, 2018, at 12:30 p.m., Resident A was re-interviewed with the Administrator. Resident A stated right after her interview with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 14 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 surveyor on May 23, 2018, LVN 1 came into her room and asked what she had said to the surveyor. Resident A stated she felt "scared". Resident A stated she would be more comfortable if LVN 1 was not her nurse anymore. Resident A stated she felt "frightened". Resident A admitted that she lied to the DON and SW on May 23, 2018. Resident A apologized and stated she lied because she knew the SW was friends with LVN 1. Resident A was observed crying and anxious during the interview. After the Resident A's interview, the Administrator stated the allegation made by Resident A was cause for concern. Review of the facility policy and procedure, "Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropiration Prevention," dated November 2018, indicated, "...detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse. The process should be available to patients, family members, advocates and staff to report abuse in a manner that elicits immediate attention without fear of retribution...Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations..."

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 09/24/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 15 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of abuse and prevent further potential abuse for one resident, Resident A, when: 1. Resident A's daughter's allegation of daily verbal abuse by Licensed Vocational Nurse 1 (LVN 1) towards Resident A, communicated on May 16, 2018, was not reported by the Unit Manager (UM), and; 2. LVN 1 continued to have access and be Resident A's nurse without the the allegation of abuse thoroughly investigated after Resident A's daughter communicated to the UM daily verbal abuse by LVN 1 towards Resident A on May 16, 2018. These failures resulted in the potential for continued abuse for Resident A. Findings: On May 21, 2018, at 1:55 p.m., Resident A's daughter was interviewed. Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 16 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 daughter stated on May 16, 2018, she telephoned the facility and spoke with the UM. Resident A's daughter stated she told the UM that Resident A was verbally abused daily by LVN 1. Resident A's daughter stated she told the UM that Resident A had been crying because of LVN 1. Resident A's daughter stated the UM told her because she alleged "abuse", she (UM) would have to report it, and that LVN 1 would not be Resident A's nurse anymore. Resident A's daughter stated when she visited on May 19, and May 20, 2018, LVN 1 was still her mother's nurse. On May 23, 2018, at 11:45 a.m., an unannounced visit was conducted at the facility. Resident A's record was reviewed. Resident A was readmitted to the facility on April 9, 2018 with diagnoses that included COPD (chronic obstructive pulmonary disease - obstructive lung disease characterized by long term breathing problems), diabetes and bipolar disorder (mental disorder characterized with periods of depression and elevated mood). Resident A's history and physical dated April 12, 2018, indicated shortness of breath and anxiety as Resident A's chief complaint. The history and physical further stated Resident A was alert and oriented. The Minimum Data Set (MDS - an assessment tool) dated April 16, 2018, indicated Resident A had a BIMS score of 15 (Brief Interview Mental Status--determines a resident's cognitive status, a score of 13-15 indicates cognitively intact). The document indicated Resident A required limited to extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The document further indicated Resident A had not had a bath or shower the last seven days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 17 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 Review of the staffing assignment for May 23, 2018, indicated LVN 1 was Resident A's nurse at the time of the visit. On May 23, 2018, at 11:50 a.m., Resident A was observed in her room. Resident A was sitting up in bed receiving a breathing treatment through a nebulizer (respiratory drug delivery device used to administer medication in the form of mist inhaled, to relieve shortness of breath and difficulty breathing). Resident A was also observed with a nasal cannula (device applied in the nostrils used to deliver supplemental oxygen) connected a portable oxygen tank at 3 liters per minute. Resident A was interviewed. Resident A stated she had COPD and diabetic neuropathy (nerve damage caused by diabetes). Resident A stated because of shortness of breath from COPD, and pain from diabetic neuropathy, she was unable to perform her daily activities of living without extensive assistance. Resident A also stated she was dependent on her breathing treatments and pain medications to relieve her symptoms. Resident A stated LVN 1 told her she, "Takes too much medication." Resident A stated LVN 1 told her she (LVN 1) would call my doctor to stop giving me too much medications. Resident A stated LVN 1 would comment, "Oh yes it's that four hour thing."-- referring to her medication administration times, every time she had to come and administer her medications. Resident A stated she ended up crying every time. Resident A stated she had told the Social Worker (SW) and the UM that she did not want LVN 1 to be her nurse anymore but they told FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 18 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 her they were short staffed. Resident A stated she felt "uncomfortable" with LVN 1. Resident A stated LVN 1 was "demeaning". Resident A stated she felt "intimidated" and "anxious" because of LVN 1's comments. Resident A stated "I am afraid they will retaliate on me, I am scared of her (LVN 1) ...they're in control of my medications." Resident A was observed having difficulty breathing while talking, teary, and anxious during the interview. On May 23, 2018, at 1:15 p.m., the UM was interviewed with the Assistant Administrator (AA) in the room. The UM stated she remembers receiving a call from Resident A's daughter. The UM stated Resident A's daughter mentioned Resident A "did not like the nurse...she mentioned abuse". The UM stated she told Resident A's daughter that she would have to report it (abuse). The UM stated she was unable to remember the date and time of when she received the phone call from Resident A's daughter regarding the "abuse" allegation. The UM confirmed that when she received the call from Resident A's daughter she did tell her that LVN 1 would not be working with Resident A anymore. The UM stated she reported the allegation of "abuse" made by Resident A's daughter to the Administrator. The UM stated she talked to Resident A about the "abuse", but Resident A told her it was not true. The UM stated she did not document the interview with Resident A because, "The SW usually does it." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 19 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 UM stated if an allegation of abuse was made the alleged perpetrator, "Should be removed right away" and the allegation investigated. The UM stated Resident A's case was an "exception" because Resident A told them it was not true. The UM stated she told Resident A "The nurses do not do that (abuse)." The UM stated she did not do anything anymore after she interviewed Resident A. Resident A's record was reviewed with the UM and the AA during the interview. Both confirmed there was no documented evidence of the interview or investigation conducted by the UM with Resident A regarding the allegation of abuse communicated by Resident A's daughter on May 16, 2018. On May 23, 2018, at 2:15 p.m., the (Director of Nursing) DON was interviewed. The DON stated she was not aware of the allegation of abuse communicated to the UM by Resident A's daughter on May 16, 2018. On May 23, 2018, at 2:30 p.m. the staffing assignment from May 1, through May 23, 2018 was reviewed with the AA. The AA confirmed that LVN 1 continued to be Resident A's nurse after the allegation of abuse was communicated by Resident A's daughter to the UM on May 16, 2018. The staffing assignment indicated, LVN 1 was Resident A's nurse on May 17, 19, 20, and 23, 2018 (total of four days after the allegation of abuses was made). On May 29, 2018, at 10:30 a.m., a follow up visit was conducted at the facility. The Administrator was interviewed. The Administrator stated the UM never mentioned "abuse" regarding Resident A to her. The Administrator stated if she knew Resident A's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 20 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 daughter had "alleged abuse" she would have reported it right away to the Department. The Administrator stated she would also have initiated an investigation immediately. Review of the facility policy and procedure, "Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropiration Prevention," dated November 2018, indicated, "...detection and prevention of abuse by implementing a process that supports immediate reporting of suspected abuse...the facility must have evidence that all allegaed violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process...Once reported, the center conductes a timely, thorough and objective investigation of any allegations of abuse..."

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 09/14/2018 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to identify the underlying cause, evaluate and intervene, for one resident, Resident A. Resident A only received a shower twice from April 9, 2018 through May 22, 2018. This failure had the potential to result in poor personal hygiene for Resident A. On May 23, 2018, at 11:45 a.m., an unannounced visit was conducted at the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 21 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 A's record was reviewed. Resident A was readmitted to the facility on April 9, 2018 with diagnoses that included COPD (chronic obstructive pulmonary disease - obstructive lung disease characterized by long term breathing problems), diabetes and bipolar disorder (mental disorder characterized with periods of depression and elevated mood). Resident A's history and physical dated April 12, 2018, indicated shortness of breath and anxiety as Resident A's chief complaint. The history and physical further stated Resident A was alert and oriented. The Minimum Data Set (MDS - an assessment tool) dated April 16, 2018, indicated Resident A had a BIMS score of 15 (Brief Interview Mental Status--determines a resident's cognitive status, a score of 13-15 indicates cognitively intact). The document indicated Resident A required limited to extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The document further indicated Resident A had not had a bath or shower the last seven days. Resident A's physician's orders included breathing treatments routinely every four hours and every one hour as needed for shortness of breath, as well as pain medications every 12 hours routinely and every four hours as needed. On May 23, 2018, at 11:50 a.m., Resident A was observed in her room. Resident A was sitting up in bed receiving a breathing treatment through a nebulizer (respiratory drug delivery device used to administer medication in the form of mist inhaled, to relieve shortness of breath and difficulty breathing). Resident A was also observed with a nasal cannula (device applied in the nostrils used to deliver supplemental oxygen) connected a portable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 22 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 oxygen tank at 3 liters per minute. Resident A was interviewed. Resident A stated she had COPD and diabetic neuropathy (nerve damage caused by diabetes). Resident A stated because of shortness of breath from COPD, and pain from diabetic neuropathy, she was unable to perform her daily activities of living without extensive assistance. Resident A also stated she was dependent on her breathing treatments and pain medications to relieve her symptoms. Resident A stated, it took a month from her readmission on April 9, 2018, before she was able to get showered. Resident A stated because she needed her pain medication and breathing treatment, prior to being able to get out of bed, she told the nurses to come back after she had her medications for them to take her to the shower room. Resident A stated no one came to take her to the shower room after she had her medications. Resident A stated she had been "cleaning herself" while in bed, but could not wash her hair. On May 23, 2018, at 1:15 p.m., the UM was interviewed with the AA in the room. The UM stated Resident A's shower days were Wednesday and Saturday evenings. The UM stated she was not aware that Resident A did not get showered for a month after she was readmitted. The UM stated she was not aware of the reason why Resident A had not been getting showered. Resident A's record was reviewed with the UM and the AA during the interview. Both confirmed the following: -Resident A's shower days were Wednesdays and Saturday evenings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 23 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 April 9, through May 23, 2018, Resident A's record indicated the resident received a shower only on two occasions---May 9, 2018 and May 21, 2018. -On April 11, 25, 28, May 2, 5, 12, and 19, 2018, Resident A's record indicated "refused" shower or bath. There was no documented evidence explaining the refusal and the number of attempts made to try to give Resident A a shower or bath. -On April 14, 18, 21, and May 19, 2018, Resident A's other scheduled shower days, the record indicated a shower or bath was "Not Applicable". -There was no documented evidence of initiated attempts to identify the underlying cause of Resident A's shower or bath refusals. -There was no documented evidence of why Resident A's shower or bath were "Not Applicable", on the days Resident A was supposed to have a shower or bath. On May 23, 2018, at 2:15 p.m., the DON was interview. The DON stated there should also be documentation about why Resident A has been refusing showers. The DON further stated she was not aware that Resident A had not been receiving a shower or bath. On May 23, 2018, at 2:45 p.m., LVN 1 was interviewed. LVN 1 stated she was not aware that Resident A had not been receiving showers. On May 30, 2018, at 2:06 p.m., a telephone interview was conducted with CNA 1 regarding Resident A's showers. CNA 1 stated Resident A refused showers because of difficulty FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 24 of 25 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: _______________ 555297 (X3) DATE SURVEY COMPLETED 08/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET HILLS POST ACUTE 1717 W Stetson Ave Hemet, CA 92545 (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 breathing and pain. CNA 1 stated, the nurses didn't "give her pain medications or breathing treatment on time." CNA 1 stated, "Honestly, nurses are not paying attention...we tell them all the time." CNA 1 stated "A lot of new nurses...they don't know her (Resident A) routine." CNA 1 further stated "Her inhaler is very important to her..she (Resident A) always has a hard time breathing." On May 30, 2018, at 2:10 p.m., a telephone interview was conducted with CNA 2 regarding Resident A's showers. CNA 2 stated Resident A refused because she is usually out of breath. CNA 2 stated "I tell the nurse." On May 30, 2018, at 2:24 p.m., a telephone interview was conducted with CNA 3 regarding Resident A's showers. CNA 3 stated Resident A refused showers because she has a hard time breathing. CNA 3 stated she reported to the nurse every time Resident A refused her showers. Review of Resident A's care plans indicated: - initiated, April 9, 2018, "(Resident A) has ADL (activities of daily living) Self-care deficit related to gen (general) weakness, decreased mobility from COPD. Requires limited to extensive assist...Assist with bathe/shower as needed..." -initiated, April 9, 2018, "Chronic (constant) neuropathic (nerve) pain to extremities...Adjust times of ADL (activities of daily living) and treatment activities so that occur after analgesia benefits have been achieved..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q6MB11 Facility ID: CA240000567 If continuation sheet 25 of 25