Other·February 6, 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 revisit and partial-extended survey conducted from October 2, 2018, through October 5, 2018. Representing the California Department of Public Health: Surveyor 22921, HFEN; Surveyor 37626, HFEN; and Surveyor 38477, HFEN. The facility census was 31 residents. The sample size was nine residents. Due to the facility's failure to ensure abnormal laboratory results were reported to the physician and acted upon timely for one resident (Resident 1) which resulted in Resident 1's hospitalization, and after a similar deficiency which resulted in actual harm for two residents during the survey conducted on August 6, 2018, through August 8, 2018, for which the revisit was conducted, the Administrator and Director of Staff Development were verbally notified of an Immediate Jeopardy situation on October 3, 2018, at 4:42 p.m. The Immediate Jeopardy was removed in the presence of the Administrator at the facility on October 5, 2018, at 4:18 p.m., after the facility's plan of action to remove the immediacy was reviewed and verified to have been implemented.

F684 Quality of Care

F684 10/31/2018 SS=K 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: 1VEW12 Facility ID: CA240000902 If continuation sheet 1 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 CFR(s): 483.25 § 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 by: Based on interview and record review, the facility failed to ensure five of nine sampled residents (Residents 1, 4, 5, 6, and 8) received treatment and care in accordance with professional standards of practice when: 1. The facility failed to notify the physician of abnormal laboratory results timely for Residents 1, 4, 5, and 6. a. For Resident 1, this failure resulted in a delay in treatment and hospitalization due to progressively increasing Blood Urea Nitrogen (BUN, test for kidney and liver function) and Creatinine (test for kidney function) levels. Due to the facility's failure to ensure abnormal laboratory results were reported to the physician and acted upon timely for Resident 1, who required hospitalization, the Administrator and Director of Staff Development were verbally notified of an Immediate Jeopardy situation on October 3, 2018, at 4:42 p.m. The Immediate Jeopardy was removed in the presence of the Administrator at the facility on October 5, 2018, at 4:18 p.m., after the facility's plan of action to remove the immediacy was reviewed and verified to have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 2 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 implemented; b. For Resident 5, this failure resulted in the physician to not be aware of the resident's condition potentially causing a delay in treatment, such as increasing Resident 5's fluid intake; and c. For Resident 6, this failure also resulted in the physician to not be aware of the resident's condition potentially causing a delay in treatment, such as adjusting Resident 6's blood thinning medication. 2. The facility failed to assess Resident 4 for signs and symptoms of a urinary tract infection when the facility received an abnormal urinalysis laboratory result. This failure resulted in the potential for Resident 4 to experience unnecessary pain and discomfort, and delay in treatment; and 3. The facility failed to call 911 (emergency services) when Resident 8 had symptoms of choking and experienced a change in condition. This failure resulted in Resident 8 to not receive the necessary emergency treatment, such as an assessment of respiratory (breathing) status and treatment for a possible airway obstruction, which may have prevented Resident 8's death. Findings: 1a. A record review for Resident 1 was conducted on October 2, 2018. Resident 1 was admitted to the facility on September 17, 2018, with diagnoses including congestive heart failure (weakness of the heart that leads to a build up of fluid in the lungs and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 3 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 surrounding tissue), bronchitis (infection of the main airway of the lung), and acute kidney failure (when the kidney stopped working). The laboratory report received by the facility on September 28, 2018, at 7:10 a.m., was reviewed and indicated the results of Resident 1's blood specimen, taken on September 27, 2018, at 5:30 p.m., included the following: a. BUN 65 mg (milligrams)/(per) dL (deciliter, metric unit of capacity equal to one tenth of a liter of blood), reference range (RR, normal range): 7-25 mg/dL; b. Creatinine 1.99 mg/dL, RR: 0.70 -1.30 mg/dL; and c. BUN/Creatinine Ratio (test to determine kidney function) 32.7, RR: 10.0-20.0. The fax (document transmission) confirmation indicating the laboratory results were sent to Resident 1's physician on September 28, 2018, at 10:32 p.m. (15 hours after the laboratory results were received by the facility) was reviewed. There was no documented evidence Resident 1's physician received the laboratory report, or if any new treatment orders were given by the physician for Resident 1. The facility document titled, "...HMO & Medicare Charting...," dated September 29, 2018, at 2:07 a.m., was reviewed and indicated Resident 1 was alert, oriented, able to make himself understood and could understand others. The document indicated Resident 1 had recent lab work completed and the results were pending (in progress). The facility document titled, "Health Status Note," dated September 29, 2018, at 11:43 p.m., was reviewed and indicated, "...at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 4 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 approximately 2300 (11 p.m.)...the resident was lying on the lobby floor...two skin tears to his left elbow was noted and one skin tear to his left lower leg was noted...when asked if he fell he stated he tripped over his wheelchair..." The facility document titled, "Health Status Note," dated September 30, 2018, at 2:08 a.m., was reviewed and indicated, "...the resident has been consistently anxious...he has tried to get up "a billion times"...stating that he wants to go to the parking lot because his wife is waiting for him..." The facility document titled, "Health Status Note," dated September 30, 2018, at 12:36 p.m., was reviewed and indicated, "...Labs drew on 9/27/18 (September 27, 2018) and reported to (name of Nurse Practitioner [NP]) BUN noted to be 65 and sCr (serum creatinine) 1.99 also report...resident noted to be confused today versus yesterday. new (sic) orders obtained for NS (normal saline) 1L (liter) @ (at) 75ml/hr (milliliter per hour)..." (The NP was notified by the facility 53 hours after the facility received the abnormal laboratory results on September 28, 2018. Resident 1 experienced a fall and a change in mental status prior to the NP notification.) The facility document titled, "Health Status Note," dated September 30, 2018, at 7:41 p.m., was reviewed and indicated, "Throughout shift resident has been agitated and non compliant with following requests, has been placed on IV (intravenous) hydration for increased BUN...LAbs (sic) collected per MD (physician) order, awaiting results..." The facility document titled, "Progress Notes," dated October 1, 2018, at 1:19 a.m., was reviewed and indicated, "Received stat lab results and called MD...BUN was 88 (was 65 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 5 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 on September 27, 2018), creatinine 3 (was 1.99 on September 27, 2018)...MD gave n/o (new order) to send res (resident) to ER (emergency room) d/t (due to) worsening kidney function and increased confusion..." The facility document titled,"Health Status Note," dated October 1, 2018, at 4:56 a.m., was reviewed and indicated, "Res (resident) was picked-up via AMR (American Medical Response-a medical emergency transportation company) with 2 attendants @ (at) 0225 (2:25 a.m.) to (name of acute hospital) ER (emergency room). The facility document titled, "Health Status Note," dated October 1, 2018, at 6:58 a.m., was reviewed and indicated, "...resident will be admitted..." An interview was conducted with Licensed Vocational Nurse (LVN) 1 on October 2, 2018, at 2:32 p.m. LVN 1 stated she faxed the laboratory report to the physician on September 28, 2018, at 10:32 p.m. LVN 1 stated the physician would normally review the laboratory results and send a fax to the facility with a response. LVN 1 stated when the facility did not receive a response from the physician, the facility would call the physician within a few hours, especially if the results were abnormal. LVN 1 reviewed Resident 1's record and verified there was no documentation indicating the facility followed up with the physician. A telephone interview was conducted with the NP on October 2, 2018, at 4:07 p.m. The NP stated the facility should have called the physician to report the abnormal lab results right away. The NP stated if he had received the abnormal results on September 28th instead of September 30th, he could have ordered the IV hydration sooner. The NP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 6 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 acknowledged there was a delay in treating Resident 1. An interview was conducted with the Director of Nursing (DON) on October 2, 2018, at 4:43 p.m. The DON reviewed Resident 1's record and stated, "I expect that if the nurse doesn't hear a response from the doctor after faxing they should call the doctor." When asked about the time frame when the nurse should follow up with the physician after faxing, the DON stated, "NOC (night) shift at some point should have followed up." The DON verified there was no documentation indicating the facility followed up with the physician after faxing the abnormal laboratory results for Resident 1. According to the web article, "Acute kidney injury (AKI)," published by the National Kidney Foundation in 2017, "Acute kidney injury... is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days...Acute kidney injury is common...especially in older adults...Signs and Symptoms...may include...Confusion...It is important that AKI is found as soon as possible...because it can lead to kidney failure...or death....tests to measure kidney function...A creatinine level greater that 1.4 for men may be an early sign that the kidneys are not working properly...A normal BUN level is between 7 and 20. As kidney function decreases, the BUN level rises...." Due to the facility's failure to ensure abnormal laboratory results were reported to the physician and acted upon timely for Resident 1, who required hospitalization, the Administrator and Director of Staff Development were verbally notified of an Immediate Jeopardy situation on October 3, 2018, at 4:42 p.m. The facility's plan of action to remove the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 7 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 immediacy was received and reviewed on October 3, 2018, at 8:04 p.m. The facility's plan of action was verified to have been implemented on October 5, 2018, at 4:11 p.m. The Immediate Jeopardy was removed in the presence of the Administrator at the facility on October 5, 2018, at 4:18 p.m. b. The record for Resident 5 was reviewed on October 4, 2018. Resident 5 was admitted to the facility on October 19, 2017, with diagnoses including muscle weakness, heart failure, chronic obstructive pulmonary disease (respiratory disease), end stage renal disease (kidney disease), and iron deficiency anemia (low iron level in the blood). A laboratory result received by the facility on September 21, 2018, at 7:08 a.m., for the blood drawn on September 20, 2018, at 4:15 p.m., indicated the following tests were abnormal: a) Reticulocyte count (number of new red blood cells in the body) 2.9% (percent), reference range (RR): 0.0-2.0%; b) BUN (test for kidney and liver function) 42 mg/dL, RR: 7-25 mg/dL; c) Chloride (test for kidney function) 109 mEq (milliequivalent, one-thousandth of an equivalent of a chemical element)/L (liter of blood, RR: 98-107 mEq/L; d) BUN/Creatinine ratio (test for kidney function) 35.3, RR: 10.0-20.0; e) Hemoglobin (iron protein in red blood cells) 10.7 g (grams)/dL, RR: 11.2-15.7 g/dL; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 8 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 f) Hematocrit (volume of red blood cells) 33.5%, RR: 34.1-44.9%. A handwritten note on the bottom of the laboratory report indicated the report was faxed to the physician on September 21, 2018, at 8:31 a.m. There was no documentation indicating Resident 5's physician received the laboratory report, or if any new treatment orders were given by the physician for Resident 5. The facility document titled, "Progress Note," dated September 22, 2018, at 11:14 a.m., (28 hours after the laboratory report was received by the facility) was reviewed and indicated, "...Called NP to make aware of lab results. 09/20/18...No new orders at this time..." An interview was conducted with LVN 2 on October 5, 2018, at 11:24 a.m., LVN 2 reviewed Resident 5's laboratory results and stated the facility should have followed up to see if the physician received the abnormal results. c. The record of Resident 6 was reviewed on October 4, 2018. Resident 6 was admitted to the facility on September 4, 2018, with diagnoses which included acute embolism and thrombosis (blood clot) of unspecified vein of the lower extremity and pneumonia (lung infection). Resident 6's record included a physician order, dated September 17, 2018, which indicated, "...Pt/INR (PT, Prothrombin Time - test used to help detect bleeding disorder; International Normalized Ratio- test used to monitor how well the blood- thinning medication was working) every night shift every Wed (Wednesday)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 9 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 A laboratory report received by the facility for Resident 6, dated September 27, 2018, at 7:15 a.m., for a blood draw done on September 26, 2018, at 3:50 p.m., was reviewed and indicated a PT of 18.2 with a reference range of 11 to 13.6 sec. (seconds). Resident 6's "Progress Notes," dated September 27 2018, at 7:48 a.m., was reviewed and indicated, "...res (resident) PT/INR from 9/26/18: PT high 18.2...MD faxed at 0748, awaiting response..." There was no documented evidence the facility followed up with the physician regarding the abnormal PT laboratory test results for Resident 6 until September 28, 2018, at 11 a.m., (27 hours after the facility received the laboratory results). On October 5, 2018, at 10:40 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated she should have called the physician on September 27, 2018, to follow up on the abnormal PT laboratory test results for Resident 6. The facility policy and procedure titled, "Physician Notification of Lab/X-ray Results," revised August 29, 2018, was reviewed. The policy indicated, "...It is the policy of (initials of facility) to assure that the physician is notified of all abnormal lab/x-ray results so that prompt, appropriate action may be taken if indicated for the resident's care..." The policy did not indicate a specific time frame for notification and follow up with the physician for abnormal laboratory test results. 2. The record for Resident 4 was reviewed on October 4, 2018. Resident 4 was admitted to the facility on September 24, 2018, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 10 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 diagnoses including atrial fibrillation (heart condition), elevated prostate specific antigen (PSA-enzyme secreted by the prostate gland), and generalized muscle weakness. A laboratory result received by the facility on September 26, 2018, at 5:33 p.m., for the specimen collected on September 26, 2018, at 7:07 a.m., indicated the following abnormal urine test results: a) Protein 1+, reference range (RR): Negative; b) Urobilinogen (increased levels in urine can indicate liver disease) 2.0 mg/dL, RR: 0.2-1.0 mg/dL; c) Leukocyte Esterase (test for white blood cells in urine) 2+, RR: Negative; d) Appearance cloudy, RR: clear to slightly cloudy; e) Red Blood Cell 6-10, RR: 0-2; and f) White Blood Cell > (greater than) 50, RR: 05. The report indicated a urine culture (test for bacteria) was pending. A handwritten note on the bottom of the laboratory report indicated the report was faxed to the physician on September 26, 2018, at 10:40 p.m. The facility document titled, 'Progress Note," dated September 27, 2018, at 1:16 a.m., was reviewed and indicated, "Res (resident) result came in for UA (urinalysis) and abnormal levels read as follows...MD was made aware via fax on 9/26 @2240 (sic). No new orders at this time, pending md (sic) response..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 11 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 There was no documentation indicating Resident 4 was assessed for signs and symptoms of a possible urinary tract infection (fever, pain, burning upon urination, confusion), or if the physician received the abnormal laboratory results prior to September 27, 2018, at 1:16 a.m. The urine culture report for Resident 4 was received by the facility on 9/28/2018, at 1:33 p.m. The report indicated abnormal results. A facility document titled, "Progress Note," dated September 28, 2018, at 9:44 p.m., (eight hours after the urine culture result was received by the facility and 23 hours after the abnormal urinalysis result was received by the facility) was reviewed and indicated, "...called medical director (name of physician) to make aware we received Resident's urine culture results...Informed MD Resident has foul smelling urine, c/o (complaints of) dysuria (pain when urinating), as well as persist (sic) increase in confusion. Received new verbal order for Levaquin (antibiotic)..." An interview was conducted with LVN 2 on October 5, 2018, at 11:24 a.m., regarding Resident 4's abnormal urinalysis results. LVN 2 stated, "As soon as we got it (the abnormal urinalysis laboratory result) it should have been faxed to the MD. Then we should have called, especially with abnormal values." 3. On October 5, 2018, Resident 8's record was reviewed. Resident 8 was admitted to the facility on September 25, 2018, with diagnoses which included rhabdomyolysis (the destruction or degeneration of muscle tissue), hepatic failure (liver disease), and congestive heart failure. The "Progress Note," dated October 1, 2018, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 12 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 5:35 p.m., indicated, "...Unable to obtain vital signs, no palpable pulse and unable to auscultate (hear) apical pulse (heartbeat) at this time." The "Progress Note," dated October 1, 2018, at 5:37 p.m., indicated, "...This nurse was with resident in room (Resident 8's room number) administering evening medications. Resident was stable at the time and after taking ordered medication, resident began to cough at approximately 1710 (5:10 p.m.)...Resident cont (continue) to have some coughing and was able to state she felt like one of her pills was stuck...assisted resident to sit upright and she spit a pill out. At the time, resident was alert and had her eyes open. Immediately after, resident noted to tense up, mouth clamped shut and both hands were into fists. At that moment resident became unresponsive, and this nurse was unable to get a pulse...Resident was found to have a DNR (Do Not Resuscitate). Comfort measures were provided, oxygen placed at 6L (liter) via (through) Mask, suctioning provided and no secretions were noted. Resident had a faint pulse was palpable for about a minute, then was unable to palpate or auscultate a heart rate. Unable to obtain a blood pressure or oxygen saturation (measurement of oxygen in the blood) after several attempts for about 15 minutes..." There was no documented evidence the physician was notified when Resident 8 was having a change of condition, exhibiting signs of choking, and became unresponsive. There was no documented evidence in Resident 8's record the facility called 911 (emergency services) when Resident 8 was having a change of condition, exhibiting signs of choking, and became unresponsive. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 13 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 On October 5, 2018, at 2:25 p.m., the Interim Director of Nursing (IDON) was interviewed. The IDON stated if she were the nurse taking care of Resident 8, she would have called 911. The IDON further stated the nurse should have called 911. On October 5, 2018, at 3:37 p.m., a telephone interview was conducted with LVN 4. LVN 4 stated it was after 5 p.m. when she was giving Resident 8's evening medications. LVN 4 stated she was giving Resident 8 the evening medications which included a calcium (a supplement) tablet, a magnesium (a supplement) tablet, lactulose (medication used to treat constipation and also used to reduce the amount of ammonia in the blood), and one other medication she could not remember. LVN 4 stated Resident 8 took her pills one by one and Resident 8 told her, "Ok, it was down." LVN 4 stated shortly after Resident 8 told her the pill was down, Resident 8 started coughing. LVN 4 stated Resident 8 told her, "I felt like a pill coming back up." LVN 4 stated Resident 8 spit out a pill. LVN 4 further stated, "I guess, it was the calcium tablet." LVN 4 stated Resident 8 suddenly tensed up. The staff could not find a pulse and she was pale. LVN 4 stated she could not recall if someone called 911, and stated, "I didn't." On October 5, 2018, at 4:20 p.m., a telephone interview was conducted with the Attending Physician (AP). When the AP was asked if the staff should have called 911, the AP responded, "Yes, the staff should have called 911 and then deal with me." The AP further stated residents who were DNR still need to be treated. On October 5, 2018, the facility's policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 14 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 procedure titled, "Change of Condition," revised August 23, 2017, was reviewed. The policy indicated: "...A change of condition is defined as any emergent or non-emergent deviation from the residents normal health...that requires a physician's intervention and significant alteration in the treatment plan...Examples of emergent changes in condition that require physician notification and/or emergency intervention include, but are not limited to: Nonresponsive, Absent vital signs..."

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

F867 10/31/2018 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (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 a comprehensive plan of action to correct quality deficiencies which were identified during a survey conducted on August 6, 2018, through August 8, 2018, related to the facility's laboratory system. The committee failed to include and implement a plan for timely notification of the physician and follow up of abnormal laboratory test results. This failure resulted in the physician not being notified of abnormal laboratory results and follow up related to those lab results not being done timely for four of nine sampled residents (Residents 1, 4, 5, and 6). As a result, quality FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 15 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 deficiencies continued to be present during the facility's revisit survey (Cross reference F684). Findings: On October 2, 2018, at 3:18 p.m., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON) regarding the facility's QAA process. The ADM stated the facility had developed an improvement plan to address the problem of the labs not being done as ordered by the physician, which was the problem identified during the original survey. When asked if the facility reviewed the complete laboratory system (the process from receiving the lab test order to notifying the physician of the results and following up with the physician for treatment orders) to identify quality issues when they developed the plan, the DON stated they looked at the process from the initial order to reporting results to the physician. On October 5, 2018, the facility's "PERFORMANCE IMPROVEMENT PROJECT (PIP) GUIDE," dated August 13, 2018, was reviewed. The guide indicated the key area for improvement was, "Staff to have re-education: order entry, ability to identify high risk labs & meds, improved documentation." The goal indicated, "Lab orders completed as ordered by M.D. (physician)." The plan did not identify any concerns regarding the notification of and following up for abnormal laboratory results to the physician. On October 5, 2018, at 9:58 a.m., an interview was conducted with the ADM. The ADM stated she felt the QAPI (Quality Assessment Process Improvement) addressed the issue of labs not being done as ordered by the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 16 of 17 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: _______________ 555463 (X3) DATE SURVEY COMPLETED 10/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia 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 ADM acknowledged the facility should have addressed the facility's complete laboratory system, including notification of abnormal test results to the physician and following up with the physician for treatment orders, during the QAA process. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1VEW12 Facility ID: CA240000902 If continuation sheet 17 of 17