Other·November 1, 2017

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 survey for the investigation of one facility reported incident and one complaint. Facility reported incident number CA00515005, and complaint number CA00531502. Representing the California Department of Public Health: Surveyor 22384, HFEN. The inspection was limited to the specific complaint reported and does not represent the findings of a full inspection of the facility. Deficiencies were issued for facility reported incident number CA0051005, and complaint number CA00531502.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 10/24/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 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: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.25 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nursing interventions and monitoring, (to include nursing assessments regarding anti-anxiety and sleeping medications) were implemented for Resident A who had a history of falls (to include a previous fall at the facility), and failed to ensure the resident's physical status did not deteriorate outside the limits of the normal aging process. This failure resulted in the resident falling and striking his head, which required acute care hospitalization. Resident A subsequently died three days after his second fall due to an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 intracranial hemorrhage (bleeding inside the skull) extending from the right frontal lobe to the right temporal lobe. Findings: A review of Resident A's record was conducted. Resident A was admitted to the facility on December 7, 2016, with a diagnosis of chronic obstructive pulmonary disease, (a progressive lung disease) and depression. A review of the resident's neurological assessment dated December 12, 2016, at 12:05 a.m., indicated Resident A was, "Awake alert and oriented to person, place, time and purpose. Eyes open spontaneously, speech clear, face symmetrical, sensation intact all extremities and moves all extremities ... " A review of the Morse Fall Scale (numerical scale indicating a resident's risk for falls), dated December 7, 2016, at 10:31 p.m., was conducted. Resident A's Morse Fall Scale score was 65. The document indicated a Morse Fall Scale score of greater than 46 placed the resident at a high risk for falling. Among the medications Resident A was prescribed included plavix and aspirin, both blood thinners (according to WebMD, 2016, side effects of those two medications include bleeding). In addition, Resident A was receiving xanax and lorazepam (medications to treat anxiety). Comments printed on the resident's medication administration record indicated xanax and lorazapam increase the risk of cognitive impairment, falls, and fractures. Further record review indicated restoril 15 milligrams (mg) was prescribed for Resident A at bedtime as needed for insomnia. Comments printed on the physician's order reflected, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 "Caution, Geriatric or debilitated patients: Decrease dose to 7.5 mg. po (orally) 30 minutes before bedtime. The risk of over sedation, dizziness, confusion, ataxia (lack of muscle coordination) and falls increases significantly with larger doses of benzodiazepines (a class of drugs to treat anxiety and insomnia) in elderly or debilitated patients." Resident A was also receiving norco 5/325 mg. orally every six hours as needed (norco, according to the U.S. National Library of Medicine (2016) is a narcotic pain medication with side effects including lightheadedness, dizziness and fainting). The physician document titled "Progress Notes" dated December 12, 2016 at 3 p.m., indicated "Fall precautions." A review of the Nursing Progress Notes dated December 12, 2016, at 11:27 p.m., was conducted. The document indicated on December 12, 2016, at 7:45 p.m., Resident A had an unwitnessed fall and was found on the floor next to the bed. The record indicated Resident A had received lorazepam .5 mg on December 12, 2016, at 5:06 p.m., two and a half hours prior to his fall which occurred at 7:45 p.m., and xanax .5 mg 15 minutes prior to his fall. A review of the Nursing Progress Notes dated December 15, 2016, at 11 p.m., (three days after Resident A's first fall), indicated the resident sustained a second fall, and was found on the floor next to the bed with a laceration to his left forehead. Resident A was transferred to the Emergency Room (ER), where the laceration was repaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 record reflected prior to the resident's second fall on December 15, 2016, Resident A received lorazepam 0.5 mg. at 6:31 p.m. (five hours and nine minutes prior to falling), norco 5/325 mg. at 9:03 p.m., (two hours and 57 minutes prior to falling), and restoril 15 mg, at 9:04 p.m., (two hours, 56 minutes) prior to his fall at 11 p.m. There was no documentation that indicated Resident A was reassessed for his response to the medications lorazepam or restoril since his initial fall on December 12, 2016, at 7:45 p.m. Resident A returned to the facility on December 16, at 2:15 a.m. On December 16, 2016, at 6:30 a.m., Resident A began to have seizure activity. 911 emergency response was called and the resident was transported to the ER. Resident A was admitted and subsequently died on December 18, 2016, at 2:35 p.m., from an intracranial hemorrhage three days after he fell at the facility on December 15, 2016. An interview was conducted with the Licensed Vocational Nurse (LVN) 1, on December 20, 2016, at 9:20 a.m. LVN 1 stated Resident A was discovered on the floor, on December 12, 2016, at 7:45 p.m. LVN 1 stated when she telephoned the resident's physician to notify him of Resident A's fall she did not inform him the resident was receiving two blood thinners (plavix and aspirin). An interview was conducted with the Charge Nurse (CN) 1 on December 20, 2016, at 11 a.m. CN 1 stated the certified nurses assistant, (CNA) 1, told her after she changed Resident A's linen on December 15, 2016, she forgot to put the bed alarm back on. An interview was conducted with the Interim FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 Chief Nursing Officer (ICNO) on December 20, 2016, at 10:35 a.m. The ICNO stated a care plan which addressed Resident A's high risk of fall was not initiated. The ICNO further stated a low bed was not ordered for Resident A after the resident's initial fall, nor were any additional interventions implemented for Resident A after his initial fall on December 12, 2016. The ICNO was unable to find documentation to indicate Resident A was assessed for his response to all medications given prior to his fall. According to the facility's policy, "Fall Prevention/Risk Assessment (Revised April 4, 2016), fall precautions are safety interventions initiated to decrease the potential for a resident's exposure to harm." A review of the facility policy, "Fall Prevention/Risk Assessment (Revised/Reviewed 4/2016)," was conducted. The purpose was indicated as, "To identify residents at risk for falls and to establish guidelines for prevention of resident falls."The policy indicated, "The licensed Nurse will institute a plan of care that identifies the fall risk score and the interventions for that fall risk score...A High (fall) Risk is a score of 46 and above." The procedure indicated among the following possible interventions based upon a resident who is assessed as a High Risk of fall based on the Morse Fall Scale are, "Obtain an order for a low bed if appropriate for patients' diagnosis and Monitor patients' response to medication..." The facility failed to ensure additional nursing interventions were implemented, to include updating the care plan, for Resident A, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 assessed as being at a high risk for falls, after he sustained an initial fall at the facility. This failure potentially resulted in the resident falling from his bed a second time, striking his head. Resident A died three days after his second fall at the facility when he sustained an intracranial hemorrhage due to blunt force trauma.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 09/25/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 facility failed to ensure nursing interventions to prevent accidents (falling) were implemented for Resident A, who was assessed as being at a high risk for falls. These failures potentially resulted in the resident falling from his bed and striking his head. In addition, the resident was not monitored for his response to xanax and lorazepam, (medications for anxiety), or restoril (for sleep). Resident A subsequently passed away three days after falling from his hospital bed to the floor, when he sustained an intracranial hemorrhage (bleeding inside the skull) due to blunt force trauma. Findings: A review of Resident A's record was conducted. Resident A was admitted to the facility on December 7, 2016, with a diagnosis of chronic obstructive pulmonary disease. Resident A had a history of pneumonia, seizures, depression, and coronary artery disease. A review of the Morse Fall Scale (numerical scale indicating a resident's risk for falls), dated December 7, 2016, at 10:31 p.m., was conducted. Resident A's total Morse Fall Scale score was 65 as the resident had a history of falling and forgot his physical limitations (the resident used a wheelchair for mobility). The document indicated a Morse Fall Scale score of greater than 46 placed the resident at a high risk of falling. Among the medications Resident A was prescribed included plavix and aspirin, both blood thinners. (according to WebMD, 2016, side effects of those two medications include bleeding). In addition, Resident A was receiving xanax and lorazapam. Comments indicated under the resident's medication administration records indicated xanax and lorazapam FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 increase the risk of cognitive impairment, falls, and fractures. Further record review indicated restoril 15 milligrams (mg) was prescribed for Resident A at bedtime as needed for insomnia. Comments indicated under the physician's order reflect, "Caution, Geriatric or debilitated patients: Decrease dose to 7.5 mg. po (orally) 30 minutes before bedtime. The risk of oversedation, dizziness, confusion, ataxia (lack of muscle coordination) and falls increases significantly with larger doses of benzodiazepines (a class of drugs to treat anxiety and insomnia) in elderly or debilitated patients." Record review failed to show that the physician was notified regarding decreasing Resident A's dose of restoril from 15 mg to 7.5 mg. A review of the Nursing Progress Notes dated December 12, 2016, at 11:27 p.m., was conducted. The document indicated on December 12, 2016, at 7:45 p.m., Resident A had an unwitnessed fall and was found on the floor next to the bed. Resident A had received xanax .5 mg at 7:28 p.m. on December 12, 2016, 15 minutes prior to his fall. The resident received lorazepam .5 mg on December 12, 2016, at 5:06 p.m., two and a half hours prior to his fall. An interview was conducted with the Licensed Vocational Nurse (LVN) 1, on December 20, 2016, at 9:20 a.m. LVN 1 stated Resident A was discovered on the floor, on December 12, 2016, at 7:45 p.m. A review of the Nursing Progress Notes dated December 15, 2016, at 11 p.m., three days after Resident A's first fall on December 12, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 2016, was conducted. The resident was found on the floor next to the bed with a laceration to his left forehead. Resident A was transferred to the Emergency Room (ER) where he received stitches to the laceration. The record reflected on December 15, 2016, Resident A received restoril 15 mg, at 9:04 p.m., two hours prior to his fall at 11 p.m. An interview was conducted with the Charge Nurse (CN) 1 on December 20, 2016, at 11 a.m. CN 1 stated the certified nurses assistant, (CNA) 1, told her after she changed Resident A's linen on December 15, 2016, she forgot to put the bed alarm back on. Documentation indicated the following: Resident A returned to the facility on December 16, at 2:15 a.m. On December 16, 2016, at 6:30 a.m., Resident A began to have seizure activity. 911 emergency response was called and the resident was transported to the ER. Resident A was admitted and subsequently died on December 18, 2016, at 2:35 p.m., from an intracranial hemorrhage three days after he fell at the facility on December 15, 2016. An interview was conducted with the Interim Chief Nursing Officer (ICNO) on December 20, 2016, at 10:35 a.m. The ICNO stated a care plan which addressed Resident A's high risk of fall was not initiated. The ICNO further stated a low bed was not ordered for Resident A after the resident's initial fall, nor were any additional interventions implemented for Resident A after his initial fall on December 12, 2016. The ICNO was unable to find documentation to indicate Resident A was assessed for his response to all medications given prior to his fall. A review of the facility policy, "Fall Prevention/Risk Assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 (Revised/Reviewed 4/2016)," was conducted. The purpose was indicated as, "To identify residents at risk for falls and to establish guidelines for prevention of resident falls." The policy indicated, "The licensed Nurse will institute a plan of care that identifies the fall risk score and the interventions for that fall risk score...A High (fall) Risk is a score of 46 and above." The procedure indicated among the following possible interventions based upon a resident who is assessed as a High Risk of fall based on the Morse Fall Scale are, "Obtain an order for a low bed if appropriate for patients' diagnosis and Monitor patients' response to medication..."

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 09/22/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure nursing interventions and sufficient monitoring, (to include nursing assessments regarding anti-anxiety medications, sleeping medications, and medication dosages), were implemented for Resident A who had a history of falls, to include a previous fall at the facility. These failures resulted in the resident falling a second time striking his head, which required acute care hospitalization. Resident A subsequently died three days after his second fall due to an intracranial hemorrhage (bleeding inside the skull) extending from the right frontal lobe to the right temporal lobe. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 review of Resident A's record was conducted. Resident A was admitted to the facility on December 7, 2016, with a diagnosis of chronic obstructive pulmonary disease (a progressive lung disease) and depression. A review of the Morse Fall Scale (numerical scale indicating a resident's risk for falls), dated December 7, 2016, at 10:31 p.m., was conducted. Resident A's Morse Fall Scale score was 65. The document indicated a Morse Fall Scale score of greater than 46 placed the resident at a high risk of falling. Among the medications Resident A was prescribed included plavix and aspirin, both blood thinners (according to WebMD, 2016, side effects of those two medications include bleeding). In addition, Resident A was receiving xanax and lorazepam (medications to treat anxiety). Comments printed on the resident's medication administration record indicated xanax and lorazapam increase the risk of cognitive impairment, falls, and fractures. Further record review indicated restoril 15 milligrams (mg) was prescribed for Resident A at bedtime as needed for insomnia. Comments printed on the physician's order reflected, "Caution, Geriatric or debilitated patients: Decrease dose to 7.5 mg. po (orally) 30 minutes before bedtime. The risk of over sedation, dizziness, confusion, ataxia (lack of muscle coordination) and falls increases significantly with larger doses of benzodiazepines (a class of drugs to treat anxiety and insomnia) in elderly or debilitated patients." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 also receiving Norco 5/325 mg. orally every six hours as needed (Norco, according to the U.S. National Library of Medicine (2016) is a narcotic pain medication with side effects including lightheadedness, dizziness and fainting). The physician document titled, "Progress Notes" dated December 12, 2016, at 3 p.m., indicated "Fall precautions." A review of the Nursing Progress Notes dated December 12, 2016, at 11:27 p.m., was conducted. The document indicated on December 12, 2016, at 7:45 p.m., Resident A had an unwitnessed fall and was found on the floor next to the bed. The record indicated Resident A had received lorazepam .5 mg on December 12, 2016, at 5:06 p.m., two and a half hours prior to his fall which occurred at 7:45 p.m., and xanax .5 mg 15 minutes prior to his fall. There was no documentation that indicated Resident A was assessed or monitored for his response to the medication lorazepam, or the xanax. A review of the Nursing Progress Notes dated December 15, 2016, at 11 p.m., (three days after Resident A's first fall), indicated the resident sustained a second fall, and was found on the floor next to the bed with a laceration to his left forehead. Resident A was transferred to the Emergency Room (ER), where the laceration was repaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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 record reflected prior to the resident's second fall on December 15, 2016, Resident A received lorazepam 0.5 mg. at 6:31 p.m. (five hours and nine minutes prior to falling), norco 5/325 mg. at 9:03 p.m. (two hours and 57 minutes prior to falling), and restoril 15 mg, at 9:04 p.m., (two hours, 56 minutes) prior to his fall at 11 p.m. There was no documentation which indicated Resident A was assessed or monitored for his response to the medications lorazepam, or restoril, or that non pharmacological interventions were utilized since his initial fall on December 12, 2016, at 7:45 p.m. Further record review failed to show that Resident A's physician was informed that the resident was receiving two blood thinners, aspirin and plavix when he fell on December 12 and 15, 2016. The record indicated the following: Resident A returned to the facility on December 16, at 2:15 a.m. On December 16, 2016, at 6:30 a.m., Resident A began to have seizure activity. 911 emergency response was called and the resident was transported to the ER. Resident A was admitted and subsequently died on December 18, 2016, at 2:35 p.m., from an intracranial hemorrhage three days after he fell at the facility on December 15, 2016. An interview was conducted with the Licensed Vocational Nurse (LVN) 1, on December 20, 2016, at 9:20 a.m. LVN 1 stated Resident A was discovered on the floor, on December 12, 2016, at 7:45 p.m. LVN 1 stated when she telephoned the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (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's physician to notify him of Resident A's fall she did not inform him the resident was receiving two blood thinners (plavix and aspirin). An interview was conducted with the Interim Chief Nursing Officer (ICNO) on December 20, 2016, at 10:35 a.m. The ICNO stated a care plan which addressed Resident A's high risk of fall was not initiated to include monitoring the patient for side effects of the anti-anxiety, pain, sleep, and blood thinning medication he was receiving. The ICNO was unable to find documentation to indicate Resident A was assessed for his response to all medications given prior to his fall. A review of the facility policy, "Fall Prevention/Risk Assessment (Revised/Reviewed 4/2016)," was conducted. The purpose was indicated as, "To identify residents at risk for falls and to establish guidelines for prevention of resident falls." The policy indicated, "The licensed Nurse will institute a plan of care that identifies the fall risk score and the interventions for that fall risk score...A High (fall) Risk is a score of 46 and above." The procedure indicated among the following possible interventions based upon a resident who is assessed as a High Risk of fall based on the Morse Fall Scale are, "Obtain an order for a low bed if appropriate for patients' diagnosis and Monitor patients' response to medication..." Review of the death certificate indicated the cause of Resident A's death was "Intracranial Hemorrhage," and "Blunt Force Head Trauma." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 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: _______________ 555623 (X3) DATE SURVEY COMPLETED 10/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HEMET VALLEY HEALTHCARE CENTER 371 N Weston Pl Hemet, CA 92543 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility failed to ensure additional nursing interventions to include nursing assessments and monitoring regarding anti-anxiety medications, sleeping medications, and medications dosages, were implemented for Resident A assessed as being at a high risk for falls, after he sustained an initial fall at the facility. This failure potentially resulted in the resident falling from his bed a second time, striking his head. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DF9O11 Facility ID: CA240001502 If continuation sheet 17 of 17