Other·November 19, 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 represents the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number: CA00599394. Representing the California Department of Public Health: Surveyor 29337, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00599394.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 09/28/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) 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: YIDG11 Facility ID: CA240001502 If continuation sheet 1 of 8 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 09/18/2018 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 and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 2 of 8 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 09/18/2018 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 address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report Resident 1's transfer/discharge from the facility to the local ombudsman office. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 3 of 8 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 09/18/2018 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 On August 21, 2018, the record for Resident 1 was reviewed. Resident 1 was admitted to the facility on July 19, 2018, and transferred to another skilled nursing facility on July 23, 2018. Resident 1 was admitted to the facility for short term care, with diagnoses that included status post subacute cerebral vascular accident (CVA - stroke), blind, deaf, and altered mental status. Resident 1 previously resided in an assisted living facility and was expected to return to her previous living situation. Resident 1 was admitted for physical therapy, occupational therapy, strengthening and conditioning. On July 21, 2018, Resident 1 was assessed by the physical therapy department and was determined to be not appropriate for skilled rehabilitation due to "... pt is bed bound and has not ambulated in several years. Pt also has dementia and is not able to participate with skilled PT ..." On July 21, 2018, the Occupational Therapy department attempted to assess Resident 1, "... however, pt refused to participate in therapy and demonstrated agitation ..." In the ensuing days, Resident 1 was combative, confused, and refused therapies and medications. Resident 1 had no family and personnel at the assisted living facility stated they could not accept her back due to the need for more care than could be afforded at the facility. On July 23, 2018, Resident 1 was transferred by ambulance, to another skilled nursing facility for custodial long term care. On August 8, 2018, at 11 a.m., the Director of Nurses (DON) was interviewed and stated Resident 1 refused care, physical therapy, and occupational therapy. The DON stated, "We only take (admit) short term rehab (rehabilitation) since 2016. If a resident needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 4 of 8 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 09/18/2018 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 long term care, the case manager locates another facility that takes both short and long term care." On August 8, 2018, at 1:20 p.m., the Case Manager (CM) was interviewed and stated there was no documentation Resident 1's lateral transfer to another skilled nursing facility was reported to the local ombudsman office. The CM stated, "I was gone for the day. We are working on a new system (to not miss reporting when one person is out of the office)." The CM stated she was responsible for reporting all discharges and transfers to hospitals or skilled nursing facilities to the ombudsman office.

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

F842 09/27/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 5 of 8 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 09/18/2018 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 records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 6 of 8 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 09/18/2018 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 services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to accurately identify and document the condition and services provided to Resident 2 during his stay at the facility Findings: On August 21, 2018, the record for Resident 2 was reviewed. Resident 2 was admitted to the facility on June 18, 2018, with diagnoses that included congestive heart failure (chronic progressive condition that affects the pumping power of the heart muscle), cardiomyopathy (group of diseases that affect the heart muscle), and status post cerebral vascular accident (CVA - stroke). Resident 2 was admitted for rehabilitation. The Medication Administration Record (MAR) was reviewed and indicated, Resident 2 was to be administered two intravenous antibiotics (Zosyn every 8 hours and Daptomycin every 24 hours) from June 18 through July 25, 2018, for treatment of gangrenous toes. The record contained photographs of the gangrenous toes. The Interdisciplinary Team Conference Record dated June 27, 2018, indicated Resident 2 had gangrene to the left big toes and 3rd and 5th toes. The record indicated Resident 2 left the facility against medical advice (AMA) on July 23, 2018, two days before IV antibiotic treatment was completed. The admitting History and Physical (H & P), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 7 of 8 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 09/18/2018 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 signed and dated June 19, 2018, by the physician, indicated there were no skin rashes. The extremities nor the gangrenous toes were addressed and were not included in the admitting diagnoses. On August 21, 2018, at 12:45 p.m., the Director of Nurses (DON) was interviewed. The DON stated the admitting H & P was incomplete, inconclusive, and did not reflect a complete admitting diagnoses and assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YIDG11 Facility ID: CA240001502 If continuation sheet 8 of 8