Other·November 20, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification survey conducted from September 17, 2018, through September 20, 2018. Representing the California Department of Public Health: 38477, HFEN; 32192, HFEN; 36779, HFEN; 37626, HFEN; 40227, HFEN; 40308, HFEN; 40356, HFEN; and 40830, Nutrition Consultant. The facility census was 50. The sample size was 17 residents. The facility entity reported incident number CA00604214 and complaint number CA00604364 were linked and investigated during the survey. The Department was unable to substantiate the allegation, but identified other violations for the entity reported incident number C00604214 and complaint number CA00604364 (linked).

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

F609 10/11/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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: GOCQ11 Facility ID: CA240001502 If continuation sheet 1 of 35 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 09/20/2018 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 §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state agency California Department of Public Health (CDPH) immediately, but no later than two hours, for one resident (Resident 101). This failure had the potential to place the residents in the facility at risk for harm from abuse. Findings: On September 17, 2018, at 3:15 p.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 2 of 35 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 09/20/2018 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 Director of Nursing (DON) reported an allegation of abuse to the survey team. The DON stated the allegation of abuse occured on September 16, 2018, at 11:30 a.m. (the allegation was reported 27 hours after the incident of the alleged abuse). On September 17, 2018, at 3:50 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the alleged incident of abuse occured on September 16, 2018, at 11:30 a.m. RN 1 stated Certified Nursing Assistant (CNA) 1 allegedly had an attitude towards Resident 101. RN 1 stated CNA 1 allegedly took Resident 101's call light away. RN 1 stated CNA 1 was allowed to work until the end of the shift. RN 1 stated the nurse who was working on September 16, 2018, did not notify the DON regarding the allegation of abuse. On September 19, 2018, at 10:18 a.m., RN 3 was interviewed. RN 3 stated Resident 101 was upset with CNA 1 on September 16, 2018, at approximately 11:30 a.m. RN 3 stated she did not report the incident to the DON, the physician, nor to Resident 101's family member. RN 3 stated CNA 1 worked until the end of her shift. The record of Resident 101 was reviewed on September 19, 2018. Resident 101 was admitted to the facility on September 4, 2016, with diagnoses which included chronic respiratory failure with tracheostomy (respiratory disorder needing a surgical opening through the neck for airway) and hypertension (high blood pressure). Resident 101's Minimum Data Set (MDS- an assessment tool), dated July 26, 2018, indicated his Brief Interview for Mental Status (BIMS) score was 15 (on a scale of 0-15, in which 13-15 indicated the patient was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 3 of 35 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 09/20/2018 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 cognitively intact). On September 19, 2018, at 1:44 p.m., Resident 101 was interviewed. Resident 101 stated on September 16, 2018, between 11 a.m. to 11:30 a.m, she asked CNA 1 for help. Resident 101 stated CNA 1 told her she was going to help another resident. Resident 101 stated CNA 1 returned to her room approximately 20 minutes after she asked CNA 1 for help. Resident 101 stated CNA 1 prepared to provide care to her, so CNA 1 pulled the drapes around Resident 101's bed, then moved her call light away, and removed the wash cloth from her hand. Resident 101 stated she wanted her wash cloth back, so she asked CNA 1 to return it. Resident 101 stated when CNA 1 returned the wash cloth to her, CNA 1 told her "Here." Resident 101 stated CNA 1 returned the wash cloth with an "attitude." Resident 101 stated she told CNA 1, "You do not have to yell." Resident 101 stated she was not able to answer CNA 1 right away when CNA 1 asked her if she wanted another CNA to take care of her because she was, "stunned." Resident 101 stated CNA 1 "stormed out of the room." Resident 101 stated CNA 1 did not provide her the care before she left her room, so she called for help after CNA 1 left the room and another staff went to help her. Resident 101 stated she was "scared" of CNA 1. The facility policy titled, "Abuse, Prohibition of; Training, Investigating and Reporting," dated April 2016, was reviewed. The policy indicated: "...The appropriate regulatory agency is to be contacted within the timeframes discussed in this policy...Reporting....Cases of suspected or known abuse will be...reported immediately to the appropriate agency...The Chief Hospital FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 4 of 35 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 09/20/2018 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 Executive Officer and/or Chief Nursing Officer or designee shall investigate all suspected or alleged abuse of an elder or dependent adult and report incidents to the Department of Public Health ...If the suspected or alleged incident involves serious bodily injury...shall make a written report to the Department of Public Health...within 2 (two) hours...If the suspected or alleged incident does not involve serious bodily injury...shall make a written report to the Department of Public Health...within 24 hours..." The policy did not reflect the Federal regulations requirement for reporting all allegation of abuse to CDPH within two hours.

F640 SS=E Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 10/11/2018 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 5 of 35 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 09/20/2018 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 edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS- standardized assessment tool) discharge assessments for 22 residents (Residents 21, 7, 99, 15, 10, 8, 96, 2, 11, 98, 95, 9, 94, 105, 106, 4, 13, 12, 5, 6, 97, and 14). These failures resulted in the residents' discharge assessments to not be completed and transmitted within the time requirement. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 6 of 35 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 09/20/2018 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 September 20, 2018, at 10:21 a.m., the records of 22 residents were reviewed with the Minimum Data Set Nurse (MDSN) 2. The records indicated: 1. Resident 21 was admitted to the facility on April 6, 2018, and was discharged on April 30, 2018; 2. Resident 7 was admitted to the facility on April 5, 2018, and was discharged on April 19, 2018; 3. Resident 99 was admitted to the facility on April 27, 2018, and was discharged on May 17, 2018; 4. Resident 15 was admitted to the facility on April 20, 2018, and was discharged on May 8, 2018. Resident 15's second admission to the facility was on May 14, 2018, and he was discharged on May 20, 2018; 5. Resident 10 was admitted to the facility on April 12, 2018, and was discharged on April 20, 2018; 6. Resident 8 was admitted to the facility on April 6, 2018, and was discharged on April 27, 2018; 7. Resident 96 was admitted to the facility on April 19, 2018, and was discharged on May 16, 2018; 8. Resident 2 was admitted to the facility on August 8, 2018, and was discharged on August 13, 2018; 9. Resident 11 was admitted to the facility on March 3, 2018, and was discharged on April 27, 2018; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 7 of 35 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 09/20/2018 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 10. Resident 98 was admitted to the facility on April 27, 2018, and was discharged on May 11, 2018; 11. Resident 95 was admitted to the facility on April 18, 2018, and was discharged on May 6, 2018; 12. Resident 9 was admitted to the facility on April 6, 2018, and was discharged May 20, 2018; 13. Resident 94's first admission to the facility was on March 22, 2018, and was discharged on April 6, 2018. Resident 94's second admission to the facility was on April 12, 2018, and was discharged on May 3, 2018; 14. Resident 105 was admitted to the facility on May 2, 2018, and was discharged on May 16, 2018; 15. Resident 106 was admitted to the facility on May 3, 2018, and was discharged on May 17, 2018; 16. Resident 4 was admitted to the facility on March 26, 2018, and was discharged on April 10, 2018; 17. Resident 13 was admitted to the facility on March 21, 2018, and was discharged on May 11, 2018; 18. Resident 12 was admitted to the facility on April 16, 2018, and was discharged on May 3, 2018; 19. Resident 5 was admitted to the facility on March 31, 2018, and was discharged on April 27, 2018; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 8 of 35 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 09/20/2018 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 20. Resident 6 was admitted to the facility on April 2, 2018, and was discharged on April 19, 2018; 21. Resident 97's first admission to the facility was on April 25, 2018, and he was discharged on May 12, 2018. Resident 97's second admission to the facility was on May 12, 2018, and he was discharged on July 21, 2018; and 22. Resident 14 was admitted to the facility on April 20, 2018, and was discharged on April 28, 2018. There was no documented evidence the MDS discharge assessments were completed and transmitted for Residents 21, 7, 99, 15, 10, 8, 96, 2, 11, 98, 95, 9, 94, 105, 106, 4, 13, 12, 5, 6, 97, and 14. During a concurrent interview with MDSN 2, he stated the facility was behind with completing and transmitting the discharge assessments. MDSN 2 stated the discharge assessments should have been completed and transmitted within one to two weeks after the residents were discharged. The Director of Nursing (DON) was interviewed on September 20, 2018, at 12:40 p.m. The DON stated she was aware of the residents' discharge assessments which were not completed and transmitted. The facility policy titled, "Minimum Data Set (MDS) Log and Review Guide," dated April 2016, was reviewed. The policy indicated: "...To provide a tracking mechanism to ensure timely MDS assessment review and completion...It is the policy of this facility to utilize the MDS Log to track MDS review due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 9 of 35 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 09/20/2018 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 dates and to provide an interdisciplinary communication tool to enhance timely completion of MDS reviews..." The facility's policy did not indicate the time frame requirement for completing and transmitting the MDS discharge assessment.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 10/11/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 56) had an accurate comprehensive assessment. This failure increased the potential for Resident 56 to not receive the necessary treatment and services. Findings: On September 17, 2018, at 1:23 p.m., Resident 56 was observed awake and lying in bed. In a concurrent interview with Resident 56, he stated he was legally blind (can see at 20 feet or less what a person with normal vision can see at 200 feet). Resident 56 stated he informed the staff he was legally blind. On September 19, 2018, Resident 56's record was reviewed. Resident 56 was admitted to the facility on July 17, 2018, with diagnoses which included diabetes mellitus (high blood sugar) and weakness. The "...(name of the acute hospital) History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 10 of 35 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 09/20/2018 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 Physical," dated July 14, 2018, from the acute hospital from where Resident 56 was admitted was reviewed. The "...History and Physical," indicated, "...Problem...legally blind..." The facility's "History and Physical," dated July 18, 2018, did not indicate Resident 56 was legally blind. On September 20, 2018, at 9:56 a.m., the Activity Director (AD) was interviewed. The AD stated she was not aware Resident 56 was legally blind. On September 20, 2018, at 12:10 p.m., the Social Service Designee (SSD) was interviewed. The SSD stated Resident 56 informed her that he had macular degeneration (an eye disorder that causes vision loss). The SSD stated she documented this on her note upon Resident 56's admission. The SSD stated she should have referred Resident 56 to an eye doctor for his macular degeneration. On September 20, 2018, the Minimum Data Set (MDS-an assessment tool) was reviewed with MDS Nurse 1. The MDS comprehensive assessment, dated July 24, 2018, indicated, "...Section B...Vision...adequate..." In a concurrent interview with MDS Nurse 1, she confirmed Resident 56's vision was assessed in the MDS as adequate. MDS Nurse 1 stated Resident 56's MDS admission assessment for vision was inaccurately completed. On September 20, 2018, at 12:15 p.m., the Director of Nursing (DON) was interviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 11 of 35 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 09/20/2018 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 The DON stated Resident 56's vision should have been accurately assessed. The facility's policy and procedure titled, "Minimum Data Set (MDS) Log and Review Guide," dated April, 2016, was reviewed. The policy indicated: "...The MDS Assessment Nurse will enter all new admissions and in-house residents on the MDS Log upon admission or upon their first MDS reviews..." The facility was not able to provide a policy for accuracy of MDS assessments.

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

F685 09/21/2018 §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident§483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure an eye consultation and/or referral was arranged for one of one sampled residents (Resident 56). This failure had the potential for Resident 56 to experience a delay of treatment which may lead to worsening of Resident 56's vision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 12 of 35 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 09/20/2018 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 Findings: On September 17, 2018, at 1:23 p.m., Resident 56 was observed awake and lying in bed. In a concurrent interview with Resident 56, he stated he was legally blind. Resident 56 stated he had informed the staff that he was legally blind. On September 19, 2018, at 2:01 p.m., Resident 56 was interviewed. Resident 56 stated the facility was aware of his blindness. Resident 56 stated the facility had not addressed his vision. Resident 56 stated, "It would be nice to be seen by an eye doctor." On September 19, 2018, Resident 56's record was reviewed. Resident 56 was admitted to the facility on July 17, 2018, with diagnoses which included diabetes mellitus (high blood sugar) and weakness. The "...(name of the acute hospital) History and Physical," dated July 14, 2018, from the acute hospital from where Resident 56 was admitted was reviewed. The "...History and Physical," indicated, "...Problem...legally blind..." The facility's "History and Physical," dated July 18, 2018, did not indicate Resident 56 was legally blind. On September 20, 2018, at 12:10 p.m., the Social Service Designee (SSD) was interviewed. The SSD stated Resident 56 informed her that he had macular degeneration (an eye disorder that causes vision loss). The SSD stated she should have referred Resident 56 to an eye doctor for his macular degeneration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 13 of 35 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 09/20/2018 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 September 20, 2018, at 12:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 56's vision should have been accurately assessed and an eye appointment should have been arranged. The facility's policy and procedure titled, "Clothing, Shoes, Eyeglasses and Other Necessary Personal items," dated April, 2016 was reviewed. The policy indicated: "...To assist resident in obtaining necessary personal items such as...eyeglasses...Should professional services be required to obtained necessary items...i.e. (example) eyeglasses...the Social Service Representative will instruct the resident's Registered Nurse to contact the physician and request the appropriate consult..."

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

F759 09/21/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (5%), when two of 33 medications observed administered were not administered as ordered by the physician for one of four sampled residents (Resident 28), as follow: 1. Ferrous sulfate (iron supplement) 325 mg (milligrams) was ordered, and 450 mg was administered; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 14 of 35 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 09/20/2018 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 2. Florastor (saccharomyces boulardii- a type of yeast used to treat stomach and intestinal problems) 500 mg was ordered, and an undetermined dose was administered. These failures caused Resident 28 to receive doses of ferrous sulfate and Florastor which were different from what was ordered by the physician . These failures had the potential to cause Resident 28 to have stomach and intestinal symptoms, such as constipation, diarrhea, nausea, abdominal cramps, or vomiting. Findings: On September 19, 2018, beginning at 9 a.m., a medication pass observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed administering medications to Resident 28. Resident 28 was observed lying in her bed, non-responsive, and with a gastric tube (G-tube - a tube connected to the stomach used to administer liquid nutrition, medications, and supplements). 1. LVN 1 was observed to pour one, five (5) ml (milliliter) unit dose container of ferrous sulfate liquid 300 mg/(per) 5 ml, and a portion of a second 5 ml container of ferrous sulfate liquid 300 mg/5 ml, into a medication cup (a 30 ml cup used to administer medications). The medication cup was observed to contain 7.5 ml of ferrous sulfate liquid. In a concurrent interview, LVN 1 stated the medication cup contained "7.5" (ml - a total of 450 mg ferrous sulfate). LVN 1 was observed to administer the 7.5 ml of ferrous sulfate liquid to Resident 28 through her G-tube. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 15 of 35 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 09/20/2018 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 September 19, 2018, at 1:16 p.m., an interview was conducted with LVN 1. LVN 1 stated when she administered medications to Resident 28 at 9 a.m. (of September 19, 2018), the physician's order she had for ferrous sulfate was for 325 mg. LVN 1 stated she administered 7.5 ml (of 300 mg/5 ml - a total of 450 mg of ferrous sulfate). LVN 1 stated she should have administered 5.4 ml of ferrous sulfate liquid 300 mg/5 ml. LVN 1 confirmed she did not administer the ordered dose. The "Medication Administration Record" indicated, "Ferrous Sulfate (300 mg) Liquid...Feeding Tube Every Day...325 mg 5.416 ml," with a start date of September 17, 2018. 2. LVN 1 was observed to open two capsules of Florastor 250 mg/capsule (total dose 500 mg). LVN 1 poured the powder into a medication administration cup. LVN 1 was observed to dissolve the Florastor powder by pouring water into the medication cup with the Florastor powder in it. LVN 1 was observed to administer the dissolved Florastor to Resident 28 through her G-tube. During administration, when LVN 1 was attempting to push the plunger into the 60 ml syringe she was using, the plunger slipped, and some of the dissolved Florastor spilled out onto the bed sheet. In a concurrent interview, LVN 1 stated the size of the area on the sheet wet with the dissolved Florastor was "...seven (7) inches by six (6) inches." On September 19, 2018, at 2:15 p.m., an interview was conducted with LVN 1 and Registered Nurse (RN) 1. When asked about the administration of the dissolved Florastor to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 16 of 35 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 09/20/2018 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 Resident 28 at 9 a.m. (of September 19, 2018), LVN 1 confirmed the Florastor was dissolved in water and was in a medication administration cup. LVN 1 confirmed some of the dissolved Florastor liquid spilled out on the bed when she was administering it to Resident 28. LVN 1 confirmed Resident 28 did not receive the entire dose of 500 mg of Florastor, as ordered by the physician. LVN 1 further stated she was supposed to notify her supervisor or the physician. LVN 1 stated she did not notify a nursing supervisor or the physician. RN 1 confirmed LVN 1 should have notified a nurse supervisor or the physician. On September 19, 2018, Resident 28's record was reviewed. The record indicated she was admitted to the facility on July 8, 2016. The record included a physician's order dated June 14, 2018, for "SACCHAROMYCES BOULARDII CAPSULE...FLORASTOR...500 mg...DX (diagnosis)...GI (gastrointestinal) PROPHYLAXIS (to prevent disease and promote health)..." The facility policy and procedure titled, "Medication Administration," Revised March 2016, was reviewed. The policy indicated, "...Medication is considered to be given in error if any of the following conditions are present...Wrong dose...The person discovering the error is responsible for...Notifying the physician...Notifying the Director of Nursing..."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 09/25/2018 §483.60(c) Menus and nutritional adequacy. Menus mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 17 of 35 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 09/20/2018 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 §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure: 1. One kitchen staff member followed the recipe for preparing pureed rice correctly; and 2. One kitchen staff member used a four ounce scoop (specialized utensil to serve food) instead of a three ounce spoodle (part spoon, part ladle) as specified in the facility recipe for serving rice. These failures had the potential for the residents to not receive the proper nutritive value, serving amount of food, and/or palatability, according to the facility menu. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 18 of 35 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 09/20/2018 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 Findings: 1. On September 18, 2018, the facility recipe for "Puree Rice," was reviewed. The recipe indicated, "Salt, Kosher...1/8 Teaspoon..." During the lunch tray observation on September 18, 2018, at 12:25 p.m., Cook 1 was observed preparing pureed rice. Cook 1 was observed not to add the 1/8 teaspoon of salt according to the facility recipe. In a concurrent interview, Cook 1 confirmed she did not add any salt to the pureed rice as indicated on the facility menu. 2. On September 18, 2018, the facility recipe for "Rice Pilaf," was reviewed. The recipe indicated, "Portions: 1-3/4 - 3 Oz (ounce) Spoodle..." During the lunch tray observation on September 18, 2018, beginning at 11:46 a.m., Cook 2 was observed using a four ounce scoop instead of a three ounce spoodle, according to the facility regular diet menu for the rice pilaf. On September 18, 2018, at 12:39 p.m., Cook 2 was interviewed. Cook 2 stated, "The three ounce ladle got stuck in the rice, so I used a four ounce scoop." On September 19, 2018, at 10:28 a.m., the Senior Area General Manager for Food and Nutrition Services (GM) was interviewed. The GM confirmed the facility recipes should be followed. The GM stated the food quantity should be distributed according to the facility menu.

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5) FORM CMS-2567(02-99) Previous Versions Obsolete

F806 Event ID: GOCQ11 09/25/2018 Facility ID: CA240001502 If continuation sheet 19 of 35 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 09/20/2018 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 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure two of 28 residents (Residents 175 and 180) received their food preferences, when: 1. Resident 175 preferred vanilla Ensure (nutritional supplement), as indicated on her dietary meal service card, but received chocolate Ensure; and 2. Resident 180's dietary meal service card did not indicate her dietary preferences and dislikes. These failures resulted in Resident 175 to not receive Ensure according to her preference. These failures had the potential for Resident 180 to not receive food according to her preferences and may result in weight loss for Residents 175 and 180. Findings: 1. During the dining observation on September 17, 2018, at 12:34 p.m., Resident 175 was observe to receive chocolate Ensure on her lunch tray. In a concurrent interview, Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 20 of 35 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 09/20/2018 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 175 stated she liked vanilla Ensure. On September 20, 2018, the dietary meal services card for Resident 175 was reviewed. The card indicated Resident 175 preferred vanilla Ensure at lunch. 2. During the dining observation on September 18, 2018, at 10:04 a.m., the family member (FM) for Resident 180 was interviewed. The FM stated, "Resident 180 did not receive the best breakfasts." The FM stated she had to bring in meals for Resident 180. The FM stated Resident 180 did not get a good choice of meal alternatives. The FM stated the DSS visited Resident 180, but did not have "no fish," which was Resident 180's request, listed on Resident 180's dietary meal service card. The FM stated Resident 180 did not receive her food choices. The FM stated Resident 180 was not offered alternatives for her meals. In a concurrent interview with Resident 180, she stated, "There is a metal taste in the food." Resident 180 stated she did not like the Ensure. The dietary meal service card for Resident 180 was reviewed concurrently. Resident 180's dietary service card indicated to give Ensure at all meals. The dietary meal service card did not indicate preferences or dislikes. The facility was not able to provide a policy and procedure regarding dietary preferences.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 09/25/2018 §483.60(i) Food safety requirements. The facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 21 of 35 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 09/20/2018 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 §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices were followed when: 1. One kitchen staff member did not wash her hands between handling food items; 2. One kitchen staff member did not sanitize the food thermometer prior to obtaining the temperature of the Caesar chicken breast; 3. One kitchen staff member did not use sanitary precautions while preparing a hamburger bun, lettuce, and tomato; and 4. Light red residues were observed inside the top portion of the ice machine. These failures had the potential to spread food borne illnesses to residents in the facility. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 22 of 35 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 09/20/2018 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 1. During the lunch tray observation on September 18, 2018, beginning at 11 a.m., Cook 1 was observed to pull the handle of the oven door to open it, held the oven mittens, and took the tray of Caesar chicken breast out of the oven. Cook 1 proceeded to hold the thermometer and took the temperature of the chicken. Upon retrieval of the thermometer from the chicken, a small piece of chicken was observed at the end of the thermometer. Cook 1 was observed to flick the piece of chicken off the thermometer with her bare hand. The piece of the chicken was observed to fall into the chicken breasts in the tray. Cook 1 was not observed to perform handwashing and/or wear gloves through the observation. In a concurrent interview, Cook 1 stated she did not wash her hands in between handling multiple items (oven door handle, oven mittens, and tray) and the Caesar chicken breast. 2. During the lunch tray observation on September 18, 2018, beginning at 11 a.m., Cook 1 was observed placing a thermometer in the Caesar chicken breast. Cook 1 was not observed to sanitize the thermometer prior to placing the thermometer into the chicken breast to obtain its temperature. In a concurrent interview, Cook 1 stated she did not sanitize the thermometer before using it to obtain the temperature of the Caesar chicken breast. 3. During the lunch tray line observation on September 18, 2018, at 12:15 p.m. Cook 2 was observed holding a three ounce ladle (a deepbowled long-handled spoon) with gloved hands, then placing the three ounce ladle on the kitchen counter behind the steam table. Cook 2 was then observed to pick up a four FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 23 of 35 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 09/20/2018 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 ounce scoop (specialized utensil to serve food). Cook 2 was then observed to touch a hamburger bun and placed lettuce and tomato slices on top of a hamburger patty with her same gloved hands. Cook 2 was observed to not wash her hands or change her gloves in between touching the three ounce ladle, a four ounce scoop, and the hamburger bun, lettuce, and tomato slices. In a concurrent interview, Cook 2 confirmed she did not wash her hands and change her gloves prior to touching the hamburger bun and placing the lettuce and tomato slices on top of the hamburger patty. The facility policy and procedure titled, "Personal Hygiene," revised May 2016, was reviewed. The policy indicated, "...HAND WASHING...between handling different types of food..." 4. During the initial kitchen tour on September 17, 2018, beginning at 9:09 a.m., with the Dietary Service Supervisor (DSS), an observation was made of light red residues inside the top portion of the ice machine. In a concurrent interview, the DSS confirmed there was an accumulation of light red residues inside the top portion of the ice machine. The DSS stated there should not be residues inside the top portion of the ice machine. The facility policy and procedure titled, "Dispensing of Ice and Cleaning of Ice Machines," dated May 2018, was reviewed. The policy indicated, "...The Food and Nutrition Services Department prepares and dispenses ice under strict procedures to prevent the transmission of disease...Inside of the ice FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 24 of 35 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 09/20/2018 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 machines are cleaned and sanitized monthly per established cleaning procedure..."

F814 SS=E Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 09/25/2018 §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure two trash containers were covered. This failure had the potential to expose the residents to infections and foodborne illnesses caused by flies and vermin. Findings: During the initial tour of the kitchen on September 17, 2018, at 9:55 a.m., conducted with the Dietary Service Supervisor (DSS), two uncovered trash containers were observed in the parking lot outside the kitchen back door. One uncovered trash container was observed with filled white plastic bags. The other uncovered trash container were filled and observed to have cardboard boxes on top of the contents. There were numerous flies observed flying and landing on the exposed items in the containers. In a concurrent interview with the DSS, the DSS confirmed the trash containers should have been covered. According to the 2017 FDA (Food and Drug Administration) Food Code, in section 5501.113, part A(2) and B, titled, "Covering Receptacles," indicated: "Receptacles and waste handling units for refuse, recyclables, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 25 of 35 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 09/20/2018 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 returnables shall be kept covered: (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment." The facility policy and procedure titled, "Trash Handling/Trash Removal/Pick-Up Schedule," revised September 2018, was reviewed. The policy indicated, "...It is the responsibility of the individuals placing items in receptacles to assure the lids are closed after any deposit is made...Receptacle lids must be closed after every drop off of trash."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 09/23/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 26 of 35 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 09/20/2018 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 include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 27 of 35 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 09/20/2018 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 Based on observation, interview, and record review, the facility failed to ensure infection prevention precautions were being followed for two of 17 residents (Residents 73 and 24) when: 1. One staff member was observed to enter Resident 73's contact isolation room (room where precautions were used to prevent the spread of bacteria, viruses, and other infectious organisms) without putting on personal protective equipment (PPE - gown and gloves); 2. Resident 73's family member (FM) was observed to enter Resident 73's contact isolation room without wearing the proper PPE; and 3. Resident 24's suction catheter tip was found on top of Resident 24's bed, not in use, and uncovered. These failures had the potential to spread infection to other residents in the facility. Findings: 1. During the initial tour of the facility on September 17, 2018, at 11:25 a.m., Physical Therapy Aide (PTA) was observed entering Resident 73's contact isolation room without wearing PPE. In a concurrent interview with the PTA, the PTA stated he should have put on a gown and gloves before entering Resident 73's contact isolation room. The PTA stated Resident 73 was on contact isolation for a wound on her abdomen. On September 17, 2018, at 11:32 a.m., Registered Nurse (RN) 2 was interviewed. RN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 28 of 35 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 09/20/2018 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 2 stated Resident 73 was placed on contact isolation beginning September 13, 2018, when the laboratory results indicated she was positive for Methicillin-resistant Staphylococcus aureus (a bacterial infection which is highly resistant to certain antibiotics). On September 19, 2018, Resident 73's record was reviewed. Resident 73 was admitted to the facility on August 23, 2018, with diagnoses which included wound debridement and excision of necrotic skin (cleansing and removal of unhealthy skin). 2. During the initial tour of the facility on September 17, 2018, at 11:29 a.m., Resident 73's FM was observed entering Resident 73's contact isolation room without wearing PPE. In a concurrent interview, Resident 73's FM stated he was aware of the contact isolation sign outside Resident 73's room. Resident 73's FM stated he made a mistake. On September 17, 2018, at 11:31 a.m., an interview was conducted with the Certified Nursing Assistant (CNA) 2. CNA 2 stated she did not educate Resident 73's FM on the proper PPE use. On September 20, 2018, at 9:25 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 73's FM should be wearing the proper PPE. The undated facility policy and procedure titled, "TRANSMISSION-BASED PRECAUTIONS," was reviewed. The policy indicated, "...CONTACT PRECAUTIONS...In addition to wearing gloves...when entering the room...ensure that hands to [sic] not touch potentially contaminated environmental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 29 of 35 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 09/20/2018 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 surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments...In addition to wearing a gown...when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room...or wound drainage..." 3. On September 17, 2018, at 10:21 a.m., Resident 24 was observed sitting in a wheelchair beside her bed, alert, and verbally responsive. Resident 24 was observed to have a Yankauer (type of suction tip) on top of her bed, not in use, and without a protective cover. In a concurrent interview with the resident, Resident 24 stated she suctioned herself occasionally. On September 17, 2018, at 10:23 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the suction tip should have been inside a bag before and after use. The record of Resident 24 was reviewed with RN 1 on September 20, 2018. Resident 24 was admitted to the facility on December 29, 2015, with diagnoses which included chronic respiratory failure with tracheostomy (surgical opening through the neck for airway), diabetes mellitus (high blood sugar), and chronic obstructive pulmonary disease (lung disease). The facility policy titled, "Respiratory Care Services," revised February 2014, was reviewed. The policy did not include how the suction tip would be protected in between each use.

F926 SS=E Smoking Policies CFR(s): 483.90(i)(5)

F926 09/25/2018 §483.90(i)(5) Establish policies, in accordance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 30 of 35 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 09/20/2018 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 with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure policies were established and implemented regarding smoking safety for four of four sampled smoking residents (Residents 123, 323, 324, and 329), when: 1. The designated smoking area was not covered and was exposed to the sun and rain; 2. Residents 123, 323, 324, and 329, were observed to have their own cigarettes and lighter in their possession; and 3. Smoking assessments were not completed for Residents 123, 323, 324, and 329. These failures increased the potential for accidents and injuries to Residents 123, 323, 324, 329 and to other smoking residents. Findings: 1. On September 17, 2018, at 10:57 a.m., an observation was conducted at the designated smoking area (outside the South station) by the 200 hall. There was a sign on the wall indicating, "NO SMOKING WITHIN 20 FEET FROM THE BUILDING." There were three Residents (Residents 123, 324, and 329) observed in this area. Residents 123, 324, and 329 were observed sitting in their wheel chairs, smoking, in this area. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 31 of 35 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 09/20/2018 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 designated smoking area was noted to be hot and there was no cover observed for the residents. In a concurrent interview with Residents 123, 324, and 329, they stated it was hot in the designated smoking area. Resident 329 stated, "It's hot here...we don't stay longer." Resident 329 further stated, "It should have something like an umbrella." Resident 329 stated she had been smoking in this area since she was admitted to the facility. Resident 324 stated, "Yes, it's hot here." On September 17, 2018, at 1:15 p.m., Residents 123, 324, and 329, were observed sitting in their wheelchairs and smoking on the patio near the Occupational Therapy (OT) room. This smoking area was noted to be hot and there was no cover observed for the residents. Residents 123, 324, and 329, stated it was hot in this smoking area also. Resident 329 stated,"It is always hot in this place. A shade would be nice." On September 18, 2018, at 9:55 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated residents complained of heat with limited shading in the smoking area. On September 19, 2018, at 1:37 p.m., the Assistant Activity Staff (AAS) was interviewed. The AAS stated the designated smoking area was hot, and the facility should have provided a comfortable smoking area to protect the residents from the heat of the sun and when it rained. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 32 of 35 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 09/20/2018 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 September 20, 2018, at 9:28 a.m., an interview was conducted with the Associate Administrator (AA). The AA stated the designated smoking area was not a good place for the residents to smoke because it was too close to the building (less than 20 feet). 2. On September 17, 2018, at 1:15 p.m., Residents 123, 324 and 329, were observed with their own cigarettes and cigarette lighters in their possession. In a concurrent interview with Residents 123, 324 and 329, they stated they kept their own cigarettes and lighters. On September 18, 2018, at 1:35 p.m., an observation at the smoking patio was conducted. Resident 323 was observed with a staff member, sitting in his wheel chair, and was smoking. Resident 323 was observed with his own cigarettes and cigarette lighter on his possession. In a concurrent interview with Resident 323, he stated he kept his own cigarettes and cigarette lighter in his possession. The facility's policy and procedure titled, "Smoking by Residents," dated April 2016, was reviewed. The policy indicated: "...Store all smoking materials in medication rooms labeled with the resident (sic) name..." 3. On September 17, 2018, at 10:57 a.m., an observation was conducted at the designated smoking area (outside the South station) by the 200 hall. There were three Residents (Residents 123, 324, and 329) observed sitting in their wheel chairs and smoking in this area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 33 of 35 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 09/20/2018 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 September 19, 2018, record reviews were conducted for Residents 123, 323, 324, and 329. -Resident 123 was admitted to the facility on August 31, 2018, with diagnoses which included syncope (loss of conciousness and muscle strength) and hypertension (high blood pressure). -Resident 323 was admitted to the facility on September 16, 2018, with diagnoses which included bilateral lower leg cellulitis (skin infection). -Resident 324 was admitted to the facility on August 29, 2018, with diagnoses which included left tibia/fibula (bones in the lower leg) fracture. -Resident 329 was admitted to the facility on September 6, 2018, with diagnoses which included right hip arthroplasty (replacement/repair). There was no documented evidence a smoking assessment was completed for Residents 123, 323, 324, and 329. On September 20, 2018, at 10:15 a.m., the Social Service Designee (SSD) was interviewed. The SSD confirmed there were no smoking assessments completed for Residents 123, 323, 324, and 329. On September 20, 2018, at 10:20 a.m., the DON was interviewed. The DON confirmed there were no smoking assessments completed upon admission for Residents 123, 323, 324, and 329. The DON stated the smoking assessments should have been completed on admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 34 of 35 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 09/20/2018 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 The facility's policy and procedure titled, "Smoking by Residents," dated April 2016, was reviewed. The policy indicated: "... Smoking is permitted only in the facility's designated smoking area...Determine on admission if the resident is a smoker and advise of smoking areas and policy..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GOCQ11 Facility ID: CA240001502 If continuation sheet 35 of 35