Other·February 19, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted from August 18, 2019 to August 22, 2019. Representing the California Department of Public Health: Surveyor 40000, HFEN; Surveyor 36779, HFEN; Surveyor 37626, HFEN; and Surveyor 40988, HFEN; One facility reported incident and one complaint were investigated during the recertification survey. Facility reported incident number CA00651379. Complaint number CA00651406. The facility census was 64 residents.

F578 SS=D Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 09/16/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or 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: J52Y11 Facility ID: CA240001502 If continuation sheet 1 of 54 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 08/22/2019 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 medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure written information on advanced directive (AD, a legal document in which a person specified what actions should be taken for his/her health if he/she was no longer able to make decisions for themselves) was provided to the resident and/or resident's representative for one of four residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 2 of 54 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 08/22/2019 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 reviewed for AD (Resident 17). This failure had the potential for Resident 17 and/or Resident 17's representative to not be informed of Resident 17's right to refuse medical or surgical treatment. Findings: On August 20, 2019, at 09:21 a.m., Resident 17's record was reviewed. Resident 17 was admitted to the facility on September 20, 2016, with diagnoses which included chronic respiratory failure (inability to breathe) and persistent vegetative state (coma). The "Provider Orders for Life-Sustaining Treatment (POLST- order form that documented the patient's treatment wishes; not an AD)," dated September 21, 2016, signed by Resident 17's family member, was reviewed. The POLST form indicated, "...Attempt Resuscitation/ CPR (cardiopulmonary resuscitation - manual chest compressions and mouth-to-mouth breathing; this meant to prolong a person's life by all medically effective means)." Section D of the POLST form, which included the discussion of AD with the resident or the resident representative and if the resident had an AD or not, was not completed. There was no documented evidence a written information on AD was provided to Resident 17 and/or Resident 17's representative. On August 20, 2019, at 2:50 p.m., an interview and concurrent review of Resident 17's records were conducted with the Registered Nurse Supervisor (RNS). The RNS stated there was no documentation a written information on AD was provided to Resident 17 and/or Resident 17's representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 3 of 54 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 08/22/2019 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 policy titled, "Advance Health Care Directives," revised May 2016, indicated, " ...Purpose: To maintain a patient's right to make health care decisions on their own behalf and to honor those wishes according to regulations/statutes through Advance Health Care Directives...For Patients/ Residents With "Decision-Making Capacity...(name of facility) shall provide each adult individual, at the time of admission as an inpatient, written information describing...An individual's rights under California statues and Court decisions to accept or refuse medical or surgical treatment and to formulate Advance Health care Directives...For Patients Who Lack Capacity ...the facility shall document in the patient's medical record all efforts made to contact any agent, Surrogate, or a family member or other person the hospital reasonably believes has the authority to make health care decisions on behalf of the patient ..." The policy did not include the process for providing written information on AD when the resident has no decision-making capacity.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 09/16/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 4 of 54 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 08/22/2019 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 is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the physician was notified of a change of condition, for one of 16 residents reviewed (Resident 45), when Resident 45's blood sugar was above 400 mg/dl (milligram/deciliter - unit of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 5 of 54 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 08/22/2019 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 measurement). This failure had the potential to result in a delay of care and treatment for Resident 45. Findings: On August 20, 2019, Resident 45's record was reviewed. Resident 45 was admitted to the facility on August 2, 2019. The facility document titled, "Cumulative Diagnosis List," dated August 2, 2019, indicated Resident 45 had diagnoses which included diabetes mellitus (abnormal blood sugar). The facility document titled, "PHYSICIAN ADMITTING ORDERS," dated August 2, 2019, indicated, "Insuline (sic) Lispro (medication to lower blood sugar)...glucose (blood sugar) level in mg/dl...351-400 mg/dl = 11 units (of Lispro to be administered to the resident if the blood sugar was at this level)...Greater than 400 mg/dl...notify physician..." The untitled facility document, dated August 2019, indicated Resident 45's blood sugar on August 9, 2019, at 4:30 p.m., was 438 mg/dl. The document indicated Resident 45 received 11 units of Insulin Lispro on August 9, 2019, at 4:30 p.m. There was no documented evidence the physician was notified of Resident 45's blood sugar of 438 mg/dl. On August 21, 2019, at 11:39 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2. RN 2 stated Resident 45's blood sugar on August 9, 2019, at 4:30 p.m., was 438 mg/dl. RN 2 stated there was no documentation the physician was notified of Resident 45's blood sugar which was greater than 400 mg/dl. RN 2 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 6 of 54 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 08/22/2019 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 physician should have been notified of Resident 45's blood sugar when it was greater than 400 mg/dl on August 9, 2019. On August 21, 2019, at 3:54 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 45's blood sugar on August 9, 2019, at 4:30 p.m., was 438 mg/dl. LVN 1 stated she did not notify the physician of Resident 45's blood sugar of 438 mg/dl on August 9, 2019. LVN 1 further stated the physician should have been notified of Resident 45's blood sugar when it was greater than 400 mg/dl. The facility policy and procedure titled, "...Change in Condition," revised April 2016, was reviewed. The policy indicated, "...It is the policy of this facility that all changes in resident condition will be communicated to the physician...A Change of Condition is defined as any change in the resident's physical, mental, or emotional health..."

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

F609 09/16/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 7 of 54 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 08/22/2019 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 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 not later than two hours, for one of one resident reviewed for abuse (Resident 21). This failure had the potential to place the residents in the facility at risk for harm from abuse. Findings: On August 18, 2019, at 1:40 p.m., Resident 21 was observed awake and lying in bed. During a concurrent interview, Resident 21 stated on August 18, 2019, between 1:30 a.m. and 2:30 a.m., he pressed his call light. Resident 21 stated a nursing assistant (NA) answered his call light. Resident 21 stated, "The NA jumped on me, told me why did you press your call light, quit pushing your call button, press the light here." Resident 21 stated he was surprised when the NA "hollered and treated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 8 of 54 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 08/22/2019 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 me with an attitude, rude." On August 19, 2019, at 9:20 a.m., Resident 21's family member (FM) was interviewed. The FM stated on August 18, 2019, she visited Resident 21 between 9 to 9:30 a.m. The FM stated Resident 21 told her about the NA who answered his call light after midnight on August 18, 2019. The FM stated Resident 21 told her the NA said, "Quit pushing your call light over and over, something like that, press the call light on your bed." The FM stated, "That was rude." The FM stated she reported the incident to Registered Nurse (RN) 3 on August 18, 2019, at approximately 10 a.m. During a concurrent interview with Resident 21, Resident 21 stated, "I was shocked and mad." On August 20, 2019, at 2:48 p.m., RN 3 was interviewed. RN 3 stated on August 18, 2019, she received a change of shift report from the night shift supervisor the FM of Resident 21 was upset with the NA who answered Resident 21's call light and told Resident 21, "Why are you pushing the light, the bed control is on the bedrail" (RN 3's shift started at 7 a.m., approximately four to five hours from the time of the incident). RN 3 stated she did not have a communication with Resident 21's FM about the incident. RN 3 stated she did not report the incident to anybody after she received the report. RN 3 stated "I believe the abuse allegation should be reported to your office within 24 hours." On August 21, 2019, Resident 21's record was reviewed. Resident 21 was admitted to the facility on August 2, 2019. There was no documented evidence the alleged incident between the NA and Resident 21 on August 18, 2019, was reported to CDPH. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 9 of 54 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 08/22/2019 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, 2019, CDPH received a facility reported incident report regarding an allegation of abuse involving Resident 21. On August 21, 2019, at 2:51 p.m., the Quality Director (QD) was interviewed. The QD stated the allegation of abuse "should have been reported sooner" to CDPH. The facility policy titled, "ABUSE, PROHIBITION OF; TRAINING, INVESTIGATING AND REPORTING, "dated October 2018, was reviewed. The policy indicated, "...To provide a method for the prevention of any type of dependent adult or elderly abuse/neglect/exploitation and to identify and appropriately report any actual or suspected dependent adult or elderly abuse/neglect/exploitation...If the suspected or alleged incident does not involve serious bodily injury, the Chief Hospital Executive Officer/Chief Nursing Officer or designee shall make a telephone report...immediately or as soon as possible and shall make a written report to the Department of Public Health...within 2 (two) hours..."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 09/16/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 10 of 54 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 08/22/2019 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 (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the plan of care was developed, for one of 16 residents reviewed (Resident 45), when Resident 45 sustained a fall on August 9, 2019. This failure had the potential for facility staff to be unaware of Resident 45's fall incident and for delay of necessary care to prevent further incidents of fall for Resident 45. Findings: On August 19, 2019, at 3:41 p.m., Resident 45 was observed lying in bed and watching TV. In a concurrent interview, Resident 45 stated she fell this morning. Resident 45 stated she had fallen before while in the facility and was unable to remember when it was. On August 20, 2019, Resident 45's record was reviewed. Resident 45 was admitted to the facility on August 2, 2019, with diagnoses which included muscle weakness and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 11 of 54 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 08/22/2019 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 neuropathy (nerve disease which caused weakness and numbness). The facility document titled, "NURSING NOTES," dated August 9, 2019, at 5:30 p.m., indicated, "...Late entry...when arrived to room pt (patient/resident) was still up with arms hanging on walker, suddenly gave up and slide self to floor..." There was no documented evidence a plan of care was developed to address Resident 45's fall on August 9, 2019. On August 21, 2019, at 10:56 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2. RN 2 stated there was no documentation a plan of care was developed to address Resident 45's fall incident on August 9, 2019. RN 2 stated there should have been a plan of care to address Resident 45's fall incident on August 9, 2019. The facility policy and procedure titled, "Fall/Found on the Floor," revised April 2016, was reviewed. The policy indicated, "...Include the following in documentation...CARE PLAN...Date incident occurred...State type of incident and cause or possible cause...add goal "will have no further incident of fall"...Under approaches write approaches based on cause of incident..."

F684 SS=E Quality of Care CFR(s): 483.25

F684 09/16/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 12 of 54 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 08/22/2019 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 care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, for two of 16 residents reviewed (Residents 197 and 29), the facility failed to ensure: 1. Assessment, monitoring, care, and treatment were provided for Resident 197's edema on both lower extremities (legs and feet). This failure had the potential to result in a delay of care and treatment for Resident 197; and 2. Resident 29 was turned and repositioned every two hours and the hand splints (device to prevent contractures [joint stiffening] from developing or worsening) were applied as ordered by the physician. These failures had the potential for Resident 29 to develop pressure ulcer (a wound caused by pressure and/or friction) and worsening of hand contractures. Findings: 1. On August 18, 2019, at 12:09 p.m., Resident was observed lying in bed watching TV. Resident 197 was observed to have her lower extremities elevated on pillows. Resident 197 consented to have the blankets on her lower extremities removed. Resident 197's lower extremities were observed to be swollen from the calf to the toes. In a concurrent interview, Resident 197 stated her lower extremities were swollen. Resident 197 stated she was not aware of what care the facility was providing for the swelling of her lower extremities. On August 22, 2019, Resident 197's record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 13 of 54 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 08/22/2019 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 was reviewed. Resident 197 was admitted to the facility on August 9, 2019. The facility document titled, "Cumulative Diagnosis List," dated August 9, 2019, indicated Resident 197 had diagnoses which included deep vein thrombosis (blood clot) in the left knee. The facility document titled, "RESIDENT DATA COLLECTION...ADMISSION NOTES," dated August 9, 2019, indicated Resident 197 had edema on both lower extremities. The facility document titled, "DAILY SKILLED NURSE'S NOTE," dated August 10, and 11, 2019, indicated, "...Edema...No..." The "DAILY SKILLED NURSES'S NOTE," dated August 12, 2019, indicated, "...Edema...Yes..." The document did not indicate the location and characteristic of the edema. There was no documented evidence the edema on Resident 197's lower extremities was assessed and monitored. On August 22, 2019, at 11:36 a.m., the Minimum Data Set (MDS - an assessment tool) Nurse (MDSN) was interviewed. The MDSN stated a resident with edema may be at risk for fluid overload (excessive fluid in the blood), and breathing and skin issues. The MDSN stated there was no documentation of an assessment and monitoring of Resident 197's edema on both lower extremities. The MDSN stated there should have been a comprehensive assessment of Resident 197's edema on both lower extremities so the facility would be able to monitor if Resident 197's swelling was improving or worsening. On August 22, 2019, at 11:50 a.m., Resident 197 was observed with the Assistant Director of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 14 of 54 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 08/22/2019 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 Nursing (ADON). Resident 197 was observed to have non-pitting edema (swelling of the skin that does not result in persistent indentation when skin was pressed) from the calf to the toes. During a concurrent interview with the ADON, the ADON stated the licensed nurse should not have missed Resident 197's edema on both lower extremities because it ws very apparent due to its visible appearance. The ADON stated Resident 197's edema on both lower extremities should have been assessed and monitored. The facility policy and procedure regarding edema assessment, care, and management was requested from the ADON. On August 22, 2019, at 3:35 p.m., the ADON was interviewed. The ADON stated the facility did not have a policy regarding the assessment, care, and management of edema. 2. On August 18, 2019, Resident 29's record was reviewed. The record indicated Resident 29 was re-admitted to the facility on July 7, 2019, with diagnoses including sacral decubiti (pressure sore/ injury- a wound by the tailbone caused by pressure and/or friction), respiratory failure (inability to breathe), and anoxic encephalopathy (loss of brain function due to lack of oxygen). a. On August 18, 2019, at 11:40 a.m., Resident 29 was observed in her room in bed. Resident 29's hands were noted to be contracted in a partial fist shape and bent towards her body. Resident 29's hands were observed to not have hand splints on. On August 20, 2019, at 10:18 a.m., an interview was conducted with Resident 29's family member (FM). The FM stated he did not think the facility staff was applying the hand splints and "her hands are like fists now." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 15 of 54 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 08/22/2019 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 20, 2019, at 3:30 p.m., an interview was conducted with RNA 1. RNA 1 stated she was supposed to apply hand splints to Resident 29's hands on Monday through Friday each week. RNA 1 stated she was supposed to apply the hand splints for two hours and take them off for two hours throughout her shift from 7 a.m. to 7 p.m. RNA 1 stated she would take the hand splints off Resident 29 at the end of her shift and apply them on the following day when her shift started. RNA 1 stated the days she worked "on the floor" (as a Certified Nurse Assistant) she did not provide RNA services to Resident 29. RNA 1 stated she was the only RNA in the unit. On August 20, 2019, at 4 p.m., an interview and concurrent review of Resident 29's record was conducted with the Registered Nurse Supervisor (RNS). The RNS stated there was no documentation the RNA applied hand splints to Resident 29 on July 10, 16, and 17, and August 8, and 13, 2019. The RNS stated the physician order to apply the hand splints to Resident 29's hands was for "Monday through Friday." The RNS stated Resident 29 should have had hand splints applied, as ordered, on July 10, 16, and 17, and August 8 and 13, 2019. On August 22, 2019, Resident 29's record was reviewed. The record included a document titled, "Progress Note..," dated February 5, 2019. The document indicated, "...Physical Therapist here to assess. Recommends bilat (bilateral - both right and left) hand splints for contracture..." The document titled, "Patient Care Summary...," included a physician's order which indicated, "...Start Date...07/08/2019 (July 8, 2019)...Frequency...MTWTF (Monday, Tuesday, Wednesday, Thursday, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 16 of 54 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 08/22/2019 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 Friday)...RNA to Apply Resting Hand Splints..." There was no documentated evidence hand splints were applied to Resident 29 on July 10, 16, and 17, and August 8, and 13, 2019. The facility policy and procedure titled, "Orthotic (an artificial support or brace) Devices," revised March 2016, was reviewed. The policy indicated, "...It is the policy of this facility that orthotic devices be applied...per physician's orders..." b. On August 21, 2019, Resident 29's record was reviewed. The document titled, "Progress Note Inquiry," dated June 7, 2019, was reviewed. The document indicated, "...WOUND CARE DEPARTMENT...COCCYX (tailbone)...PRESSURE INJURY STAGE 3 (extended into the tissue below the skin)...PRESSURE INJURY PREVENTION, TURN PATIENT FROM SIDE TO SIDE EVERY TWO HOURS TO REDISTRIBUTE PRESSURE..." The document titled, "INTERDISCIPLINARY CARE PLAN," dated July 7, 2019, was reviewed. The document indicated, "...At risk for impaired Skin integrity related to impaired mobility and disease process...Turn and reposition patient (Resident 29)every 2 (two) hrs (hours) ..." An untitled care plan document, dated July 7, 2019, was reviewed. The document indicated, "...Sacral decubitus Wound Infection...Reposition side to side q (every) 2 (hours) and PRN (as needed)..." The document titled, "Daily...Activities," dated July 7, 2019, to August 21, 2019, was reviewed. There was no documented evidence Resident 29 was turned every two hours on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 17 of 54 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 08/22/2019 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 multiple days. On August 21, 2019, at 3:30 p.m., an interview and concurrent review of Resident 29's record were conducted with the RNS. The RNS stated the certified nurse assistants (CNA's) were supposed to turn Resident 29 every two hours on both day and night shifts every day. The RNS stated there was no documentation Resident 29 was turned every two hours on July 8, 11, 13, 18, 20, 21, 22, 24, 25, 26, 27, 31, and August 1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 14, 16, 17, 18, and 19. The RNS confirmed if Resident 29 was not turned every two hours, it could contribute to the development or worsening of pressure ulcers. The RNS confirmed Resident 29 should have been turned every two hours every day and there should have been documentation indicating that it was done. The publication titled, "Prevention and Treatment of Pressure Ulcers: Repositioning and Mobilization - an extract from the Clinical Practice Guideline," published by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific, dated 2014, was reviewed. The publication indicated, "...Repositioning and mobilizing individuals is an important component in the prevention of pressure ulcers...by definition pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia (loss of oxygen) and inevitable tissue damage...Reposition all individuals at risk of, or with existing pressure ulcers...Repositioning of an individual is undertaken to reduce the duration and magnitude of pressure over FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 18 of 54 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 08/22/2019 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 vulnerable areas of the body...When planning an individual' s repositioning schedule, it is important to first assess his or her risk of pressure ulcers, paying particular attention to level of activity and mobility, as those with reduced activity and mobility are more prone to pressure ulcer damage..."

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 09/16/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure tube feeding (TF) formula/e (liquid nutrition administered through a tube) were administered according to the physician's orders and facility policy and procedure, for two of three residents reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 19 of 54 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 08/22/2019 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 for TF (Residents 27 and 198) when: 1. For Resident 27, the TF formula administered was not labeled with the resident's name, and the date and time the TF formula bottle was opened and hung (connecting the bottle to the tubing and connecting the tubing to the resident's G tubea tube in the stomach for liquid nutrition). This failure had the potential for the staff to not be able to monitor the amount of infused TF formula accurately and may cause gastrointestinal (relating to the stomach and intestines) distress or infection due to the administration of tube feeding that was no longer good for use. 2. For Resident 198, the TF formula administered on August 21, 2019, was not the TF formula ordered by the physician. This failure had the potential for Resident 198 to not receive adequate nutrition. Findings: 1. On August 18, 2019, Resident 27's record was reviewed. Resident 27's record indicated she was admitted to the facility on July 9, 2019, with diagnoses including respiratory failure (inability to breathe), brain damage, nausea with vomiting, gastrostomy (G tube), tracheostomy (airway tube), and dependence on a ventilator (breathing machine). On August 18, 2019, at 12:30 p.m., Resident 27 was observed in bed with a TF formula infusing through a G tube. The bottle of TF formula was observed to be not labeled with Resident 27's name, nor the date and time it was opened and started to be administered to Resident 27. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 20 of 54 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 08/22/2019 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 Concurrently, RN 1 was requested to come into Resident 27's room to look at the bottle of TF formula currently hanging and infusing into Resident 27. During a concurrent interview, RN 1 stated the bottle of TF formula was not labeled with Resident 27's name, nor the date and time the formula bottle was hung. RN 1 stated, "It should have been labeled." On August 21, 2019, at 9:45 a.m., an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS confirmed Resident 27's bottle of TF formula should have been labeled with Resident 27's name and the date and time it was opened and hung. The RNS stated there was no documentation indicating when Resident 27's bottle of TF formula was opened and hung. On August 21, 2019, the facility policy and procedure titled, "Monitoring for Residents with Continuous Gastrostomy/Tube Feeding," revised March 2016, was reviewed. The policy indicated,"...Feeding tube and bottle should be changed every 24 hours and marked with resident's name, room number and date...Chart time...and...other pertinent information." 2. On August 21, 2019, starting at 8:24 a.m., medication administration observation was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 was observed to pour TF formula from a bottled labeled Vital AF Advance Formula (type of TF formula) into a 250 milliliter (ml- unit of measurement) cup. The TF bottle was concurrently reviewed and indicated an open date of August 20, 2019. LVN 2 was observed to administer the full cup of Vital AF Advance Formula through Resident 198's gastrostomy tubing (GT). On August 21, 2019, Resident 198's record was reviewed. Resident 198 was admitted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 21 of 54 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 08/22/2019 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 on August 14, 2019. The "History and Physical," dated August 15, 2019, indicated Resident 198 was admitted with diagnoses which included throat cancer and cerebrovascular accident (stroke). The facility document titled, "PHYSICIAN'S TELEPHONE ORDERS," dated August 15, 2019, indicated, "...bolus feeding TID (three times a day) of Isosource 1.5 cal (calories) 250 cc (cubic centimeters, equivalent to ml - unit of measurement)..." The untitled facility document, dated August 4, 2019, indicated bolus feeding of 250 cc of Isosource 1.5 was administered to Resident 198 from August 16, 2019 to August 21, 2019. On August 21, 2019, at 10:13 a.m., a concurrent interview and record review was conducted with LVN 2. LVN 2 stated Resident 198 had an order for bolus feeding of 250 ml of Isosource (type of TF formula) 1.5 cal TID. LVN 2 showed the bottle of TF formula she used for Resident 198. The bottle of TF formula was labeled Vital AF Advance Formula 1.2. LVN 2 stated the kitchen staff gave her the TF formula bottle and the bottle was started on August 20, 2019. LVN 2 stated the kitchen staff told her Vital AF 1.2 was comparable with Isosource 1.5. LVN 2 stated she should have clarified with the dietary manager if Vital AF 1.2 was comparable to Isosource 1.5. On August 21, 2019, at 2:34 p.m., the Clinical Nutrition Manager/Registered Dietitian (CNM/RD) was interviewed. The CNM/RD stated the dietary staff provided TF formula to the licensed nurses. On August 21, 2019, at 2:44 p.m., a concurrent interview and record review was conducted with the CNM/RD. The CNM/RD stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 22 of 54 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 08/22/2019 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 198 had an order for bolus feeding of Isosource 1.5. The CNM/RD stated the facility document titled, "ENTERAL NUTRITION FORMULARY GUIDE," dated May 2018, indicated the Isosource 1.2 was comparable to Jevity 1.2 (product the facility uses). The CNM/RD stated the facility should have used Jevity 1.5 for Isosource 1.5. A subsequent interview and record review with the CNM/RD was conducted. The CNM/RD stated the nutritional values for Isosource 1.5 and Vital AF 1.2 were different. The CNM/RD stated the order for Isosource 1.5 should have been clarified before any TF formula was administered to Resident 198. The facility policy and procedure titled, "Physician's prescriptions (Orders)," revised April 2016, was reviewed. The policy indicated, "...Physician's prescriptions which...in the nurse's judgment should not be accomplished without further review or clarification, will not be implemented until clarification has been provided..."

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/16/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the nebulizer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 23 of 54 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 08/22/2019 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 (machine used to administer breathing treatment) dispenser set (tubing and a medication container) and the storage bag were changed and labeled with a date according to facility policy, for one of one resident reviewed for respiratory infection (Resident 31). This failure may cause Resident 31 to have respiratory infection. Findings: On August 18, 2019, at 11:56 a.m., Resident 31 was observed awake and lying in bed. A nebulizer machine was observed on top of Resident 31's night stand. A breathing treatment dispenser set was observed attached to the nebulizer machine and was stored inside a plastic bag. The plastic storage bag was observed to have a date labeled "7/21" (July 21). The breathing treatment dispenser set was observed to not be labeled with a date (of when it should be changed or when it was started to be used). During a concurrent interview with Resident 31, he stated he was receiving breathing treatments daily. Resident 31 stated he did not know when the breathing treatment dispenser set and the storage bag were changed. On August 18, 2019, at 12:05 p.m., Licensed Vocational Nurse (LVN) 3 was observed to come into Resident 31's room. In a concurrent interview with LVN 3, LVN 3 stated the breathing treatment dispenser set and storage bag should have been changed weekly to prevent infection. On August 21, 2019, the record of Resident 31 was reviewed. Resident 31 was admitted to the facility on July 2, 2019. The "History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 24 of 54 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 08/22/2019 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 23, 2019, indicated Resident 31 had diagnoses which included chronic obstructive pulmonary disease and asthma (lung diseases which may have difficulty of breathing). The "PHYSICIAN'S TELEPHONE ORDERS," dated July 21, 2019, indicated, "Change nebulizer treatments to q AM (every morning) & (and) @ (at) 1800 (4 p.m.) q day for SOB (short of breath)/wheezing." The facility policy titled, "Schedule of Resident Equipment Change," dated April 2016, was reviewed. The policy indicated, "...To Decrease the risk of infection...All equipment used by residents will be changed regularly...nebulizer...change weekly..."

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 09/16/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident's need for fluid restriction was assessed and implemented, for two of two residents reviewed for dialysis (hemodialysis process of removing excess water and toxins from the blood) (Residents 196 and 40) when: 1. For Resident 196, the facility failed to coordinate with the dialysis center of the need for fluid restrtriction (need to limit the amount of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 25 of 54 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 08/22/2019 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 liquids the resident can have each day); and 2. For Resident 40, the facility failed to follow the fluid restriction as ordered by the physician. These failures had the potential for Residents 196 and 40 to develop complications such as fluid overload (too much fluid in the blood). Findings: 1. On August 18, 2019, at 11:40 a.m., Resident 196 was observed sitting at the edge of the bed in her room. Resident 196's over bed table was observed to have a water pitcher (approximately 32 ounces [840 milliliter {ml}]) at bed side. During a concurrent interview, Resident 196 stated she had dialysis every Tuesday, Thursday, and Saturday. Resident 196 stated she was on fluid restriction but did not know how much. Resident 196 stated she usually drank half of the water pitcher, the fluids served during meals, and a cup-size (approximately 240 ml) of hot tea in the morning. On August 20, 2019, at 12:11 p.m., Resident 196's pitcher and a plastic cup was observed at the bedside. The pitcher was observed to have approximately 200 ml of water. The plastic cup with a straw was observed to be half-filled with water. On August 21, 2019, Resident 196's record was reviewed. Resident 196 was admitted to the facility on August 9, 2019. The "History and Physical," dated August 9, 2019, indicated Resident 196 had diagnoses which included end-stage renal disease (ESRD - kidney disease in which the kidneys are not functioning well) and pleural effusion (fluids in the lung/s). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 26 of 54 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 08/22/2019 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 document titled, "PHYSICIAN ADMITTING ORDERS," dated August 9, 2019, indicated, "...Dialysis T (Tuesday), TH (Thursday), Sat (Saturday) @ (at) (name of dialysis center)..." There was no documented evidence Resident 196's need for fluid restriction was determined. There was no documented evidence the facility coordinated with the dialysis center nor with the physician regarding Resident 196's need for fluid restriction. The "Daily Assessment Inquiry," dcumented by the Clinical Nutritional Manager/Registered Dietitian (CNM/RD) on August 15, 2019, was reviewed. There was no documented evidence the CNM/RD reviewed the need to limit Resident 196's fluid intake to a certain amount. The facility document titled, "INTAKE AND OUTPUT RECORD (I & O)," dated August 9 to 22, 2019, indicated Resident 196 had fluid intake of 990 ml to 2690 ml daily (Resident 196 received an average of 1700 ml fluids a day). On August 22, 2019, at 10:48 a.m., a concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 196 did not have an order for fluid restriction. The ADON stated Resident 196 was evaluated by the facility RD on August 15, 2019. The facility document titled, "Daily Assessment Inquiry," dated August 16, 2019, was reviewed with the ADON. The document indicated, "...Dietitian Recommendation(s) to Physician...Continue with Renal Dialysis diet and monitor intake for need for supplementation..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 27 of 54 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 08/22/2019 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 ADON was concurrently observed to call the dialysis center and spoke with the dialysis RD. The ADON stated the dialysis RD told her Resident 196 should be on fluid restriction of 1000 ml a day. On August 22, 2019, at 10:56 a.m., a concurrent interview and review of Resident 196's record was conducted with with the facility RD. The facility RD stated she did not communicate with the dialysis RD regarding Resident 196. The facility RD stated she should have communicated with the dialysis RD regarding any changes in the diet order or need for fluid restriction. On August 22, 2019, at 12:31 p.m., the ADON provided a copy of a document titled, "Nutrition Profile Report (Monthly)," from the dialysis center. During a concurrent interview, the ADON stated she requested the document from the dialysis center on August 22, 2019, at 10:48 a.m. The document was reviewed concurrently. The document included a diet order, dated March 13, 2019, which indicated, "...Fluid cc (ml) / (over) 24 hr (hour)...1200..." The ADON stated Resident 196 should have been on fluid restriction of 1200 ml daily to prevent fluid overload. The ADON stated the facility should have coordinated with the dialysis center for the need for fluid restriction for Resident 196. 2. On August 18, 2019, at 11:23 a.m., Resident 40 was observed awake and lying in bed in her room. A water pitcher was observed on top of Resident 40's bedside table. The water pitcher was observed to be half filled with melting ice. During a concurrent interview, Resident 40 stated the staff provided the water pitcher for ice. On August 21, 2019, at 11:17 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 28 of 54 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 08/22/2019 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 Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated Resident 40 was on 1000 ml per day fluid restriction per day. LVN 3 stated Resident 40 should not have a water pitcher at the bedside. LVN 3 stated the certified nursing assistant (CNA) should ask the nurse before giving ice or water to Resident 40. On August 21, 2019, at 12:27 p.m., CNA 1 was interviewed. CNA 1 stated he was assigned to Resident 40 and he was not aware Resident 40 had a water pitcher in his room. CNA 1 was aware Resident 40 was on fluid restriction. CNA 1 stated Resident 40 should not have a pitcher with water at the bedside. CNA 1 was concurrently observed to go inside Resident 40's room and removed Resident 40's water pitcher from the room. On August 22, 2019, at 11:55 a.m., LVN 4 was interviewed. LVN 4 stated Resident 40 was on fluid restriction and Resident 40 should not have a water pitcher at the bedside to prevent fluid overload (excessive fluid in the blood). On August 22, 2019, the record of Resident 40 was reviewed. Resident 40 was admitted to the facility on July 26, 2019. The "History and Physical," dated July 30, 2019, indicated Resident 40 had diagnoses which included ESRD on hemodialyis. Resident 40's record included a document titled, "PHYSICIAN ADMITTING ORDERS," dated July 26, 2019. The document indicated, "... Fluid Restriction 1000 ml/day ESRD..." According to the article titled, "Hemodialysis Facts Sheet," dated 2013, published by the American Nephrology Nurses' Association, "...Nutritional Management: Typical Recommendations...Fluids limited to 1-1.5 liters (1000 to 1500 ml) plus urine output per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 29 of 54 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 08/22/2019 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 day..." The facility policy titled, "Fluid Restrictions," dated April 2016, indicated "...PURPOSE: To ensure that the correct fluid allowance is provided...Physician orders for fluid restrictions will be implemented in collaboration with Nursing...The distribution of daily fluid allowance will be determined by Nursing..."

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

F759 09/16/2019 §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 medication error rate was less than five percent when: 1. For Resident 18, the Aspirin (medication for pain and blood thinning) 81 mg (milligram, unit of measurement) EC (enteric coated- coated to protect the medication from stomach acids) was crushed and administered by mouth; 2. For Residents 7 and 10, multiple medications were crushed and administered together through the gastrostomy tube (GT tube in the stomach for liquid nutrition or medication administration); and 3. For Resident 198, the buspirone (medication to treat anxiety) was not administered as ordered. These failures resulted in a medication error rate of 28.9 percent (11 errors out of 38 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 30 of 54 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 08/22/2019 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 opportunities; each medication which was crushed and administered together was calculated in the error rate). Findings: On August 21, 2019, medication administration observation was conducted with Registered Nurse (RN) 1. The following were observed: 1. At 8:09 a.m., RN 1 was observed to prepare medications for Resident 18, which included Aspirin EC 81 mg, one tablet. RN 1 was observed to place the Aspirin EC with the other medications in a single plastic pouch and crushed them all together. RN 1 was observed to pour all crushed medications into a medicine cup and mixed them with apple sauce. RN 1 was observed to administer the crushed medications to Resident 18 by mouth. On August 21, at 10:45 a.m., Resident 18's record was reviewed with RN 1. Resident 18 was admitted to the facility on July 30, 2015. The "Medication Administration Record," dated July, 2019, included a physician order which indicated, "Aspirin [81 MG] TABLET, DELAYED RELEASE (DR/EC) ORAL EVERY DAY..." The facility document titled, "Oral Dosage Forms That Should Not Be Crushed 2015," published by ISMP (Institute for Safe Medication Practices- the gold standard for medication safety information) was reviewed with RN 1. The document indicated "Aspirin enteric-coated" was in the list of medications which should not be crushed. In a concurrent interview with RN 1, RN 1 stated Aspirin EC was on the "Do Not Crush List." RN 1 stated Aspirin EC should not have been crushed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 31 of 54 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 08/22/2019 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 policy titled, "Medication Crushing Guidelines," dated 2012, was reviewed. The policy indicated, "...MEDICATIONS THAT SHOULD NOT BE CRUSHED OR CHEWED The solid dosage forms of many medications should not be crushed or chewed for a variety of reasons...The rationale for not crushing medications includes...Enteric Coated Tablets are designed to pass through the stomach whole and then dissolve in the intestinal tract. Reasons for this type of formulation include...to prevent the destruction of the medication by stomach acid...to prevent the medication from irritating the stomach lining, and...to achieve a prolonged action from the medication..." 2a. At 8:50 a.m., RN 1 was observed to prepare the medications for Resident 10 which included: - Amlodipine (blood pressure medication) 10 mg, one tablet; - Vitamin C (vitamin supplement) 500 mg, one tablet; - Multivitamin, one tablet; - Aspirin 81 mg, one tablet; and - Escitalopram (anti-depressant) 10 mg, one tablet. RN 1 was observed to put all five medications together in a plastic pouch. RN 1 was observed to crush the five medications in the plastic pouch together. RN 1 was observed to pour all crushed medications from the plastic pouch into one medicine cup. RN 1 was observed to mix the crushed medications with 30 milliliters (ml - unit of measure) of water. RN 1 was observed to administer the crushed medications all together to Resident 10 through Resident 10's G-tube. During a concurrent interview with RN 1, RN 1 stated it was ""ok" to crush medications and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 32 of 54 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 08/22/2019 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 mix them together. On August 21, 2019, Resident 10's record was reviewed. The facesheet indicated Resident 10 was admitted to the facility on October 9, 2015, with diagnoses that included respiratory failure (failure to breathe). 2b. At 9:20 a.m., RN 1 was observed to prepare medications for Resident 7 which included: - Vitamin C 500 mg, one tablet; - Multivitamin (a supplement), one tablet; - Tizanidine (muscle relaxant) four (4) mg, one tablet; and - Famotidine (used to treat heartburn) 20 mg, one tablet. RN 1 was observed to put the five medications in one plastic pouch. RN 1 was observed to crush the five medications together in a plastic pouch. RN 1 was observed to pour all crushed medications from the plastic pouch into one medicine cup. RN 1 was observed to mix the crushed medications with 30 ml of water. RN 1 was observed to administer the crushed medications together to Resident 7 through Resident 7's G-tube. On August 21, 2019, Resident 7's record was reviewed. Resident 7 was admitted to the facility on December 7, 1995. The History and Physical," dated June 10, 2019, indicated Resident 7 had diagnoses that included vegetative state (coma). On August 21, 2019, at 5:54 p.m., RN 1 was interviewed. RN 1 confirmed that she crushed Resident 10 and 7's medications together and administered the medications all at once through the Residents 10 and 7's G-tubes. RN 1 further stated this was how she administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 33 of 54 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 08/22/2019 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 medications through the G-tube. On August 21, 2019, at 5:52 p.m., the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated RN 1 should not have crushed the medications together nor have administered the crushed medications together when administering through a G-tube. The RNS further stated medication administered through the G-tube should have been given one at a time. According to the ISMP article, "Preventing Errors when Administering Drugs Via an Enteral Feeding Tube," dated May 6, 2010, "...the most common improper administration techniques include mixing multiple drugs together to give at once...mixing two or more drugs together, whether solid or liquid forms, creates a brand new, unknown entity with an unpredictable mechanism of release and bioavailability... Safe Practice Recommendations...Prepare separately. Each medication should be prepared individually so it can be administered separately...Administer separately. Each medication should be administered separately through the feeding tube..." The facility policy titled, "Enteral Tube Medication Administration," revised June 2016, indicated "...the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes..." 3. On August 21, 2019, at 8:40 a.m., medication administration observation for Resident 198 was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 was observed to administer the following medications to Resident 198: - Mirtazapine (medication for depression) 30 mg, one tablet; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 34 of 54 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 08/22/2019 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 - Prednisone (steriod medication) 20 mg, one tablet; - Symbicort (inhaler) 160 - 4.5 microgram (mcg), two puffs; - Tudorza Pres (inhaler) 400 mcg, one puff; - Magnesium oxide (supplement) 400 mg, one tablet; - Finasteride (medication to treat enlarged prostate) 5 mg, one tablet; - Nicotine TD (medication for smoking cessation) 21 mg / 24 hour, one patch; - Daliresp (medication to treat lung disease) 500 mcg, one tab; and - Subutex (pain medication) 8 mg, one tablet On August 21, 2019, Resident 198's record was reviewed. Resident 198 was admitted to the facility on August 14, 2019. The "Cumulative Diagnosis List," dated August 14, 2019, indicated Resident 198 had diagnoses which included anxiety (mood disorder). The facility document titled, "PHYSICIAN ADMITTING ORDERS," dated August 14, 2019, indicated, "...Buspiron (medication to treat anxiety) 10 mg PO (by mouth) BID (twice a day)..." LVN 2 was observed to not administer buspiron to Resident 198 during the medication administration observation on August 21, 2019 at 8:40 a.m. On August 21, 2019, at 9:47 a.m., a concurrent interview and record review with LVN 2 was conducted. LVN 2 stated Resident 198 had an order for buspiron 10 mg to be given at 9 a.m. LVN 2 stated she did not give the buspiron to Resident 198. LVN 2 stated, "I missed it." The facility policy and procedure titled, "...Medication Administration," revised April 2016, was reviewed. The policy indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 35 of 54 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 08/22/2019 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 "...Medication will be administered upon the order of a physician...Medication errors...Medication is considered to be given in error if any of the following conditions are present...omission (not given) of a dose..."

F760 SS=E Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 09/16/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure insulin (medication to treat abnormal blood sugar) was administered as ordered by the physician, for one of 16 residents reviewed (Resident 45). This failure had a potential to result in a delay in treatment and in complications of abnormal blood sugar for Resident 45. Findings: On August 19, 2019, at 3:35 p.m., Resident 45 was observed lying in bed watching TV in her room. In a concurrent interview, Resident 45 stated she had an infection of the wound on her back and groin. On August 20, 2019, Resident 45's record was reviewed. Resident 45 was admitted to the facility on August 2, 2019. The "Cumulative Diagnosis List," dated August 2, 2019, indicated Resident 45 had diagnoses which included sacral abscess (infected wound at the lower back) and diabetes mellitus (abnormal blood sugar). The facility document titled, "PHYSICIAN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 36 of 54 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 08/22/2019 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 ADMITTING ORDERS," dated August 2, 2019, indicated the following insulin orders: - "...Insuline (sic) Lispro (rapid-acting insulin to lower blood sugar) 100 unit/ml (milliliter - unit of measurement)...subcutaneous (S/Q - injection into the fat layer between skin and muscle) AC (before meals)/ (and) HS (bedtime)...150 - 200 mg (milligram)/deciliter (blood sugar level) = (give) 3 (three) units; 201-250 mg/dl = 5 units; 251 - 300 mg/dl = 7 units; 301 - 350 mg/dl = 9 units; 351 - 400 mg/dl = 11 units; Greater than 400 mg/dl = units Notify physician...; - "...Insulin Detemir Sol. (Levemir - insulin to treat increase in blood sugar when rapid acting insulin had stopped working) 20 unit/0.2 ml Subcutaneous at HS..." The facility document titled, "PHYSICIAN'S TELEPHONE ORDERS," dated August 4, 2019, indicated, "...Increase Levemir to 25 units S/Q daily..." The "PHYSICIAN'S TELEPHONE ORDERS," dated August 14, 2019, indicated, "...Levemir 35 units...add 5 units to sliding scale...Fax me BS (blood sugar) reading every 5 (five) day (sic)..." The physician's order was noted by the licensed nurse on August 14, 2019, at 6 p.m. The untitled facility document, for August 2019, indicated the following: - On August 14, 2019, at 4:30 p.m., Resident 45's blood sugar was 493 mg/dl. 11 units of the insulin Lispro was administered to Resident 45; - On August 14, 2019, at 5 p.m., 25 units of Levemir was administered to Resident 45; and - On August 14, 2019, at 6 p.m., 35 units of Levemir and additional five units of insulin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 37 of 54 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 08/22/2019 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 Lispro were administered to Resident 45 (a total of 60 units of Levemir was administered to Resident 45). There was no documented evidence five units of insulin Lispro was added to the sliding scale coverage from August 14, 2019 at 9 p.m. and thereafter, as ordered by the physician. There was no documented evidence 35 units of Levemir, as ordered by the physician, was administered to Resident 45 daily from August 15, 2019 and thereafter. There was no documented evidence the physician was notified of Resident 45's blood sugar every five days, as ordered by the physician. On August 21, 2019, at 11:39 a.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2 and the Assistant Director of Nursing (ADON). The ADON stated the physician ordered Levemir to increase from 25 units to 35 units. The ADON stated an additional five units of insulin Lispro should have been added to the sliding scale coverage for Resident 45. RN 2 stated the physician's order on August 14, 2019, was confusing. RN 2 stated the order should have been clarified with the physician. On August 21, 2019, at 11:42 a.m., RN 2 was observed to place a telephone call to the Attending Physician (AP) who wrote the insulin order on August 14, 2019. During a concurrent interview, RN 2 stated according to the AP, the Levemir was to be increased to 35 units once a day from August 14, 2019 and thereafter (not 60 units of Levemir as was administered to Resident 45 on August 14, 2019). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 38 of 54 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 08/22/2019 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 RN 2 stated according to the AP, five units of insulin Lispro was to be added to each of the sliding scale insulin coverage from August 14, 2019, and thereafter. RN 2 stated 25 units of Levemir was administered to Resident 45 from August 14, 2019 to August 21, 2019. RN 2 stated Resident 45 should have received Levemir 35 units from August 14, 2019, to August 21, 2019. RN 2 stated the five units of insulin Lispro to be added to each of the sliding scale coverage was not carried out from August 14, 2019, from 5 p.m., and thereafter. RN 2 stated there was no documentation of the physician being notified of Resident 45's blood sugar readings on August 19, 2019 (five days after the supposed changes of the insulin were ordered), as ordered by the physician on August 14, 2019. RN 2 stated the physician should have been notified of Resident 45's blood sugar readings on August 19, 2019. On August 21, 2019, at 3:54 p.m., a concurrent interview and record review with LVN 1 were conducted. LVN 1 stated Resident 45's blood sugar on August 14, 2019, at 4:30 p.m., was 493 mg/dl. LVN 1 stated she administered 11 units of the insulin lispro to Resident 45 on August 14, 2019, at 4:30 p.m. LVN 1 stated she administered 25 units of Levemir to Resident 45 on August 14, 2019, at 5 p.m. LVN 1 stated she notified the physician during his visit to the facility on August 14, 2019, at 5:30 p.m. and the physician ordered 35 units of Levemir and to add five units of insulin lispro to be given only on August 14, 2019. LVN 1 stated she administered five units of insulin lispro and Levemir 35 units on top of the 25 units of Levemir she initially administered on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 39 of 54 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 08/22/2019 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 August 14, 2019, at 4:30 p.m. (total of 60 units of Levemir, 25 units more than what should have been administered). On August 22, 2019, at 9:03 a.m., the attending physician (AP) was interviewed regarding the blood sugar of Resident 45. The MD stated during his visit to the facility on August 14, 2019 at around 5 p.m., LVN 1 notified him of Resident 45's blood sugar above 400 mg/dl. The AP stated he reviewed Resident 45's blood sugar. The AP stated Resident 45's blood sugars were uncontrolled. The AP stated he wrote an order to increase Levemir to 35 units, to add five units of insulin Lispro to each sliding scale coverage, and to fax Resident 45's blood sugar readings to him every five days. The AP stated he notified LVN 1 of the new orders. The AP stated the Levemir 35 units should have been given every day after he ordered it on August 14, 2019 and thereafter to Resident 45. The AP stated five units of insulin Lispro should have been added to each of the sliding scale coverage after he ordered it on August 14, 2019 and thereafter to Resident 45. The AP stated if the order for the Levemir and the insulin Lispro were not clear, the licensed nurse should have clarified with him. The AP stated he was not aware a total of 60 units Levemir was administered to Resident 45 on August 14, 2019, at 6 p.m. The AP stated, "That's why the blood glucose was around 76 on the labs drawn the following day." The AP stated Resident 45 could have gone to "hypoglycemia (low blood sugar)" because of the additional 35 units of Levemir administered to Resident 45 on August 14, 2019. The AP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 40 of 54 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 08/22/2019 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 further stated if Resident 45's blood sugar was not controlled, Resident 45 could have complications such as infections, delayed wound healing, or other body organ damage. On August 22, 2019, at 9:07 a.m., the ADON was interviewed. The ADON stated the order on August 14, 2019 should have been clarified with the AP. The ADON stated the physician's order on August 14, 2019 for Resident 45's change in Levemir and sliding scale coverage was not faxed to the pharmacy for review. The ADON stated the new order of Levemir and insulin lispro should have been faxed to the pharmacy for review. The facility policy and procedure titled, "...Physician's Prescriptions (Orders)," revised April 2016, was reviewed. The policy indicated, "...Physician's prescriptions which cannot be deciphered (be read or understood), or are incomplete, or which, in the nurse's judgment should not be accomplished without further review or clarification, will not be implemented until clarification has been provided..."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 09/16/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 41 of 54 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 08/22/2019 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 biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure discontinued medications and expired food supplements were not readily available for use. These failures had the potential for the residents to receive expired food supplements and to receive discontinued medications. Findings: On August 20, 2019, starting at 9:17 a.m., the Medication Room (MR) at the skilled nursing facility was inspected with the Assistant Director of Nursing (ADON). The following were found inside the MR: - Two cartons of 11 fluid ounces of protein drink with an expiration date of March 11, 2019 (five months from the time of inspection), readily available for use; and - Eight syringes of Lovenox (medication to treat blood clots) 80 milligrams (mg, unit of measurement) in a box labeled with Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 42 of 54 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 08/22/2019 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 207's name was found with the house supply medications. The box of Lovenox was delivered to the facility on August 26, 2018. In a concurrent interview with the ADON, she stated the protein drink was expired and should have been discarded. The ADON stated Resident 207 was discharged from the facility on September 9, 2018. The ADON stated Resident 207's Lovenox should have been discarded when Resident 207 was discharged from the facility on September 9, 2018, and should not be readily available for use. The facility policy and procedure titled, "MEDICATION DESTRUCTION," revised June 2016, was reviewed. The policy indicated, "...Discontinued medications and medications left in the facility after a resident's discharge are destroyed..." The facility policy and procedure titled, "...Floor Supplies," dated May 2018, was reviewed. The policy indicated, "...To develop and maintain a mechanism to deliver safe and accurate floor stock items for patient use...Foods are discarded according to the expiration/pull date..."

F770 SS=D Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 09/16/2019 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 43 of 54 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 08/22/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the physician's order for Complete Blood Count (CBC - blood test for blood cells and anemia), Complete Metabolic Panel (CMP - blood test that measured the levels of sugar and electrolytes in the body and kidney function), and Magnesium level (blood test that measured magnesium -an electrolyte important in the heart and nervous function) were completed as ordered by the physician, for one of 16 residents reviewed (Resident 199). This failure had the potential for medical condition/s to not be identified timely and/or a delay in the care and treatment for Resident 199. Findings: On August 20, 2019, Resident 199's record was reviewed. Resident 199 was admitted to the facility on August 11, 2019. The "History and Physical," dated August 13, 2019, indicated Resident 199 had diagnoses which included heart failure (heart condition) and pressure ulcer (bed sore). The facility document titled, "PHYSICIAN'S TELEPHONE ORDER," dated August 13, 2019, indicated, "...check CBC, CMP, Magnesium 8/13/19 (August 13, 2019)..." There was no documented evidence CBC, CMP, and Magnesium levels were completed on August 13, 2019. On August 20, 2019, at 12:34 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 3. RN 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 44 of 54 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 08/22/2019 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 stated Resident 199 had an order for CBC, CMP, and Magnesium levels to be drawn on August 13, 2019. RN 3 stated there were no results in Resident 199's record of the CBC, CMP, and Magnesium levels which were ordered to be done on August 13, 2019. RN 3 stated the laboratory request was placed in the computer on August 13, 2019, at 4:20 p.m., and it was cancelled because it was past the blood draw time of 6 a.m. RN 3 stated the laboratory requests on August 13, 2019, was not carried over on August 14, 2019. RN 3 stated the laboratory request for Resident 199 on August 13, 2019, should have been completed the following day (August 14, 2019). RN 3 stated she was not able to explain why Resident 199's laboratory request was missed on August 13, 2019, or on August 14, 2019. The facility policy and procedure titled, "...Laboratory Work Flow," revised January 2019, was reviewed. The policy indicated, "...The Phlebotomy team begins morning rounds at 0400 (4 a.m.) daily. All orders on Electrolytes...CBCs...chemistry profiles and panels...that have been ordered between the afternoons on the previous day to 0400 on the current day will be drawn on morning rounds..."

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

F812 09/16/2019 §483.60(i) Food safety requirements. The facility must §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 45 of 54 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 08/22/2019 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 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 food was stored and handled in a safe manner when, 1. During the initial kitchen observation on August 18, 2019, the following were observed: a. In the dry storage room was a plastic container with a food item inside a blue bag. The container was not labeled with the date the food item was received, what the food item was, or the date it was opened; b. In refrigerator number four, there were two pans of jello labeled with a use by date of August 17, 2019, readily available for use; and c. In refrigerator number one, there was one nine pound block of feta cheese labeled with a use by date of July 5, 2019, readily available for use. 2. The quaternary ammonium test strip (Quat a sanitizing agent used to test the chemical concentration of the solution) used on August 20, 2019, was expired and readily available for use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 46 of 54 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 08/22/2019 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 These failures had the potential to cause residents to be exposed to contaminated food. Findings: 1. On August 18, 2019, at 10 a.m., a tour of the subacute kitchen was conducted with the Executive Chef (EC). The following were observed: a. In the dry storage room, a plastic container, with a food item inside a blue bag in it, was observed. There was no label indicating the date the food item was received, what the food item was, or the date it was opened; b. In refrigerator number 4, two pans of prepared jello were observed with a use by date of August 17, 2019, readily available for use; and c. In refrigerator number 1, one nine pound block of feta cheese was observed with a use by date of July 5, 2019, readily available for use. In a concurrent interview with the EC, he confirmed there was no label on the plastic container in the dry storage room. The EC stated the container should have been labeled with the name of the food item, the date it was received, and the date it was opened. The EC also stated the two pans of jello and the feta cheese were past the use by dates and should not have been available for use. The policy and procedure titled, "Food Storage," revised May 2016, was reviewed. The policy indicated, "...PURPOSE...To safety (sic) store food and prevent contamination...Upon receiving...Date all products...Manufacturer's expiration, 'use by'...dates must be adhered to...Dry food, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 47 of 54 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 08/22/2019 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 which is opened or removed from original packaging, should be...clearly labeled...Prepared foods are discarded after 3 (three) days if not used..." 2. On August 20, 2019, starting at 8:35 a.m., a follow up visit in the skilled facility kitchen was conducted with Cook 1 and the Dietary Manager (DM). Cook 1 was observed to test the quaternary ammonium solution. The label on the test strip that was used by Cook 1 was reviewed. The test strip indicated an expiration date of July 15, 2019. During a concurrent interview with Cook 1, Cook 1 stated she was not aware the test strip was expired. In a concurrent interview with the DM, the DM stated the test strip should not have been used when it was expired. The facility policy titled, "DISHWASHING," dated May 2018, was reviewed. The policy indicated, "...Ensure adequate sanitation of dishes, pots, pans an utensils...using test strips to ensure proper concentration is used..."

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

F880 09/16/2019 §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: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 48 of 54 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 08/22/2019 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 §483.80(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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 49 of 54 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 08/22/2019 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 §483.80(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: Based on observation, interview, and record review, the facility failed to ensure infection prevention measures were implemented for three of three residents reviewed for infections (Residents 45, 199, and 197) when: 1. For Resident 45, the peripherally inserted central catheter (PICC - long catheter inserted through the vein of the arms and legs to provide intravenous treatment) dressing was not changed according to the facility policy and procedure; 2. For Resident 199, the midline (longer catheter used in the vein) dressing was not changed according to the facility policy and procedure; and 3. For Resident 197, the site of the peripheral intravenous (IV) line was not changed according to the facility policy and procedure. These failures had the potential for Residents 45, 199, and 197 to develop skin and blood infections. Findings: 1. On August 19, 2019, at 3:35 p.m., Resident 45 was observed lying in bed. Resident 45 was observed to have an IV line at her upper arm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 50 of 54 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 08/22/2019 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 a dressing labeled with a date of August 9, 2019. In a concurrent interview, Resident 45 stated the IV was used for IV antibiotic (medication to treat infection). Resident 45 stated the IV line dressing was changed more than a week ago. On August 19, 2019, Resident 45's record was reviewed. Resident 45 was admitted to the facility on August 2, 2019, with diagnoses which included septic shock (severe body reaction to an infection). The facility document titled, "INTRAVENOUS THERAPY MEDICATION RECORD (IVR)," for August 2019, indicated, "...PICC...Central Dsg (dressing) Change: Q (every) Wed (Wednesday) NOC (night shift) & (and) PRN (as needed)..." The IVR indicated Resident 45's PICC line dressing was changed on August 9, 2019. There was no documented evidence the PICC line dressing was changed after August 9, 2019. The facility document titled, "Care Plan Peripheral IV Therapy," dated August 3, 2019, indicated, "...Potential for infection related to direct IV access to the blood...Change sterile and transparent dressings..." There was no documented evidence of a physician's order for IV care and management. On August 19, 2019, at 3:57 p.m., a concurrent interview and record review was conducted with Registered Nurse (RN) 2. RN 2 stated there was no physician's order for the care and management of Resident 45's IV access site. RN 2 stated there should have been a physician's order for the care and management of the IV access site. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 51 of 54 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 08/22/2019 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 RN 2 stated Resident 45's PICC line dressing was changed on August 9, 2019. RN 2 stated PICC line dressing was to be changed once a week every Wednesday to prevent the development of infections on the IV site. RN 2 stated Resident 45's PICC line dressing should have been changed on August 16, 2019. 2. On August 19, 2019, at 11:26 a.m., Resident 199 was observed to be lying in bed. Resident 199 was observed to have an IV access site at the right upper arm with a dressing labeled with a date of August 7, 2019. In a concurrent interview, Resident 199 stated she had completed the IV therapy. Resident 199 stated the IV access had not been used. On August 20, 2019, Resident 199's record was reviewed. Resident 199 was admitted to the facility on August 2, 2019, with diagnoses which included pressure ulcer on the left heel (open wounds caused by pressure). The facility document titled, "INTRAVENOUS THERAPY MEDICATION RECORD (IVR)," for August 2019, indicated Resident 199 had a midline at the right upper arm. The document did not indicate when the midline IV site or dressing was changed. The facility document titled, "Care Plan Peripheral IV Therapy," dated August 3, 2019, indicated, "...Potential for infection related to direct IV access to the blood...Change sterile and transparent dressings..." There was no documented evidence of a physician's order for IV care and management. On August 20, 2019, at 2:53 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 stated Resident 199 had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 52 of 54 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 08/22/2019 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 midline catheter. RN 2 stated the midline catheter site was changed on August 7, 2019. RN 2 stated there was no physician's order for the care and management of Resident 199's IV access site. RN 2 stated the hydration (IV fluids were infused using the IV catheter) for Resident 199 ended on August 13, 2019. RN 2 stated the IV access site should have been discontinued if not being used. RN 2 was observed to go into Resident 199's room. In a concurrent interview, RN 2 stated Resident 199's IV access site dressing was dated August 7, 2019. RN 2 stated the IV access site dressing should have been changed every week according to facility protocol. 3. On August 18, 2019, at 12:15 p.m., Resident 197 was observed lying in bed. Resident 197 was observed to have an IV access site at the right wrist. The IV access site dressing was observed to not be labeled with a date of when it was inserted or changed. In a concurrent interview, Resident 197 stated she remembered the IV site at her right wrist was inserted before she got admitted to the facility. On August 18, 2019, at 12:29 p.m., a concurrent observation of Resident 197 and interview with RN 3 was conducted. RN 3 stated Resident 197's peripheral IV line was not dated. RN 3 stated she remembered Resident 197 had the IV line at the right wrist when she was admitted to the facility on August 9, 2019. RN 3 stated the IV access site should have been changed every three days because of the potential for infection or complication. On August 22, 2019, Resident 197's record was reviewed. Resident 197 was admitted to the facility on August 9, 2019. The "Cumulative Diagnosis List," dated August 9, 2019, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 53 of 54 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 08/22/2019 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 indicated Resident 197 had diagnoses which included deep vein thrombosis (blood clot) and neurogenic bladder (bladder control was lacking due to nerve or brain injury). The facility document titled, "PHYSICIAN'S TELEPHONE ORDER," dated August 13, 2019, indicated, "...Rocephin (antibiotic to treat infection) 1 (one) gm (gram) IV daily until 8-1719 (August 17, 2019) for UTI (urinary tract infection)..." There was no documented evidence of a physician's order for IV care and management for Resident 197. There was no documented evidence the IV site was changed after August 9, 2019. The facility policy and procedure titled, "...Management of Intravascular Access Devices," revised March 2016, indicated, "...Dressing Change...PICC...weekly..." The facility policy and procedure titled, "...Intravenous Policy," revised March 2016, indicated, "...all individual infusions must be on the specific order of a physicians (sic)...The date, time...and the initials of the nurse doing the procedure must be documented on the IV/MAR (Medication Administration Record) and on the tape at the insertion site...Peripheral I.V. sites shall be changed to a new site every forty-eight to seventy-two (48-72) hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: J52Y11 Facility ID: CA240001502 If continuation sheet 54 of 54