Health inspection·May 9, 2024

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his records. The MR further verified Resident 7 did not have the capacity to understand and make decisions and he did not have an appointed resident representative since admitted in March 13, 2024. On April 24, 2024, at 6:35 p.m., an interview with a concurrent record review was conducted with the Social Service Director (SSD). The SSD stated the facility's process was, if a resident was determined to not have the capacity to understand and make decisions and there was no other decision maker, the Interdisciplinary Team (IDT - a group of healthcare professionals) will meet and determine if the Bioethics committee (facility committee that consists of the facility's licensed healthcare professionals including the Administrator) will be the appointed healthcare decision maker for the resident. The SSD stated she was a member of the IDT team. The SSD verified Resident 7 did not have the capacity to understand and make healthcare decisions. The SSD stated Resident 7's assigned healthcare decision maker should be the facility's Bioethics Committee. The SSD was unable to provide documented evidence on how Resident 7's decision maker should be the Bioethics Committee was determined by the IDT team. In addition, the SSD was unable to show documented evidence the POLST and Consent to treat were discussed by the IDT team and the Bioethics Committee since Resident 7's admission on [DATE] to present. The facility's undated policy and procedure titled, .admission To Secured Unit when Resident Lacks Capacity and There Is No Person With Legal Authority To Make Health Care Decisions On Behalf Of The Resident . was reviewed. The policy indicated, .WHEN A RESIDENT LACKS CAPACITY AND THERE IS NO PERSON WITH LEGAL AUTHORITY TO MAKE HEALTH CARE DECISIONS ON BEHALF OF THE RESIDENT, THE IDT WILL REVIEW THE PHYSICIAN'S PRDERS FOR SECURED UNIT PLACEMENT AND PROVIDE APPROPRIATE RECOMMENDATIONS FOR THE RESIDENT .An IDT meeting will review the physician's assessment of the resident's condition to include at a minimum .H&P (History and Physical) that indicates lack of capacity .Appropriate diagnosis that include cognitive impairment .A discussion of the desires of the resident where known .The type of medical treatment to be used in resident's care .Documented decision by IDT with recommendations, as appropriate for admission to the Secured Unit .The IDT will refer any resident with unresolved or conflicting issues identified for follow up with the Bioethics Committee. The IDT will review the Bioethics Committee's recommendation for further follow up . The facility's undated policy and procedure titled, Bioethics Committee, was reviewed. The policy indicated, .THE BIOETHICS COMMITTEE SHALL ACT TO RESOLVE CONFLICTS REGARDING BIOETHICS IN AREAS OF CONFUSION AND UNCERTAINTY .IT IS THE POLICY OF THIS FACILITY TO INCORPORATE A COMMITTEEE KNOWLEDGEABLE IN ETHICAL PROCEDURES, AS PERTAIN TO HEALTHCARE .The committee has an active duty, as health care providers, to proceed based upon the established principles of bioethics and particularly, the primary principle of do no harm .The committee will investigate and render decisions on each bioethics issue, taking under consideration capacity versus competency', the wishes of the resident, and whether any relevant consent is truly informed or negotiated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On April 24, 2024, at 5: 18 p.m., an interview with a concurrent record review was conducted with the Medical Records (MR). Resident 7 was admitted to the facility on [DATE], with diagnoses including schizophrenia (type of personality disorder that affects a person's ability to think, feel, and behave clearly). The following documents of Resident 7 were reviewed: The Physician's History and Physical, dated March 15, 2024, indicated, .This resident .does not have the capacity to understand and make decisions .Surrogate Decisionmaker .None of file . The Minimum Data Set (MDS-an assessment tool), dated March 19, 2024, indicated Resident 7's BIMS Summary Score (a screener that aids in detecting cognitive impairment. Scores as follows: 13-15: cognitively intact; 8-12: moderately impaired; 0-7: severe impairment) was 2 (two - severe impairment). There was no documented evidence of a completed and signed Physician's Orders for Life Sustaining Treatment (POLST- a legal document signed by the resident if with capacity to make decision or resident legal representative, and physician, that indicate a resident's preference for life sustaining treatment) and a Consent to Treat form in Resident 7's facility medical record. In a concurrent interview, the MR stated the POLST and Consent to Treat form should have been completed and signed by the resident's assigned representative and physician upon his admission to the facility. The MR stated he did not know why Resident 7 did not have a signed POLST and Consent to Treat form in his records. On April 24, 2024, at 6:35 p.m., an interview with a concurrent record review was conducted with the Social Service Director (SSD). The SSD stated the facility's process was, if a resident was determined to not have the capacity to understand and make decisions and there is no other decision maker, the Interdisciplinary Team (IDT) will meet and determine if Bioethics (facility committee that consists of the facility's licensed healthcare professionals including the Administrator) will be the appointed healthcare decision maker for the resident. The SSD verified Resident 7 did not have the capacity to understand and make healthcare decisions. The SSD stated Resident 7's assigned healthcare decision maker was the facility's Bioethics Committee. The SSD was unable to provide documented evidence on how this was determined by the IDT team. In addition, the SSD was unable to provide documented evidence Resident 7's POLST and Consent to Treat form were discussed by the IDT team and the Bioethics Committee since Resident 7's admission on [DATE], to present. The facility's undated policy and procedure titled, Bioethics Committee, was reviewed. The policy indicated, .THE BIOETHICS COMMITTEE SHALL ACT TO RESOLVE CONFLICTS REGARDING BIOETHICS IN AREAS OF CONFUSION AND UNCERTAINTY .IT IS THE POLICY OF THIS FACILITY TO INCORPORATE A COMMITTEEE KNOWLEDGEABLE IN ETHICAL PROCEDURES, AS PERTAIN TO HEALTHCARE .The committee has an active duty, as health care providers, to proceed based upon the established principles of bioethics and particularly, the primary principle of do no harm .The committee will investigate and render decisions on each bioethics issue, taking under consideration capacity versus competency', the wishes of the resident, and whether (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 any relevant consent is truly informed or negotiated . Level of Harm - Minimal harm or potential for actual harm The facility's undated policy and procedure titled, POLST was reviewed. The policy indicated, THIS FACILITY WILL PROVIDE RESIDENTS WITH THE UPDATED JANUARY 1, 2016 POLST THAT IS VOLUNTARY AND INCLUDES PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT .THIS POLST WILL .ALLOW RESIDENTS TO HAVE MORE CONTROL OVER THEIR CARE .ALLOW BOTH THE DOCTOR AND PATIENT TO SPECIFY THE TYPES OF MEDICAL TREATMENT THAT THE PATIENT WISHES TO RECEIVE AT THE END OF LIFE .BECOMPLETED BY A PHYSICIAN, NURSE PRATCTITIONER OR PHYSCIAN ASSISTANCT AND THE PATIENT OR HIS/HER LEGALLY RECOGNIZED HEALTHCARE DECISIONMAKER . Residents Affected - Some Based on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST-a legal document signed by the resident if with capacity to make decision or resident legal representative, and physician, that indicate a resident's preference for life sustaining treatment) was identifiable, accurate, and updated, for three of seven residents reviewed (Resident 2, 6, and 7). This failure had the potential for Residents 2, 6, and 7 to receive inappropriate or delayed treatment. Findings: 1. On April 24, 2024, Resident 2's record was reviewed. Resident 2 was admitted on [DATE], with diagnoses including primary hypertension (elevated blood pressure), and syphilis (sexually transmitted disease caused by bacteria). The following documents of Resident 2 were reviewed: - The Physician's History and Physical, dated March 5, 2024, indicated Resident 2's decision making capacity was fluctuating; - The POLST, dated March 4, 2024, indicated, Do Not Attempt Resuscitation/DNR No Hospitalization for Any Reason . POLST section D does not have Resident 2 or Resident's Representative signature or date; and - The Social Services Note, dated March 12, 2024, indicated, .Interdisciplinary Team (IDT) spoke with resident's (family member), he mentioned he would be involved in (Resident 2) care . he gave verbal consent to treat (tx), admission to secured unit and full code POLST . There was no documented evidence Resident 2's POLST (dated March 4, 2024) was updated to a Full Code Status as of April 24, 2024. On April 24, 2024, at 3:17 p.m., an interview and concurrent record review were conducted with the Director of Nursing (DON). The DON stated there was no updated POLST in Resident 2's record to indicate a full code status. She stated the updated POLST (April 24, 2024) should have been in the chart since March 12, 2024. The DON stated Resident 2 having the wrong POLST could be a serious adverse event for the resident. On April 24, 2024, at 2:28 p.m. an interview was conducted with the Social Services Director (SSD). The SSD stated that on admission Resident 2 was self-responsible and her husband was the emergency contact. The SSD stated Resident 2 started exhibiting behaviors on April 12, 2024. The SSD stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Springs Care Center 1441 Michigan Avenue Beaumont, CA 92223 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 signed her POLST on March 4, 2024. The SSD stated during an IDT meeting on March 12, 2024, with Resident 2's family member, on the phone, he gave verbal consent for Resident 2 to be full code. The SSD stated the POLST should have been updated as soon as possible. The SSD stated Resident 2 had fluctuating capacity to make decisions. In addition, the SSD was unable to show documented evidence of the updated POLST since IDT meeting with Resident 2's husband on March 12, 2024, to present. On April 24, 2024, at 2:20 p.m., an interview and concurrent record review was conducted with Registered Nurse (RN) 1. RN 1 stated the Resident 2's POLST, dated March 4, 2024, indicated, Do Not Attempt Resuscitation/DNR No Hospitalization for Any Reason . was the POLST she made copies of and sent with Resident 2 when the resident was transferred to the acute hospital on April 23, 2024. RN 1 stated she did not verify the POLST with the physician before sending the documents with Resident 2 during transfer. RN 1 stated she was not aware that Resident 2 was a full code. 2. On April 24, 2024, Resident 6's record was reviewed. Resident 6 was admitted on [DATE], with diagnoses including schizophrenia (serious mental disorder in which people interpret reality abnormally), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss interest). The following documents of Resident 6 were reviewed: - The Physician's History and Physical, dated December 17, 2023, indicated Resident 6 did not have the capacity to understand and make decisions; - The POLST, dated May 11, 2022, indicated, Full Treatment with section D check off for no Advanced Directives. POLST section D did not have Resident 2 or Resident 2's representative signature. Resident 6's POLST was signed by SSD/Bioethics (Social Service Director)/Bioethics (facility committee that consists of the facility's licensed healthcare professionals including the Administrator); and - The Interdisciplinary Team (IDT - a group of healthcare professionals) Quarterly Notes, dated January 22, 2024, indicated the IDT met with resident's Responsible Party (RP-person designated to make decisions) who was the (family member) via teleconference. The IDT team reviewed Resident 6's current diagnosis, treatment and the POLST with no changes being made at this time. On April 24, 2024, at 6:00 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON) on Resident 6's chart. The DON stated there was no updated POLST in Resident 6's chart. The DON stated the POLST was signed by SSD/Bioethics on May 11, 2022, should have been updated and signed by Resident 2's assigned RP (family member) after IDT meeting on January 22, 2024. The DON stated there was no documented evidence as to why the SSD/Bioethics committee determined and signed Resident 2's POLST on May 11, 2022. The DON stated Resident 2's updated POLST with RP's signature should have been in Resident 2's medical chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555135 If continuation sheet Page 5 of 5