Health inspection·June 21, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 2) whereabout was being frequently monitored. This failure potentially could have contributed for Resident 2 to be able to wander to Resident 1's room and was found on top of the resident on April 27, 2024. Findings: A review of Resident 2 ' s medical record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s History and Physical (H&P), dated November 17, 2023, indicated Resident 2 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities). A review of Resident 2 ' s Minimum Data Set (MDS- an assessment tool) dated March 29, 2024, indicated Resident 2 had severely impaired cognition. A review of Resident 2 ' s care plan dated May 16, 2022, indicated Resident 2 was . at risk for leaving safe area without authorization, leaves premises without authorization secondary to dementia as evidenced by resident wanders around the facility hallway and to other resident rooms .Interventions * Monitor at frequent intervals .Redirect resident to alternatives .provide 1:1 if indicated to redirect behaviors on interim basis . A review of Resident 1's medical record was conducted. Resident 1's 'admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (reduced circulation to a body part other than brain or heart), hypertension (high blood pressure), and anxiety (mental health condition). Resident 1's History and Physical dated June 29, 2024, indicated Resident 1 cannot make decisions. On May 7, 2024, at 10:53 a.m., an interview with Certified Nursing Assitant (CNA) 1 was conducted. CNA 1 stated Resident 1 was non-verbal. CNA 1 stated on April 27, 2024, at the beginning of the morning shift, she was passing breakfast trays when she found Resident 2 on top of Resident 1. CNA 1 stated Resident 1's gown was lifted; her upper body was exposed, and her briefs were undone. CNA 1 stated Resident 2 was touching Resident 1's chest. CNA 1 stated Resident 1 saw her, got off the bed, and tried to fight her (CNA 1). CNA 1 stated Resident 1 looked scared, and she reported the incident immediately to Licensed Vocational Nurse (LVN) 1. CNA 1 further stated Resident 2 had behavior of going into other residents ' rooms. On May 7, 2024, at 1:08 p.m., an interview with LVN 1 was conducted. LVN 1 stated on April 27, (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555135 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 06/21/2024 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)