Health inspection·April 10, 2025

F 0580 Level of Harm - Actual harm Residents Affected - Few (Certified Nursing Assistant) reported patients O2 level at 35, patient was noted not having his nasal cannula on. O2 was placed and went up to 80. Nasal cannula was switched to non-rebreather mask and O2 levels went up to 87 . On [DATE], at 3:19 p.m., during an interview, the Registered Nurse (RN 1) stated on [DATE], at approximately 10 a.m., Resident 1 had removed his oxygen, and his oxygen levels were low. RN 1 stated that they placed a non-rebreather mask on at 10 liters to get the oxygen levels up. RN 1 stated they notified the resident's physician, and the physician ordered for Resident 1 to be transferred to the GACH. On [DATE], at 1:41 p.m., during an interview, RN 2 stated that if a resident had low oxygen saturation of 57%, they would place oxygen at high flow oxygen (form of non-invasive respiratory support that delivers high volumes of oxygen directly to the patient through nasal cannulas), contact the resident's physician, and would transfer the resident to the hospital. On [DATE], at 3:21 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated that on [DATE], Resident 1 was removing his oxygen, and his oxygen saturation was at 57% before paramedics came. LVN 1 stated she was at the bedside with Resident 1 until the medics came to transport Resident 1 to the GACH. On [DATE], at 11:52 a.m., during a telephone interview, LVN 2 stated that normal oxygen saturation should be above 90%. LVN 2 stated that they should notify the physician if a resident's oxygen saturation is below 90%. LVN 2 stated that Resident 1 had an order for oxygen by nasal cannula at 3 liters, however, on [DATE], around midnight, she was alerted by the Certified Nursing Assistant that Resident 1's oxygen saturation was 35%, and he was removing his oxygen. LVN 2 stated that they should have contacted the physician to report Resident 1's low oxygen saturation. On [DATE], at 3:58 p.m., during a telephone interview with the Attending Physician (AP), the AP stated, he was not aware Resident 1 had an episode of low oxygen saturation level after midnight on [DATE], or that a non-rebreather mask was used. The AP stated he was informed by licensed staff at around 11 a.m. on [DATE]. The AP stated, he was not informed of the resident's earlier low oxygen saturation of 35%. The AP stated, if he had been informed of earlier episode of the low oxygen saturation level, he would have sent the resident to the hospital. On [DATE], at 4:26 p.m., during a telephone interview with the Director of Nursing (DON), she stated, Resident 1 had a change in condition around 1:37 a.m. on [DATE], due to low oxygen saturation, which dropped to 35. The DON stated, the resident should have been transferred to the hospital at that point. The DON stated that the licensed nurse should have closely monitored the resident, but there was no documentation that the resident was closely monitored. The DON stated, the physician was not notified until around 11 a.m. The DON stated the delay in notifying the physician could have affected the resident's treatment. A record review of Resident 1's eINTERACT SBAR [situation, background, assessment, recommendation], Summary for Providers, dated [DATE], at 11:57 a.m., indicated .At 11:20 AM, resident was noted not wearing his oxygen. Upon entering the room, resident's HOB [head of bed] was on fowlers (sic) position [a medical term for a body position in an upright in bed with head and back supported at an angle of 45 to 60 degrees]. Upon assessment, resident was pale, awake, alert but altered (thinking, awareness, or behavior is abnormal), skin was warm to touch, VS [vital sign] has significant O2 [oxygen] level of 56%, went up to 88-91% after we put him on non-rebreather (sic) mask on 5L [liters] oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555297 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 555297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Hills Post Acute 1717 West Stetson Avenue Hemet, CA 92545 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 0580 MD made aware with an order to send resident to ED for further treatment and management. Level of Harm - Actual harm A review of Resident 1's Emergency Department Records, dated [DATE], at 1:25 p.m., indicated XXX[AGE] year-old male patient (Resident 1) presents to the ER (Emergency Room) .for evaluation of difficulty in breathing. History is limited due to patient's altered level of consciousness. Patient is difficult to arouse and is unable to answer questions .Procedures in the Emergency Department .Procedure Narrative: Endotracheal Intubation . Intubation indications: respiratory failure and severe hypoxemia. It was felt the patient required emergency intubation . Residents Affected - Few A review of Resident 1's hospital document titled, Discharge Summary, dated [DATE], indicated, Resident 1 was pronounced deceased following confirmation of asystole (complete absence of electrical activity in the heart), absent heart sounds, no spontaneous respirations, no pupillary or corneal reflex. Resident 1 was admitted with shortness of breath and lethargy (reduced alertness, slow response, or drowsiness). Resident 1's Plan of Care noted a diagnosis of Acute Hypercapnic Hypoxic Respiratory Failure (a serious medical condition where the lungs cannot provide enough oxygen to the body and cannot remove enough carbon dioxide [colorless and odorless gas]) likely secondary to Pneumonia (an infection of the lungs), Healthcare Associated Pneumonia (pneumonia that developed in a facility). The resident required reintubation and mechanical ventilation (a life-support technique that uses a machine to move air in and out of the lungs). The discharge diagnosis was cardiac arrest secondary to acute respiratory failure and pneumonia caused by ESBL (Extended-Spectrum Beta-Lactamase - bacteria resistant to many commonly used antibiotics). A review of the facility's policy and procedure titled Change in a Resident's Condition or Status revised February 2021, indicated .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) . d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555297 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 555297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Hills Post Acute 1717 West Stetson Avenue Hemet, CA 92545 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 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 observation, interview, and record review, the facility failed to ensure one of eight residents, (Resident 3), was safe from a fall, when the Certified Nursing Assistant, (CNA 1), repositioned Resident 3 away from her while changing Resident 3's briefs. This failure caused discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. Resident 3 was transferred to the hospital for evaluation. Findings: On March 21, 2025, at 11:42 a.m., an unannounced visit to the facility on four complaints and a Facility Reported Incident was initiated. A review of Resident 3's medical records indicated he was originally admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Alzheimer's disease, (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), acquired absence of left leg below knee, and legal blindness. A review of Resident 3's History and Physical dated October 25, 2024, indicated he did not have the capacity to make decisions. A review of Resident 3's Minimum Data Set (an assessment tool), dated January 26, 2025, indicated, Resident 3 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed). On March 21, 2025, at 3:44 p.m., a telephone interview was conducted with the Certified Nursing Assistant, (CNA 1). CNA 1 stated on March 16, 2025, between 8:30 p.m. to 9 p.m., she was changing Resident 3's brief. CNA 1 stated she was standing on the left side of the bed and Resident 3 was lying on his back. CNA 1 stated that she had instructed Resident 3 to turn to the right, and was preparing to walk to the right side, and Resident 1 turned and fell off the bed headfirst. CNA 1 stated, Resident 3 required moderate (the resident does more than half of the effort, but staff provided some physical help) to maximal assistance with bed mobility. On March 24, 2025, at 1:11 p.m., observed Resident 3 lying in bed on his back. There were no side rails in use, and he was on an air mattress. On March 24, 2025, at 1:11 p.m., an interview was conducted with Resident 3. Resident 3 stated on an unknown date, unknown persons pushed him out of bed, and he fell on his head. On March 24, 2025, at 3:37 p.m., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 3. CNA 2 stated that when repositioning Resident 3, she preferred having two person assistance to ensure a safe turn. CNA 2 stated, when repositioning residents alone, she would instruct the resident to turn towards her to prevent a fall from the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555297 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 555297 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Hills Post Acute 1717 West Stetson Avenue Hemet, CA 92545 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On March 25, 2025, at 1:47 p.m., an interview was conducted with the Assistant Director of Nursing, (ADON). The ADON stated that Resident 3 had experienced a fall on March 16, 2025. The ADON stated, it was determined CNA 1 had rolled Resident 3 away from her, which resulted in a fall. The ADON stated that Resident 3 was transferred to the hospital for evaluation and later returned to the facility. A review of Resident 3's eINTERACT SBAR, [situation, background, assessment, recommendation], Summary for Providers dated March 16, 2025, at 9:41 p.m., indicated .LN [licensed nurse] was notified by staff on shift that resident had a fall during patient care, LN rush to residents room, no cognitive changes, during skin assessment resident was noted with discoloration to the top of the head accompanied with 4/10 pain, discoloration to the left side of cheek, and skin tear to the left elbow. staff on shift safely assisted resident to bed. [name of doctor] was notified and order was receive (sic) to send patient to ER [emergency room] for CT scan of the head . A review of Resident 3's IDT [Interdisciplinary Team] – Fall dated March 17, 2025, at 2:35 p.m., indicated . At risk for falls due to impaired balance/poor coordination, left BKA, [below the knee amputation] non-ambulatory and prefers to be in bed most of the time, potential medication side effects, sensory (blindness) deficit , (sic) dementia, forgetfulness, and psychosis . Resident was transferred to ER for CT scan of head and further evaluation. Staff education on technique for rolling resident when providing care in bed . A review of Resident 3's Progress Notes dated March 19, 2025, at 10:01 p.m., indicated Resident returned from [name of hospital] via gurney . A review of Resident 3's Care Plan initiated March 16, 2025, indicated Focus .Falls: Resident had a witnessed fall 3/16/25 and is at risk for injury .Interventions . Staff education regarding turning resident towards staff when providing care in bed . A review of the facility's policy and procedure titled Falls -Clinical Protocol revised March 2018, indicated .1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . 5. Falls should be categorized as . c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555297 If continuation sheet Page 5 of 5