Health inspection·July 31, 2025

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 interventions for fall prevention were implemented for two of seven residents, (Resident 1 and Resident 7).This failure had the potential for Resident 1 and Resident 7 to fall and sustain serious injuries. Findings:On July 30, 2025, at 11:07 a.m., an unannounced visit to the facility on a complaint investigation was initiated.1.A review of Resident 1's medical records indicated that resident was admitted on [DATE], with diagnoses of systemic lupus erythematosus, (SLE - a chronic autoimmune disease where the body's immune system mistakenly attacks its own healthy tissues and organs), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), dementia, (a chronic or persistent disorder of mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), muscle wasting and atrophy, (the loss of muscle mass and strength), and adult failure to thrive, (AFTT - a syndrome in older adults characterized by weight loss, decreased appetite, poor nutrition, and inactivity indicating a decline in physical and psychological health).A review of Resident 1's History and Physical dated July 17, 2025, indicated resident had intermittent capacity to make decisions.On July 30, 2025, at 12:20 p.m., an interview was conducted with Resident 1. Resident 1 stated she had been at the facility for a month. Resident 1 stated she recalled falling after tripping over her shoes. Resident 1 was unable to account for the date, or time of the incident. Resident 1 stated she did not have any injuries from the fall. Resident 1 stated she gets physical therapy every day and that she had been instructed to use the call light and call for assistance before getting out of bed. On July 30, 2025, at 3:10 p.m., an interview was conducted with Resident 1's Responsible Party, (RP). The RP stated that Resident 1 had been in the facility since March 2025 and had approximately four falls. The RP stated upon admission, he informed them that she was a fall risk. The RP stated in July 2025, Resident 1 slipped out of bed while reaching for her belongings placed on a wheeled table.On July 31, 2025, at 3:31 a.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated, for all residents who are at high risk for fall, or who have had more than one fall, the interventions should include: bed in low position, call light within reach, all frequently used personal items should be within reach. On July 31, 2025, at 8:20 a.m., an interview was conducted with the Physical Therapist, (PT). The PT stated, on July 24, 2025, Resident 1 slipped out of bed while reaching for the over-bed table. The PT stated, personal items should have been kept within reach to prevent over-reaching and falling out of bed. A review of Resident 1's Care Plan initiated May 7, 2025, indicated Focus. Resident is at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental (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: 555297 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 07/31/2025 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)