Inspection·June 27, 2022

F 0578 Residents 1, 29, 238, and 240. Level of Harm - Minimal harm or potential for actual harm 2. Resident 10 was admitted to the facility on [DATE], with diagnosis which included sepsis (infection in the blood). The MDS, dated [DATE], indicated Resident 10 had a BIMS score of 14 (cognitively intact). Residents Affected - Some On June 21, 2022, at 4:08 p.m., a concurrent interview and record review was conducted with the Social Service Designee (SSD). She stated the facility's process was to offer information regarding formulating an AD to the resident upon admission. She stated a copy of an AD should be placed in the resident's record if the resident had formulated an AD. She stated discussion about AD should be documented in the resident's record. The SSD stated there was no documentation information regarding formulating an AD was provided to Residents 1, 29, 238, and 240. She stated information regarding formulating an AD should have been provided to the residents. The SSD stated the progress notes, dated April 7, 2022, indicated Resident 10 had an AD. The SSD was not able to provide a copy of Resident 10's AD. She stated she was not sure if the facility made attempts to obtain a copy of the resident's AD since April 7, 2022. She stated the facility should have followed up with the resident to obtain a copy of his AD and be included in the resident's record. The facility's policy and procedure titled, Advance Health Care Directives, dated March 2021, was reviewed. The policy indicated, .To maintain a patient's right to make health care decisions on their own behalf and to honor those wishes according to regulations/statues through Advance Health Care Directives .facilities shall provide each adult individual, at the time of admission .written information describing .an individual's rights under the California Statues and Court decisions to accept or refuse medical or surgical treatment and to formulate Advance Health Care Directives .The facility's policy regarding these rights to make health care decisions and to formulate Advance Health Care Directives, and the way such decisions and Directives will be implemented .Facility shall document in the individual's medical record whether or not the individual has executed an Advance Health Care Directives .The patient shall be encouraged to provide a copy of their Advance Health Care Directive to be placed in the chart by the caregiver at the time of admisssion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 2 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical supplies were dated, and expired medical supplies were removed from storage and not readily available for use. These failures increased the potential for the residents in an already vulnerable state to receive expired medical supplies with less accuracy and effectiveness. Findings: On [DATE], beginning at 9:53 a.m., during the medication storage area inspection in the sub-acute unit was conducted with Registered Nurse (RN) 1, the following medical supplies were observed to be undated and expired, and were readily available for use: 1. Two Accu-Chek Inform II control solutions (used to calibrate the Accu-Chek Inform II machine [machine that measures the sugar in the blood]) were found with no label indicating when it was opened or used by date; 2. Two Accu-Chek Inform II control solutions were found with a used by date of [DATE]; In a concurrent interview with RN 1, she stated the Accu-Check solution should have been dated when opened to know when the control solution should have been discarded. She stated the Accu-Chek control solutions should have been discarded after 60 days upon opening the bottle. The facility policy and procedure titled, BLOOD GLUCOSE MONITORING, revised [DATE], was reviewed. The policy indicated, .An on-going system for monitoring and evaluating Quality Control testing is conducted for each area where blood glucose testing is performed .Accu-Chek Inform II Control Solutions .are stable for 60 days after opening or until the manufacturer's expiration date printed on the label, whichever comes first. Expiration date other than the manufacturer's, must be clearly written on both bottles . 3. Four specimen collection swabs were found with an expiration date of [DATE]; 4. One plastic container of saline solution 0.9% (sterile water) 200 ml/milliliter (ml-unit of measurement) was found with an expiration date of [DATE]; and 5. Four plastic containers of sterile water for inhalation (500 ml) were found with expiration dates of [DATE], [DATE], [DATE], and [DATE]. In a concurrent interview with RN 1, she stated the specimen swabs, one plastic container of 0.9% saline solution, and four plastic containers of sterile water for inhalation were expired and should have been discarded. On [DATE], at 10:06 a.m., the medication storage area in the skilled nursing unit was inspected with RN 2. Seven bio patches (medicated dressing) with expiration dates of [DATE] and [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 3 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In a concurrent interview with RN 2, she stated the expired bio patches should have been discarded and not readily available for use. The facility policy and procedure titled, CENTRAL SUPPLY - GENERAL ORGANIZATION, dated [DATE], was reviewed. The policy indicated, .It is the responsibility of the Director/Manager of Materiel [sic]Management and the department's personnel staff to ensure that the proper rotation of all supply items is maintained . The facility policy and procedure titled, Medication Management, dated [DATE], was reviewed. The policy indicated, .Expired, damaged and/or contaminated medications - Unusable medication are segregated and stored in a locked location until they are removed from the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 4 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and review of facility documents, the facility failed to provide food and nutrition services according to professional standard of food service safety for 19 of 19 sampled residents, when the fresh salad and the fruit cocktail served to all residents were not covered. This failure had the potential for food contamination and foodborne illnesses. Findings: On June 20, 2022, at 12:16 p.m., during lunch meal observation in the skilled nursing facility. Registered Nurse (RN) 2 was observed checking all the residents' tray to verify the diet orders. The fresh salad in the styrofoam cups and fruit cocktail placed in the small cups were observed not covered on all the meal trays. The meal trays were served to the 19 residents. In a concurrent interview with RN 2, she stated the fresh salad and the fruit cocktail should have been covered. On June 20, 2022, at 12:42 p.m., an interview was conducted with Resident 87, she stated there were times she had received food not covered, like salad or desert. On June 22, 2022, at 1:36 p.m., an interview was conducted with the Director of Food and Nutrition Service (DFNS). She stated all the food items coming from the kitchen should be covered when being served to all residents. The facility's policy and procedure titled, FOOD PREPARATION AND PRODUCTION GUIDELINES, dated October 2020, was reviewed. The policy did not include information on covering food when serving to resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 5 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: Residents Affected - Many 1. Multiple food items stored in the walk-in refrigerator and walk-in freezer were not labeled with the name of the food item, the date open, prepared date or use-by date; 2. Open food items stored in the dry storage area were not labeled with the name of the food item, the opened date, or use-by date; 3. The kitchen can opener had an accumulation of a thick brown substance on and around the blade; and 4. One dented can in the dry storage area was readily available for use. These failures had the potential to place the residents of the facility at risk for foodborne illness, or to receive an incorrect food, or outdated food items. Findings: On June 20, 2022, beginning at 9:25 a.m., during the kitchen tour with the Director of Food and Nutrition Service (DFNS) in the skilled nursing facility, the following items were observed stored in the walk-in refrigerator: - 22 Styrofoam cups of fresh salad, were not labeled with the name of the food item, prepared date, or use-by date; - Eight Styrofoam boxes containing food, were not labeled with the name of the food item, prepared date, or use-by date; - One dark brown frozen meat for thawing, was not labeled with the name of the food item, and the start and end date of thawing; - One box of frozen sausage link for thawing, was not labeled with the start and end date of thawing; and - One box of frozen smoked bacon for thawing, was not labeled with the start and end date of thawing. The following opened food items were observed stored in the dry food storage area not labeled with the name of the food item, the opened date, or use-by date; - One container of uncooked pasta; and - One bag of quinoa. In a concurrent interview with the DFNS, she confirmed the food items in the walk-in refrigerator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 6 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0812 Level of Harm - Minimal harm or potential for actual harm were not labeled with the name of the food item, prepared date or use-by date. The DFNS stated the food items for thawing should have been labeled with the start and end date of thawing. The DFNS stated all food items in the walk-in refrigerator and dry food storage area should have been labeled and dated. Residents Affected - Many On June 20, 2022, at 9:40 a.m., during a kitchen observation in the skilled nursing facility, the can opener attached to the table in the food preparation area was observed with a thick brown substance on and around the blade. In a concurrent interview with the Director of Food and Nutrition Service (DFNS), she confirmed there was a thick brown substance on and around the blade of the can opener. The DFNS took the can opener to the sink and stated to the kitchen staff, It needs to be washed. The DFNS stated the can opener should have been cleaned after each use. An undated facility document titled, PRACTICE FOR SHARPS - CAN OPENER, KNIVES, was reviewed. The document indicated, .Can opener and knives are washed after each use . On June 20, 2022, beginning at 9:55 a.m., during the kitchen tour with the Executive Chef in the sub-acute unit, the following items were observed stored in the walk-in refrigerator: - One plate of tuna salad was not labeled with the name of the food item, prepared date, or use-by date; - One package of shredded jack cheese was opened and not labeled with the date opened, or use-by date; - One container of Glucerna Carb Steady (milk - meal replacement suppliment drink for diabetics [person with abnormal blood sugar]) with a use-by date of June 1, 2022; - One box of potato salad with a use-by date of June 18, 2022; - One tub of plain yogurt with a use-by date of May 20, 2022; - One package of grated parmesan cheese with a use-by date of June 18, 2022. One dented can of Campbell's soup was observed in the dry food storage area readily available for use. In a concurrent interview with the Executive Chef, she stated the above food items in the walk-in refrigerator were not labeled with the name of the food item, prepared date or use-by date. She stated the above opened food items in the walk-in refrigerator should have been labeled with an open and use-by date. The Executive Chef stated the food items that were outdated should have been removed and discarded. She stated the dented can should have been removed. The facility's policy and procedure titled, Food and Nutrition-Expired/Recalled Products, dated October 2019, was reviewed. The policy indicated, .Outdated and recalled products will not be provided to patients .Food and Nutrition employees will .Check expiration dates on a daily basis .Discard outdated or recalled products immediately . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 7 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility's policy and procedure titled, Food and Nutrition - Food Storage, dated October 2020, was reviewed. The policy indicated, .Date all products to ensure first in-first out procedure .Products must be checked to detect unacceptable items, i.e., dented, swollen or rusted cans .Manufacture's expiration, use by .dates must be adhered .Dry food, which is opened or removed from original packaging, should be .clearly labeled .All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers .All foods set up for service must be protected by sneezeguards or otherwise covered to prevent contamination .Frozen meats are pulled 3 days prior to preparation and cooked on the 3rd day as a standard practice .All items will be labeled, covered and dated when placed in refrigerators or freezers using an established labeling rule .Prepared foods are discarded after 3 days if not used . 2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 8 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure a clean environment for the residents and visitors was provided when one dumpster was observed without a lid and the lids of two dumpsters were not securely closed. Residents Affected - Many This failure had the potential to attract pests, insects, and vermin which could create an unsanitary environment for vulnerable residents residing in the facility. Findings: On June 23, 2022, at 10:35 a.m., three dumpsters were observed outside the facility. One dumpster was observed without a lid and contained garbage trash. The lides of two dumpsters (one with garbage trash and one with cardboard boxes) were observed to be wide open (not securely closed). On June 23, 2022, at 10:38 a.m., an interview was conducted with the Dietary Manager (DM). The DM stated one dumpster was missing a cover lid and the two dumpsters lids were wide open. He stated the dumpster lids should have been completely closed. The facility's policy and procedure titled, Medical Waste Management Plan, dated June 23, 2022, was reviewed. The policy indicated, .Regular waste will be stored in a secured area inside the lidded containers and ensure the lid remains closed at all times .To prevent rodents and vectors from entering the facility . According to Federal Food Code 2017, published by the United States Food & Drug Administration, .Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas .Outside receptacles must be constructed with tight-fitting lids or covers to prevent scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 9 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when multiple facility staff did not wear the proper PPE (Personal Protective Equipment mask, gown, gloves, face shield or goggles) while providing care or working inside the PUI Unit (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]), when: Residents Affected - Some 1. One facility staff was observed wearing N95 mask (a mask to filter airborne particles) over a surgical mask while cleaning inside the resident's room in the PUI unit, located in the Skilled Nursing Facility (SNF); and 2. Facility staff in the Sub Acute Unit (SA) were observed not wearing a face shield or goggles while providing direct patient care to the PUI residents. In addition, one facility staff was observed wearing an N95 mask over a long facial hair. These failures had the potential to result in the transmission of infection to the vulnerable residents residing in the facility. Findings: 1. On June 20, 2022, at 11:45 a.m., The Housekeeper (HS) was observed exiting room [ROOM NUMBER] (a PUI room) in the SNF unit, wearing an N95 mask over a surgical mask. In a concurrent interview with the HS, she stated she finished cleaning room [ROOM NUMBER]. The HS stated she liked to have the surgical mask underneath the N95 mask because it added extra protection. She further stated there were no instructions given to her not to wear the N95 mask over a surgical mask. On June 22, 2022, at 4:39 p.m., the Director of Nursing (DON) was interviewed. She stated double masking was not allowed. She stated the N95 mask should not be worn with any surgical mask underneath or over the N95 mask. She stated wearing a surgical mask underneath the N95 mask would compromise the seal around the face and the mask itself. According to the web article published Centers for Disease Control and Prevention (CDC) titled, Types of Mask and Respirators, updated January 28, 2022, .NIOSH (National Institute for Occupational Safety and Health - a government agency for the prevention of work-related injury and illness)-Approved Respirators .NIOSH approves many types of filtering respirators. The most widely available are N95 respirators .Do NOT wear NIOSH approved respirators .With other masks or respirators . 2. On June 22, 2022, at 11:14 a.m., a Certified Nursing Assistant (CNA) 1 was observed changing the linens inside room [ROOM NUMBER] (a PUI room) wearing N95 mask, gown, and gloves. CNA 1 was observed without a face shield. A sign was posted by the door at room [ROOM NUMBER] which indicated to wear N95 mask, gown, gloves, and face shield during direct patient care. On June 22, 2022, at 11:16 a.m., CNA 2 was observed inside room [ROOM NUMBER] (PUI room) providing snacks to the resident who was sitting on the bed. CNA 2 was observed standing beside the bed talking to the resident. He was observed wearing gown, gloves, and N95 mask. He was observed not wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 10 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some face shield while providing care to the resident. There was a sign by the door indicating the PPE to use when providing care to the residents (gown, gloves, N95, and face shield). On June 22, 2022, at 11:18 a.m., CNA 2 was observed wearing BYD DE2322 (a brand of N95), over a long beard (about three inches long). The N95 was observed to not have a tight seal on the chin as the beard was thick and long. In a concurrent interview with CNA 2, he stated he was fit tested for the N95 mask he was wearing. CNA 2 stated he was assigned to rooms [ROOM NUMBERS] (PUI rooms). He stated he provided snacks and water for the resident in room [ROOM NUMBER]. He stated he would know what PPE to use as it was posted by the door in the resident's room. He stated room [ROOM NUMBER] had a sign posted to use full PPE such as gown, gloves, N95 mask, and face shield when providing care. He further stated he was not wearing face shield when he provided care to the residents in the PUI rooms. On June 22, 2022, at 11:27 a.m., CNA 1 was observed wearing N95 mask. In a concurrent interview with CNA 1, she stated she was assigned to room [ROOM NUMBER] (a PUI room). She stated the resident in room [ROOM NUMBER]B required total care. She stated she was not wearing a face shield when she provided care to the residents in the PUI rooms. On June 22, 2022, at 4:39 p.m., an interview with the Infection Preventionist (IP) was conducted. He stated, all staff must wear proper PPEs while working in the PUI unit which includes, gloves, gowns, N95 mask, face shield or goggles. He stated N95 mask must not be worn with any other mask (i.e., surgical mask). On June 22, 2022, at 11:36 a.m., the Registered Nurse Supervisor (RNS) was interviewed. She stated they have 17 residents in the sub acute unit and all were considered PUI residents. She stated the sign on the door by the resident's room indicated the PPE to use when providing direct care to the PUI residents (gown, gloves, N95, and face shield). She stated direct care to the residents were cleaning residents, medication administration, repositioning, feeding, or any care provided less than six feet apart. She stated face shield was not mandatory to use during resident care, It's just a preference, we need to update the sign. On June 22, 2022, at 11:46 a.m., the Infection Preventionist (IP/SA) in the subacute unit was interviewed. She stated the staff did not need to wear a face shield when providing care to the PUI residents. The policy or the guidelines used by the facility which indicated face shield was not required to be used in the PUI rooms. On June 22, 2022, at 12:07 p.m., an observation of medication administration was conducted with the IP/SA. She was observed to administer medication through the Gtube (gastrostomy tube - used to give food and medicine to the stomach) without wearing a face shield. On June 22, 2022, at 12:45 p.m., the RNS was interviewed. She stated the facility followed CDC (Centers for Disease Control and Prevention) guidelines regarding the use of PPE. She stated based on the CDC guidelines, health care personnel should be wearing eye protection while providing care to PUI residents. She stated the facility staff have not been wearing face shield or goggles when providing care to their residents. On June 22, 2022, at 4:50 p.m., an interview with the DON was conducted. She stated all staff working in the PUI unit should wear the following PPEs: gown, gloves, N95 mask and face shield or googles (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 11 of 12 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 555623 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hemet Valley Healthcare Center 371 North Weston Pl Hemet, CA 92543 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when providing direct patient care. She stated any facial hair should be trimmed or cut as it compromises the seal of the N95 mask. She further stated they follow CAL OSHA guidance (a government agency for the prevention of work-related injury and illness) for fit testing of the N95 mask. On June 23, 2022, at 11:05 a.m., an interview with the Employee Health Nurse ([NAME]) was conducted. She stated she performed fit testing for all employees. She stated CNA 2 completed his N95 mask fit testing and passed with his facial hair. She further stated she followed CAL OSHA's guidance for N95 fit testing. According to the web article published by the U.S. Department of Health and Human Services on Centers for Disease Control and Prevention (CDC) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated February 2, 2022, .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use NIOSH-approved N95 .gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face . According to the CAL OSHA guidance, titled, Respiratory Protection in the Workplace, dated April 1, 2021, indicated, .The employer shall select and provide an appropriate respirator based on the respiratory hazard(s) to which the worker is exposed and workplace and user factors that affect respirator and reliability .fit testing. This subsection requires that, before an employee may be required to use any respirator with a negative or positive pressure tight-fitting facepiece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. This subsection specifies the kinds of fit tests allowed the procedures for conducting them, and how the results of the fit tests must be used .Facepiece seal protection .The employer shall not permit respirators with tight-fitting face piece to be worn by employees who have: facial hair that comes between the sealing surface of the facepiece and the face or that intervenes with valve function; or any condition that interferes with the face-to-facepiece seal or valve function . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555623 If continuation sheet Page 12 of 12