Hemet Valley Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the shower gurney's (a mobile, waterproof device designed to transport and bathe individuals who cannot sit upright safely) wheel brakes, used to transfer one of three sampled residents (Resident 1), were locking properly to secure positioning during resident transfer and bathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety and sanitation were observed in the kitchen when: 1. Nine one-gallon containers of barbeque (BBQ) sauce were undated;2. One box of rice pilaf was found to be undated;3. Multiple prepared food items in refrigerator 3 were found to be uncovered and opened to air. These failures had the potential to result in the spread of foodborne illness to the residents who consumed meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medical food and dressing change supplies were not stored in the medication storage areas, and readily available for use. This failure had the potential for residents to receive ineffective medical food supplements and medical supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were observed, and the facility policies and procedures related to infection control were implemented when: 1. The facility did not report to the California Department of Public Health (CDPH- state agency responsible for public health in California, enforcing some of the laws affecting healthcare facilities) of a COVID 19 (coronavirus - a contagious respiratory infection) outbreak when the facility had one COVID-19 positive staff and four COVID-19 positive residents on February 5, 2025. This failure resulted in the state agency being unaware of the presence of a COVID-19 outbreak in the facility and had the potential of delayed implementation of infection control measures to address COVID-19; and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan (a detailed written document that outlines a resident's healthcare needs, goals, and treatment strategies) was developed, for four of four residents (Residents 2, 14, 16, and 17) , when the residents had COVID -19 (coronavirus - a contagious respiratory infection) infection. This failure had the potential for the staff not to be aware of the appropriate interventions needed to be implemented to address the resident's changes in health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment, for one of 21 residents (Resident 4), when Resident 4 was placed in the activity room when the resident was re-admitted back to the facility for five days. This failure had the potential to negatively affect the resident's emotional and social well-being.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Federal (Center for Medicare & Medicaid Services- CMS) database for the second Fiscal Quarter (FQ) of the year. This failure had the potential to result in inaccuracy of numbers of Direct Care Staff needed to provide care to residents. This failure also prevented the provision of complete and accurate direct care staffing information to the public.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Information regarding formulation of Advanced Directive (AD- a written document that indicates a resident's medical wishes) was provided to the Residents' Representatives (RR), for two of 14 residents reviewed for AD (Residents 18 and 7); and 2. Resident 11's AD was not readily available in the resident's medical record. These failures had the potential for the resident/resident representative's current wishes for medical care not to be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents reviewed for unnecessary medication (Residents 17 and 18) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when: 1. For Resident 17, the facility did not have the prescriber-documented rationale for extended use of the as-needed (PRN) lorazepam (a psychotropic medication for anxiety) beyond 14 days; 2. For Resident 18, the facility did not monitor the effectiveness of the antipsychotic (quetiapine - medication to treat mental illness). These failures had the potential to result in unnecessary use of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and sanitary food preparation were followed in the kitchen when: 1. Multiple items in the walk-in refrigerator, freezer, and dry storage area were not labeled and/or left open to air; 2. Multiple kitchen equipment and areas in the kitchen were not clean; 3. Cooking pans were stacked wet with puddle of water at the bootom of each pot; and 4. Freezers 2 and 3 had ice buildup on the floors. This failure had the potential to place the residents at risk for foodborne illness or to receive an incorrect food or outdated food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One out of four licensed nurses used her finger to check the water temperature before use for diluting medications and flushing the feeding tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach or small intestine) for Resident 2; 2. Two out of four nurses did not perform hand hygiene before administering eye drops to Residents 2 and 5; and 3. One suction canister was found not labeled or dated. These failures had the potential to spread infections between residents and staff.

Inspectors wroteBased on interview and record review, for one of 18 residents, the facility failed to ensure interventions were placed to address Resident 4's frequent shower refusals . This failure had a potential to result in a delay in the care and treatment of Resident 4's skin conditions and to develop new skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to develop policies and procedures for the monthly drug regimen review. This failure had the potential for delayed identification of harmful drug interactions, side effects, and inadequate monitoring that could negatively impact residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 9.68% when three medication errors occurred out of 31 opportunities during medication administration, for two out of four residents (Residents 2 and 5). This failure resulted in medications not given according to the prescriber's orders and/or manufacturer's specifications and had the potential for residents to not receive the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and sanitary environment was provided, when two (2) air vents above Resident 17 and 107's beds were found to be stained with dark colored dust particles. This failure had the potential to cause and/or worsen medical conditions of the residents who have respiratory conditions which could lead to respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three sampled residents (Resident A): 1. Proper positioning of a female resident with lower extremity (legs and feet) contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) was implemented during urine sample collection with the use of a straight catheter (a flexible tube inserted into the urethra [where urine passes out of the body]). Resident A's hip and leg/thigh were lifted up six inches from the mattress for urine collection. In addition, the licensed nurse continued to collect a urine sample from Resident A despite hearing an abnormal sound from Resident A's hip area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of three sampled residents (Resident A), an injury of unknown origin was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours, when Resident A was found to have a bluish discoloration on the side of the eye. This failure had the potential to result in a delay of the implementation of appropriate action and the provision of protection for Resident A and placed other residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: 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.

Inspectors wroteBased 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. This failure had the potential to attract pests, insects, and vermin which could create an unsanitary environment for vulnerable residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure; 1. The residents and/or resident's representative (RR) was provided a written information regarding formulating an Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions), for four of 13 residents reviewed for AD (Resident 1, 29, 238 and 240); and 2. A follow up with the resident was conducted regarding obtaining a copy of the resident's AD, for one of 13 residents reviewed (Resident 10). These failures had the potential to result in not determining and/or following the residents' wishes related to the provision of medical treatment and health care services when the residents become unable to make decisions for themselves.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: 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. [...]