Highland Springs Care Center

F-F908)

These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Findings:

On July 22, 2024, at 8:30 a.m., during a concurrent walk-through observation and interview inside the kitchen with the Dietary Manager (DM), the following were observed:

1. One toaster had brown-yellowish grime buildup in the front dial control.

The DM stated the the toaster is old and needs to be replaced, and the brown-yellowish discoloration was grime build-up. The DM further stated grime should not have been present, as it could cross-contaminate food and cause foodborne illness.

2. One blue cutting board was had multiple deep cuts, indentations, and damaged. Further observed were two green cutting boards with yellowish discoloration, multiple deep cuts, and indentations.

The DM stated the blue cutting board was damaged with parts of the plastic lifted, and the green cutting boards had deep cuts, indentations with yellowish discoloration from food residue.

The DM stated the cutting boards should not be like that, the surface should be clean, smooth, and undamaged to prevent the growth of microorganisms (germs) that could cause cross contamination and food borne illness.

3. The left and right sides of the oven and the front inside surfaces of the left and right oven doors had brown discoloration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0812 The DM stated the equipment is old, and the brown discoloration was rust. The DM further stated the oven should not be like that, the rust can fall into the resident's food, causing cross-contamination and leading to Level of Harm - Minimal harm or food borne illness. potential for actual harm 4. On July 23, 2024, at 2:44 p.m., during a concurrent observation of mealt tray carts and interview inside the Residents Affected - Some kitchen with the Registered Dietician (RD) and the Maintenance Assistant (MA), the following were observed:

- The front right metal area of cart #3 was reinforced with another metal and had brown discoloration.

- The front right metal area of cart #4 had brown discoloration.

The RD stated the front right corners of the two meal tray carts were wearing out, with surfaces that were not smooth and had brown discoloration.

The RD stated the meal tray carts should not have rust and should have a smooth surface to prevent bacterial growth, which could cause cross-contamination and lead to food borne illness.

The MA stated the metal at the front right corner of meal tray cart #3 had been welded with a different metal and both carts #3 and #4 had brown discoloration, the MA further stated the brown discoloration was due to corrosion and deterioration.

On July 24, 2024, at 3:13 p.m., during an interview with the RD, she stated her expectation was for the kitchen to be clean, with no grime or dust and all equipment to be in safe operating condition, free from corrosion, deterioration, and damage.

The RD stated the toaster should be clean with no grime build up, as grime could cross-contaminate food and lead to foodborne illness.

The RD stated cutting boards should not have deep indentation, damage, and stain. The RD further stated plastic particles from damaged cutting boards could get into food and the indentations can harbor bacteria, leading to cross- contamination and foodborne illness.

The RD stated any decomposition on any kitchen equipment should not be present and rust is a food safety hazard that can fall into food causing cross-contamination and cause foodborne illness.

A review of the facility policy and procedure titled, Sanitizing Equipment and Surfaces, undated, indicated, . Dietary staff should ensure that all equipment .are clean and in good condition .

A review of the facility policy and procedure titled, Cutting Board Cleaning, undated, indicated, .All cutting boards should be clean and in good condition .Dietary staff to ensure all cutting boards are in good condition .

A review of the facility policy and procedure titled, Maintenance, undated, indicated, .Kitchen Appliances . inspect all .appliances in the kitchen to determine that they are working properly .are undamaged .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0812 A review of the facility policy and procedure titled, Maintenance Service, dated December 2009, indicated, . Maintenance .shall be provided to all areas of the building .and equipment .maintaining .the equipment in a Level of Harm - Minimal harm or safe and operable manner at all times . potential for actual harm

A review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.12 Cutting Surfaces, Residents Affected - Some indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize .As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces .

A review of the FDA Food Code 2022, 4-101.11 Equipment Characteristics, indicated, .FOOD-CONTACT SURFACES of EQUIPMENT .shall be .(D) to have a smooth, easily cleanable surface and .(E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .

A review of the FDA Food Code 2022, Annex 4-501.11 Equipment Good Repair and Proper Adjustment, indicated, .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed .Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50309 potential for actual harm Based on observation, interview, and record review, the facility failed to provide safe and sanitary storage of Residents Affected - Few personal food for one of one resident (Resident 56) when two expired bags of marshmallows were found inside the resident's closet and were readily available for consumption.

This failure had the potential to place Resident 56 at risk for foodborne diseases (illness that result from ingestion of contaminated food).

Findings:

On [DATE REDACTED], at 5:17 p.m., a review of Resident 56's medical records indicated he was admitted to the facility

on [DATE REDACTED].

A review of Resident 56's History and Physical, dated [DATE REDACTED], indicated he had a fluctuating capacity to understand and make decisions.

On [DATE REDACTED], at 9:40 a.m., during a concurrent observation and interview inside Resident 56' room, two bags of expired marshmallows were found in the resident's closet. One of the bags was opened and had a hardened texture. Resident 56 stated the marshmallows were gifts from last Christmas (7 months ago). Resident 56 further stated, I snack on them occasionally.

On [DATE REDACTED], at 3:04 p.m., during a concurrent observation and interview inside Resident 56's room with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 56 had two bags of expired marshmallows indisde his closet readily available to eat. LVN 5 further stated if Resident 56 consumes the expired marshmallows, it could cause stomach upset.

On [DATE REDACTED], at 3:30 p.m., during a concurrent observation and interview inside Resident 56's room with Nursing Assistant (CNA) 1, she stated Resident 56 had two expired bags of marshmallows inside his room closet. CNA 1 further stated, the expired marshmallows should not have been there because they could cause stomachache if consumed.

On [DATE REDACTED], at 5:26 p.m., during an interview with the Director of Nursing (DON), she stated her expectation was that expired food should have been discarded and not readily available for consumption by the resident.

The DON further stated if a resident ate expired food, it could cause stomach issues.

A review of the facility policy and procedure titled, Resident's Refrigerator/Freezer Storage, undated, indicated, .7. Only cooked/packaged items are allowed to be stored .8. Food items that are expired or beyond the best buy date are discarded .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36684 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection control Residents Affected - Few practices were observed when:

1. Registered Nurse (RN) 2, did not perform the appropriate hand hygiene prior to, in between, and after a resident contact during a blood sugar check and administration of insulin (medication used for high blood sugar) for one of seven residents observed (Resident 4); and

2. For one of two residents (Resident 347), when a Physical Therapy Assistant (PTA) failed to perform hand hygiene and disinfect ankle weights used after providing care on the resident, who is on an enhanced barrier precautions (EBP - infection prevention and control practices that can help reduce the spread of infection).

These deficient practice had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and spread of diseases and infection to the facility staff, residents, and visitors.

Findings:

1. On July 24, 2024, at 3:46 p.m., an observaiton with a concurrent interview was conducted with RN 2. RN 2 stated Resident 4 was due for a blood sugar check. The following were observed:

- At 3: 49 p.m, RN 2 found Resident 4 in the front lobby and brought her back to her room. RN 2 was observed to not wear gloves or perform hand hygiene before and after pushing Resident 4's wheelchair to her room;

- At 3:50 p.m., RN 2 explained to Resident 4 she will check her blood sugar, RN 2 wore gloves and proceeded to check Resident 4's blood sugar using the glucometer machine (device used to check bloos sugar level). RN 2 was observed to not have perfomed hand hygiene prior to and after checking Resident 4's blood sugar;

- At 4:05 p.m., RN 2 went back to the medication cart and stated she will check Resident 4's the physician orders for insulin. RN 2 wore gloves while she disinfected the glucometer machine, disposed of the used needle and blood sugar test strip in the sharps container, and threw the used alcohol swab and plastic cup in

the trash.

RN 2 removed used gloves and donned new a new pair of gloves and stated she will prepare Resident 4's insulin. RN 2 proceeded to check Res 4's physician's order for insulin and stated she will need one unit of insulin from the KwikPen (type of insulin brand).

RN 2 was not observed to have performed hand hygiene between cleaning her medication cart and equipment and preparing Resident 4's insulin;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0880 - At 4:10 p.m., RN 2 went back to Resident 4's room and explained the procedure of insulin administration to

the resident. RN 2 donned a new pair of gloves and proceeded to administer the insulin via KwikPen on Level of Harm - Minimal harm or Resident 4's right upper arm. potential for actual harm RN 2 went back to the medication cart and disposed of the used needle, plastic cup, and alcohol swab. RN 2 Residents Affected - Few recorded the insulin administered to Resident 4.

RN 2 was not observed to have performed hand hygiene prior to and after administering insulin to Resident 4.

In a concurrent interview, RN 2 stated the facility's policy on hand hygiene practice during blood sugar checks and administration of insulin on residents. RN2 stated she forgot to perform hand washing prior to and after checking Resident 4's blood sugar and prior to and after the administartion of insulin.

RN 2 stated she should have washed her hands prior to and after checking Resident 4's blood sugar and prior to and after the administration of Resident 4's insulin.

On July 24, 2024, at 4:45 p.m., the Infection Preventionist (IP) Nurse was interviewed. The IP nurse stated

the expectation was the licensed nurses should wash their hands before and after performing a blood sugar check and before and after administering insulin on a resident, even if gloves were worn during the procedure.

The IP Nurse stated RN 2 should have washed her hands prior to and after checking Resident 4's blood sugar, prior to and after administering Resident 4's insulin.

The facility's policy and procedure titled, Insulin Administration, dated March 2023, was reviewed. The policy indicated, .Purpose .To provide guidelines for the safe administration of insulin .Steps in the Procedure . Wash hands .Check blood glucose per physician order or facility protocol .Check the order for the amount of insulin .Select an injection site .Clean injection site .Depress the plunger and remove the needle .Dispose of needle in designated container .Wash hands .

50309

2. During an observation on July 23, 2024, at 9:19 a.m., the PTA was observed entering an isolation room (special hospital rooms that keep patients separate from other people while they receive medical care) wearing a gown and gloves prior to performing therapy on resident. The PTA was observed applying ankle weights around the residents' lower legs.

During a concurrent observation and interview with the PTA, on July 23, 2024, at 9:32 a.m., the PTA was observed not performing hand hygiene after removing her gloves and not disinfecting the ankle weights after use.

The PTA stated, she should have performed hand hygiene and disinfected the weights before bringing them outside of the room because of infection control and the spread of germs to other residents and staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0880 During an interview on July 24, 2024, at 3:36 p.m., with the Infection Prevention Nurse (IPN), the IPN stated resident was on EBP due to foley catheter use. IPN stated hand hygiene was important to prevent the Level of Harm - Minimal harm or spread of infection which could lead to an outbreak. IPN stated staff are expected to follow the EBP potential for actual harm guidelines posted outside the resident's door, and further stated the PTA should have washed her hands and disinfected the ankle weights after rehab exercise. Residents Affected - Few Resident 347's record was reviewed. Resident 347 was admitted to the facility on [DATE REDACTED], with diagnoses which included multidrug-resistant organisms (MDRO - bacteria that have become resistant to certain antibiotics) and extended spectrum beta-lactamase (ESBL - a strain of bacteria that is hard to treat) in his urine.

During a review of the facility policy and procedure titled, Cleaning and Disinfecting Non-Critical Resident-Care Items,, undated, indicated the policy is to provide guidelines for disinfection of resident care items .Section sub-titled Equipment and Supplies .indicated the following equipment and supplies will be necessary .soap and water, disinfectant solution, wipes, paper towels and PPE as needed.

During a review of the facility policy and procedure titled, Policies and Practices- Infection Control, undated, indicated, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections .Preventing Spread of Infection .the facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

During a review of the facility policy and procedure titled, Enhanced Barrier Precautions, dated June 2024, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .5. EBPs are indicated for residents with wounds and or indwelling medical devices regardless of MDRO colonization .8. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36038 potential for actual harm Based on interview and record review, the facility failed to ensure that one of five residents reviewed for Residents Affected - Few immunizations (Resident 58) was offered the pneumococcal vaccine (vaccines against the bacterium Streptococcus pneumoniae [bacteria that can cause pneumonia]).

This failure had the potential for Resident 58 not fully protected against pneumonia (infection of lungs).

Findings:

A review of Resident 58's ADMISSION RECORD, indicated, .Resident 58, is [AGE] year old, admitted to the facility on [DATE REDACTED], with diagnoses which included chronic obstructive lung disease (COPD-respiratory problem).

On July 24, 2024, at 8:37 a.m., during a concurrent interview and review of Resident 58's immunization record, with the Infection Preventionist (IP), the IP stated Resident 58 received one dose of pneumococcal (PPSV23) on april 24, 2023. The IP stated residents who received one dose of Pneumococcal (PPSV23) should be offerred a second dose of pneumococcal (PCV20) after one year. The IP further stated the facility follows current CDC (Centers for Disease Control and Prevention - responsible for protecting public health and safety) guidelines. The IP stated there was no documentation that Resident 58 was offerred the second dose of the pneumococcal vaccine after one year from the initial dose.

During a review of the facility policy and procedure titled, Policy: Pneumococcal immunization, dated February 1, 2023, indicated, .The facility will offer pneumococcal vaccines to all residents to ensure that all residents are up to date with pneumococcal vaccination based on CDC guidance .

During a review of CDC Website - www.cdc.gov/pneumococcal /hcp/vaccination, the document titled Pneumococcal Recommendation, dated June 27, 2024, indicated, .Previously received only PPSV23: PCV 15 OR 1 dose PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 47202 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure, one toaster, two oven doors, Residents Affected - Some the left and right sides of the oven and four meal tray carts were maintained in a safe operating condition.

These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Findings:

On July 22, 2024, at 8:30 a.m., during a concurrent observation and interview inside the kitchen of the toaster with the Dietary Manager (DM), the toaster dial had chipped and peeled plastic film. The DM stated

the toaster was old and needs to be replaced. The DM further stated bacteria can grow into the chipped and peeled areas, can cross contaminate the food and cause food-borne illness.

On July 22, 2024, at 8:40 a.m., during a concurrent observation and interview inside the kitchen with the DM,

the left and right sides of the oven were observed with chipped and peeled paint, and had brown discoloration. During further observation, the front inside surfaces of the left and right oven doors had brown discoloration.

The DM stated the equipment is old, the brown discoloration was rust and the oven paint was chipped and peeled. The DM further stated the oven should not be like that, the rust and peeled paint can fall into the resident's food, causing cross contamination leading to foodborne illness.

On July 23, 2024, at 2:44 p.m., during a concurrent observation and interview inside the kitchen of meal tray carts with the Registered Dietician (RD) and the Maintenance Assistant (MA), the following were observed:

- The left and right sides of four meal tray carts were with chipped and peeled vinyl sticker.

- The front right metal area of cart #3 was reinforced with another metal and had brown discoloration.

- The front right metal area of cart #4 had brown discoloration.

The RD stated the left and right sides of the four meal tray carts were with chipped and peeled vinyl sticker and the front right corner metal of the two meal tray carts were wearing out, the surface is not smooth and with brown discoloration, further stated rust is brown in color.

The RD stated the meal tray carts should have no rust, have a smooth surface, no chipping or peeling to prevent bacterial growth that could cause cross contamination and lead to food borne illness.

The MA stated the metal at the front right corner of meal tray cart #3 was welded with a different metal and both cart #3 and cart #4 was with brown discoloration, the MA further stated the brown discoloration was corrosion and deterioration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0908 On July 24, 2024, at 3:13 p.m., during an interview with the RD, she stated her expectation was all the kitchen equipment should be in a safe operating condition, free from corrosion, deterioration and damages. Level of Harm - Minimal harm or potential for actual harm The RD stated rust, peeled paint, or any decomposition on any kitchen equipment should have not been there. The RD further stated rust, peeled paint, vinyl or platic is a food safety hazard that can fall into food Residents Affected - Some and could cross contaminate and cause foodborne illness.

A review of the facility policy and procedure titled, Maintenance, undated, indicated, .Kitchen Appliances . inspect all .appliances in the kitchen to determine that they are working properly .are undamaged .

A review of the facility policy and procedure titled, Maintenance Service, dated December 2009, indicated, . Maintenance .shall be provided to all areas of the building .and equipment .maintaining .the equipment in a safe and operable manner at all times .

A review of the Federal and Drug Administration (FDA) Food Code 2022, 4-101.11 Equipment Characteristics, indicated, .FOOD-CONTACT SURFACES of EQUIPMENT .shall be .(D) to have a smooth, easily cleanable surface and .(E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .

A review of the FDA Food Code 2022, Annex 4-501.11 Equipment Good Repair and Proper Adjustment, indicated, .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed .Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 555135 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555135 B. Wing 07/25/2024

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)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 50204

Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment for one of eight residents (Resident 87) when multiple damaged window blinds were observed.

This failure had the potential to disrupt the residents' daily living needs and environment.

Findings:

On July 22, 2024, at 11:30 a.m., during a concurrent observation and interview with Resident 87's room. Multiple damaged blinds were observed. Resident 87 stated it is too bright and she used curtains to block the light coming through the damaged blinds.

On July 24, 2024, at 8:19 a.m., during an interview with the Maintenance Supervisor (MS), He stated he was aware about the damaged window blinds in Resident 87's room. He stated, the blinds need to be replaced.

On July 24, 2024, at 8:35 a.m., during an interview with the Facility Administrator (FA), the FA stated she was aware that the damaged window blinds needed to be repaired. The FA further stated the blinds should have been replaced or repaired to provide home like environment for the residents.

A review of facility policy and procedure titled, Maintenance Service, dated December 2009, indicated, .The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .maintaining the building in good repair .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 555135