Hemet Hills Post Acute

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

administration. The DON stated there was no reason not to administer the medication as it was delivered

on time for the scheduled dose and the nurse should have administered the medication. The DON stated there was no documentation indicating the medication was administered. The DON stated it was important to administer the medication to prevent adverse reactions from a missed dose related to her diagnosis of hypothyroidism.A review of the facility policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/02/2026

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 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, for one of nine resident reviewed for infection control (Resident 8), proper infection control measures were implemented when Certified Nursing Assistant (CNA) 1 did not wear personal protective equipment (PPE - equipment, such as gloves and gown, used to protect against infection or illness) upon entering Resident 8's room, who was on contact isolation precautions (an infection control intervention to reduce transmission of multidrug-resistant organisms (bacteria that have become resistant to multiple antibiotics)).The failure had the potential to result in cross contamination and increasing the spread of infection among a vulnerable population.Findings:On December 5, 2025, at 11:40 a.m., an observation was conducted outside Resident 8's room. A contact isolation sign was posted outside Resident 8's room, along with a PPE cart containing gowns and gloves.

The sign indicated, .STAFF MUST.Put on gloves before room entry.Put on gown before room entry.On December 5, 2025, at 11:47 a.m. an observation was conducted inside Resident 8's room. Resident 8 activated his call light. CNA 1 entered the room without a gown or gloves and turned off the call light by pressing the button beside the bed.On December 5, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE REDACTED] with diagnoses including extended spectrum beta lactamase (ESBL bacteria that are resistant to many antibiotics) to the right foot wound. A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated September 24, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool to assess cognitive function) score of 12 (moderate cognitive impairment). A review of

the facility document titled, Order Listing Report, dated December 5, 2025 indicated, .Strict Single Room Isolation with: Contact Precautions due to ESBL.On December 5, 2025, at 2:30 p.m. an interview was conducted with CNA 1. CNA 1 stated Resident 8 was on contact isolation precautions. CNA 1 stated she did not wear a gown or gloves prior to entering Resident 8's room to clear the call light. CNA 1 stated she should have worn a gown and gloves prior to entering Resident 8's room. CNA 1 further stated this was important to prevent the spread of infection.On December 19, 2025, at 11:31 a.m. an interview was conducted with the Infection Preventionist (IP). The IP stated based on the CDC's contact isolation sign and

the facility's policy, CNA 1 should have worn a gown and gloves prior to entering Resident 8's room. The IP stated it was important to follow the CDC guidelines and facility policy to protect others from infection or cross contamination.On December 19, 2025, at 2:08 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated it was the best practice to wear a gown and gloves prior to entering a resident's room who was on contact isolation precautions. The DON stated CNA 1 should have followed the facility policy of wearing a gown and gloves prior to entering Resident 8's room. The DON stated it was important to follow the facility's policy to reduce the transmission of infection.A review of the facility policy and procedure titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022 indicated, .Contact Precautions.Staff.wear gloves.when entering the room.Staff.wear a disposable gown upon entering the room.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet