Hemet Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Hemet Hills Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF686Apr 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure care and treatment for pressure injuries (P/Is - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for five of five residents reviewed for pressure injuries (Residents 98, 92, 18, 357, and 49), when: 1. The facility staff did not assess or evaluate the staging of pressure injuries in accordance with standards of practice. In addition, there was a delay in providing further interventions/treatment of the P/Is; and 2. The facility did not have a process in the timely notification of the Interdisciplinary Team (IDT - a group of healthcare professionals), which included the Registered Dietitian (RD). […]

• Actual harm, patternF687Apr 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure appropriate foot care was provided, for five of 32 residents reviewed for foot care, (Residents 98, 47, 84, 14 and 26). The facility did not consistently trim the residents' toenails, kept the residents' toenails clean and initiate referral to podiatrist for evaluation and further care. This failure resulted in the residents developing long, yellowed, and hypertrophied (thickened) toenails causing pain and discomfort, and did not promote the maximum ADL (activities of daily living) potential for Residents 98, 47, 84, 14 and 26. Findings: 1. On April 17, 2023, at 3:58 p.m., a concurrent observation and interview was conducted with Resident 98. Resident 98 was observed lying in bed, awake and alert. […]

• Actual harm, isolatedF580Apr 10, 2025

  Based on interview and record review, the facility failed to notify the physician timely when one of eight sampled residents (Resident 1) had an oxygen saturation (measures of how effectively the body is transporting oxygen from the lungs to the tissues) of 35%. This failure caused a delay in provision of appropriate interventions resulting in prolonged discomfort and hypoxemia (abnormally low concentration of oxygen in the blood) for Resident 1, requiring transfer to the general acute care hospital (GACH). […]

• Actual harm, isolatedF684Dec 13, 2023

  Based on interview, and record review, the facility failed to ensure Resident 1 ' s urinary catheter, (a hollow tube inserted into the bladder to drain or collect urine), was secured in place for one of four residents, (Resident 1). This deficient practice caused skin erosion on the penis and pressure injuries, (injury to skin and underlying tissue resulting from prolonged pressure on the skin), on the testicles. Findings: On December 13, 2023, at 1:32 p.m., an unannounced visit to the facility on a complaint investigation was initiated. […]

• No harm, potential for more than minimal, widespreadF814Apr 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure the garbage bin lid was securely closed. This failure had increased the potential to attract rodents and spread infection affecting 121 medically compromised residents. Findings: On April 17, 2023, at 11:15 a.m., during the initial tour of the kitchen with the Food Service Director (FSD), the garbage bin located outside the building was observed to be over-filled and the lid was not securely closed. The garbage bin was observed opened approximately one and a half feet-high. […]