Health inspection·June 10, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm treatments will include care-specific details, including: a. The date and time the procedure/treatments was provided. b. the name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/ treatment. d. Whether the resident refused the procedure/treatment. e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documentation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 2 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 maintain personal hygiene of the fingernails for one of nine sampled residents (Resident 122). Residents Affected - Few This failure had the potential to spread infections and for Resident 122 to develop skin problems and injuries. Findings: During an observation on June 7, 2022, at 3:33 PM, in room [ROOM NUMBER], Resident 122 was lying on his bed alert, awake, and verbal. Resident 122's right hand was contracted and had long fingernails with black colored substance underneath the nails. During an observation on June 9, 2022, at 12:50 PM, in room [ROOM NUMBER], Resident 122 still had long fingernails with black colored substance underneath the nails. During an interview with Resident 122, on June 9, 2022, at 12:54 PM, Resident 122 stated, My nails are so dirty. If I were home this could have been trimmed, but staffs here are not even checking it. During an interview with Certified Nurse Assistant (CNA 2), on June 9, 2022, at 1:35 PM, CNA 2 stated, During admission, we bring stuffs for their ADLs [Activity of Daily Living - activities related to personal care]. On the ADL kit we have soap, toothbrush, toothpaste, dentures, urinal, bed pans, and lotions. When it comes to grooming, we check their hair and nails and make sure it's clean. CNA 2 further stated that Resident 122's fingernails need to be trimmed because it's long and dirty. CNA 2 verified that Resident 122 needs assistance on nail trimming because his right hand was contracted. During an interview with the Director of Nursing (DON), on June 10, 2022, at 3:44 PM, the DON stated, If resident needs assistance with ADLs, the CNA should assist them performing their ADLs that includes proper grooming. A review of Resident 122's Face Sheet (document with patient's information) indicated that Resident 122 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia (paralysis of one side of the body) and Hemiparesis (another term for hemiplegia) following Cerebral Infarction (occurs as a result of lack of adequate blood supply to brain cells depriving oxygen and vital nutrient which cause parts of the brain to die off) affecting Left Non-Dominant Side, Muscle Wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and Atrophy (a gradual decline in effectiveness), and Generalized Muscle Weakness. A review of Resident 122's Documentation Survey Report, for the month of June 2022, under the section of ADL - Personal Hygiene, indicated that Resident 122 was totally dependent and required one-person physical assist with Activities of Daily Living - Personal Hygiene. A review of Resident 122's MDS (Minimum Data Set - clinical assessment tool that measures health status of patients in the nursing home), Comprehensive Skilled Review Note, dated June 2, 2022, under the section of Skilled Services Notes, indicated, Continue to monitor and manage decline in ADL function related to CVA (Cerebrovascular Accident - when blood flow to a part of your brain is stopped (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 3 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0677 either by a blockage or rupture of a blood vessel) . Level of Harm - Minimal harm or potential for actual harm A review of Resident 122's MDS, Comprehensive Skilled Review Note, dated June 2, 2022, under the section of Therapy Services, indicated, .2. Training/education needed for upcoming week [OT (Occupational Therapy - healthcare professionals who treat injured, ill, or disabled patients through the therapeutic use of everyday activities)]. Patient requires skilled OT services to increase with ADLs . Residents Affected - Few A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised on March 2018, indicated, Policy Statement . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, . a. Hygiene (bathing, dressing, grooming, and oral care) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 4 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the urinary catheter (a flexible tube used to empty the bladder and collect urine) drainage bag and tubing off the floor for one of three sampled residents (Resident 123). This failure had the potential to cause urinary tract infections [an infection in any part of the kidneys, bladder, or urethra (the tube which empties urine from the bladder)] to Resident 123. Findings: During an observation on June 7, 2022, at 10:36 AM, in room [ROOM NUMBER], Resident 123 was lying on his bed alert, awake, and responsive. Resident 123 had an indwelling foley catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) attached to the drainage bag. Catheter drainage bag and tubing was on the floor. Certified Nurse Assistant (CNA 1) entered Resident 123's room and did not check Resident 123's catheter drainage bag and tubing on the floor. During an interview with CNA 1, on June 7, 2022, at 10:39 AM, CNA 1 verified that catheter drainage bag should be hanging on the side of the bed and not on the floor to prevent contamination. During an interview with the Director of Nursing (DON) on June 9, 2022, at 7:24 AM, the DON stated urine drainage bag should be hanging on the side of the bed and not on the floor to avoid back flow of the urine that may cause urinary tract infection. A review of Resident 123's Face Sheet (document with patient's information), indicated Resident 123 was admitted to the facility on [DATE], with diagnoses which included Urinary Tract Infection and Benign Prostatic Hyperplasia (enlargement of the prostate) with Lower Urinary Tract Symptoms (group of urinary symptoms triggered by an obstruction, abnormality, infection, or irritation of the bladder, urethra, and/or prostate in men), Muscle Wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and Atrophy (a gradual decline in effectiveness), and Generalized Muscle Weakness. A review of the facility's policy and procedure titled, Catheter Care, Urinary, revised on September 2014, indicated, Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections . Infection Control . b. Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 5 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically inserted for the administration of medications and nourishment) was verified for placement for one sampled resident (Resident 61) prior to administration of medications. This failure had the potential to place Resident 61 at risk for complications such as aspiration (a condition in which stomach content enter the lungs) and peritonitis (inflammation of the inside wall of the abdomen) and place the resident's health and safety at risk. Findings: During a review of Resident 61's clinical record, the Face Sheet (contains demographic and medical information) indicated Resident 61 had diagnoses that included chronic obstructive pulmonary disease (a condition involving narrowing of the airways and difficulty or discomfort in breathing), cerebral infarction (disease resulting to damage in the brain from interruption of its blood supply), and hypertension (high blood pressure). During a medication administration observation on June 9, 2022, at 8:00 AM, inside Resident 61's room, with Licensed Vocational Nurse (LVN 1), LVN 1 administered Vitamin C (dietary supplement), Ferrous Sulfate (medication to prevent/treat anemia), and Vitamin D (dietary supplement) via GT to Resident 61. LVN 1 did not verify the placement of the GT prior to medication administration. During a review of Resident 61's Physician Order Summary Report, dated June 9, 2022, the document indicated, Check/Auscultate Placement of Feeding Tube Before Administration of Meds/& Or Fluids. During an interview on June 9, 2022, at 8:07 AM, with LVN 1, she acknowledged the finding and stated she should have checked the GT placement just before administering medications. During an interview on June 9, 2022, at 8:50 AM, with Registered Nurse Supervisor (RN-S), RN-S stated it is her expectation for staff to check GT placement before med administration. She also stated this is important to ensure medication is administered in the stomach and not anywhere the abdomen. During an interview on June 9, 2022, at 11:40 AM, with the Director of Nursing (DON), she stated that LVN 1 came to her earlier and informed her that she forgot to check GT placement during the medication observation for Resident 61. During a concurrent interview and record review of the facility's Administering Medications through an Enteral Tube, on June 9, 2022, at 11:41 AM, with the DON, she stated the facility's policy and procedure on administration of medications using GT was not followed. During a review of the facility's Policy and Procedure (P&P), titled Administering Medications through an Enteral Tube, revised November 2018, the P&P indicated, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Steps in the Procedure .6. Verify placement of the feeding tube. a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 6 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe and effective pharmaceutical services (the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life) for one out of three sampled residents (Resident 67) when two doses of warfarin (medication to treat and prevent blood clots) were not available. This failure had the potential for Resident 67 to experience serious adverse clinical outcomes, including but not limited to blood clots. Findings: During a record review of Resident 67's clinical record, the face sheet (contains demographic information) indicated, Resident 67 was admitted to the facility on [DATE], with the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction(occurs as a result of lack of adequate blood supply to brain cells depriving oxygen and vital nutrient which cause parts of the brain to die off) affecting left non-dominant side and atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly and the risk of the development of blood clots). A record review of Resident 67's Order Summary Report, dated May 2, 2022, indicated, Warfarin Sodium 5 mg (milligram- units of measurement for dose) by mouth in the evening for atrial fibrillation. During a review of a facility document titled, Progress Notes, dated May 16, 2022, at 5:37 PM, indicated, held no meds on hand. LVN 4 was not available for interview. During a review of a facility document titled Progress Notes dated May 20, 2022, at 5:27 PM, indicated, awaiting on pharmacy, resident said ok to wait until delivered, medication has been ordered already. LVN 5 was not available for interview. During a concurrent interview and record review of Resident 67's Progress Notes and PACS-Medication Administration Record with Registered Nurse Supervisor (RN-S), on June 10, 2022, at 2:50 PM, RN-S stated Resident 67 did not receive warfarin sodium 5 mg on May 16 and 20, 2022, and did not inform the doctor or the nursing supervisor. RN-S further stated outcome of not giving the medication will be stroke, and her expectation from staff is to inform nursing supervisor, doctor, and call pharmacist. RN-S also stated that it is facility's responsibility to educate staff. During a concurrent interview and record review of Resident 67's Progress Notes and PACS-Medication Administration Record with Director of Nursing (DON), on June 10, 2022, at 3:32 PM, DON stated medication was not administered and nurse did not inform Physician or nurse supervisor. DON further stated if resident miss taking warfarin as ordered, Resident 67 will have a stroke. She stated her expectation from the staff is to inform the nurse supervisor and doctor. DON also stated that it is facility's responsibility to educate their staff especially licensed nurses. During a review of the facility's policy titled Medication and Treatment Orders revised July 2016, indicated, Policy Interpretation and Implementation .14. Order for anti-coagulant will be prescribed only with appropriate clinical and laboratory monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 7 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0755 a. The attending physician must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 8 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure the established resident meal menu was followed by the facility kitchen for the residents' lunch on June 8, 2022, for nine out of nine residents (Residents 12, 125, 122, 8, 19, 51, 66, 32, & 14) with diet orders for pureed texture (a type of modified diet that turns the shape and structure of food into a consistency similar to pudding and mashed potatoes). This failure resulted in all the residents with pureed texture diet orders not receiving their full serving of facility-prepared lunch, according to the facility's established menu for June 8, 2022. Findings: During an observation on June 8, 2022, at 11:36 AM, within the facility's kitchen, kitchen staff were preparing to commence tray line (systematic process described as serving and preparing meal plates and trays from heated food containers) to begin preparing the residents' lunch meal plates and trays for distribution. During an observation on June 8, 2022, at 12:48 PM, with the Director of Dietary Services (DDS), the DDS provided two resident lunch meal test trays for tasting, temperature and texture verification with the Surveyor. Per observation and verification with the DDS, one lunch meal test tray was prepared as a regular texture meal (meal was not modified in any way to change the shape or texture of the meal), and the second lunch meal test tray was prepared as a pureed texture meal. During a concurrent observation and interview on June 8, 2022, at 12:55 PM, with the DDS, it was observed that the puree-prepared resident lunch meal test tray was missing the Wheat Roll menu item, while the Wheat Roll menu item was available for the regular texture resident lunch meal test tray. The DDS observed and compared the two respective meal trays and stated the Wheat Roll menu item was missing for all the puree-prepared resident lunch meal trays that were just served for the residents' lunch. An observation of the facility kitchen staff preparing and/or serving the pureed Wheat Roll menu item for the puree-prepared resident lunch meal trays was not recalled during the kitchen's tray line observation. The DDS stated the facility usually included the bread roll menu item for the puree-prepared resident meals, as per the menu. The DDS further stated the bread roll menu item for the pureed resident meals was missed for the lunch meals just prepared and served to the residents. The DDS further stated all facility prepared and served resident meals have to be the same, while following their indicated and ordered meal textures. During a review of the facility menu titled, Good for Your Health Menus, dated between June 6, 2022 through June 12, 2022, the menu indicated the following items were to be served for the residents' lunch on June 8, 2022: Tahitian Chicken . Wheat Roll . During a review of the Cooks Spreadsheet, Summer Menus, dated for June 8, 2022, the Cooks Spreadsheet, Summer Menus indicated the Wheat Roll menu item for the residents' lunch was to be included and served for the residents receiving pureed meals, as per their diet orders. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated for the year of 2020, the P&P indicated, . 4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 9 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences . Procedures . 2. Menus are written for regular and modified diets in compliance with the diet manual . During a review of the facility's guideline titled, Recipe: Pureed Breads, Cakes, Cookies . And Other BREAD PRODUCTS, dated March 2017, the guideline indicated, . Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets . 5. Follow the portion size to serve as per the cook's spreadsheet . 6. Serve on trayline at room temperature or warm . Event ID: Facility ID: 055001 If continuation sheet Page 10 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 the safe storage, preparation, distribution, and/or serving of food for the residents when: Residents Affected - Many 1) One out of six staff members working in the facility kitchen was not wearing a hair net that covered all her head hair. 2) One out of one can opener in the facility kitchen was not clean when readily available and installed for kitchen staff use. 3) One out of one facility ice machine was not clean, per internal inspection of the ice machine's components. 4) One can of food was found to be expired and readily available within the facility's dry food storage area. 5) One food bowl used for serving pureed meals to indicated residents was not clean. These collective failures had the likelihood to negatively affect the quality and safety of the food prepared and served by the facility to at least 62 out of 65 Residents in the facility who had diet orders for food and/or beverage consumption by mouth in the facility. Findings: 1) During an observation on June 7, 2022, at 8:13 AM, within the facility kitchen, a Dietary Aide (DA 1) was observed washing dishware at the sink counter. DA 1 was observed wearing a hairnet that was pulled back from the top of her head, exposing the unrestrained front half of her scalp and respective head hair. During an interview on June 7, 2022, at 8:15 AM, with DA 1, DA 1 stated she helped prepare food for facility residents, in addition to helping with general cleaning in the facility kitchen. DA 1 was asked about her hairnet, and she stated she always wore her hairnet, but realized her hairnet was not covering the entire top of her head. DA 1 further stated and confirmed her hairnet exposed the front half of her scalp and exposed her unrestrained head hair. DA 1 stated she did not check her hairnet placement after applying her face mask and stated she should have checked her hairnet for acceptable placement on her head. DA 1 further stated she knew she was expected to wear a hairnet that covered the entire top of her head and all of her head hair. During an interview on June 7, 2022, at 8:23 AM, with the Director of Dietary Services (DDS), the DDS stated staff were expected to wear their hairnets to cover the entire top of their head and all of their head hair while in the facility kitchen. The DDS further stated staff were aware of this expectation. During an interview on June 7, 2022, at 8:36 AM, with the Registered Dietician Nutritionist/Consultant Dietician (RDN), the RDN stated the facility kitchen staff were expected to know they must wear a hairnet that covered all of their head hair and were expected to check the placement of the hairnet after donning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 11 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 During a review of the facility's policy and procedure (P&P) titled, Dress Code for Women and Men, dated for the year 2018, the P&P indicated, Purpose: Appropriate dress in the Food and Nutrition Department . Proper Dress: Women: . 6. Hair net or hat which completely covers the hair . Men: . 6. Hat for hair, if hair is short. 7. Hair net for hair, if hair is long . 2) During an observation on June 7, 2022, at 10:16 AM, within the facility kitchen, the facility's single can opener was observed to be installed and readily available for use by kitchen staff. The can opener blade was observed - the blade was not clean, covered with film and sediment matter. During a concurrent observation and interview on June 7, 2022, at 10:18 AM, with the DDS, within the facility kitchen, the DDS observed the facility can opener and stated the can opener blade was not clean. The DDS stated the can opener blade was expected to be cleaned after every use. The DDS stated again the can opener blade was not clean, as was expected. A fellow Dietary Aide (DA 2) within the facility kitchen kindly interrupted and stated the can opener was last used in the morning, before the day's breakfast on June 7, 2022. During a review of the facility's policy and procedure (P&P) titled, Can Opener and Base, dated for the year 2018, the P&P indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation . 3) During an observation on June 7, 2022, at 3:17 PM, within the maintenance room containing the facility's single ice machine, the Janitor (Janitor 1) began taking the ice machine apart in the presence of the DDS for internal inspection of the machine's cleanliness. The exterior panels of the ice machine were removed to expose the machine's internal components. During a concurrent observation and interview on June 7, 2022, at 3:41 PM, with the facility's Administrator (ADM), at the facility's ice machine, black-colored build-up on the ice machine's internal wiring, adjacent to the ice machine's metal ice forming grid and ice product chute, was observed. The ADM confirmed the black-colored build-up observed was able to be removed from the machine's internal wiring with a clean gloved finger. During a concurrent observation and interview on June 7, 2022, at 3:49 PM, with the DDS and the Maintenance Supervisor (MS), at the facility's ice machine, the DDS and the MS stated they observed the Surveyor's ability to remove the black-colored build-up from the ice machine's internal wiring, adjacent to the ice machine's metal ice forming grid and ice product chute. The MS stated the facility's ice machine should have not been like that. Photos of the black-colored build-up from the ice machine's internal wiring were taken with a state-issued mobile phone. During an interview on June 8, 2022, at 9:40 AM, with the DDS, the DDS stated in regard to the facility's ice machine, he was responsible for communicating with the MS to assure the ice machine was being cleaned. The DDS further stated, based on the previous day's observation of the facility's ice machine and the removeable black-colored build-up from the ice machine's internal wiring, the cleaning frequency of the facility ice machine's internal components should be increased. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated for the year 2020, the P&P indicated, Policy: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacture recommendation's . During a review of the facility ice machine's manufacturer guidelines titled, C0322 through C1030 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 12 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 Air and Water Cooled User Manual, dated July 2006, the manufacturer guidelines indicated, Cleaning, Sanitation and Maintenance. This ice system requires three types of maintenance: . Sanitize the ice machine's water system . It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained . 4) During an observation on June 8, 2022, at 10:58 AM, within the facility kitchen's dry food storage area, a sealed can of La Choy Fancy Sliced Water Chestnuts was located on a canned food supply shelf, with a labeled received date of October 29, 2021, and a Best By date of April 23, 2022. During a concurrent observation and interview on June 8, 2022, at 11:00 AM, with the DDS, within the facility kitchen's dry food storage area, the DDS stated expired food items should not be on the food storage shelves and all expired items were discarded. The DDS observed the identified sealed can of La Choy Fancy Sliced Water Chestnuts and confirmed the food product was expired. The DDS further stated the expired item should have not been found on the shelf and should have been discarded. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated for the year 2020, the P&P indicated, Policy: Food and supplies will be stored properly and in a safe manner . 8. Food stores should be arranged in food groups to facilitate storing, locating and taking inventories . No food will be kept longer than the expiration date on the product . 5) During an observation on June 9, 2022, at 5:50 AM, within the facility's kitchen, kitchen staff were preparing the breakfast meal for the facility residents. During an observation on June 9, 2022, at 6:31 AM, within the facility's kitchen, an oval-shaped bowl with a white-colored surface was observed with green-colored specks and spots along the surface area that would usually contact plated food. The observed bowl was located within the tray line area, amongst stacked clean dishware, readily available for use by kitchen staff to plate food for indicated resident meals. During a concurrent observation and interview on June 9, 2022, at 6:31 AM, with the Registered Dietician Nutritionist/Consultant Dietician (RDN), within the facility's kitchen, near the tray line area, the RDN observed the suspect bowl. The RDN stated and confirmed the identified oval-shaped bowl with green-colored specks and spots along the surface was not clean. The RDN further stated the identified bowl should have not been like that, and the RDN was observed to scrape off the green, hardened residue from the bowl's surface with a clean butter knife. During a concurrent observation and interview on June 9, 2022, at 6:43 AM, with a Dietary Aide (DA 3), DA 3 observed the stack of oval-shaped bowls that were the same type as the bowl found to be unclean and stated this particular type of bowl is used to serve and plate food for pureed meals. During a review of the facility's policy and procedure (P&P) titled, Dish Washing, dated for the year 2018, the P&P indicated, Policy: All dishes will be properly sanitized through the dishwasher . Procedure: 1. Gross food particles shall be removed by careful scraping and pre-rinsing in running water . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 13 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report Prothrombin Time (PT- a test to evaluate blood clotting) and International Normalized Ratio (INR- blood test to check if a medication that prevents blood clots is working the way it should) test results to physician for one sampled resident (Resident 67). This failure had the potential for Resident 67 to experience serious adverse clinical outcomes, including but not limited to bleeding or blood clots, due to lack of communication and/or oversight. Findings: During a record review of Resident 67's clinical record, the face sheet (contains demographic information) indicated, Resident 67 was admitted to the facility on [DATE], with the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction(occurs as a result of lack of adequate blood supply to brain cells depriving oxygen and vital nutrient which cause parts of the brain to die off) affecting left non-dominant side and atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly and the risk of the development of blood clots). During a record review of Resident 67's Laboratory and Pathology Services, collected on May 5, 2020, at 6:54 PM, indicated elevated results. Resident 67's PT was 20.3 and INR 1.82 (normal range PT 11.8 to 13.8 and INR 0.90 to 1.10, elevated results could cause blood clots in the brain, lungs, heart, and death). It did not indicate that PT/ INR results were reported to the physician. A review of Resident 67's entire medical record did not indicate documentation that PT/ INR results were reported to the Physician. During a concurrent interview and record review with Registered Nurse Supervisor (RN-S), on June 10, 2022, at 2:45 PM, RN-S stated Resident 67's PT/INR specimen was collected on May 5, 2022, at 6:54 PM, and results were not reported to the Physician. RN-S further stated that outcome of not reporting the labs are bleeding or stroke and her expectation from staff is to report test results to the doctor and document. RN-S also stated nurse did not the facility follow the policy. During a concurrent interview and record review of Resident 67's Progress Notes, with the Director of Nursing (DON), on June 10, 2022, at 3:32 PM, DON stated, I don't know if the nurse reported this lab results to the doctor or forgot to document. DON further stated that they did not have documentation of reporting PT/INR results, and her expectation from staff is to report the test results to the doctor and document it. DON also stated it is facility's responsibility to educate staff. During a review of the facility's policy titled Charting and Documentation, revised July 2017, indicated, Policy Interpretation and Implementation .3. Documentation in the medical record will be objective (not, opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatments was provided. b. the name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/ treatment. d. Whether the resident refused the procedure/treatment. e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 14 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol, revised September 2012, indicated, Review by Nursing Staff: 1. A nurse will review all results. a. If the staff who first receive or review labs and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. The person who is to communicate results to a physician will review and be prepared to discuss, the following (to the extent that such information available): . b. Major diagnoses, allergies, pertinent current medications, other recent pertinent lab work, actions already taken to address results and treat the resident as indicated . 3. Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communication with others who may also need to speak with the physician. Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. During a review of the facility's policy titled Medication and Treatment Orders revised July 2016, indicated, Policy Interpretation and Implementation .14. Order for anti-coagulant will be prescribed only with appropriate clinical and laboratory monitoring. a. The attending physician must periodically record in the progress notes the results of the laboratory monitoring and the review for potential complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 15 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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** 3. During an observation in the Yellow Zone hallway, on June 8, 2022, at 12:01 PM, HSKP 1 was in room [ROOM NUMBER] wearing disposable gloves while cleaning and collecting trash bag from resident's room. A Certified Home Health Aide (CHHA 1) was standing in front of room [ROOM NUMBER] and asked for a clean plastic bag from HSKP 1. The HSKP 1 handed a plastic bag from her cart to CHHA 1 without changing her gloves. CHHA 1 placed a backpack in the plastic bag. Residents Affected - Some During an interview with CHHA 1, on June 8, 2022, at 12:04 PM, CHHA 1 stated, I asked for a clean plastic bag to place my personal items before going inside the resident's room. During an interview with HSKP 1, on June 8, 2022, at 12:06 PM, HSKP 1 stated, I just finished cleaning the room and collected the trash, but I did not change my gloves before giving her a clean plastic bag. She further stated, I know I have to make sure my hands are clean or change my gloves before touching clean items to prevent the cross contamination. During an interview with the Director of Nursing (DON) and Infection Preventionist Nurse (IPN) in the DON's office, on June 9, 2022, at 2:32 PM, the DON stated, Handwashing is very important to prevent the spread of infection. The IPN stated, Hand hygiene is very important to avoid spreading of disease. If not doing properly, it could cause infection to somebody. The IPN further stated that every time a staff touch things from dirty to clean, staff should get or use a new gloves or do hand washing. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised on August 2019, indicated, The facility considers hand hygiene the primary means to prevent the spread of infection. 4. During an observation on June 9, 2022, at 12:32 PM, in the [NAME] Zone hallway, LVN 1 was wearing N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and face shield. LVN 1's N95 was down to her chin. Her mouth and nose were exposed while preparing the medications in front of room [ROOM NUMBER]. During an observation and concurrent interview with LVN 1, on June 9, 2022, at 12:35 PM, in front of room [ROOM NUMBER], LVN 1's N95 was still down on her chin. The LVN 1 stated, I am not comfortable in wearing this because I can't breathe, and I feel dizzy. The LVN 1 further stated, I take responsibility of whatever federal or state regulations that I'm not following, and I know the consequence of not properly wearing the face mask. There's no COVID infection in this room so I think it's okay to put this down because I can't take this anymore. During an interview with IPN, on June 10, 2022, at 10:18 AM, the IPN stated, All staff should be wearing face masks at all times when they are in the facility except when they are in private area where there's no residents or other staffs, especially the COVID positivity rate here in [County] is high that's why we require the staffs to wear N95 instead of surgical face mask for more protection. The IPN further stated, We don't have a staff here that has medical condition that may prevent him or her to wear a face mask at all times. But if the staff is wearing a face shield, it's okay if staff has no face mask because I believe there's a guideline that it's okay to wear a face shield only because COVID is not a droplet precaution. And if you're wearing a face shield and no face mask, the particles will not go on the side because the mouth is covered by the face shield. Wearing a face (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 16 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 shield will not give the same protection as wearing a face mask but it's okay to use the face shield alone without a face mask when talking to visitors because the mouth is still covered. The IPN was not able to provide a facility policy or CDC (Centers for Disease Control and Prevention) guidelines that face shield can replace the use of a face mask. During an interview with the DON and Registered Nurse Consultant (RN-C), on June 10, 2022, at 10:27 AM, the DON stated, All staffs should be properly wearing a face mask while working inside the facility. The DON further stated they will in-service and educate the staffs regarding the proper use of face masks. The RN-C verified that all healthcare workers in a nursing facility regardless of vaccination status should wear a face covering like a surgical mask or higher at all times for infection control and prevention. The RN-C further stated that using a face shield cannot replace the use of face mask because that will not give the same protection as wearing a face mask especially during close contact with visitors. A review of the facility's policy and procedure titled, Established Covid19 Zones for Infection Control, revised on August 2019, indicated, Policy Interpretation and Implementation . 3. [NAME] Zone: . b. Staff only attending to residents in the [NAME] Zone will wear the following PPE (Personal Protective Equipment equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses): Either a surgical or N95 face mask, face shield or goggles. A review of the facility's COVID-19 Mitigation Plan, updated on January 3, 2022, indicated, . 4. Personal Protective Equipment . I. If there are COVID-19 cases identified in the facility the staff are provided and are wearing recommended PPE for all care of residents, in line with the most recent CDPH (California Department of Public Health) PPE guidance and in conjunction with CDC recommended contingency plans . K. All SNF (Skilled Nursing Facilities) personnel wear facemasks and eye protection while in the facility if the COVID-19 Pandemic is ongoing as part of universal source control. A review of CDPH Guidance for the Use of Face Masks to All Californians, dated April 20, 2022, indicated, .Masking Requirements: Masks are required for all individuals in the following indoor settings, regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KN94s) with good fit are highly recommended: o Healthcare settings (applies to all healthcare settings). o Long Term Care Settings & Adult and Senior Care Facilities . A review of CDC guidelines for Healthcare Workers regarding Infection Control for Nursing Homes, updated on February 2, 2022, indicated, .Implement Source Control Measures: Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of infection when they are breathing, talking, sneezing, or coughing. 5. During an initial tour observation on June 7, 2022, at 11:30 AM, inside Resident 168's room, Resident 168 was lying in bed, on oxygen at 5 liters per minute (LPM- unit for volume) via NC attached to an oxygen concentrator (medical device that gives extra oxygen) and watching television. He was alert, oriented, and able to communicate his needs. On his left side, a NC attached to a portable oxygen tank was seen on the floor and a nebulizer mask was on top of the bedside table. During a concurrent observation and interview on June 7, 2022, at 11:32 AM, with Registered Nurse Supervisor (RN-S), RN-S acknowledged that the NC was on the floor, nebulizer mask was on top of the bedside table, and there was no plastic bag to put these respiratory equipment. RN-S stated that these were unacceptable, and it is the facility's policy to date and put these equipment in a plastic bag when not used. She further stated this was an infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 17 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 During a review of Resident 168's clinical record, the Face Sheet (contains demographic and medical information) indicated Resident 168 was readmitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a condition involving narrowing of the airways and difficulty or discomfort in breathing), acute respiratory failure (a condition where in the body fails to maintain gas exchange), and heart failure (a long-term condition in which the heart cannot pump blood well enough to meet body's needs). During a concurrent interview and record review of the facility's Prevention of Infection Respiratory Equipment policy and procedure (P&P), on June 8, 2022, at 11:06 AM, with the Infection Preventionist Nurse (IPN), the IPN stated these respiratory supplies/equipment should be dated for staff to know when to replace them and staff were expected to monitor and put them inside a labeled plastic bag when not in use. IPN also stated that keeping these used respiratory supplies inside the plastic bag will help minimize the risk for infection and cross contamination. IPN further stated the facility's policy and procedure was not followed in this instance. During a review of the facility's policy and procedure (P&P), titled, Prevention of Infection Respiratory Equipment, revised November 2011, the P&P indicated, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment among residents and staff. Infection Control Considerations Related to Oxygen Administration: 4. Change the oxygen cannula and tubing every seven (7) days, or as needed. 5. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Obtain equipment (i.e., administration set-up, plastic bag, gauze sponges). 4. Store the circuit in a plastic bag, marked with a date and resident's name and replace tubing and plastic bag once a week. Based on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Soiled isolation gown was disposed of in an open trash bin attached to the medication cart for one out of four medication carts. 2. Soiled isolation gowns were not disposed of in the closed lid trash bin in two out of 14 rooms in the Yellow Zone [Resident under isolation observation for suspected COVID-19 (an infectious disease that will cause respiratory illness)]. 3. Housekeeping Staff (HSKP 1) did not perform hand hygiene after cleaning resident's room and before touching clean plastic bag in the Yellow Zone. 4. Licensed Vocational Nurse (LVN 1) failed to properly wear face covering while preparing medications and during closed contact with visitors in the [NAME] Zone (a designated area with residents that have not had recent exposure from COVID-19, cleared from previous COVID-19 diagnosis, or have completed observation period without symptoms and with a negative test) hallway. 5. Resident 168's used nasal canula (NC- a tubing to deliver oxygen in small amount through nostrils) connected to the portable oxygen tank and nebulizer (a device producing a fine spray of liquid, used for example for inhaling a medicine) mask were not properly labeled and stored per facility's policy. These failures had the potential for cross contamination and spread of infection which can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 18 of 19 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 055001 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redlands Healthcare Center 1620 W Fern Ave Redlands, CA 92373 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 adversely affect the health and wellbeing of 72 medically compromised residents, staffs, and visitors. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. During an observation on June 7, 2022, at 9:00 AM, in the Yellow Zone hallway in front of room [ROOM NUMBER], soiled isolation gown was disposed in open trash bin attached to the medication cart. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN 2) on June 7, 2022, at 9:02 AM, LVN 2 verified that soiled isolation gown was disposed in the medication cart opened trash bin. She further stated soiled isolation gown should have been disposed in the closed lid trash bin inside resident's room to prevent spread of infection. During a concurrent interview with Director of Nursing (DON), on June 7, 2022, at 9:04 AM, the DON stated she expected staff to dispose soiled isolation gowns in the closed trash bin in resident's room. 2. During an observation on June 7, 2022, at 9:06 AM, in rooms [ROOM NUMBERS], soiled yellow isolation gowns were noted inside open trash bins without lids. During a concurrent observation and interview with the Administrator (ADM), on June 7, 2022, at 9:20 AM, the ADM acknowledged trash bins in the isolation rooms had no lids. She stated staff needed to ensure soiled Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were discarded properly in the closed lid trash bins. A concurrent observation and interview were conducted with the Director of Nursing (DON) on June 7, 2022, at 9:22 AM. The DON stated closed trash bins in rooms [ROOM NUMBERS] in the Yellow Zone were missing and she expected staff to properly discard PPEs in the closed trash bins to contain spread of infection. She further stated staff should inform housekeeping if trash bins had no lids in residents rooms. During an interview with Infection Preventionist Nurse (IPN), on June 7, 2022, at 9:25 AM, he stated trash bins should have closed lids. During an interview with Maintenance Supervisor (MS), on June 7, 2022, at 9:30 AM, she acknowledged trash bins had no lids in rooms [ROOM NUMBERS] in Yellow Zone and it was housekeeping department's responsibility to provide trash bins with lids to resident rooms in the Yellow Zone. The facility's policy and procedure Personal Protective Equipment-Contingency and Crisis Use of Isolation Gowns, dated April 2020, .General Procedure for Donning and Doffing Gowns: 2. To remove gown: e. Fold or roll into a bundle and discard in a waste container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055001 If continuation sheet Page 19 of 19