Health inspection·March 10, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 17's, Clinical Note Entry dated January 24, 2023, at 3:01 PM, which indicated .resident is HOH(Hard of hearing) with no hearing aids . The DON stated there was a discrepancy in the two observations and there was a gap in Resident 17's care. During an interview on March 10, 2023, at 11:25 AM, with Resident 17, Resident 17 stated she still could not hear. Resident 17 acknowledged that at times staff must raise their voice because of her hearing deficit. Resident 17 stated she had notified the staff members that she had difficulty with hearing. Resident 17 stated she hoped she was not becoming deaf and would like to have her ears checked by a physician. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs dated March 2021, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The document further indicated, .2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 2 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 28) was provided a safe, clean, comfortable, and homelike environment when Resident 28's wheelchair was not found in good repair. This failure had the potential to result in discomfort for Resident 28, which could have negatively impacted the resident's quality of life. Findings: During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest, where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated, the wheelchair was provided to him by the facility and had been torn since he was admitted in October 2021. During a concurrent observation and interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), in the IP's office, Resident 28's wheelchair was observed. The IP stated the wheelchair needs to have an easily wipeable surface and due to the rips in the vinyl and exposed fabric, it would not be easily wipeable. The IP further stated it was a risk for infection. During an interview on March 9, 2023, at 10:38 AM, with the Director of Nursing (DON), the DON stated, they did not have a process to track maintenance and inspections of resident's wheelchairs in the facility. The DON further stated Resident 28's wheelchair condition was not maintained to the appropriate standard and could have been a safety and infection risk. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, the P&P indicated, .2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a. clean, sanitary, and orderly environment . During a review of the facility's P&P titled, Medical Equipment Management Plan, revised May 2022, the P&P indicated, Objective: To provide a safe environment through proper selection, use, testing, and maintenance of Medical Equipment .The [Director of Building and Grounds] establishes and maintains a current, accurate and separate inventory of all equipment included in a program of planned inspections or maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 3 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0641 Ensure each resident receives an accurate assessment. 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 accurately assess a resident with a hearing deficit when one of three sampled residents (Resident 17), Minimum Data Set (MDS -a federally mandated assessment for residents in nursing homes) who was known by the staff to have a hearing deficit. Residents Affected - Few This failure had the potential to cause Resident 17 to receive inadequate care at the facility and adversely affect Resident 17's quality of life and ability to function since the time of admission. Findings: During a concurrent observation and interview on March 7, 2023, at 8:02 AM, with Resident 17, in Resident 17's room, Resident 17 was observed to be hard of hearing. Resident 17 requested surveyor to repeat what was said because she could not hear. Surveyor repeated what was said multiple times, while spoken louder, slower, and closer to Resident 17's ear. Resident 17 stated she would have to talk to her son about getting hearing aids. During an observation on March 7, 2023, at 9:48 AM, in Resident 17's room, the Administrator asked Resident 17 how she was doing. Resident 17 stated she could not hear what the Administrator said to her. After the Administrator repeated what was said in a louder tone, Resident 17 stated that she could still not hear what was being said to her. The Administrator did not clarify what was being told to her and exited the room. During a concurrent observation and interview on March 8, 2023, at 9:48 AM, in Resident 17's room, with Registered Nurse 1 (RN 1) explained to Resident 17 she was going to begin performing wound care on the Resident's heels. Resident 17 stated she couldn't hear. RN 1 repeated what was said louder and closer to Resident 17's ear. Resident 17 stated she was in a lot of pain, yelped when gently touched, and requested RN 1 to perform wound care when resident was not in as much pain. RN 1 agreed to come back when Resident 17 was ready for wound care. When asked if Resident 17 has always had difficulty hearing, RN 1 stated her hearing has been like that since she was admitted . During a concurrent observation and interview on March 9, 2023, at 7:53 AM, in Resident 17's room, a Certified Nurse Assistant 1 (CNA 1) assisted Resident 17 in getting ready to eat breakfast. CNA 1 told Resident 17 after breakfast CNA 1 would assist Resident 17 in getting dressed. Resident 17 stated she could not hear what CNA 1 said. CNA 1 increased her volume and spoke closer to Resident 17's ear and repeated what was said. Resident verbalized she understood the words after breakfast . but did not hear what was said after. CNA 1 reiterated what was said once more and spoke loudly and distinctly. Resident 17 smiled, agreed to care, and thanked CNA 1. When asked if Resident 17 has hearing aids, CNA stated Resident 17 does not wear hearing aids. CNA 1 further stated Resident 17 cannot hear because staff was wearing a face mask. During a concurrent interview and record review on March 9, 2023, at 2:33 PM, with RN 1 (whose additional role is to do MDS assessments) RN 1 stated Resident 17 was certainly hard of hearing. RN 1 reviewed Resident 17's MDS assessment dated [DATE], which indicated in Section B - Hearing, Speech, and Vision, Resident 17's hearing was documented as 0. Adequate - no difficulty in normal conversation, social interaction, listening to TV. During a record review of the Face Sheet, (contains admission and demographic information) dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 4 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few March 10, 2023, the Face Sheet showed Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's Disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), depression, and cachexia (weakness and wasting of the body due to severe chronic illness). During another record review with RN 1, titled, Clinical Note Report, dated January 24, 2023, at 15:01 (3:01 PM), indicated .she is HOH (hard of hearing) no hearing aids . RN 1 stated based on the two assessments, Resident 17's hearing deficit was not captured on the MDS. During a concurrent interview and record review on March 10, 2023, at 8:57 AM, with the Director of Nursing (DON), the DON reviewed the MDS dated [DATE], which indicated in Section B - Hearing Speech, and Vision, Resident 17 had 0. Adequate - no difficulty in normal conversation, social interaction, listening to TV. The DON also reviewed Resident 17's record titled, Clinical Note Entry dated January 24, 2023, at 3:01 PM, which indicated .resident is HOH with no hearing aids . The DON stated there was a discrepancy in the two observations and there was a gap in Resident 17's care. During an interview on March 10, 2023, at 11:25 AM, with Resident 17, Resident 17 stated she still could not hear. Resident 17 acknowledged that at times staff must raise their voice because of her hearing deficit. Resident 17 stated she had notified the staff members that she had difficulty with hearing. Resident 17 stated she hoped she was not becoming deaf and would like to have her ears checked by a physician. During a review of the facility's policy and procedure (P&P), titled, Charting and Documentation, dated July 2017, the P&P indicated, The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P further indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 5 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of four sampled residents (Resident 9 and Resident 28) receiving anticoagulant (blood thinner) medication. This failure had the potential to cause adverse health outcomes such as bleeding and hemorrhage (profuse discharge of blood from a ruptured blood vessel) which may lead to hospitalization and/or death. Findings: 1. During an interview on March 7, 2023, at 11:16 AM, with Resident 9's responsible party (RP), RP stated Resident 9 is taking Xarelto (anticoagulant medication to prevent blood clots), and Resident 9 would get bruises whenever her blood is drawn for laboratory work. RP further stated after Resident 9's recent stroke, communication became harder because Resident 9 did not talk as much. During a review of Resident 9's medical record, the Face Sheet, (contains admission and demographic information) dated March 10, 2023, the Face Sheet indicated Resident 9 was admitted on [DATE], with diagnoses that included aphasia (disorder that affects communication) following cerebral infarction (stroke caused by a blood clot), cardiac arrythmia (irregular heartbeat), and dementia (impaired ability to remember, think, or make decisions). During a review of Resident 9's record titled, Medications, a physician ordered Xarelto 20 mg (milligram unit of measurement) tablet Every 1 Day on February 26, 2023. During a concurrent interview and record review on March 10, 2023, at 8:40 AM, with the Director of Nursing (DON), the DON reviewed Resident 9's care plan, and verified there was no care plan in place for anticoagulant medication and/or Xarelto. The DON further stated a care plan for anticoagulant medications is important because it explains the risks and benefits of a blood thinner, what signs and symptoms to be cautious for, when to notify a physician, and how to intervene if those signs and symptoms were present. During a review of the facility's policy and procedure (P&P), titled, Care Plan, Comprehensive Person Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. During a review of the History & Physical (H&P) for Resident 28, dated November 21, 2022, the H&P indicated, Resident 28 was admitted on [DATE], with a diagnoses that included Alzheimer's dementia (a progressive loss of intellectual functioning, impairment of memory and personality change), hypertension (blood pressure is higher than normal), atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart), and heart failure (long term weakness of the heart muscle). During a review of Physician Orders for Resident 28, dated March 10, 2023, the Physician Orders indicated, an order for Eliquis (an anticoagulant medication to prevent serious blood clots) 5 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 6 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0656 (milligram-unit of measurement) tablet two times daily, dated November 23, 2022. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 28's clinical record, the record indicated there was no care plan developed for anticoagulant use. Residents Affected - Few During a concurrent interview and record review on March 9, 2023, at 10:23 AM, with the DON, Resident 28's medical record was reviewed. The DON reviewed and verified Resident 28's care plan documentation and stated there was no care plan in place for Resident 28's anticoagulant use. The DON agreed that there should be one, so staff would know about things to monitor for a resident who is at risk for bleeding. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, .7. The comprehensive, person-centered care plan: e. reflects currently recognized standards of practice for problem areas and conditions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 7 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 follow professional standards of practice for urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) care for one of three sampled residents (Resident 28), when Resident 28 was instructed to hold his catheter during a urinary catheter irrigation (a sterile procedure to flush the urinary catheter to keep it clear and working properly) procedure. This failure had the potential to result in a urinary tract infection (UTI - an infection in any part of the urinary system) due to improper handling of the urinary catheter, which could have caused the resident harm. Findings: During a review of the Face Sheet (contains admission and demographic information) for Resident 28, dated March 10, 2023, the Face Sheet indicated, Resident 28 was admitted on [DATE], with a diagnosis of, but not limited to, benign prostatic hypertrophy (BPH-a condition causing slowing or blockage of the urine stream out of the bladder), and obstructive and reflux uropathy (urine cannot drain out of the bladder). During a concurrent observation and interview on March 7, 2023, at 11:00 AM, with Resident 28, in Resident 28's room, Resident 28's urinary catheter was observed to have cloudy urine and white sediment build up in the line. Resident 28 stated, he has had his urinary catheter changed approximately 19 times since his admission and he would frequently complain of abdominal pain when the line would get clogged. Resident 28 further stated, his line would get irrigated twice a day by nursing staff. During a review of the Physician Orders for Resident 28, on March 10, 2023, the Physicians Orders indicated, an order for acetic acid (a medication used to cleanse the inside of the bladder to prevent infection and calcium build up for people with long term catheter use) 0.25% (percent strength) irrigation solution two times daily for catheter sediment, dated February 6, 2023. During an interview on March 7, 2023, at 3:08 PM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she had performed the catheter irrigation for Resident 28 that afternoon but had not performed an acetic acid flush for urinary catheters in her career. During a concurrent observation and interview on March 7, 2023, at 3:17 PM, with the MDS (Minimum data set - a computerized assessment tool) Nurse and Resident 28, in Resident 28's room, Resident 28 described to the MDS Nurse that LVN 2 performed his catheter irrigation but instructed the resident to assist with the procedure by holding the catheter during the flush and manipulate it by pinching the flexible tube while LVN 2 performed the procedure. Resident 28 further stated he has never had to hold his catheter during an irrigation before but did as he was instructed. The MDS Nurse stated it was not a standard practice to have residents assist with their catheter care, since it is to be an aseptic (sterile) procedure. During an interview on March 8, 2023, at 7:55 AM, with Resident 28, Resident 28 stated he did not feel it was his job to hold the catheter line during catheter care and he did not feel comfortable doing that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 8 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 During an interview on March 9, 2023, at 10:23 AM, with the Director of Nursing (DON), the DON stated, it was not the normal process for the residents to hold the catheter themselves during catheter irrigation. The DON further stated, the risk of the resident touching a catheter during an aseptic procedure is an increased risk of infection for an already compromised resident. During an interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), the IP stated it was their expectation that licensed staff do not have the residents hold their own catheter during catheter irrigation. The IP stated, LVN 2 should have asked another LVN to assist, someone licensed and trained in the procedure. The IP further stated the risk of the resident manipulating the catheter during irrigation is risk for entry of infection. During a review of the facility's policies and procedures (P&P) titled, Catheter Care, Urinary, revised September 2014, the P&P indicated, Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections .General Guidelines: 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 9 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 observation, interview, and record review, the facility failed to ensure the accurate administration of prescribed drugs and biologicals, when a medication was not administered as ordered by the physician for one of seven sampled residents (Resident 17). This failure resulted in Resident 17 receiving a doubled dosage of an ordered laxative medication which resulted in a medication error and had the potential to cause adverse drug effects to the resident. Findings: During a review of the Face Sheet (contains admission and demographic information) for Resident 17, the Face Sheet indicated, Resident 17 was admitted on [DATE], with a diagnosis of Alzheimer's disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions), encounter for palliative care (specialized medical care for people living with a serious illness), bed confinement, and pressure ulcer of sacral region- stage 4 (full thickness damage to the skin and underlying soft tissue of the lower back, just above the tailbone, with exposed fat, muscle, or bone). During an observation on March 9, 2023, at 10:00 AM, in Resident 17's room, Licensed Vocational Nurse 1 (LVN 1) was observed performing medication pass for Resident 17. LVN 1 administered two tablets of Senna Plus (a combination laxative and stool softener) 8.6mg- 50mg (milligram-unit of measurement) by mouth. The medication bubble packaging (presorted monthly supply of prescriptions for daily dispensing) came with two tablets in each bubble and was labeled for Resident 17, with the following indication: Senna 8.6mg-50mg two tablets twice daily. During a review of the Medication Administration Record (MAR) for Resident 17, dated March 2023, the MAR indicated, Resident 17 had a physician order for Senna Plus 8.6mg-50mg tablet (1 tablet) two times daily for bowel management hold for loose stools. During a concurrent interview and record review on March 9, 2023, at 10:10 AM, with LVN 1, LVN 1 reviewed the MAR for Resident 17 and stated, the order for Resident 17's Senna Plus came from hospice. LVN 1 reviewed the [Hospice] Plan of Care for Resident 17, dated January 24, 2023, and the hospice order for medications indicated, Senna Plus 50mg-8.6mg tablet 1 tablets orally 2 times a day for bowel management. LVN 1 stated the wrong dose of Senna was given to Resident 17. During an interview on March 9, 2023, at 10:45 AM, with the Director of Nursing (DON), the DON stated, nurses should be monitoring for medication discrepancies at all points, when a medication is ordered, loaded into the medication cart, and when it is pulled to be administered to a resident. The DON further stated LVN 1 should have followed the physician's order. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2019, the P&P indicated, Policy Statement: Medications are administered in a safe and timely manner . 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 10 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 medication. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Medication Ordering and Receiving from Pharmacy, dated October 2012, the P&P indicated, .B. 1). A licensed nurse: c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 11 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 maintain a sanitary kitchen environment when: Residents Affected - Many 1) The two ice machines that provide ice for 37 of 38 residents of the facility, were not clean to sight and touch. Ice machine 1 had a yellowish build-up in the ice chute (where ice is dispensed and travels from the ice maker to enter the ice bin). Ice machine 2 had a brownish build-up. This had the potential to contaminate the ice and cause foodborne illness. 2) The walk-in freezer that provides storage of food for 37 of 38 residents had liquid food spills, food crumbs and trash on the floor. This had the potential for microorganism growth and to attract pests. 3) The cabinet below the steam table (appliance that keeps food warm after it's been prepared and cooked) in the dining room that services meals for 37 of 38 residents had food crumbs and a rusty liquid spill. This had the potential for microorganism growth and to attract pests. Findings: 1. During an observation of Ice Machine 1, on March 7, 2023, at 9:00 AM, in the beverage area of the dining room, a yellowish-brown residue was noted in the ice chute. During an interview on March 7, 2023, at 9:05 AM, with Registered Dietician 1 (RD 1), she stated the ice machine bin is cleaned monthly by staff and quarterly they have a contract company come in and clean the area that was observed to have the build-up (the internal components where the ice is made and dispensed). RD1 observed the yellowish residue that was removed with a paper towel and stated they would need to change the cleaning schedule from quarterly to monthly. During an observation of Ice Machine 2 and concurrent interview with Maintenance on March 7, 2023, at 10:18 AM, in the kitchen, a brown residue was noted on the ice chute. The Maintenance acknowledged the build-up and stated it should not be there. During an interview on March 9, 2023, at 2:11 PM with RD 2 she stated her expectation is that the ice machines in the dining room and the kitchen are to not have any build-up. During a record review of the Health Center Ice Machine Monthly Cleaning Log 2023, indicated, the date for last internal cleaning is January 18, 2023. During record review of the main kitchen Ice Machine Monthly Cleaning Log dated 2023 indicated, the date for last internal cleaning is January 18, 2023. During a record review of FDA Federal Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensil, (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. In addition, 4-602.11 indicates, (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 12 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 specifications, at a frequency necessary to preclude accumulation of soil or mold. Also ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 2. During observation on March 7, 2023, at 8:15 AM, in the kitchen walk-in freezer, there was some sliced potato lying on the ground at entry, a dark pink/purple spill was noted on the floor of the freezer under the shelving, there was crumbs and some trash on the floor of the freezer. During an interview on March 7, 2023, at 8:15 AM, RD1 and RD2 were shown the spillage. RD1 stated they ran out of the specific cleanser that will clean a walk-in freezer and it is currently unavailable from the company that provides it. During an interview on March 9, 2023, at 2:11 PM with RD 2 she stated, it is her expectation that the walk-in freezer floor to be kept clean. During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, Food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 3. During an observation on March 7, 2023, at 8:46 AM, in the dining area, where food from the main kitchen is kept warm and plated then distributed to residents, the cabinet below steam table had crumbs on the floor, and a leakage of fluid and brown/rust colored staining to the floor of the cabinet. During an interview on March 7, 2023, at 8:46 AM, RD 1 acknowledged that it was dirty. During an interview on March 9, 2023, at 2:11 PM with RD 2, she stated that her expectation is the cabinet needs to be kept clean. During a record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 13 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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** Based on observation, interview, and record review, the facility failed to observe infection prevention and control measures for two of two sampled residents (residents 28 and 30) when: Residents Affected - Few 1. Resident 28's wheelchair was ripped. 2. Resident 30's toothbrush and hair comb were found in a shared bathroom sink, unlabeled. These failed practices had the potential for the spread of infection and placing residents' health and safety at risk of a highly susceptible population of 39 residents. Findings: 1. During a concurrent observation and interview on March 7, 2023, at 10:40 AM, with Resident 28, in Resident 28's room, the vinyl fabric (a durable, waterproof, man-made synthetic leather) lining of Resident 28's wheelchair was observed to be torn on both sides of the backrest where it connected to the wheelchair frame. The exposed fabric was partially covered with dirty, peeling, paper medical tape. Resident 28 stated the wheelchair was provided to him by the facility and had been torn since he was admitted in October 2021. During an interview on March 9, 2023, at 10:38 AM, with the Director of Nursing (DON), the DON stated Resident 28's wheelchair condition was not maintained to the appropriate standard and could have been a safety and infection risk. During a concurrent observation and interview on March 10, 2023, at 9:51 AM, with the Infection Preventionist (IP), in the IP's office, Resident 28's wheelchair was observed. The IP stated the wheelchair needs to have an easily wipeable surface and due to the rips in the vinyl and exposed fabric, it would not be easily wipeable. The IP further stated it was a risk for infection. During an interview on March 10, 2023, at 11:20 AM, with Environmental Services 1 (EVS 1), EVS 1 stated a torn wheelchair surface with exposed fabric could not be properly sanitized. During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, revised October 2018, the P&P indicated, .6. a. Environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces are appropriately cleaned. 2.During a review of Resident 30's clinical record, the face sheet (contains demographic and medical information) indicated Resident 30 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (the most common cause of dementia - an impaired ability to think, remember, or make decisions) and generalized anxiety disorder (persistent worrying). During a concurrent observation and interview with Certified Nursing Assistant 5 (CNA 5), on March 9, 2023, at 7:54 AM, in the shared bathroom of Resident 30 and 186, a comb and a wet toothbrush was on the bathroom sink. It did not have a label to indicate who it belonged to. CNA 5 stated, I thinks it's Resident 30's, I will go ahead and write her name. During an interview on March 9, 2023 at 8:00 AM, with Certified Nursing Assistant 5 (CNA 5), in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 14 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 - Few Resident 30's shared bathroom, CAN 5 stated, Resident 30 should have a new set of toothbrush and comb because it was just lying on the bathroom sink with no label. During an interview with Licensed Vocational Nurse 5, (LVN 5), on March 10, 2023, at 10:39 AM, she stated, resident belongings should be labeled with their initials or full names to prevent cross contamination, it's an infection control issue. During an interview with the Administrator, on March 10, 2023, at 10:49 AM, he stated, it's their practice to separate and label the residents belongings with their name and/or initials. We don't have a policy but it's common sense, it's sanitary and infection control practice. A review of the facility's policy and procedure (P&P) titled, Admitting the Resident: Role of the Nursing Assistant, revised September 2013, the P&P indicated, Purpose. The purposes of this procedure are to assist the resident to his/her room and to help alleviate concerns and answer questions that the resident and family may have. Steps in the procedure: .11. Write the resident's name on the appropriate articles (i.e., water pitcher, cup, urinal, denture cup, etc.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 15 of 16 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 055914 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plymouth Village 819 Salem Drive 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure a safe environment for all residents in the facility, when an open gap on the dining room floor was present. Residents Affected - Few This failure had the potential to impose a tripping hazard for the residents and could have contributed to resident falls with injuries. Findings: During an observation on March 7, 2023, at 11:00 AM, an open gap in the flooring of the dining room floor was observed, measuring approximately six inches long and one inch wide. An interview on March 7, 2023, at 11:00 AM, with the Administrator, the Administrator stated, he didn't know why the gap in the flooring was there. The Administrator stated, he will get it fixed immediately. During an interview on March 8, 2023, at 12:08 PM, with Maintenance, Maintenance stated, he didn't know how long the open gap had been there. Maintenance stated the gap in the floor may have been there for a few months, due to the build-up of dirt around it. During an interview on March 9, 2023, at 10:53 AM, with the Administrator, the Administrator stated, housekeeping was responsible for mopping the floor, and they never reported about the open gap in the flooring of the dining area. During a review of the facility's policy and procedure titled Slips and Falls dated September 13, 2018, the P&P included the following: Policy: This community implements the following procedures to minimize the risk of slips, trips, and falls. Procedure 5. Keep aisles and passageways clear and in good repair, with no obstruction across or in aisles that could create hazard .18. Eliminate uneven floor surfaces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055914 If continuation sheet Page 16 of 16