Other·October 31, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification survey conducted from July 9, 2018 to July 12, 2018. Representing the California Department of Public Health: Surveyor 38477, HFEN; Surveyor 22921, HFEN; Surveyor 37626, HFEN; Surveyor 36779, HFEN; Surveyor 25338, HFES; Surveyor 39920, HFEN; Surveyor 40000, HFEN; and Surveyor 40036, HFEN. The facility census was 35. The sample size was 13 residents.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 08/03/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 1 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: 3. On July 9, 2018, at 11:17 a.m., Resident 6 was observed with a Foley catheter (FC). During a concurrent interview, Resident 6 stated he had a FC due to multiple sclerosis (MS - a disease of the brain and spinal cord). Resident 6 stated that prior to going to appointments, his private caregiver FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 2 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disconnected the FC tubing from the drainage bag and plugged the tubing. On July 11, 2018, at 4:13 p.m., LVN 2 was interviewed. LVN 2 stated that the FC was being plugged by Resident 6's private caregiver when Resident 6 went to appointments. On July 11, 2018, at 4:25 p.m., Resident 6's record was reviewed with LVN 3. Resident 6 was admitted to the facility on July 17, 2015, with diagnoses including multiple sclerosis, quadriplegia (paralysis of all four limbs), and neuromuscular dysfunction of the bladder (condition in which a person lacked control of urination). During a concurrent interview with LVN 3, she stated there was no documentation the physician was notified Resident 6's private caregiver was disconnecting Resident 6's FC tubing from the drainage bag. LVN 3 stated there was no documentation a physician order was obtained for Resident 6's private caregiver to disconnect the FC tubing from the drainage bag. On July 12, 2018, at 11:09 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated the physician should have been notified as soon as the facility was aware of Resident 6's private caregiver disconnecting the FC tubing from the drainage bag. On July 12, 2018, at 1:20 p.m., the policy and procedure (P&P) for disconnecting the FC tubing from the drainage bag was requested from the Director of Staff Development (DSD). The DSD stated the facility did not have a P&P specifically for disconnecting FC tubing from the drainage bag and plugging the tube. Based on observation, interview, and record review, the facility failed to ensure the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 3 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician was notified when: 1. Resident 32 had a significant weight loss (5 percent [%] weight loss in a month); 2. Resident 8 had an elevated BUN (blood urea nitrogen- blood test for kidney function) level; and 3. Resident 6's caregiver had been disconnecting Resident 6's Foley catheter (FCa tube inserted into the bladder to drain urine) from the drainage bag. These failures had the potential for delayed treatment and decline in health for Residents 32 and 8, and for Resident 6 to experience complications such as a urinary tract infection. Findings: 1. The record of Resident 32 was reviewed on July 10, 2018. Resident 32 was admitted to the facility on June 16, 2018, with diagnoses which included hypothyroidism (lack of thyroid hormone), muscle weakness, and anemia (low red blood cells). Resident 32's weight record indicated the following weights: -140 pounds on June 19, 2018; -124 pounds on June 29, 2018; and -120 pounds on July 1, 2018. There was no documented evidence in Resident 32's record the facility notified the physician of Resident 32's significant weight loss of 20 pounds, from June 19, 2018 to July 1, 2018 (14.28 % weight loss in 12 days). On July 10, 2018, at 2:42 p.m., Licensed Vocational Nurse (LVN)1 was interviewed. LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 4 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1 stated the facility should have notified the physician of Resident 32's weight loss from June 19, 2018 to July 1, 2018. The facility policy titled, "Monitoring of Residents Weights," dated November 30, 2016, was reviewed. The policy indicated: "...It is the policy of the (facility name) to provide the necessary and care of services (sic) to attain or maintain the highest practicable, physical, mental, and psych-social well being of each resident... After receiving the weekly/monthly weight variance report, a licensed nurse will notify the physician in a timely manner when significant, unplanned weight change (loss/gain) is observed... Significant weight change is defined as: 5 lbs (pounds) or 5 % (percent) in one month (30 days)..." 2. On July 11, 2018, the record of Resident 8 was reviewed. Resident 8 was admitted to the facility on January 31, 2017, with diagnoses which included chronic atrial fibrillation (abnormal heart rhythm), anemia, and hypertension (high blood pressure). Resident 8's record indicated the following laboratory test results, dated May 3, 2018; - BUN level of 56, with a reference range of 725 mg/dL (milligrams per deciliter- unit of measurement); and - BUN/Creatinine ratio (laboratory test for kidney function) level of 49.1, with a reference range of 10.0 - 20.0. On July 11, 2018, at 11:50 a.m., Resident 8's record was reviewed with the Minimum Data Set (MDS-standardized assessment tool) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 5 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Nurse (MDSN). There was no documented evidence the physician was notified about the abnormal BUN and BUN/Creatinine ratio laboratory test results. During a concurrent interview, the MDSN stated, "It was missed." The facility policy titled, "Change of Condition," dated August 23, 2017, was reviewed. The policy indicated: "...A change of condition is defined as any emergent or non-emergent deviation from the resident's normal health, mental and/or psychosocial status that requires a physician's intervention and significant alteration in the treatment plan... Examples of a change of condition include, but are not limited to: ...Abnormal lab (laboratory) results..."

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 08/03/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 6 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 7 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a written notification of transfer was provided to the resident or the resident's representative and a copy to the office of the state long-term care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 8 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ombudsman for one of four residents (Resident 20). This failure caused Resident 20 to not be aware of the circumstances related to the transfer, the information about the appeal process and the appeal rights, and the contact information of the ombudsman. This failure also increased the potential for the ombudsman to not be aware of Resident 20's transfer to the acute hospital. Findings: On July 9, 2018, at 11:10 a.m., Resident 20 was observed lying in the bed and sleepy. Resident 20's family member (FM) was in the room. During a concurrent interview with Resident 20's FM, the FM stated Resident 20 was transferred to the hospital last May 2018. Resident 20's FM further stated she did not receive a written notice of transfer when Resident 20 was transferred to the acute hospital. On July 11, 2018, at 10:06 a.m., Resident 20's record was reviewed. Resident 20 was originally admitted to the facility on May 16, 2018, with diagnoses which included pneumonia (lung infection) and congestive heart failure (failure of the heart to pump blood). The physician's order, dated May 24, 2018, at 3:26 p.m., indicated, "...Send to (name of the acute hospital) for further evaluation due to dizziness..." The "Progress Notes," dated May 24, 2018, at 4:01 p.m., indicated, "...transported at this time via gurney (a wheeled stretcher)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 9 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE There was no documented evidence a written notice of transfer was provided to Resident 20 or to his representative. On July 11, 2018, at 10:16 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the nurses did not provide a written notice to the resident and/or the family when a resident was transferred to an acute hospital. LVN 1 further stated, "we verbally notify them." On July 11, 2018, at 10:30 a.m., the Social Service Designee (SSD) was interviewed. The SSD stated she was responsible for notifying the ombudsman when a resident was transferred to an acute hospital. The SSD stated she was not aware of the requirement to provide a written notice to the resident or to the resident's representative, and a copy of the written notice to the ombudsman when a resident was transferred to an acute hospital. The SSD further stated the facility should have provided a written copy of the notice of transfer to the resident or to the resident's representative and a copy to the ombudsman, when a resident was transferred to an acute hospital. On July 12, 2018, at 10:14 a.m., the Administrator (ADM) was interviewed. The ADM stated she was aware of the regulation to provide a written notice of transfer to the resident or to the resident's representative and a copy to the ombudsman. The ADM stated she was not aware the facility staff were not providing written notice of transfer to the resident or the resident's representative, and a copy to the ombudsman, when a resident was transferred to an acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 10 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospital. The ADM stated the notice of transfer should have been completed and provided to the resident or to the resident's representative when a resident was transferred to an acute hospital. The ADM further stated a copy of the notice should have been sent to the ombudsman. The facility's policy titled, "Ombudsman/Resident and/or family notification of discharge/transfer," dated November 22, 2017, was reviewed. The policy indicated: " ... It is the policy of (name of the facility) to notify the resident/residents responsible party and the Ombudsman's office when a resident is discharged or transferred out of the facilty..." The policy did not include the requirement for the facility to provide a written notice of transfer to the resident or the resident's representative and to send a copy of the notice to the ombudsman when a resident was transferred to an acute hospital.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 08/03/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 11 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop and implement a plan of care for one of three sampled residents who smoked (Resident 14), and for one of one sampled resident (Resident 32) with a significant weight loss (5 percent [%] weight loss). This failure increased the potential for Residents 14 and 32 to not be able to receive the care and services they needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 12 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. On June 10, 2018, at 10:19 a.m., Resident 14 was observed smoking in the facility's patio. Resident 14 was being supervised and assisted by a family member while smoking. During a concurrent interview with Resident 14, she stated she smoked two times a day, and if the family member was not available to assist her when she wanted to smoke, her friends supervised her when she smoked. Resident 14 further stated sometimes when she asked the facility staff for smoking assistance the staff told her they were not available. On July 11, 2018, at 8:38 a.m., Resident 14's record was reviewed with Licensed Vocational Nurse (LVN) 1. Resident 14 was admitted to the facility on June 8, 2018, with diagnoses which included muscle weakness, and hemiplegia (weakness affecting one side of the body). There was no documented evidence an assessment for smoking and a plan of care for smoking was developed and implemented for Resident 14. During a concurrent interview with LVN 1, she stated the facility was aware Resident 14 smoked. LVN 1 stated the admitting nurse should have completed the smoking assessment and the plan of care for smoking upon Resident 14's admission. 2. The record of Resident 32 was reviewed on July 10, 2018. Resident 32 was admitted to the facility on June 16, 2018, with diagnoses which included hypothyroidism (lack of thyroid hormone), muscle weakness, and anemia (low red blood cells). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 13 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 32's weight record indicated the following weights: -140 pounds on June 19, 2018; -124 pounds on June 29, 2018; and -120 pounds on July 1, 2018. Resident 32 had a 20 pound weight loss between June 19, 2018 through July 1, 2018 (14.28 % weight loss of Resident 32). There was no documented evidence a plan of care was developed and implemented for Resident 32's significant weight loss. On 07/10/18 02:42 p.m., Resident 14's record was reviewed with LVN 1. LVN 1 stated the facility should have completed a plan of care for Resident 14's weight loss. The facility policy titled, "Care Planning Process," dated November 20, 2017, was reviewed. The policy indicated: "...Care, treatment and services are planned to ensure that they are appropriate to the resident's needs. Therefore, it is the policy of (facility name) to provide an individualized, interdisciplinary plan of care for residents that is appropriate to the resident's needs, strengths, limitations and goal... Within three (3) days of completion of the comprehensive assessments, residents shall have a computerized plan of care generated by the registered nurse or the licensed practical/vocational nurse..."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 08/03/2018 §483.21(b) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 14 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the care plan for the Foley catheter (FC - a tube inserted into the bladder to empty the urine) care was updated for one of three sampled residents (Resident 6). This failure had the potential for Resident 6 to experience delay in treatment and to have complications such as urinary tract infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 15 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On July 9, 2018, at 11:17 a.m., Resident 6 was observed with a Foley catheter (FC). During a concurrent interview, Resident 6 stated he had been using FC due to multiple sclerosis (MS - a disease of the brain and spinal cord). Resident 6 stated his private caregiver disconnected the FC from the drainage bag and plugged the tubing with a plug prior to going to appointments. On July 11, 2018, at 4:25 p.m., a record review was conducted with Licensed Vocational Nurse (LVN) 3. Resident 6 was admitted to the facility on July 17, 2015, with diagnoses including multiple sclerosis, quadriplegia (paralysis of all four limbs), and neuromuscular dysfunction of the bladder (condition in which a person lacked control of urination). There was no documented evidence a care plan was completed for Resident 6's private caregiver to disconnect the FC tubing from the drainage bag and to plug the tubing. During a concurrent interview, LVN 3 stated Resident 6's care plan related to the indwelling FC was not updated. LVN 3 stated the care plan related to the indwelling FC of Resident 6 should have been updated. The facility policy titled, "Care Planning Process", dated November 20, 2017, was reviewed. The policy indicated: "...The care plan will be ...revised as needed to meet the needs of the resident's changing condition ..."

F684 SS=D Quality of Care CFR(s): 483.25

F684 08/03/2018 § 483.25 Quality of care Quality of care is a fundamental principle that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 16 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the blood pressure (BP) measurement was not taken on the left arm of a resident who had a history of left breast cancer with lumpectomy (surgical removal of breast tissue) and radiation therapy (use of x-ray for treatment), for one of one resident (Resident 235). This failure increased the potential for Resident 235 to experience medical complications such as swelling of the left arm. Findings: On July 11, 2018, at 9:15 a.m., an observation of a medication pass was conducted with Licensed Vocational Nurse (LVN) 2. Resident 235 was observed to be lying in bed and awake. LVN 2 was observed to take Resident 235's BP on her left arm. Resident 235 was observed to hold her right arm out while LVN 2 was taking her BP on her left arm. Resident 235 stated, "You're not supposed to do anything to that (left) arm." LVN 2 completed taking the BP, removed the stethoscope from her ears, and removed the blood pressure cuff from Resident 235's left arm. Resident 235 was observed to repeat stating, "You're not supposed to do anything to that arm." LVN 2 stated, "I forgot. I'm sorry." On July 11, 2018, at 4 p.m., an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 17 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with Resident 235. Resident 235 stated when she first came from the hospital to the facility, she had a wrist band on her left wrist which indicated not to take her BP or draw blood on her left arm. Resident 235 stated the facility staff "cut off" the wrist band. Resident 235 stated when she first came to the facility, she told the nurse not to do anything on her left arm because of her history of left breast cancer with lumpectomy and radiation therapy. Resident 235 stated when the nurse took her BP on her left arm this morning, she did not like it because the nurse was not supposed to. On July 11, 2018, at 4:10 p.m., a review of Resident 235's record was conducted. Resident 235 was admitted to the facility on June 27, 2018. Resident 235's baseline care plan summary indicated she had a history of left breast cancer. The "Pre-Operative History and Physical," dated June 20, 2018, indicated, "...Past History...She had a left breast lumpectomy and radiation..." On July 11, 2018, at 4:22 p.m., an interview was conducted with LVN 2. LVN 2 stated she should not have taken Resident 235's BP on her left arm. LVN 2 stated she forgot. On July 12, 2018, at 9:20 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have a policy indicating how to take the blood pressure for a resident with a history of breast cancer. On July 12, 2018, at 11:35 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 confirmed if a resident had a history of breast cancer, they were not supposed to take BP's or draw blood on the arm on the side with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 18 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the breast cancer history. According to the article titled, "Breastconserving Surgery (Lumpectomy)," from the American Cancer Society website, revised September 15, 2017, the "...Side effects of BCS (breast-conserving surgery or lumpectomy) may include...lymphedema, a type of swelling, in the arm..." According to the undated article titled, "Breast Cancer: Lymphedema After Treatment," from the John Hopkins Medicine website, "...Lymphedema can occur months or years after treatment...Radiation treatments to the under arm lymph nodes can cause scarring and blockages that further increase the risk of lymphedema...Preventing infection and injury...Protecting the arm on the side of the surgery is very important after breast surgery...Be aware of activities that put too much pressure on the affected arm (arm on the same side of the surgery)...Ask for all blood pressure tests to be done on the unaffected arm..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/03/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 19 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was assessed for smoking safety for one of three sampled residents (Resident 14). This failure increased the potential for Resident 14 to experience injury such as burn. Findings: On June 10, 2018, at 10:19 a.m., Resident 14 was observed smoking in the facility's patio. Resident was being supervised and assisted by a family member while smoking. In a concurrent interview with Resident 14, she stated she smoked two times a day, and if (family member) was not available to assist her when she wanted to smoke, her friends supervised her. Resident 14 further stated that sometimes when she asked the facility staff for smoking assistance the staff told her they were not available. On July 10, 2018, the record of Resident 14 was reviewed. Resident 14 was admitted to the facility on June 8, 2018, with diagnoses which included muscle weakness and hemiplegia (weakness affecting one side of body). There was no documented evidence a smoking assessment was completed for Resident 14. On July 11, 2018, at 8:38 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the admitting nurse should have completed Resident 14's smoking assessment upon admission. The Facility policy titled, "Resident Smoking Policy," dated July 10, 2018, was reviewed. The policy indicated: "...The facility will conduct a smoking assessment for those residents who choose to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 20 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE smoke. The assessment will be completed within 72 hours of initial admission to the facility..."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 08/03/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 21 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to administer sodium chloride (salt tablet medication) in a timely manner, when ordered by the physician for a critical low sodium serum level (sodium blood levels less than or equal to 125 milliequivalents per liter [mEq/L]), for one of one resident (Resident 85). This failure increased the potential for Resident 85 to experience medical complications related to a low sodium serum level such as fatigue, headache, irritability, muscle spasms or cramps, loss of appetite, confusion, and convulsions. Findings: On July 9, 2018, at 3:50 p.m., Resident 85 was observed in his room, lying in bed. In a concurrent interview, Resident 85 stated he needed the salt tablets the doctor ordered, but the pharmacy had not delivered them. On July 9, 2018, at 4:10 p.m., Licensed Vocational Nurse (LVN) 3 was observed to enter Resident 85's room. In a concurrent interview, LVN 3 stated the doctor ordered salt tablets for Resident 85 yesterday (July 8, 2018), but they have not received them yet from the pharmacy. LVN 3 stated she called the pharmacy this morning and they told her they did not deliver them. LVN 3 stated, "No one (from the pharmacy) notified us." On July 11, 2018, at 4 p.m., a review of Resident 85's record was conducted. Resident 85 was admitted to the facility on July 5, 2018, with diagnoses including urinary tract infection, pneumonia (lung infection), hypertensive heart disease (heart disease), and heart failure (heart disease). The "History and Physical," dated July 8, 2018, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 22 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated, "Significant Lab (laboratory result) low sodium." Resident 85's lab results, dated July 8, 2018, indicated his sodium level in the blood was at 122, with the reference range at 136 to 145 mEq/L. The lab report indicated the sodium level was a "Critical Result..." The physician's order, dated July 8, 2018, at 2:22 p.m., indicated, "Sodium Chloride Tablet 1 GM (gram) Give 1 tablet by mouth two times a day for critical low sodium **to be continued until sodium levels within range**" On July 12, 2018, at 10:13 a.m., an interview and concurrent record review were conducted with RN 1. RN 1 stated the pharmacy delivery slip indicated the sodium chloride tablets were delivered on July 9, 2018, at 7:30 p.m. (17 hours after the nurse received the physician's order). Resident 85's medication administration record (MAR) for sodium chloride on July 8, 2018, at 5 p.m., indicated "9." RN 1 stated the number "9" meant "other." RN 1 stated the nurse's progress note for that entry indicated the medication was not administered because it was not available. RN 1 stated if a physician ordered a new medication at 2 p.m., the resident would receive the evening dose that day. The MAR indicated Resident 85 received the first dose of sodium chloride tablet on July 10, 2018, at 9 a.m. (43 hours after it was ordered). On July 12, 2018, at 11:20 a.m., an interview was conducted with the Director of Pharmacy (DOP). The DOP stated when a new medication was ordered, it was sent out on the next delivery run. The DOP stated there were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 23 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE delivery runs every four hours. The DOP stated the pharmacy received the faxed order for sodium chloride tablets for Resident 85 on July 8, 2018, at 2:39 p.m.. The DOP stated the sodium chloride tablets should have been on the 5:30 p.m. delivery run. On July 12, 2018, at 11:45 a.m., an interview was conducted with Resident 85's physician, Medical Doctor (MD) 1. MD 1 confirmed when he ordered the sodium chloride tablets for Resident 85, he wanted him to receive a dose that night. MD 1 stated the facility told him the pharmacy did not deliver them. MD 1 stated he was "very concerned about this issue." MD 1 stated it was "a really important issue." MD 1 stated it was important for the sodium level to be managed correctly for Resident 85 who had a diagnosis of heart disease. According to the Stanford Health Care "Laboratory Critical/ Panic Value List," dated 2018, the critical value for sodium was less than 125 millimole per liter (unit of measurement equivalent to mEq/L). On July 12, 2018, the facility's policy and procedure titled, "IA1: PROVIDER PHARMACY REQUIREMENTS," dated October 2012, was reviewed. The policy indicated, "...new medication orders are received and available for administration as soon as possible on the next routine delivery..."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/03/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 24 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 25 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, for one of five unnecessary medication reviews, the facility failed to ensure the routine use of lorazepam 0.5 mg (milligram) twice a day (an anti-anxiety medication) was necessary to maintain the resident's psychological well-being (Resident 13). This failure had the potential to result in unwanted side effects related to the excessive dosing of the resident's medication. Findings: On July 12, 2018, at 1:19 p.m., Resident 13's record was reviewed. The resident had an order for lorazepam 0.5 mg one tablet by mouth every 12 hours as needed for anxiety manifested by (M/B) fidgeting, dated January 4, 2018. The January 2018 medication administration record (MAR) was reviewed. The MAR indicated the resident received the as needed lorazepam 24 out of 28 days (from January 4 through January 31, 2018). The resident received the medication once per day on all 24 days, between the hours of 5 p.m. and 9:31 p.m. The resident did not receive the medication twice daily in any of the 24 days. The record indicated a change in the lorazepam order to 0.5 mg one tablet by mouth every 12 hours (routine) for anxiety M/B crying on February 1, 2018. The order was later on clarified for fidgeting on February 19, 2018. Since February 1, 2018, the resident had been receiving lorazepam 0.5 mg twice daily (approximately over 5 months). On July 12, 2018, at 1:54 p.m., Resident 13 was interviewed. The resident knew she was taking lorazepam, but was not aware that the medication order was changed from as needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 26 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to routine basis. Upon further interview, Resident 13 stated she previously took the medication before going to bed because she gets "jittery and nervous" (once daily = 0.5 mg). The resident was not able to explain the reason the physician ordered to change the medication to twice daily since February 2018 (1 mg daily). On July 12, 2018, at 2:19 p.m., Resident 13's record was reviewed with the Social Service Designee (SSD) and Director of Nursing (DON). In a concurrent interview with the SSD, she stated the order for lorazepam was changed from "as needed" to "routine" because the resident asked for the medication on a routine basis. The January 2018 MAR was reviewed with both DON and SSD, where the MAR indicated the resident was requesting the medication once daily (0.5 mg per day). When the lorazepam order was changed to routine, the resident started receiving 1 mg daily, which was twice the amount the resident was receiving in January 2018. Both SSD and DON were not able to find documented evidence necessitating the resident to receive the increased in the daily of the lorazepam to 1 mg. The facility policy and procedure titled, "Psychotherapeutic Drug Policy (dated November 22, 2017)," was reviewed. The policy indicated: "...The staff shall monthly summarize the incidence of behavior episodes... ...The IDT (interdisciplinary team) will make recommendations for dose reductions or increases as clinically appropriate and in coordination with applicable regulations for dose reductions to the 'lowest effective dose'..."

F803 SS=D Menus Meet Resident Nds/Prep in Adv/Followed FORM CMS-2567(02-99) Previous Versions Obsolete

F803 Event ID: GUK811 08/03/2018 Facility ID: CA240000902 If continuation sheet 27 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.60(c)(1)-(7) §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: During observation, interview, and record review, the facility cook did not follow the recipe in preparing the pureed Orzo Pilaf (starchbased food item). This had the potential to result in insufficient caloric intake affecting residents on pureed diet (four residents). Findings: On July 11, 2018, at 10:40 a.m., Cook 1 was observed pureeing the Orzo Pilaf. In a concurrent interview, Cook 1 stated she was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 28 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE preparing five servings. The cook placed the following items in the blender: - Rice (cooked); five servings of # 8 scoop (a total of 2 1/2 cups); - One cup of milk (2% reduced fat); and - One tablespoon (Tbsp) of margarine. The cook blended the food items and placed the pureed food in the steamer. The recipe titled, "Pureed Potatoes, Rice and other Grains (undated)," was reviewed. The recipe indicated, for five servings, the ingredients were the following: - Rice cooked; 2 1/2 cups; - Milk (2%); 1 1/4 cups; - Margarine; 1 Tbsp; and - Thickener (powder when mixed would thicken the consistency of food/drink); 1/2 Tbsp. The recipe was reviewed with Cook 1. In a concurrent interview with Cook 1, she stated she used one cup of milk (instead of 1 1/4 cups) because the food item "gets runny". When asked the reason she did not add the thickener as indicated on the recipe, the cook stated it was not needed because the food item would get thick. Subsequently, the Food Service Director (FSD) was interviewed. The FSD stated the cook should have followed the recipe for the Orzo Pilaf. The residents' diet list, dated July 9, 2018, was reviewed. The list included four residents on pureed diet. The facility's "Week at a Glance" menu was reviewed. The lunch menu for July 11, 2018, included Orzo Pilaf. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 29 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility's policy titled, "Standardized Recipes (undated)," was reviewed. The policy indicated, "Policy: Standardized recipes will be used for all products prepared and will note appropriate seasonings in order to assure acceptance from the residents...Use standardized recipes provided with the menu cycle..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 08/03/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure drinks were stored to ensure safe consumption when the following items were found in the refrigerator: 1. Approximately twenty 8-ounce cups of preFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 30 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE poured milk were stored without label; and 2. A 16-ounce container pre-filled with orange juice with no lid cover and without any label. These failures had the potential to result in residents to receive milk and/or juice which were not be safe for consumption. Findings: On July 9, 2018, at 9:17 a.m., during the initial kitchen tour conducted with the Food Service Director (FSD), the following were found in the refrigerator: - A tray with approximately twenty 8-ounce cups of pre-poured milk were stored without label; and - A 16-ounce container pre-filled with orange juice with no lid cover and without any label. In a concurrent interview with the FSD, he stated the cups of milk (or the tray) and the orange juice should have a prepared date or used-by-date. In addition, the FSD stated the orange juice container should have a lid or plastic cover. The facility's policy titled, "Food Storage (dated August 9, 2017)," was reviewed. The policy indicated, "...Use 'use-by-dates' on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Chart..." The facility's storage chart indicated: "Recommended storage time at 35-41 (degrees Fahrenheit)... *Milk, Liquid Whole or Low fat - opened...1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 31 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE week... *Juices (bottled, reconstituted, frozen, canned) - opened...1 week..."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 08/03/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 32 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to address the handling of the Foley catheter (FC - a tube inserted into the bladder to drain urine) by the private caregiver for one of three sampled residents (Resident 6). This failure had the potential for Resident 6 to experience complications such as urinary tract FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 33 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infection. Findings: On July 9, 2018, at 11:17 a.m., Resident 6 was observed with a Foley catheter (FC). During a concurrent interview, Resident 6 stated he had been using FC due to multiple sclerosis (MS - a disease of the brain and spinal cord). Resident 6 stated that prior to going to appointments, his private caregiver disconnected the FC from the drainage bag and plugged the tubing with a plug. On July 11, 2018, at 4:13 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated she was aware Resident 6's FC tubing was being disconnected from the drainage bag and plugged by the resident's private caregiver when the resident went for appointments. On July 11, 2018, at 4:25 p.m., Resident 6's record was reviewed with LVN 3. Resident 6 was admitted to the facility on July 17, 2015, with diagnoses including multiple sclerosis, quadriplegia (paralysis of all four limbs), and neuromuscular dysfunction of the bladder (condition in which a person lacked control of urination). During a concurrent interview, LVN 3 stated there was no documentation the private caregiver was given education or instructions regarding the handling of the FC to prevent infection. On July 12, 2018, at 10:54 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the private caregiver for Resident 6 should have been given education in disconnecting the FC tubing from the drainage bag and plugging the FC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 34 of 35 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555463 (X3) DATE SURVEY COMPLETED 07/12/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE VILLAGE HEALTHCARE CENTER 2400 W Acacia Ave Hemet, CA 92545 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tubing. On July 12, 2018, at 1:20 p.m., the policy and procedure (P&P) for disconnecting the FC from the drainage bag was requested from the Director of Staff Development (DSD). During a concurrent interview, the DSD stated the facility did not have P&P specifically for disconnecting FC tubing from the drainage bag and plugging the FC tubing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GUK811 Facility ID: CA240000902 If continuation sheet 35 of 35