Health inspection·February 29, 2024

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 22, 2024, at 9:16 a.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, she stated the facility's practice for laboratory orders are to first obtain an order for laboratory draw. She stated the facility puts the orders into the contracted laboratory services portal. She stated the laboratory contractor would come into the facility every Monday through Friday to draw the lab samples. She stated the laboratory results were to be faxed to the facility or the facility can access the results via the laboratory contractor's portal. She stated the facility would communicate the laboratory values to the physician and resident representtive regardless of whether the results are normal or abnormal. She stated a progress note was to be created for the notifications to the physician and resident representative. She stated Resident 1 had a physician order for a laboratory draw on January 15, 2024. She stated the resident's labs were collected and resulted on January 18, 2024. She confirmed the resident had no results for January 15, 2024. She stated the facility would send the most recent lab results with resident's doctor appointments. A review of Resident 1's progress notes indicated there was no documented evidence the physician was notified of the laboratory orders scheduled on January 15, 2024 was not completed as ordered. On February 29, 2024, at 11:35 a.m., during an interview with the DON, she stated Resident 1's laboratory draw was ordered for January 15, 2024, but was not completed on January 15, 2024. She stated the facility was made aware Resident 1's laboratory tests were not done on January 15, 2024, after the physician's office notified the facility during his appointment on January 17, 2024. She stated the facility's practice for ensuring laboratory tests were to print out the list of laboratory tests from the laboratory contractor's portal daily. She stated it will indicate on the portal if the test was not done. She stated the portal was checked prior to the appointment and Resident 1 was not on the list. She stated sometimes the laboratory contractor will discontinue an order without notifying the facility. She could not state why the licensed nurses did not relay to the physician the laboratory tests were not done. She stated the lab was closed for the January 15, 2024 (holiday) and should have informed the facility that the laboratory test could be done the following day. She stated the ordered laboratory test for Resident 1 should have been done the following working day. She stated there was some missed communication between the facility's laboratory contractor and the facility. A review of the facility's policy and procedure titled, Lab order and Diagnostic Test Results, revised November 2022, indicated, .The staff will process test requisitions and arrange for test . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 2 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: Residents Affected - Some 1. The facility failed to notify the California Department of Public Health (CDPH) of an outbreak of COVID-19 (a contagious respiratory infection) and respiratory synctial virus infection (RSV - a contagious respiratory infection) according to the facility's policy and procedure and CDPH guidelines; 2. The facility staff failed to wear the appropriate personal protective equipment (PPE - equipment used to prevent or minimize exposure to infections) while providing care to a COVID-19 positive resident, in accordance with the facility's policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines; and 3. A licensed nurse reported to work without testing for COVID-19 after exposure to COVID-19 positive residents. The licensed nurse developed COVID-19 symptoms and was tested positive for COVID-19. In addition, the facility did not conduct active screening for COVID-19 symptoms among facility staff. These failures had a potential for the transmission of COVID-19 and RSV among residents and facility staff. Findings: 1. On January 30, 2024, at 10:35 a.m., during an interview with the Administrator (ADM), she stated the facility had COVID-19 residents in a designated area of the facility. On January 30, 2024, at 10:40 a.m., during a tour of the facility, multiple rooms were observed with droplet precautions signs posted outside rooms. A review of the facility's census, dated January 29, 2024, indicated location of covid positive residents and the last day of transmission-based precautions for the residents. The census indicated 8 residents total noted to be COVID-19 positive during the initial tour. A review of the facility's document titled, [Facility] Infection Control Surveillance indicated the following: - The facility's first positive case of COVID-19 was identified on January 19, 2024, with subsequent cases identified on January 20, 23 & 24, 2024. (a total of 8 cases); and - The facility's first positive case of RSV was identified on January 23, 2024, and subsequent cases were identified on January 26 (72 hour later) & 28, 2024 (a total of 4 cases). On January 30, 2024, at 1:55 p.m., during an interview with the Infection Preventionist (IP), she stated the facility's COVID outbreak occurred on January 19, 2024, when a symptomatic resident tested positive for COVID. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 3 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On February 1, 2024, at 3:30 p.m., during an interview with the IP, she confirmed the facility had RSV positive residents. She stated the first cases of RSV was on January 23, 2024. She stated the RSV outbreak was reported to CDPH on February 1, 2024 (nine days after the first case of RSV). On February 6, 2024, at 11:50 a.m., during a concurrent interview and record review with the IP, she stated she refers to the state's All Facilities Letter to determine what diseases were reportable to authorities. She could not state what was the facility's policy regarding reporting. She stated the facility's first COVID-19 positive resident was identified on January 19, 2024. She stated the case was reported to CDPH on January 22, 2024. She stated she should report outbreaks within 24 hours or the following business day. On February 7, 2024, at 4:30 p.m., during an interview with the Director of Nursing (DON), She stated the facility would report COVID outbreak to the different agencies within 24 hours from the time an outbreak was determined. The DON stated the facility's first case of COVID-19 occurred on January 19, 2024 and the outbreak was reported to CDPH on January 22, 2024. She stated the facility did not report timely the COVID outbreak. The DON stated the facility would report RSV outbreak when there was three confirmed cases of RSV. Reviewed the facility's line list with the DON indicating the facility's first case of RSV was identified on January 23, 2024, and a second case was identified by line list on January 26, 2024. Confirmed with the DON the RSV cases were reported to the department on February 1, 2024. The DON stated the facility's reporting was not in-line with reporting guidelines. A review of the document titled, Recommendations for Prevention and Control of COVID-19, Influenza, and other Respiratory Viral Infections in California Skilled Nursing Facilities-2023-24, dated December 2023, indicated an outbreak for Other non-influenza, non-COVID-19 respiratory viruses is at least one case of a laboratory-confirmed respiratory pathogen, other than influenza or COVID-19 .As soon as the criteria for an outbreak are met .report to [the department] district office . A review of the facility's policy and procedure titled, Unusual Occurrence Reporting, revised December 2022, indicated, .Our facility will report the following events to appropriate agencies .An outbreak of any communicable disease .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations . 2. On January 30, 2024, during a review of the facility's census, dated January 29, 2024, indicated eight (8) residents were positive for COVID-19. On January 30, 2024, at 10:49 a.m., rooms [ROOM NUMBER] were observed to have signs outside the rooms which indicated droplet precaution. The sign indicated for the staff to perform hand hygiene, use a gown, wear N95 (a facepiece respirator that filters 95% of airborne particles), gloves, and eye protection. Isolation carts were observed outside of each room fully stocked with masks, face shields, & gowns. On January 30, 2024, at 10:52 a.m., during a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 was observed in room [ROOM NUMBER] wearing an isolation gown and N95 mask without a face shield provided care to the resident. In a concurrent interview with CNA 1, she stated she was not wearing the required PPE when she provided care to the COVID 19 positive resident. She stated she should be wearing a face shield when she provided care to COVID-19 positive resident. On January 30, 2024, at 1:55 p.m., during an interview with the Infection Preventionist (IP), she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 4 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the staff should wear an N95 mask, face shield, gown, and gloves when providing care to COVID-19 residents. She stated the staff working in the COVI-19 positive resident's rooms should wear face shields as part of the required PPE. She stated a staff without a face shield was not compliant with the facility's policy and procedure. On February 7, 2024, at 4:30 p.m., during an interview with the Director of Nursing (DON), she stated the PPE required to be worn in a COVID positive room were N95 masks, gowns, face shields, and gloves. She stated the CNA did not use the required PPE in accordance with the facility's policy and procedure during provision of care of COVID-19 positive residents. A review of the facility's policy and procedure titled, Isolation - Categories of Transmission - Based Precautions, revised September 2023 indicated, .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart .The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precaution(s), instructions for PPE, and/or instructions to see a nurse before entering the room .Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions . According to the web article published by CDC titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID - 19) Pandemic, updated May 8, 2023, indicated, .Personal Protective Equipment .HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. goggles or a face shield that covers the front and sides of the face . 3. On January 30, 2024, at 11:01 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated there is no screening for employees reporting to work and the facility does not routinely check the staff's temperature. She stated she has not been at work sick nor became sick at work. She stated if she felt ill, she would call off. On January 30, 2024, at 1:55 p.m., during an interview with the Infection Preventionist (IP), she stated the facility's COVID outbreak occurred on January 19, 2024. She stated a symptomatic resident tested positive for COVID. She stated on January 20, 2024, an employee tested positive. She stated she tested all exposed staff and residents. She stated if an employee was symptomatic with COVID, the staff come to the facility to conduct a COVID test. She stated employees check their temperatures when they arrive to work if exposed or symptomatic. She stated there was not routine screening for employees. She stated if the employee feels ill, the employee will be screened. On January 30, 2024, at 4:40 p.m., during an interview with the IP, she stated the employee who tested positive on January 20, 2024, reported to work and was notified the previous evening of exposure to a COVID positive resident. She stated the employee was supposed to test for COVID prior to starting her shift. She stated the employee developed symptoms into her shift complaining of a sore throat. She stated the employee tested positive on January 20, 2024, at around 1:30 p.m. (seven hours into the shift). She stated the employee was counseled about not testing immediately after exposure. She stated the facility's practice for employees to test on days 1, 3, & 5. She stated staff are not to report to work if ill. On February 7, 2024, at 4:30 p.m., during an interview with the Director of Nursing (DON), she stated the facility's practice was to encourage the employees to stay home if they were sick. She stated she would send the employee home if an employee reported to work ill. She stated the employee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 5 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 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 should not have come to work sick. Level of Harm - Minimal harm or potential for actual harm A review of the Licensed Nurse's (LVN) 1 COVID test result, dated January 20, 2024, at 1:30 p.m., indicated the employee tested positive for COVID-19. Residents Affected - Some A review of an employee screening form indicated the facility began conducting active screening for employees on January 31, 2024 (11 days after the onset of the facility's COVID outbreak). A review of the document titled, Recommendations for Prevention and Control of COVID-19, Influenza, and other Respiratory Viral Infections in California Skilled Nursing Facilities-2023-24, dated December 2023, indicated, .During periods of increased community transmission of respiratory viruses and in the event of an outbreak, institute active symptom screening for HCP (healthcare personnel) upon reporting to work . A review of the facility's policy and procedure titled, Sick leave policy, revised October 2022, indicated, .Employee who are tested positive for COVID will not allow to work until at least 10 days have passed since symptoms first appeared and symptoms have been resolved without retesting, minimal 5 days have passed with negative testing and employee is asymptomatic . According to the web article published by CDC titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID - 19) Pandemic, updated May 8, 2023, indicated, .Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) .Testing is recommended immediately (but not later than 24 hours after exposure) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 6 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents and resident representatives were notified timely of an outbreak of COVID-19 in the facility in accordance with the facility's policy and procedure. Residents Affected - Few This failure resulted in residents and their representatives not informed of the resident's status and placed the residents and representatives at risk for contracting the communicable diseases. Findings: On January 30, 2024, a review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (the heart not able to pump blood efficiently), hypertension, chronic renal disease, and diabetes mellitus (abnormal blood). The record further indicated the resident ' s family member as the resident ' s representative/emergency contact. On January 30, 2024, at 1:55 p.m., during an interview with the Infection Preventionist (IP), she stated the facility had one symptomatic resident tested positive for COVID-19 on January 19, 2024. She further stated an employee of the facility tested positive for COVID-19 on January 20, 2024. A review of the facility's Infection Control Surveillance form for January 2024 indicated Resident 1 tested positive for COVID-19 on January 19, 2024. On February 1, 2024, at 2:47 p.m., during a concurrent interview and record review with the Social Services (SS), she stated the facility notifies resident and resident representatives via telephone. The SS presented a facility census with the date of January 24, 2024 (5 days after the first case was identified) written on it with check marks or notes written next to resident ' s names. She stated she notified the residents and representatives on the list on the date indicated on the census. On February 1, 2024, at 4:03 p.m., during an interview with the Director of Nursing (DON), she stated COVID-19 cases are reported right away, same day if possible. On February 6, 2024, at 10:41 a.m., during an interview with Resident 1's representative, she stated she was not notified about the facility's COVID outbreak. She stated she did not receive a voicemail from the facility. She stated visited her father in the facility and the resident informed her there was no activities being held anymore and residents were to stay in their rooms. She stated her father could not state why the activities were not being held but was told to wear a mask. She confirmed she had received several notifications from the facility previously regarding her father's health status. She stated she called the facility to confirm the COVID-19 outbreak. On February 6, 2024, at 4:30 p.m., during an interview with the DON, she stated resident ' s representative was to be notified as soon as possible within 24 hours when the facility have COVID outbreak. The DON provided a document with a list of notifications to resident ' s representative dated January 21, 2024. The DON stated the notifications to the resident ' s representative regarding COVID outbreak were not done within 24 hours of identification of the outbreak. A review of the facility's COVID-19 Facility Mitigation Management Plan revised October 2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 7 of 8 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 555353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Health Care Center 8965 Magnolia Avenue Riverside, CA 92503 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 0885 indicated, Facility designates social service staff to communicate with residents and family members in 24 hours about COVID outbreak in facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555353 If continuation sheet Page 8 of 8