Inspection·March 27, 2024

F 0684 February 13 at 9 p.m., February 20 at 9 a.m., and February 27 at 9 a.m. (five doses) Level of Harm - Minimal harm or potential for actual harm A review of Resident 4's Physician orders, dated February 7, 2024, indicated, Cefepime HCL (medication to treat infection) solution reconstituted 2 GM (grams). Use 2 gram intravenously every 12 hours for diabetic foot ulcer wound Residents Affected - Some infection until 3/19/2024 (March 19, 2024). A review of Resident 4's medical record titled, Electronic Medication Administration Record (EMAR), for the month of February 2024, indicated multiple blanks (no entries) for Cefepime HCL on February 10 at 9 a.m., February 11 at 9 a.m., and February 13 at 9 p.m. (three doses). On March 7, 2024, at 3:44 p.m., during an interview with Resident 4 stated, he was receiving IV medications and had missed some doses. 1b. On March 7, 2024, a review of Resident 5's admission record indicated Resident 5 was admitted to the facility on [DATE], and discharged on March 3, 2024. Resident 5's diagnoses included wound to right hip, hypertension ((force of blood against the artery wall is too high), hyperlipidemia (imbalance of cholesterol), Type 2 diabetes (condition in which body has trouble controlling blood sugar) and chronic kidney disease (long standing disease of the kidneys). A review of Resident 5's Physician orders dated February 5, 2024, indicated, Ceftriaxone sodium (medication to treat infection) injection solution 1 gm (gram) use 1 gram intravenously one time a day for VRE (Vancomycin-resistant Enterococcus - an infection resistant to vancomycin) surgical site until 3/19/2024 (March 19, 2024). A review of Resident 5's medical record titled, Electronic Medication Administration Record (EMAR), for the month of February 2024, indicated multiple blanks (no entires) for Ceftriaxone HCL on February 8 at 9 a.m., February 10 at 9 a.m., and February 11 at 9 a.m. (three doses). A review of Resident 5's Physician orders, dated March 5, 2024, indicated, Vancomycin HCL Intravenous solution use 1000 mg (milligram) one time a day for VRE surgical site until 3/1/2024 (March 1, 2024). A review of Resident 5's medical record titled, Electronic Medication Administration Record (EMAR), for the month of February 2024, indicated no entry for Vancomycin HCL on February 20 at 9 a.m. (one dose). On March 14, 2024, at 4:19 p.m., during a concurrent interview and record review of Residents 4 and 5's record with Registered Nurse (RN) 1, she stated a blank on the EMAR means the medication was not given or it was not documented. RN 1 stated the reason for not administering the medication should be documented in the progress notes. On March 18. 2024, at 11:13 a.m., during a concurrent interview and record review of Residents 4 and 5's record with RN 2, she stated it was the RNs responsibility to document after an IV medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 2 of 5 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 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was administered or document the reason for not administering the medication. She confirmed the blank entries for the IV medications in the EMAR of Residents 4 and 5. On March 14, 2024, at 10:56 a.m., during an interview with RN 3, she stated there was a general EMAR where all medications were documented and licensed vocational nurse (LVN) left it blank under IV medications as they are not supposed to administer IV medications. They had another medication administration record just for IV medications which created confusion in documentation. A review of the facility policy and procedure titled, Administering Medications, revised April 2019, indicated .medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber orders, including any required time frame .factors that are considered include: enhancing optimal therapeutic effect of the medication .if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate in EMAR or initial and circle the MAR space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . 2a. On March 7, 2024, a review of Resident 2's admission record, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included multiple sclerosis (disease in which the immune system eats away at the protective covering of the nerves), hyperlipidemia (imbalance of cholesterol), scoliosis (a sideways curvature of the spine) and depressive disorder (depressed mood or loss of pleasure or interest in activities for long periods of time). A review of Resident 2's Physician Orders, dated March 3, 2024, indicated, L (left) gluteal (buttock) ulcer secondary to fungal rash-clean w/NS (with normal saline), pat dry and apply collagen then cover with dressing everyday shift. A review of Resident 2's medical record titled, Treatment Administration Record(TAR), dated March 5, 2024, indicated no dressing change was done to the left gluteal as ordered by the physician. On March 7, 2024, at 11:10 a.m., during an interview with Resident 2, he stated he missed wound treatment once this month. 2b. A review of Resident 4's admission record, indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included osteomyelitis (inflammation of bone caused by infection, generally in legs, arm or spine) of right ankle and foot, Type 2 diabetes (condition in which body has trouble controlling blood sugar), hyperlipidemia (imbalance of cholesterol) and hypertension (force of blood against the artery wall is too high). A review of Resident 4's Physician orders, dated February 17, 2024, indicated, Cleanse right foot plantar (relating to the sole of the foot) with normal saline pat dry applied Medi honey (used to clean and debride acute and chronic wounds) and calcium alginate (dressing used on moderate to heavy draining wounds) cover with dry dressing .everyday day shift. A review of Resident 4's medical record titled, Treatment Administration Record (TAR), dated March 1, 2024, indicated no dressing change was done to the right foot plantar as ordered by the physician. On March 7, 2024, at 3:44 p.m., during an interview with Resident 4 stated, he stated had missed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 3 of 5 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 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 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 0684 wound treatment this month. Level of Harm - Minimal harm or potential for actual harm On March 7, 2024, at 10:53 a.m., during an interview with LVN 1, she stated the wound treatment was done by the charge nurses if there was no treatment nurse available and would document in the TAR. LVN 1 stated if wound treatment was not provided as ordered, they could miss change in wound status, would delay wound healing and cause discomfort to the resident. Residents Affected - Some On March 7, 2024, at 12:16 p.m., during an interview with LVN 2, she stated when there was no designated treatment nurse, the charge nurse was responsible to do dressing change. LVN 2 stated dressing change was important for wound healing and to prevent further infection. A review of the facility policy and procedure titled, Wound Care revised October 2010 indicated, .purpose of this procedure is to provide guidelines for the care of wounds to promote healing .documentation .type pf wound care given, the date and time the wound care was given .the name and title of the individual performing the wound care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 4 of 5 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 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 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 interview and record review, the facility failed to do a dressing change on a peripherally inserted central catheter (PICC-is a thin flexible tube that is inserted into a vein in the upper arm and used to give intravenous fluids and other drugs) as ordered by the physician, for one of six sample residents (Resident 4). Residents Affected - Few This failure increased the potential for Resident 4 to acquire an infection to the area where the catheter was placed which can spread to the resident's blood and other parts of the body. Findings: On March 7, 2024, at 10:04 a.m., an unannounced visit was conducted at the facility to investigate a complaint for quality-of-care issue. On March 7, 2024, a review of Resident 4's admission record, indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included osteomyelitis (inflammation of bone caused by infection, generally in legs, arm or spine) of right ankle and foot, Type 2 diabetes (condition in which body has trouble controlling blood sugar), hyperlipidemia (imbalance of cholesterol) and hypertension (force of blood against the artery wall is too high). A review of Resident 4's Physician orders, dated February 28, 2024, indicated an order for Registered Nurse (RN) to change the PICC line dressing weekly every night shift on Wednesday. A review of Resident 4's medical record titled, Medication Administration Record (MAR), for PICC line dressing change dated February 22 and 29, 2024, noted no dressing change was done according to the physician order. On March 14, 2024, at 4:19 p.m., during a concurrent interview and record review with RN 1, she confirmed PICC line dressing change was not done. RN 1 stated if the dressing change was not done per order there could be signs of infection that could be missed, or the dressing could be soiled leading to an infection. On March 15, 2024, at 11:13 a.m., during an interview with RN 2, she stated a PICC line dressing change should be done as ordered by the RN and documented in the MAR. RN 2 stated if the dressing change was not done the resident could have an infection. A review of the facility policy and procedure titled, Central Venous Catheter Dressing Changes, revised April 2016, indicated, .the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .documentation .should be recorded in the resident's medical record, date and time dressing was changed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 5 of 5