Inspection·May 23, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 15's admission Record, indicated Resident 15 was readmitted to the facility on [DATE], with a diagnosis of major depressive disorder (mood disorder). During a review of Resident 15's Minimum Data Set, dated May 16, 2023, indicated a BIMs score of 12 (moderately impaired cognitively). Residents Affected - Some A review of Resident 15's physician orders indicated the following: - Sertraline Oral Tablet 100 mg Give 1 tablet by mouth one time a day for mood disorder ( a major health condition taht primarily affects your emotional dstatus) m/b self isolation (the act of separating oneself from others), dated May 16, 2023. During a review of Resident 15's document titled Informed Consent, the documentation did not include the frequency of the medication and the date Resident 15 signed the informed consent form. 3. During a review of Resident 17's admission Record, indicated Resident 17 was admitted to the facility on [DATE], with a diagnosis of depression. During a review of Resident 17's Minimuim Data Set, dated April 24, 2024, indicated a BIMs score of 14 (cognitively intatct). A review of Resident 17's physician orders indicated the following: - Sertraline HCL (medication to treat depression) Tablet 50 MG Give 1 tablet by mouth one time a day for Depression NOS (not otherwise specified) m/b verbalization of sadness. During a review of Resident 17's Informed Consent, did not indicate the dose and frequency for sertaline. The document did not indicate the physician's signature to indicate the physician obtained the informed consent from the resident with the use of sertraline. 4. During a review of Resident 19's admission Record, dated May 22, 2024, indicated Resident 19 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder (a mental heatlh disorder characterized by feelings of worry or fear that interferes with ones daily activities). During a review of Resident 19's Minimum Data Set, dated May 22, 2024, indicated a BIMs score of 15 (cognitively intact). A review of Resident 19's physician orders indicated the following: - Escitalopram Oxalate (medication to treat depression) Oral Tablet 10 mg, Give 1 tablet by mouth one time a day for Depression m/b verbalizations of sadness, dated February 12, 2024. - Zoloft Oral (medication to treat depression) Tablet 50 mg .Give 50mg by mouth one time a day for Depression m/b verbalization of sadness. - Xanax (medication to treat anxiety)Oral Tablet 0.5 mg (Alprazolam), Give 0.5 mg by mouth every 8 hours as needed for anxiety m/b verbalization of feeling anxious. During a review of Resident 19's medical record, there was no documented evidence an informed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 2 of 38 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 05/23/2024 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 0552 consent was obtained from Resident 19 for the use of escitalopram, Zoloft, and Xanax (new dose). Level of Harm - Minimal harm or potential for actual harm During an interview on May 22, 2024, at 3:19 p.m., with the Director of Nursing (DON). The DON stated the Resident should be aware of the psychotropic medicatons being administered and the Resident should be infomred of the use of psychotropic medications. Residents Affected - Some During an interview on May 22, 2024, at 3:40 p.m., with the DON, she stated the informed consent form for Residents 15. 17, and 19 were incomplete for the use of psychotropic medications. The DON stated the informed consent form should have been completed so the residents would know what medications they are consenting to. During an interview on May 23, 2024, at 10:20 a.m., an interview and concurrent record review was conducred with the Director of Staff Development (DSD). The DSD stated the informed consent form for the use of venlafaxine for Resident 12 was incomplete and there was no documented ICF obtained from Resident 12 for the use of bupropion. The facility policy and procedure titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised 2021, indicated, .Policy .Residents/representatives are inforomed (in advance) of .the care that will be furnished .the risks and benefits of the proposed care, treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 3 of 38 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 05/23/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for the use of apixaban (medication that helps prevent blood clots), for two of five residents (Residents 8 and 12). This failure had the potential to result in the delay in treatment and care for Residents 8 and 12. Findings: On May 22, 2024, Resident 8's record was reviewed. Resident 8 was admitted on [DATE], with diagnosis which included atrial fibrillation (a condition which causes the heart to beat faster than normal). A review of the Resident 8's Order Summary, dated April 29, 2024, indicated, .Eliquis (another name for apixaban) Oral Tablet 5 mg (milligram- unit of measurement) Give 5 mg by mouth two times a day for AFIB (atrial fibrillation). On May 22, 2024, Resident 12's record was reviewed. Resident 12 was admitted on [DATE], with diagnosis which included acute embolism (a sudden blocking of an artery) and thrombosis (a formation of blood clot). A review of Resident 12's Order Summary, dated April 29, 2024, indicated, .Apixaban Oral Tablet 2.5 mg .Give 1 tablet by mouth two times a day for DVT (deep vein thrombosis [type of blood clot that forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (action taken to prevent disease]). In further review of Resident 8 and 12's record, there was no documented evidence a care plan was developed to address Resident 8 and 12's risk for bleeding regarding the use of apixaban medication. On May 22,2024, at 3:33 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated when a resident was admitted with an order of a medication to prevent blood clot, there should be a care plan to monitor resident for bleeding. The DON was not able to provide documentation a care plan was developed to monitor Resident 8 and 12 for bleeding when residents were on apixaban. The DON further stated the physician's orders should have a care plan so the staff would know what is the plan of care related to use of certain medications. The facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 4 of 38 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 05/23/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for two of three sampled residents (Resident 17 and 28), when: Residents Affected - Few 1.The facility's Registered Dietitian (RD) failed to: a. Follow the facility's policy titled, Nutritional Assessment, to assess Resident 17's nutritional status; and monitor the effectiveness of nutritional interventions for Resident 17; and b. Follow the facility's policy titled, Weight Assessment and Intervention, to identify an unplanned severe weight loss in a timely manner for Resident 17. These failures resulted in Resident 17 to experience a severe weight loss of seven (7) pounds (lbs - unit of measurement) (6.3%) in three (3) weeks, and 10 pounds (8.8%) in 1 month which placed the resident at risk for further decline in health. 2. The facility's Registered Dietitian failed to follow the facility's policy titled, Nutrition Assessment, to assess Resident 28's nutritional status. This failure resulted in Resident 28 to experience a severe weight loss of nine (9) pounds (4.5%) in (one) 1 week and 17 pounds (8.5%), a severe weight loss, within 3 weeks which placed the resident at risk for further decline in health. Findings: According to a review of the web article titled American Academy of Family Physicians, published on February 15, 2002, .Involuntary weight loss can lead to muscle wasting (thinning or loss of muscle tissue) .depression (mood disorder) and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity (having a disease or a symptom of disease) and mortality (death). One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 (five) percent of their body weight in one month were found to be four times more likely to die within one year . According to a review of the web article titled Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), published October 2010, .Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . 1. On May 20, 2022, at 4:02 p.m., an interview was conducted with Resident 17. Resident 17 stated the food was always salty and she had not been eating. Resident 17 stated she had lost weight since she was admitted to the facility a month ago. During a review of the Resident 17's admission Record, indicated Resident 17 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 5 of 38 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 05/23/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few facility on [DATE], for rehabilitation with a diagnosis of status post open reduction and internal fixation (ORIF- puts pieces of a broken bone into place using surgery) left and right patella fracture (a break of the knee cap). During a review of Resident 17's Minimum Data Set (MDS - a standardized assessment tool), dated April 30, 2024, the MDS indicated Resident 17 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively (thought process) intact. The MDS indicated Resident 17 actively participated in the assessment process and goal setting. During a review of Resident 17's weights, the following indicated: - April 24, 2024; 112 lbs; - April 30, 2024; 108 lbs (4 lbs weight loss; 3.57% weight loss in a week from April 24, 2024); - May 9, 2024; 107 lbs (1 lb weight loss in a week from April 30, 2024; 5 lbs weight loss [4.46% weight loss in 2 weeks from April 24, 2024]); - May 14, 2024; 105 lbs (2 lbs weight loss in a week from May 9, 2024; 7 lbs weight loss [6.25% weight loss in 3 weeks from April 24, 2024]); and - May 21, 2024; 102 lbs (3 lbs weight loss in a week from May 14, 2024; 10 lbs [8.93% weight loss in a month from April 24, 2024]). During a review of Resident 17's physician's orders, dated May 22, 2024, it indicated the following dieet orders: - Diet: No added salt (no salt package with meals), order dated April 23, 2024; and - Snack of resident's choice two times a day (BID) for supplement, order dated May 4, 2024. During a review of Resident 17's snack intake for the past 30 days (April 24, 2024 to May 22, 2024), there was no documented amount of intake for the snacks at 10 a.m. and 2:00 p.m. During a review of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, completed by the Registered Dietitian (RD), indicated, .admission weight (wt.) 112# (lbs), Current wt. 108#, Diet order: NAS (no added salt - no salt packet in the meal tray) .intake 51 -100% .Snacks between meal two times per day, Skin: integrity: skin tear, no edema (swelling) .Comments: left hand 4th finger skin tear, scabs to right hand .and 4th finger, right hand middle finger, scabs to left thumb and middle finger .Assessment: Resident new admit, s/p (status post) ORIF patella (knee bone) .Current diet ordered meets estimate needs, intake fair to good. -4# (4 lbs weight loss) since admission; note on Lasix (diuretic - medication to treat fluid retention), likes to snack. Snacks added BID (twice a day) .weight monitored weekly x (times) 4 (four) weeks .Will continue to monitor and consult IDT (Interdisciplinary team - a group of health care professionals all working toward a common goal), as needed. Goal: Maintain stable weight with no significant changes, maintain intake average >/ (more than or equal to) 75 % . During a review of Resident 17's IDT weight variance progress note, dated May 3, 2024, completed by the RD, indicated, .Resident reviewed with IDT with current wt. 108#, -4 # (4 lbs weight loss) this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 6 of 38 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 05/23/2024 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 0692 Level of Harm - Actual harm week .Current diet: NAS (no added salt - no salt packet in meal tray), intake: 26 -100 %. Meds: on Lasix 20 mg (milligram - unit of measurement). Contributing Factors: Resident admitted with some edema (swelling), which is resolving. Resident likes to snack. RECOMMENDATIONS: Provide snacks BID (twice a day) between meals. Continue weekly weights . Residents Affected - Few On May 22, 2024, at 9:19 a.m., a follow up interview was conducted with Resident 17 at Resident 17's bedside. Resident 17 stated she had poor appetite due to a dislike of the provided foods as she did not like the herb, spices, and the food was too salty. Resident 17 stated she reported her food dislikes to the facility staff. Resident 17 stated sometimes she did not touch any of her meals. Resident 17 stated nobody from the facility visited her and discussed her usual weight, poor appetite, unplanned weight loss, goal weight, nutritional interventions (i.e. snacks between meals two times per day) for her weight loss or plan of nutrition care. Resident 17 stated she was unaware of the physician's order for snacks between meals BID. Resident 17 stated sometimes she received snacks, sometimes she did not. She stated she ate the snacks and sometimes she disliked them. Resident 17 stated I do not know how I am going to obtain my goal weight of 125 lbs. On May 22, 2024, at 10:13 a.m., a concurrent interview and medical record review with the Registered Dietitian of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, IDT Weight Variance Progress Note, dated May 3, 2024, and Resident 17's weight history review was conducted. The RD stated residents who triggered at IDT weight variance were those residents who experienced weight loss of 3 lbs for 1 week, 5% for 1 month, 7.5% for 3 months and 10 % for 6 months. The RD stated she focused on Resident 17's weekly weights which did not trigger for weight loss. The RD stated Resident 17 triggered for severe weight loss from admission weight on April 24, 2024. The RD admitted she should have an IDT weight assessment after May 14, 2024, when Resident 17 had a weight loss of 6.25% in 3 weeks. On May 22, 2024, at 10:25 a.m., a follow-up interview and concurrent medical record review for Resident 17 with the RD was conducted. The RD stated she could not locate documentation of a discussion with Resident 17 regarding her usual body weight (UBW), a description reviewing Resident 17's meal intake and appetite, discussion of weight loss interventions by providing snacks two times per day. The RD stated she placed a general goal of Maintain stable weight with no significant changes, without asking Resident 17's weight goal. The RD stated she was unaware of what kind of snacks Resident 17 received, and she stated she did not observe Resident 17's meal or snack intake. The RD stated she relied on nursing staff to gather meal intake information. The RD stated she was unable to locate the documentation of snacks intake in Resident 17's medical record. The RD admitted she was unable to determine whether the snacks given to Resident 17 was effective without monitoring the snacks intake. The RD admitted it was important to get Resident 17's UBW as a baseline and asked what was Resident 17's weight goal so she could have personalized the nutrition care plans to assist Resident 17 toward her weight goal. On May 23, 2024, at 8:24 a.m., a concurrent observation of meal intake and interview was conducted with Resident 17 at bedside. Resident 17 stated she received 2 sausage links, 2 pieces of waffle, half banana and 8 ounce (oz- a unit of measurement) 2% milk. Resident 17 only consumed 1 piece waffle (10 %) and 8 oz 2% milk (15 %) with total 25 % food intake which indicated poor oral intake. On May 23, 2024, at 10:00 a.m., a concurrent interview and record review with the Director of Nurses (DON) was conducted. The DON stated per the facility's policy on Weight Assessment and Intervention, Resident 17 was triggered for a severe weight loss. The DON stated the RD should have completed a weight loss assessment, evaluation, and intervention for Resident 17 after May 14, 2024, for severe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 7 of 38 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 05/23/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few weight loss. The DON could not locate any additional documentation to reflect the severe weight loss on May 14, 2024. The DON stated the RD did not follow the Weight Assessment and Intervention policy to monitor the weight loss. On May 23, 2024, at 11:36 a.m., a concurrent interview and record review of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, and IDT weight variance, on May 3, 2024, and Nutrition Assessment policy was conducted with the Director of Nursing (DON). The DON stated the RD only interpreted the information from Resident 17's electronic medical record instead of visiting Resident 17 to collect nutritional information. The DON stated she could not find Resident 17's UBW, weight goal, food preference for nutritional intervention. The DON reviewed Resident 17's meal intake was 26 -100 % in the IDT weight variance progress notes and stated the broad amount intake range did not reflect the real appetite (the amount of Resident 17's meal intake) of Resident 17 which could not reflect whether Resident 17 consumed sufficient nutrition she needed. The DON stated Resident 17's weight loss may be due to not liking the food and not eating enough. The DON stated Resident 17's weight loss could have been preventable if the RD visited Resident 17, obtained the resident's UBW, Resident 17's appetite, and interventions of the food Resident 17 wanted to eat, and monitored the effectiveness of the snacks as a nutritional intervention. On May 23, 2024, at 5:57 p.m., an observation was conducted with Resident 17's finished meal tray. Resident 17 received Shepherd's pie, chicken noodle soup, spinach, and caramel pear pudding. Resident 17 only consumed 5% Shepherd's pie, 5% spinach, 5% caramel pear pudding which indicated poor food intake . 2. During a review of Resident 28's admission Record, Resident 28 was admitted to the facility on [DATE], for rehabilitation with a diagnosis right proximal femur fracture (refers to a type of fracture that occurs in the hip region) status post ORIF. During a review of Resident 28's Minimum Data Set (MDS), dated May 3, 2024, indicated Resident 28 had a BIMS score of 13 which indicated cognitively intact. The MDS indicated Resident 28 actively participated in the assessment process and goal setting. During a review of Resident 28's Weight and Vitals Record, indicated the following weights: - April 29, 2024; 201 lbs; - May 7, 2024; 199 lbs (2 lbs weight loss in a week from April 29, 2024); - May 14, 2024, 190 lbs (9 lbs [4.5%] weight loss in a week from May 7, 2024; 11 lbs [5.4%] weight loss in 2 weeks from April 29, 2024); and - May 21, 2024; 184 lbs (6 lbs [3.15%] weight loss in a week from May 14, 2024; 17 lbs [8.45%] severe weight loss in 3 weeks from Aptil 29, 2024). During a review of the Resident 28's physician's orders, revised May 17, 2024, indicated, Fortified (Regular food items with foods added to boost the calories and protein content of meals) No added salt diet; During a review of Resident 28's Initial Nutrition Assessment, dated April 29, 2024, completed by the RD, indicated, .admission weight wt. 201#, Current wt. 201#, Diet order: NAS .intake 26 -100% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 8 of 38 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 05/23/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few Skin: Integrity: No edema (swelling) documents. Surgical incision. Skin tear to right arm .Surgical incision present on left hip .3 separate surgical incisions .Calories Needs: Based on current wt. 201 # 2250 -2500 calories .Assessment: Resident new admit, s/p fall .Current diet order meets estimate needs, intake fair to good .weight monitored weekly x 4 weeks .Recommend to continue current POC (Plan of Care) for now. Will continue to monitor and consult IDT, as needed. Goal: Maintain stable weight with no significant changes, maintain intake average >/ 75 % . During a review of Resident 28's IDT weight variance progress note, dated May 17, 2024, completed by the RD, indicated, .Resident reviewed by IDT, with current wt. of 190 #, -9 # (9 lbs weight loss) this week .Current diet: NAS, intake: 0-100 % .Contributing Factors: Variable intake. Resident adjusting to facility. RECOMMENDATIONS: Fortify current diet order. Continue weekly weights . On May 21, 2024, at 12:48 p.m., an interview was conducted with Resident 28. Resident 28 stated his usual body weight was 200 lbs and he lost his appetite since hospitalization 27 days ago. Resident 28 stated c urrently most foods taste terrible for me, and he did not know how much weight he lost. Resident 28 stated nobody from the facility visited him and discussed with him regarding his usual weight, his poor appetite, unplanned weight loss, goal weight and nutrition intervention (fortified diet) for his weight loss and get him involved in his nutrition care plan. Resident 28 was happy he received health shake (nutrition drinks with high calories used by facility as fortified food item) with his lunch meal. Resident 28 stated t his is my first time get shake and it taste so good. Resident 28's finished meal intake was concurrently observed with the following food consumed: 10 % chicken (~ [approximate] 20 calories), 5 % dessert (~ 5 calories); finished 8 oz 2 % milk (~ 120 calories); and finished 8 oz shake (~ 240 calories). Surveyor did an estimation calories Resident 28 was observed to consume total of ~ 385 calories . On May 22, 2024, at 11:06 a.m., a concurrent interview and record review of Resident 28's Initial Nutrition assessment, dated on April 29, 2024, and IDT wt. variance note, dated May 17, 2024 was conducted with the RD. The RD stated she could not locate documentation discussed with Resident 28 regarding his usual body weight (UBW), a description of visiting Resident 28 regarding his meal intake and appetite. The RD admitted she relied on nursing information regarding Resident 28's meal intake. The RD admitted she never observed Resident 28 during dining and was unaware Resident 28 had poor an appetite. The RD recommended to a fortified diet as an intervention for Resident 28's unplanned weight loss of 9 lbs on May 17, 2024. The RD stated she was unaware of the type of fortified food items the Food and Nutrition Services sent to Resident 28. The RD admitted she did not observe the acceptance and intake of fortified food items for Resident 28. The RD stated she just put a general goal or statement for Resident 28 as indicated, Goal: Maintain stable weight with no significant changes in the Initial Nutrition Assessment, on April 29, 2024, without asking Resident 28 what was his goal weight. The RD admitted she needed to obtain the UBW as baseline for nutrition care and asking Resident 28 what his weight goal so there would be a personalized nutrition interventions worked toward his goal. The RD admitted without monitoring the fortified food items intake, there was no way to evaluate the effectiveness of the intervention. On May 23, 2024, at 8:59 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 28 did not have good appetite and his usual meal intake were 30 -45 % with breakfast and lunch. Each food items Resident 28 consumed was discussed with CNA 2. There were two sausage links served. CNA 2 stated Resident 28 only consumed ½ sausage link and the other sausage link was untouched (5% ~ 50 calories), 10 % waffle (~10 calories), finish half banana (~ 60 calories), and finished 8 oz whole milk (~ 150 calories), for a total estimated calories Resident 28 consumed ~ 270 calories with his breakfast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 9 of 38 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 05/23/2024 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 0692 Level of Harm - Actual harm Residents Affected - Few On May 23, 2024, at 11:36 a.m., a concurrent interview and review of Resident 28's Initial Nutrition Assessment, on April 29, 2024, and IDT weight variance on May 17, 2024, and facility's policy of Nutrition Assessment was conducted with the DON. The DON stated the RD only interpreted the information from Resident 28's electronic medical record instead of visiting Resident 28 to collect nutritional information. The DON reviewed the meal intake on IDT Weight variance progress note on May 17, 2024, the amount intake range: 0 -100 % and stated this meal intake range was so broad that it would not reflect the appetite of the Resident 28 and unable to interpret whether the Resident consumed sufficient nutrition. The DON stated it was important for the RD to visit Resident 28 got a baseline of UBW, know Resident 28, catering Residents 28 with his preference nutrition interventions and created a personalized nutrition care plan for Resident 28 worked toward his goal. The DON stated Resident 28's weight loss could have been preventable if the RD went to visit Resident 28, obtained UBW, weight goal, be aware of the poor appetite, catering the nutritional interventions Resident 28 wanted . On May 23, 2024, at 5:46 p.m., an observation was conducted with Resident 28's finished meal tray inside Resident 28's room. Resident 28 only consumed 50 % caramel pear pudding (~ 50 calories), finished 8 oz while milk (~ 150 calories), and finished 8 oz health shake (~ 240 calories). Surveyor did an estimate calories Resident 28 ate ~ 440 calories. During a review of Resident 28's Initial Nutrition Assessment, dated April 26, 2024, completed by the RD, indicated, Resident 28 needs 2250 -2500 calories. Resident 28 consumed the following food intake with estimated calories observed on the following dates: - May 21, 2024: Lunch: 385 calories; - May 23, 2024: Breakfast: 270 calories; - May 23, 2024: Dinner: 440 calories. - Total calories: 1095 calories. Resident 28 only consumed 46 % estimated nutrition needs based on 2375 calories. During a review of the facility's policy and procedure titled, Nutritional Assessment, revised October 2017, indicated, .Policy Statement: As part of the comprehensive assessment, a nutrition assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .Policy interpretation and Implementation .As part of the comprehensive assessment, the nutrition assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition .The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .Usual body weight .A description of the resident's usual intake and appetite .Usual meal and snack patterns .Food preferences and dislike (including flavors .Dietitian .whether the resident's current intake is adequate to meet his or her nutritional needs .Sources of information for the resident nutritional assessment may include the following .Observation .Resident and family interviews .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences .Individualized care plans shall address to the extent possible .The identified causes of impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 10 of 38 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 05/23/2024 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 0692 nutrition .The president's personal preferences .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment . Level of Harm - Actual harm Residents Affected - Few During a review of the facility's policy and procedure titled, Therapeutic Diets, revised October 2017, indicated, .Policy Statement .Therapeutic diets are prescribed by the physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Policy Interpretation and Implementation .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes .The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diet .The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record .Snacks will be compatible with the therapeutic diet . During a review of the facility's policy and procedure titled, Weight Assessment and Intervention, revised March 2022, indicated, .Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain .Policy Interpretation and Implementation Weight Assessment .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .One month - 5% significant loss, greater than 5% severe loss .Three month - 7.5% significant loss, greater than 7.5% severe loss .Six months - 10% significant loss, greater than 10% severe loss . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 11 of 38 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 05/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure: 1. Three of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened. This failure had the potential for emergency medication to be unavailable when needed. 2. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Drug Control Receipt Record/Disposition Form (count sheet - an inventory sheet that keeps record of the usage of controlled medications), for two of four residents reviewed (Residents 17 and 19). This failure had the potential to not have an accurate accountability of controlled medications and the potential for abuse or misuse of these medications. In addition, both failures had the potential for not meeting the residents' therapeutic (related to healing of a disease) needs or worsening of their medical conditions. Findings: 1. On May 20, 2024, at 9:46 a.m., during an inspection of the Medication Storage room with Registered Nurse (RN 1), the oral medication e-kit and the intramuscular (IM, a technique used to deliver a medication deep into the muscles) medication e-kit were observed to be sealed with yellow locks. RN 1 confirmed the yellow lock indicated the e-kits had been opened by the nursing staff. RN 1 described the e-kit process and the expectation from the nursing staff to do the following when the e-kit was open - Should fill out the medication slip; - Leave one copy of the slip in the log book and one copy of the slip inside the e-kit; - Reseal the e-kit with a yellow lock; - The nursing staff should immediately call the pharmacy to reorder the e-kit; and - The pharmacy should replace the e-kit on the same day/evening or within 72 hours. During an inspection of the opened oral medication e-kit, two slips of paper were observed inside. The slips of paper indicated the oral medication e-kit was opened two times as follows: - On May 15, 2024, two amoxicillin (antibiotic to treat infections) 250 mg (milligram - a unit of measurement) tablets were removed and; - On May 16, 2024, one Augmentin (antibiotic to treat infections) 500 mg tablet was removed. In a concurrent interview with RN 1, RN 1 confirmed the oral medication e-kit had not been replaced (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 12 of 38 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 05/23/2024 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 0755 since May 15, 2024, and acknowledged it should have been replaced. Level of Harm - Minimal harm or potential for actual harm During an inspection of the IM e-kit, two slips of paper were observed inside. The slips of paper indicated the IM e-kit was opened two times as follows: Residents Affected - Some - On April 4, 2024, one Toradol (medication used for pain) 30 mg one milliliter (ml - unit of measurement) vial was removed and; - On April 10, 2024, one Glucagon kit (used for low blood sugar) was removed. In a concurrent interview with RN 1, RN 1 confirmed the IM e-kit had not been replaced since April 4, 2024, and acknowledged it should have been replaced. On May 20, 2024, at 10:25 a.m., during an inspection of Medication Cart A with RN 1, the narcotic e-kit inside Medication Cart A was observed to be sealed with a yellow lock, which indicated it had been opened by the nursing staff. During an inspection of the narcotic e-kit, three slips of paper were observed inside. The slips of paper indicated the narcotic e-kit was opened three times as follows: - On May 15, 2024, one hydrocodone-acetaminophen (a potent controlled medication for pain) 10-325 mg tablet was removed; - On May 17, 2024, one hydrocodone-acetaminophen (a potent controlled medication for pain) 5-325 mg tablet was removed at 5 p.m. and another tablet was removed at 10:06 p.m. for two different residents. In a concurrent interview with RN 1, RN 1 confirmed the narcotic e-kit had not been replaced since May 15, 2024, and acknowledged it should have been replaced. On May 21, 2024, at 9:37 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, regarding the e-kit process, LVN 1 stated she would have called the pharmacy for a replacement of the e-kit immediately after it was opened and the e-kit would have been replaced by pharmacy on the same night or by the following morning. On May 21, 2024, at 3:46 p.m., during an interview with the Director of Nursing (DON), the DON stated the nursing staff were expected to call the pharmacy for a replacement as soon an e-kit was opened and the pharmacy was expected to replace opened e-kits within 72 hours. During a review of the facility's policy and procedure (P&P), titled Emergency Medications, dated November 2022, indicated, .The facility shall maintain a supply of medications typically used in emergencies . 2. The count sheets for controlled medications for four random residents receiving PRN (as-needed) controlled medications were requested for review during the survey and indicated the following: a. Resident 17 had a physician's order, dated May 9, 2024, for Norco (hydrocodone-acetaminophen) 10/325 milligram tablet, 1 tablet by mouth every 6 hours as needed for moderate to severe pain 6 - 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 13 of 38 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 05/23/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On May 20, 2024, at 10:55 a.m., during a concurrent interview and record review with RN 1. Resident 17's Drug Control Receipt Record ., for Norco 10/325 mg indicated, one tablet was signed out on May 17, 2024, at 8 p.m. The MAR did not indicate the nursing staff's initials to demonstrate the hydrocodone acetaminophen 10/325 mg was administered to Resident 17 on May 17, 2024. RN 1 stated the licensed nurses were expected sign the narcotic count sheet and document on the MAR immediately after administration. RN 1 acknowledged the nursing staff signed out one hydrocodone - acetaminophen 10/325 mg tablet on the count sheet for Resident 17, but did not document the medication administration on the MAR for May 17, 2024, at 8 p.m. On May 21, 2024, at 3:36 p.m., during an interview with the DON, regarding the administration of narcotics, the DON stated the nursing staff should have removed the medication from the bubble pack, signed the count sheet and documented in the MAR at the same time. The DON stated the documentation on the count sheet should match the MAR. On May 21, 2024, at 4:03 p.m., during a concurrent interview and record review with the DON, the DON reviewed the discrepancy between the count sheet for Resident 17's hydrocodone - acetaminophen 10/325 mg tablet and the MAR dated May 2024. The DON confirmed the discrepancy and acknowledged the lack of documentation. b. Resident 19 had a physician's order, dated April 8, 2024, for Percocet (oxycodone-acetaminophen - a potent controlled medication for pain) 10/325 mg tablet, 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4 - 10. On May 20, 2024, at 3:19 p.m., during a concurrent interview and record review with LVN 2, LVN 2 stated Resident 19's count sheet for oxycodone-acetaminophen 10/325mg tablet and the MAR dated May 2024, indicated, one tablet was signed out on the narcotic count sheet but was not signed in the MAR on the following dates and times : - May 7, 2024, at 1 a.m.; - May 8, 2024, at 10:58 p.m.; - May 9, 2024, at 8:07 p.m.; - May 10, 2024, at 1:40 a.m.; - May 10, 2024, at 6:07 a.m.; - May 10, 2024, at 8:55 p.m.; - May 11, 2024, at 9 p.m.; - May 12, 2024, (time illegible); - May 13, 2024, at 8 p.m.; - May 14, 2024, at 8 p.m.; - May 15, 2024, at 9 p.m.; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 14 of 38 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 05/23/2024 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 0755 - May 16, 2024, at 8:16 p.m.; Level of Harm - Minimal harm or potential for actual harm - May 17, 2024, at 8 p.m.; - May 18, 2024, at 9 p.m.; and Residents Affected - Some - May 19, 2024, at 9 a.m. LVN 2 described the controlled medication administration process and stated nurses should have signed the narcotic out on the count sheet and documented the administration in the MAR immediately after administration. LVN 2 acknowledged the nursing staff signed out one oxycodone - acetaminophen 10/325mg tablet on the count sheet, but did not document the medication administration on the MAR on the dates and times listed above. On May 21, 2024, at 4:07 p.m., during a concurrent interview and record review with the DON, the DON reviewed the lack of documentation between the count sheet for Resident 19's oxycodone - acetaminophen 10/325 mg tablet and the MAR dated May 2024. The DON confirmed the discrepancies and acknowledged the missing documentations in the MAR for the dates and times as listed above. During a review of the facility's P&P titled Administering Medications, dated April 2019, indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication .the individual administering the medication records in the resident's medical record .the date and time the medication was administered; the dosage; the route of administration .the signature and title of the person administering the drug . During a review of the facility's P&P, titled Controlled Substances, dated November 2022, indicated, An individual resident controlled substance record is made for each resident who will be receiving a controlled substance .The record contains: name of the resident; name and strength of the medication .time of administration; method of administration .signature of nurse administering the medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 15 of 38 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 05/23/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for one of five sampled residents (Resident 19), when: 1. Zoloft (another name for sertraline [a psychotropic medication for depression]) was administered without adequate behavioral and manufacturer's specified monitoring documented during use; and 2. Escitalopram (a psychotropic medication for depression) was administered without adequate behavioral monitoring documented during use. These failures had the potential for the medication to not be optimized for best possible health outcome, and had the potential for unnecessary or prolonged use of the medication which could lead to adverse effects and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 19's admission Record, dated May 20, 2024, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included anxiety (feeling of restlessness). A review of Resident 19's physician's orders indicated the following: - February 2, 2024- .Escitalopram Oral Tablet 10 mg Give 1 tablet by mouth one time a day for depression m/b verbalizations of sadness .; and - March 21, 2024; .Zoloft Oral Tablet 50 milligram (mg, unit of measurement) by mouth one time a day for depression m/b (manifested by) verbalization of sadness . On May 22, 2024, at 2:44 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON acknowledged Resident 19 was not monitored for manufacturer specified side effects and behavior manifestations during Zoloft use. The DON stated it should have been monitored. Additionally, the DON stated Resident 19 was not monitored for behavior manifestations during escitalopram use and stated it should have been monitored. On May 23, 2024, at 3:34 p.m., during a follow-up concurrent interview and record review with the DON, the DON stated the monthly MRR reports from the Consultant Pharmacist (CP) should include identified medication irregularities such as no side effect or behavioral monitoring for psychotropic medications. The DON acknowledged there were no recommendations from the CP during the monthly MRR in March 2024 and April 2024 related to the need for monitoring of manufacturer specified side effects or behavioral during use of Zoloft and there were no recommendations related to the need for monitoring behaviors during use of escitalopram. A review of the CP's monthly MRRs for Resident 19 dated March 2024 and April 2024 indicated there were no recommendations from the CP related to the need for monitoring of manufacturer specified side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 16 of 38 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 05/23/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effects or behavioral during use of Zoloft and there were no recommendations related to the need for monitoring behaviors during use of escitalopram. A review of the Prescribing Information (PI [detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians]) for Zoloft tablets, dated August 2007, retrieved from DailyMed (website for drug resources) indicated, .All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior .monitor patients for the emergence of agitation, irritability .abnormal bleeding .Hyponatremia (when the level of sodium in the blood is lower than normal) . During a review of the facility's policy and procedures (P&P), titled Medication Regimen Reviews, dated May 2019, indicated, .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example .inadequate monitoring for adverse consequences .other medication errors, including those related to documentation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 17 of 38 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 05/23/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 two of four residents (Residents 8 and 12) who were receiving Eliquis (another name for apixaban [medication to prevent clots]) were free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of side effects related to the use Eliquis. Residents Affected - Few This failure had the potential for the side effects of Eliquis (such as bleeding, excessive bruising, and others) medication to be undetected or unrecognized for timely intervention. Findings: 1. During a review of Resident 8's admission Record, dated May 22, 2024, it indicated Resident 8 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (an irregular heartbeat). A review of Resident 8's physician's orders indicated the following: - April 29, 2024 - .Eliquis Oral Tablet 5 milligram (mg, unit of measurement) Give 5 mg by mouth two times a day for AFIB (atrial fibrillation) .; and - May 12, 2024- .Eliquis .Monitor for s/sx (signs and symptoms) of bleeding (ie. [example] nose bleed, bruising, bleeding gums, etc.) and notify MD (medical doctor) promptly if symptoms occur every Shift . On May 22, 2024 at 2:31 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated when a resident is admitted to the facility on an anticoagulant (blood thining medication) such as Eliquis, a assessment or care plan for anticoagulation and monitoring for bleeding should have been completed. On May 22, 2024 at 3:33 p.m., a concurrent interview and record review of Resident 8's physician orders and Medication Administration Record (MAR) with the DON was conducted. The DON acknowledged there was no documentation of monitoring of Eliquis medication on the MAR for bleeding for April and May of 2024. 2. During a review of Resident 12's admission Record, dated May 22, 2024, it indicated Resident 12 admitted to the facility on [DATE] with diagnoses which included embolism (blood clot) and deep vein thrombosis (DVT, a blood clot in a vein located deep inside the body) of lower extremity. A review of Resident 12's physician's orders indicated the following: - April 29, 2024- .Apixaban Oral Tablet 2.5 mg Give 1 tablet by mouth two times a day for DVT prophylaxis (prevention) .; and - May 2, 2024- .Apixaban: Monitor for s/sx of bleeding (ie. [example] nose bleed, bruising, bleeding gums, etc.) and notify MD promptly if symptoms occur. every shift . On May 22, 2024 at 3:45 p.m., a concurrent interview and record review of Resident 12's physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 18 of 38 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 05/23/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders and MAR with the DON was conducted. The DON acknowledged there were no documentation of monitoring of Apixaban medication for bleeding on the MAR for April and May of 2024. A review of the Prescribing Information (PI [detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians]) for apixaban tablets, dated June 2021, retrieved from DailyMed (a website for drug resorces) indicated, .Warnings and precautions .Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss . A review of Lexicomp online (a nationally recognized drug information resource) indicated, .apixaban .Monitor for bleeding (from nose, mouth, gums), bruising, hematoma (a bruise, a black and blue mark), changes in menstrual cycle with increased bleeding, spotting, or bleeding between cycles, nausea, vomit that is bloody or looks like coffee grounds, hematuria (blood in urine), bowel movements that are red or black, hemorrhage . During a review of the facility's policy and procedures (P&P) titled Anticoagulation - Clinical Protocol, dated November 2018, indicated, .Assess for any signs or symptoms related to adverse drug reactions due to the medication .The staff and physician will monitor for possible complications in individuals who are being anticoagulated .if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing or spitting up blood from the respiratory tract), or other evidence of bleeding, the nurse will discuss the situation when the physician before giving the next scheduled dose of anticoagulant . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 19 of 38 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 05/23/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for one of five sampled residents (Resident 19) was free from unnecessary psychotropic (affects brain activities associated with mental processes and behavior) medications when: 1. Resident 19 was receiving Zoloft (another name for sertraline [a psychotropic medication for depression mood disorder]) and was administered without adequate behavioral and manufacturer specified monitoring documented; 2. Resident 19 was receiving Escitalopram (medication for depression) and was administered without adequate behavioral monitoring documented; and 3. Resident 19 was receiving PRN (as-needed) Xanax (another name for alprazolam (medication for anxiety [feeling of restlessness) and was administered without prescriber-documented rationale and specified duration for extended use beyond 14 days. These failures had the potential to result in unnecessary use of medications for Resident 19, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression (slow or shallow breathing), constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 19's admission Record, dated May 20, 2024, it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included anxiety. A review of Resident 19's physician orders and indicated the following: - March 21, 2024 - .Zoloft Oral Tablet 50 milligram (mg, unit of measurement) by mouth one time a day for depression m/b (manifested by) verbalization of sadness .; - February 2, 2024 - .Escitalopram Oral Tablet 10 mg Give 1 tablet by mouth one time a day for depression m/b verbalizations of sadness .; and - April 12, 2024 - .Xanax Oral Tablet 0.5 mg Give 0.5 mg by mouth every 8 hours as needed for anxiety m/b feeling anxious . On May 22, 2024, at 2:44 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON acknowledged Resident 19 was not monitored for manufacturer specified side effects and behavior manifestations during Zoloft use. The DON stated it should have been monitored. Additionally, the DON acknowledged Resident 19 was not monitored for behavior manifestations during escitalopram use and stated it should have been monitored. In further review of Resident 19's medical record, there was no documented evidence the physician documented the rationale why the resident needed the PRN Xanax beyond 14 days. In addition, the end (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 20 of 38 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 05/23/2024 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 0758 date for the PRN Xanax on the physician order indicated indefinite (no end date). Level of Harm - Minimal harm or potential for actual harm On May 23, 2024 at 3:26 p.m., during a follow-up concurrent interview and record review, with the DON was conducted, the DON confirmed the end date was indefinite on the PRN Xanax order, dated April 12, 2024. The DON acknowledged the end date should have been April 26, 2024, which would have been 14 days from when the PRN Xanax was ordered. The DON stated if the resident needed more than 14 days the doctor should have been contacted. The DON verified no documentation by prescriber for rationale to extend the PRN Xanax beyond 14 days and she stated, there should have been documentation. Residents Affected - Few A review of the Prescribing Information for Zoloft tablets dated August 2007 retrieved from DailyMed indicated, .All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior .monitor patients for the emergence of agitation, irritability .abnormal bleeding .Hyponatremia (low sodium in the blood) . During a review of the facility's policy and procedures (P&P), titled Psychotropic Use, dated July 2022, indicated, .Drugs in the following categories are considered psychotropic medications .Anti-depressants .Psychotropic medication management includes .adequate monitoring for efficacy and adverse consequences .preventing, identifying and responding to adverse consequences . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 21 of 38 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 05/23/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medication error rates are below 5 percent, for two of ten residents (Residents 131 & 138), observed during medication administration. Residents Affected - Few These failures resulted in medication error rate of 19.23 percent in which resulted in medications not to be given according to the physician orders. In addition, these failures had the potential for the residents to not receive the full therapeutic (relating to the healing of disease) effects of the medications. Findings: 1. On May 21, 2024, at 8:58 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed to have prepared and administered four medications to Resident 138. The medications included one aspirin (used to prevent blood clots) enteric-coated (EC [tablet designed to pass through the stomach and get absorbed into the bloodstream by the small intestine]) tablet, one sennosides (another name for Geri-Kot [used for constipation]) tablet, and one Trelegy Ellipta (used for chronic obstructive pulmonary disease [COPD], a lung disease causing breathing problems) inhaler. During the same medication pass observation at 9:09 a.m., LVN 1 was observed to have handed the Trelegy Ellipta inhaler to Resident 138. Then, Resident 138 was observed to have inhaled one puff by mouth of the Trelegy Ellipta inhaler and was not observed to have rinsed her mouth afterwards. A review of Resident 138's physician's orders indicated the following: - May 3, 2024 - .Aspirin Oral Tablet Chewable 81 milligram (mg, unit of measurement) Give 1 tablet by mouth two times a day for DVT (deep vein thrombosis, a blood clot in a vein located deep inside the body) PPX (prevention) .; - May 3, 2024- .Sennosides - Docusate Oral Tablet 8.6-50 mg Give 1 tablet by mouth two times a day for Bowel Management hold for loose stools . - May 3, 2024- .Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 micrograms (mcg, unit of measurement) 1 puff inhale orally one time a day for COPD rinse mouth after each use . During a concurrent interview and record review on May 21, 2024, at 11:21 a.m. with LVN 1, Resident 138's medication administration record (MAR) dated May 2024 and physician's orders as listed above were reviewed. LVN 1 confirmed she administered one enteric-coated aspirin tablet instead of one chewable aspirin tablet. LVN 1 confirmed she administered one sennoside (Geri-Kot) tablet instead of the combination sennoside-docusate tablet. Additionally, LVN 1 confirmed Resident 138 did not rinse her mouth after they took one puff from the Trelegy Ellipta inhaler. LVN 1 verified the medications were not administered as ordered. On May 21, 2024, at 4:20 p.m., during an interview with the Director of Nursing (DON), regarding Resident 138's medications for aspirin, sennoside-docusate, and Trelegy inhaler, the DON stated medications should be given as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 22 of 38 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 05/23/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm 2. During a medication pass observation on May 21, 2024, at 9:21 a.m., LVN 1 was observed to have prepared and administered six medications to Resident 131, including one aspirin enteric-coated 81 mg tablet and one folic acid (a nutrient in the vitamin B complex the body needs to function) 1 mg tablet. A review of Resident 13's physician's orders indicated the following: Residents Affected - Few - May 2, 2024- .Aspirin Oral Tablet Give 1 tablet by mouth two times a day for DVT prophylaxis (prevention) . - May 2, 2024- .Folic Acid Oral Tablet Give 1 tablet by mouth one time a day for Supplement . On May 21, 2024, at 11:27 a.m., during a concurrent interview and record review with LVN 1, LVN 1 confirmed she administered one enteric-coated aspirin 81 mg tablet and one folic Acid 1 mg tablet. LVN 1 verified that the physician's orders for Aspirin tablet and folic acid tablet, both dated May 2, 2024, as listed above were missing the dose and strength. LVN 1 acknowledged the orders should have been clarified with the physician. On May 21, 2024, at 4:24 p.m., during a concurrent interview and record review with the DON, the DON verified the physician's orders for aspirin tablet and folic acid tablet, both dated May 2, 2024, were missing the dose and strength for Resident 131. The DON acknowledged the orders should have been clarified by nursing staff and stated, Can't assume. During a review of the facility's Policy and Procedure (P&P) titled Administering Medications, dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders . During a review of the facility's P&P titled Medication Orders, dated November 2014, indicated, .Recording Orders .when recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered . During a review of the facility's P&P titled Physician Orders, dated July 2016, indicated, .Licensed nurses are to carry out Healthcare Provider orders as written .Licensed nurses will notify Healthcare Providers if clarification orders are indicated based on clinical judgement . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 23 of 38 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 05/23/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the temperature in the medication refrigerator was monitored twice daily, according to the facility's protocol. This failure had the potential for the medications stored in the medication refrigerator to not be stored in a proper temperature to maintain its efficacy and/or full therapeutic effects in which can lead to unsafe administration of medications to residents. Findings: On May 20, 2024, at 9:46 a.m., during a concurrent interview and inspection of the facility's medication room with Registered Nurse (RN) 1, the medication refrigerator was observed to have contained vaccines, insulin products, a refrigerated emergency kit (medications for use in the emergency), and other refrigerated medications. RN 1 stated the medication refrigerator temperatures were expected to be checked and documented on the Temperature Log by the licensed nurse twice daily at each shift. A review of the medication refrigerator temperature logs from September 2023 to May 2024, indicated they were incomplete and/or inconsistently monitored twice daily, and as follows: - For October 2023, there were 3 missing temperature recordings (October 23, 27, and 30, 2023); - For November 2023, temperature log was missing; - For December 2023, there were 41 missing temperature recordings; 17 days without any recordings; - For January 2024, there were 4 missing temperature recordings; - For February 2024, there were 12 missing temperature recordings; and - For March 2024, there were 31 missing temperature recordings; 31 days without any morning shift recordings. On May 21, 2024, at 3:46 p.m., during an interview with the Director of Nursing (DON), the DON stated licensed nurse were expected to check and document the medication refrigerator temperature on the temperature log twice daily at each shift. On May 22, 2024, at 2:14 p.m., during a follow-up concurrent interview and record review with the DON, the medication refrigerator temperature logs from September 2023 to May 2024 were reviewed. The DON verified the temperature logs were incomplete and were not monitored consistently twice a day for October 2023, December 2023, January 2024, February 2024, and March 2024. The DON verified the temperature log was missing for November 2023. During a review of the facility's policy and procedures (P&P), titled Medication Labeling and Storage, dated February 2023, indicated, .The facility stores all medications and biologicals in locked compartments under proper temperature .The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 24 of 38 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 05/23/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure the food service employees were able to carry out the functions of food and nutrition services safely and effectively when: Residents Affected - Some 1. Prep [NAME] did not document the cooling process for tuna salad made on May 20, 2024; 2. Prep [NAME] and [NAME] 2 were unable to demonstrate the cooling process for tuna salad; 3. [NAME] 2 did not know how to calibrate thermometer; 4. Dishwasher 2 did not know how long kitchenware need to immerse into sanitizer; 5. Dishwasher 1 and Dishwasher 2 did not follow manufacturer guideline instruction time length for dipping test strip in sanitizer to check the concentration of sanitizer; 6. [NAME] 1 prepared grainy broccoli for two Residents (Resident 135 and 281) who had physician prescribed pureed diet texture (the food texture should be smooth for residents who have difficulty chewing and/ or swallowing ability) during lunch on May 21, 2024. (Cross referred F 805). These failures had the potential to cause foodborne illness for 37 out of 37 sampled residents who received foods from the kitchen and aspiration (accidentally inhaling food or liquid into the lungs) and choking for 2 Residents (Resident 135 and 281). Findings: 1. On May 20, 2024, at 3:46 p.m., an observation was conducted at walk-in refrigerator. There was a container of tuna salad labeled with prep (prepared) date: 5/20/24 (May 20, 2024) and used by date: 5/27/24 (May 27, 2024). Checked the temperature of the tuna salad indicated 56.7 degrees Fahrenheit. On May 20, 2024, at 3:50 p.m., the cooling log record review was conducted in the kitchen. Tuna salad made on May 20, 2024, was not documented in the cooling log. On May 21, 2024, at 10:14 a.m., an interview was conducted with the Prep Cook. She stated the tuna salad was made yesterday around 10 a.m. and she forgot to document in the cooling log. On May 21, 2024, at 10:34 a.m., an interview was conducted with the Food Service Director (CDM). Reviewed the temperature taken for the tuna salad on May 20, 2024, at 3:46 p.m. at 56.7 degrees Fahrenheit with the CDM. The CDM confirmed the tuna salad temperature was in the danger zone (more than 41 degrees F) for more than 4 hours. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was food service employees need to follow policy and procedure and documenting cooling process for potential hazard foods in cooling log for food safety handling practices. During a review of the job description Prep Cook, indicated, Responsibilities .Consistently follows (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 25 of 38 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 05/23/2024 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 0802 policies and procedures .within the individual department . Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Rapid Cooling of Food, revised dated November 2022, the P&P indicated, Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices .Policy Interpretation and Implementation: General Guidelines: Residents Affected - Some - The danger zone for food temperature is above 41 degrees Fahrenheit (a unit of measurement) and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. - Potentially hazardous foods (PHF) include meats, poultry, seafood, cut melon, egg, milk, yogurt, and cottage cheese. - The longer foods remain in the dangerous zone the greater the risk for growth of harmful pathogens. Therefore PHF must be maintained at below 41 degrees Fahrenheit or at above 135 degrees Fahrenheit. - Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) .may cause foodborne illness . Rapid Cooling . - Facility staff may utilize a Cooling Log for documentation of temperature measurements/times. 2. On May 21, 2024, at 10:06 a.m., an interview was conducted with the Prep Cook. She was asked to demonstrate the monitoring cooling process for tuna salad. She stated tuna salad needed to reach below 41 degrees Fahrenheit between 4 to 6 hours. On May 21, 2024, at 11:19 a.m., an interview was conducted with the CK 2. He was asked to demonstrate the monitoring cooling process for tuna salad. He stated tuna salad need to reach below 41 degrees Fahrenheit within 5 hours. On May 21, 2024, at 4:44 p.m., an interview was conducted with the CDM. She stated food service employees needed to cool down tuna salad below 41 degrees Fahrenheit within 4 hours. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was food service employees needed to follow policy and procedure cooling process for potential hazard foods for food safety handling practices. During a review of the job description Prep Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department. During a review of the job description Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department . During a review of the facility's policy and procedure (P&P) titled, Rapid Cooling of Food, revised dated November 2022, the P&P indicated, Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices .Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 26 of 38 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 05/23/2024 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 0802 Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm General Guidelines . Residents Affected - Some - Potentially hazardous foods ( .seafood .) held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) .may cause foodborne illness . 3. On May 21, 2024, at 11:19 a.m., an interview was conducted with CK 2. He was asked to demonstrate how to calibrate thermometer. He placed the digital thermometer into a bowl of ice cube cold water and stated he needed to calibrate the thermometer at 36 degrees Fahrenheit. On May 21, 2024, at 4:44 p.m., an interview was conducted with the CDM. She stated the digital thermometer needed to be calibrated at 32 degrees Fahrenheit. The CDM stated it was important the cook know how to calibrate the thermometer, so the cook could get the accurate temperature when they checked the food temperature. The CDM stated her expectation was for the cook to follow policy and procedure to calibrate thermometer. During a review of the facility's policy and procedure (P&P) titled, Thermometer Calibration, dated 2020, the P&P indicated, Guideline: All temperatures of food will be recorded using a bimetallic stem type or digital thermometer . Procedure: 2 .hold and adjust thermometer head with an appropriate tool and turn head so pointer reads 32 degrees Fahrenheit . During a review of the job description Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department . 4. Reviewed the manufacturer guideline directions for sanitizer poster posted above 3 compartment sink indicated, . immersion until thoroughly wet for at least 60 seconds . On May 20, 2024, at 3:02 p.m., an interview was conducted with Dishwasher (DS) 2 and the CDM in front of the 3 compartment sink. The DS 2 stated she need to submerge kitchenware into the sanitizer for 30 seconds. The CDM stated the kitchenware need to be submerged into the sanitizer for 1 minute (60 seconds). During a review of the job description Dish Washer, indicated, Responsibilities .Consistently follows policies and procedures .within the individual department . 5. Reviewed the manufacturer guideline directions for sanitizer poster posted above 3 compartment sink indicated, .Dip test strip for 5 seconds in test solution . On May 21, 2024, at 9:54 a.m., an interview was conducted with Dishwasher (DS) 2 in front of the 3-compartment sink. She stated she needed to dip the test strip for 10 seconds in the test solution (sanitizer) to check the concentration of the sanitizer. On May 21, 2024, at 9:56 a.m., an interview was conducted with DS 1 in front of the 3-compartment sink. He stated he needed to dip the test strip for 10 to 15 seconds in the sanitizer to check the concentration of sanitizer. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated the dishwashers needed to follow the manufacture's guideline time length to dip test strip for 5 second to check the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 27 of 38 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 05/23/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some concentration of sanitizer. The CDM explained dishwashers did not follow the manufacturer's guideline time length testing sanitizer and could lead to inaccurate reading of the sanitizer concentration. 6. On May 21, 2024, at 11:39 a. m., a noon prep pureed meal observation was conducted with [NAME] (CK) 1. [NAME] 1 prepared grainy broccoli for two Residents (Resident 135 and 281) who had physician prescribed pureed diet. On May 21, 2024, at 1:25 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pureed foods was conducted with the CDM. She stated the pureed broccoli was not smooth and contained small pieces broccoli. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was for the cooks to follow the puree diet menu and recipes. During a review of the job description Cook, indicated, Responsibilities: Prepares all foods according to the menu and the standardized recipes in a safe efficient .Ensures the proper preparation .and serving of foods as indicated on .the recipes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 28 of 38 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 05/23/2024 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for two of two residents (Resident 135 and 281) who had a physician-prescribed pureed diet (food that has been grounded, pressed and/or strained to a soft smooth consistency like pudding). This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake. Findings: (Cross referred 802) On May 21, 2024, at 11:39 a.m., a concurrent noon prep pureed meal observation and interview was conducted with [NAME] (CK) 1. CK 1 placed five scoops of broccoli in the mixer and gradually added 2.5 cups milk to make pureed broccoli. End product of pureed broccoli was observed to have some fiber. On May 21, 2024, at 1:23 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pureed foods was conducted with the Food Service Director (CDM). One teaspoon of the pureed broccoli was tasted and the pureed broccoli had grainy strands of broccoli and did not have a smooth consistency. The CDM stated the pureed broccoli was not smooth and contained small pieces of broccoli. On May 23, 2024, at 10:00 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated pureed diet should be smooth, otherwise the residents on pureed diet would experience risk of choking, aspiration and decrease meal intake due to split out foods. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. The CDM stated the residents on pureed diet who consumed the grainy broccoli were at risk for choking, aspiration, and/or spit up the grainy (rough texture) broccoli which could lead to decrease meal intake. The CDM expectation was for the [NAME] to follow the recipe and menu to make the food smooth pureed diet. During a review of Residents 135 and 281's physician's orders, included pureed diet. During a review of the undated recipe Pureed Broccoli, indicated, . Puree should achieve a smooth, pudding or soft mashed potato consistency . During a review of the facility document titled Therapeutic Diets, revised dated October 2017, indicated, .Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care .A therapeutic diet is considered a diet ordered by a physician .as part of treatment for a disease or clinical condition .to alter the texture of a diet . During a review of the facility document titled Pureed diet, dated 2022, indicated Pureed diet is designed for those individuals who have difficulty swallowing or cannot chew foods of the dental soft consistency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 29 of 38 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 05/23/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two out of nine sampled residents (Residents 12 and 15) when: Residents Affected - Few 1. Resident 12, did not receive large portions on May 21,2024 lunch meal tray according to the diet ordered by the physician; and 2. Resident 15, did not receive fortified food items (food items enriched with high calories to help gain weight) on May 21, 2024 lunch meal tray according to the diet ordered by the physician. These failures had the potential to result in not improving Resident 12 and 15's weight, further compromising Resident 12 and 15's nutritional and medical overall condition. Findings: 1. During a review of the facility provided document titled, Diet Type Report (which consist residents' name and physician diet ordered), dated May 20, 2024, indicated, Resident 12 is on large portions. A review of the Resident 12's Physician Diet Order, dated May 9, 2024, indicated, .Large portions . A review of Resident 12's Meal Tray Ticket (menu based on the resident's diet physician order), dated May 21, 2024, indicated, .Regular . On May 21, 2024, at 12:43 p.m., a concurrent meal observation, interview, and review of Resident 12's Meal Tray Ticket, dated May 21, 2024, were conducted with Resident 12 at Resident 12 bedside. Resident 12 was observed being served with regular portions and the meal tray ticket did not indicate large portion. Resident 12 stated he was supposed to have large portions. On May 22, 2024, at 4:09 p.m., a concurrent interview and review of Resident 12's diet order was conducted with the Food Service Director (CDM). The CDM stated the physician ordered large portion for Resident 12 on May 19, 2024, due to weight loss. After reviewing the picture food items being served for Resident 12 on May 21, 2024, and the meal tray ticket, the CDM admitted Resident 12 did not receive large portion on the lunch meal tray served on May 21, 2024. The CDM stated this placed Resident 32 at risk to not gain weight. On May 23, 2024, at 9:58 a.m., a concurrent interview and record review of Resident 12's physician diet order was conducted with the Director of Nursing (DON). The DON stated Resident 12 had a diet order large portions. After reviewing the picture food items being served for Resident 12 on May 21, 2024, and the meal tray ticket, the DON stated Resident 12 did not receive large portion during lunch on May 21, 2024, as ordered by the physician. The DON further stated the physician ordered large portion for Resident 12 due to unplanned weight loss. The DON stated this placed Resident 12 at risk to not gain weight. During a review of the facility policy and procedure (P&P) titled Physician Orders, revised July 2016, the P&P indicated, .Policy Overview: Physician's orders provide to the healthcare team regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 30 of 38 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 05/23/2024 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 0808 .and nutrition. The order established the medical necessity for the services provided . Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy and procedure (P&P) titled Therapeutic Diets, revised October 2017, the P&P indicated, .Policy Statement Therapeutic diets are prescribed by the physician to support the resident's treatment and plan of care . Residents Affected - Few 2. During a review of the facility provided document titled, Diet Type Report, dated May 20, 2024, the report indicated, Resident 15 is on Fortified diet. On May 20, 2024, at 9:55 a.m., an interview was conducted with [NAME] (CK) 1. He stated he did not prepare fortified food items because there was no resident on fortified diet. CK 1 stated the last time he prepared fortified items was six months ago. A review of the Resident 15's Physician Diet Order, dated August 3, 2023, indicated, .Fortification diet . A review of Resident 15's Meal Tray Ticket, dated May 21, 2024, indicated, .Regular . On May 21, 2024, at 1:07 p.m., a concurrent meal observation, interview, and review of Resident 15's Meal Tray Ticket, dated May 21, 2024, were conducted with Certified Nurse Aide (CNA) 1 at Resident 15's bedside. Resident 15 was observed being served with regular diet and meal ticket indicated regular diet. CNA 1 confirmed the Meal Tray Ticket indicated Regular diet and no fortified food items were served. On May 22, 2024, at 3:57 p.m., a concurrent interview and physician diet ordered review was conducted with the CDM. She stated the physician ordered fortified diet for Resident 15 on August 3, 2023. The CDM stated Resident who on fortified diet would receive 2 fortified food items daily like fortified hot cereal with breakfast, fortified mashed potatoes with lunch or health shake with meal. After reviewing the picture food items being served for Resident 15 on May 21, 2024, and the meal ticket, the CDM admitted Resident 15 did not receive fortified food items on the lunch meal tray on May 21, 2024. On May 23, 2024, at 10:20 a.m., a concurrent interview and Resident 15'a physician diet ordered review were conducted with the DON. She stated physician ordered fortified diet for Resident 15 on August 3, 2023. After reviewing the picture food items being served for Resident 15 on May 21, 2024, and the meal ticket, the DON stated Resident 15 did not receive fortified food items on May 21, 2024, lunch. The DON further explained fortified diet was a meal plan with food items enriched with high calories to help improve weight. Since Resident 15 did not receive fortified food items so he did not get extra calories. During a review of the facility policy and procedure (P&P) titled Physician Orders, revised July 2016, the P&P indicated, .Policy Overview: Physician's orders provide to the healthcare team regarding .and nutrition. The order established the medical necessity for the services provided . During a review of the facility policy and procedure (P&P) titled Therapeutic Diets, revised October 2017, the P&P indicated, .Policy Statement Therapeutic diets are prescribed by the physician to support the resident's treatment and plan of care . During a review of the facility provided document titled, Fortified Enhanced Power Foods Protocol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 31 of 38 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 05/23/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (FEP), dated 2022, the document indicated, .The FEP Protocol is based on the Regular diet, with foods added to boost the calories and protein content of meals . During a review of the facility provided document titled, Diet Spreadsheet - the document used to guide food service employees on food items, portions, and therapeutic diet, dated 2024, indicated .Fortified Enhanced Foods .offer a minimum of one fortified food item per meal . Event ID: Facility ID: 555463 If continuation sheet Page 32 of 38 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 05/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were implemented when: Residents Affected - Some 1. Prep [NAME] did not monitor the cooling process for tuna salad prepared on May 20, 2024; (Cross reference 802) 2. Dishwasher 1 did not cover his mustache; 3. Can opener base had residue buildup; 4. Rusted shelves were found in the kitchen; 5. Dust was found in the kitchen; 6. Trash were found on the walk-in freezer floor; 7. The ice machine's deflector (a piece of plastic cover inside ice bin to prevent harvested ice from filling up in the front of the storage bin) had residue buildup; 8. [NAME] shelves' plastic coating in refrigerator number (#) 4 was worn off; 9. The vent above the stove was covered with grease and dust; 10. Opened food items exposed to air in the walk-in freezer; 11. There was condensation on the ventilation above the dish machine; 12. Two microwaves in the dining room had residue buildup. These failures had the potential to increase the risk of cross-contamination and exposure to microorganisms that harbor foodborne pathogens, resulting in foodborne illness (stomach illness acquired from ingesting contaminated food), for 37 out of 37 residents who received food from the kitchen and were medically compromised. Findings: 1. On May 20, 2024, at 3:46 p.m., an observation was conducted at walk-in refrigerator. There was a container of Tuna Salad labeled with Preparate dated: 5/20/24 and used by date: 5/27/24. Checked the temperature of the Tuna salad indicated 56.7 degrees Fahrenheit. On May 20, 2024, at 3:50 p.m., the cooling log record review was conducted in kitchen. Tuna salad made on May 20, 2024, was not documented in the cooling log. On May 21, 2024, at 10:14 a.m., an interview was conducted with the Prep Cook. She stated the Tuna salad was made yesterday around 10 a.m. and she forget to document in the cooling log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 33 of 38 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 05/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On May 21, 2024, at 10:34 a.m., an interview was conducted with the Food Service Director (CDM). By showing the picture of the Tuna Salad took by yesterday at 3:46 p.m. at 56.7 degrees Fahrenheit, she confirmed the Tuna Salad held in the danger zone for more than 4 hours and needed to discard. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was food service employees need to follow policy and procedure and documenting cooling process for potential hazard foods in cooling log for food safety handling practices. During a review of the facility's policy and procedure (P&P) titled, Rapid Cooling of Food, revised November 2022, the P&P indicated, .Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation .General Guidelines: - The danger zone for food temperature is above 41 degrees Fahrenheit (a unit of measurement) and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness; - Potentially hazardous foods (PHF) include meats, poultry, seafood, cut melon, egg, milk, yogurt, and cottage cheese; - The longer foods remain in the dangerous zone the greater the risk for growth of harmful pathogens. Therefore PHF must be maintained at below 41 degrees Fahrenheit or at above 135 degrees Fahrenheit; - Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) .may cause foodborne illness . Rapid Cooling . - Facility staff may utilize a Cooling Log for documentation of temperature measurements/times. 2. On May 21, 2024, at 11:28 a.m., an observation was conducted with the Dishwasher (DS) 1. The DS 1 was observed to have mustache and was not covered while working in the dish washing area. On May 21, 2024, at 4:44 p.m., an interview was conducted with the CDM. The CDM confirmed DS 1's mustache was not covered and stated DS 1 needed to cover his facial hair otherwise there was a potential risk for hair to fall in any food or clean dishes. The CDM stated her expectation was any food service workers who had facial hair needed to cover facial hair while working in the kitchen. During a review of the facility's Guideline & Procedure Manual (G&P) titled, Hair Restraints, dated 2020, the G&P indicated, .Guideline: Hair restraints shall be worn by all Dining Service staff when in food production areas, dishwashing areas, or when serving foods. Procedure .Hair restraints, hats, and beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer that the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. 3. On May 20, 2024, at 9:47 a.m., a concurrent observation and interview was conducted with the CDM. The can opener base was observed to have black grime buildup. The CDM confirmed the can opener base was dirty. The CDM stated the food service employees were supposed to clean the can opener base (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 34 of 38 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 05/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after they used it. The CDM explained old particles (black grime) on the base could get into foods when the food service employees used the can opener. The CDM expectation was to keep the can opener base clean. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, .The food service area is maintained in a clean and sanitary manner .All .equipment are kept clean .All equipment, food contact surface .are cleaned . 4. On May 20, 2024, at 9:22 a.m., a concurrent observation and interview was conducted in the kitchen with the CDM. The silver shelve used as drying rack had brown grime buildup. The CDM confirmed brown grime was rust. On May 20, 2024, at 9:36 a.m., a concurrent observation and interview was conducted with the CDM at the pot storage area. The silver shelves used to store clean kitchenware had brown grime. The CDM confirmed brown grime on the silver shelves was rust. The CDM stated shelves should not have rust because rust could get into clean kitchenware. The CDM stated her expectation was to keep kitchen equipment free from rust. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised dated November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner .All .shelves are kept clean, maintained in good repair and are free from .corrosions .that may affect their use or proper cleaning . 5. On May 20, 2024, at 9:18 a.m., a concurrent general initial kitchen tour observation and interview was conducted with the CDM. Brown/ black debris was found in the kitchen in the following areas: - Wall above exit door to dining room; - Wall around ice machine: - Wall next to exit door to back; - Blower above exit door to back; - Fans in Refrigerator number (#) 3 and # 4; - Shelves in dry storage; and - Two grey color housing for vent system in walk-in refrigerator; The CDM confirmed brown/black debris was dust found in the above areas. The CDM stated the kitchen should be kept free of dust because dust could cause cross contamination. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, .The food service area is maintained in a clean and sanitary manner. All kitchen, kitchen areas .are kept clean, free from .debris . 6. On May 20, 2024, at 3:15 p.m., a concurrent observation and interview was conducted with the CDM at the walk-in freezer. There was a pen, a highlighter, plastic wraps, debris and trash found on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 35 of 38 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 05/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm floor. The CDM verified a pen, a highlighter, plastic wraps, debris and trash were found on the floor. The CDM stated the floor should be kept clean. During a review of the facility's Policy & Procedure Manual (P&P) titled, Kitchen Floors, revised December 2009, the P&P indicated, Floors shall be maintained in a clean .and sanitary manner . Residents Affected - Some During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, dated November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner. All kitchen, kitchen areas .are kept clean, free from garbage and debris . 7. On May 20, 2024, at10:38 a.m., a concurrent observation and interview was conducted with the CDM. Surveyor A white napkin was used to to check for residue buildup inside the ice bin, and the white napkin came out with black grime. The CDM stated the food service employee must have missed to clean the deflector inside the ice bin. The CDM stated there was a potential risk of cross contamination since the ice in the ice bin could touch the deflector. The CDM stated her expectation was to keep the deflector clean. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner .All .equipment are kept clean . 8. On May 20, 2024, at 11:12 a.m., a concurrent observation and interview was conducted with the CDM in front of Refrigerator # 4. There were five out of five white shelves with worn off plastic coating inside Refrigerator # 4. The CDM verified the plastic coating on all the white shelves were worn off. The CDM explained exposed metal of the white shelves could turn to rust. The CDM expectation for the kitchen equipment to be in good repair and free from breaks or cracks. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner .All .equipment are kept clean, maintained in a good repair and are free from breaks .cracks and chipped areas that may affect their use or proper cleaning . 9. On May 20, 2024, at 3:12 p.m., a concurrent observation and interview was conducted with the CDM at main cook area. The vent above the stove was observed covered with grease and dust. The CDM confirmed the vent above stove was observed covered with grease and dust and stated it should keep clean. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner .All .equipment are kept clean . 10. On May 20, 2024, at 3:37 p.m., a concurrent observation and interview was conducted with the CDM at the walk-in freezer. There were several food items (fish fillet, beef patties and bacon) that were open and exposed to air in the walk- in freezer. The CDM stated having the opened food items (fish fillet, steal patties and bacon) exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the foods. The CDM stated her expectation was for the food service employees to seal the opened food items. During a review of the facility's Policy & Procedure Manual (P&P) titled, Freezer Storage, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 36 of 38 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 05/23/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some November 2022, the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practice .All foods stored in the .freezer are covered .Wrappers of frozen foods must stay intact until thawing . 11. During a review of the U.S. FDA (Food and Drug Administration) Food Code 2022, Section 4-204.11: Ventilation Hood System, Drip Prevention, the Food Code indicated, Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT . On May 20, 2024, at 10:47 a.m., a concurrent observation and interview was conducted with the dishwasher (DS) 1 and the CDM. There was condensation above the dish machine on the ventilation. DS 1 stated the steam from the dish machine cause the condensation on the ventilation. DS 1 stated he used to wipe down the condensation on the ventilation. The CDM stated the ventilation above the dish machine was not functioning. On May 21, 2024, at 10:58 a.m., an observation was conducted. There was condensation above the dish machine on the ventilation. 12. On May 20, 2024, at 12:51 p.m., a concurrent observation and interview was conducted with the CDM at the dining room. There were two microwaves in the dining room with a label indicating for resident's use and had yellow grime buildup inside the microwaves. The CDM verified the buildup inside the microwaves and stated the microwaves needed to be kept clean. During a review of the facility's Policy & Procedure Manual (P&P) titled, Sanitization, revised November 2022, the P&P indicated, .All .equipment are kept clean . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 37 of 38 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 05/23/2024 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 observation, interview, and record review, the facility did not implement and maintain infection control procedures when the licensed nurse did not disinfect a shared stethoscope between each resident use. Residents Affected - Few This failure had the potential to spread infection that could risk the health and well - being of 2 of 37 medically compromised residents (Residents 138 and 181). Finding: On May 21, 2024, at 9:01 a.m., Licensed Vocational Nurse (LVN 1) was observed using a stethoscope and checked Resident 181's blood pressure without cleaning the stethoscope in between residents. On May 21, 2024, at 9:37 a.m. an interview was conducted with LVN 1 regarding the process for cleaning a shared stethoscope between resident. LVN 1 stated I know I didn't clean it. LVN 1 added, It (stethoscope) should be cleaned each time before and after use. A review of Resident 181's admission Record, (summary of patient information), dated May 21, 2024, indicated Resdient 181 was initially admitted to the facility on [DATE], with a diagnosis of Fracture (broken bone) to Left Femur (long bone of the leg). A review of Resdient 138's admission Record, dated May 21, 2024, indicated Resident 138 was initially admitted to the facilty on May 3, 2024, with a diagnosis of right artifical hip joint (a surgical procedure to address hip pain). On May 21, 2024, at 12:26 p.m. an interview was conducted with the Infection Preventionist (IP). The IP stated there is a process for cleaning shared devices/equipment. The items need to be disinfected with purple wipes, Sani-Cloth (brand odf disinfectant wipes). The stethoscope should have been cleaned after each use. On May 21, 2024, at 3:46 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, the policy says to clean a stethoscope in between use, before going to the next resident. The facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 2022, indicated .Policy - Resident - care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC recommendations .Reusable Items are cleaned and disinfected or sterilized between residents ([example] e.g., stethoscopes) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 38 of 38