Inspection·February 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Form, dated January 23, 2025, at 9:55 p.m., indicated .behavioral symptoms .false allegations about staff .resident making false allegations, told daughter that she is being locked up, has no food and that the CNA pushed her .recommendation of primary .hospice nurse . A review of Resident G's care plan indicated Resident has been making false accusations toward staff: locking up all the food, not feeding her, not answering call light for over an hour, leaving her in the bathroom for hours, dated January 24, 2025. There was no care plan indicating Resident G's accusation that a CNA pushed her. On January 29, 2025, at 2:10 p.m., an interview was conducted with Resident G and her family member (FM). Resident G stated she received a shower from the hospice nurse last week, and two people she had not met before came in and grabbed her under each arm and pulled her out of bed to take a shower, and she was telling them to stop. On January 29, 2025, at 4:30 p.m., during an interview with the Directof Nursing (DON) and Administrator (ADM), the DON and the ADM stated they were not aware about the allegation of physical abuse by Resident G. The ADM and the DON stated they should have reported the allegation of abuse if they had known about it. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated, .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and are thoroughly investigated by facility management. Findings .are documented and reported .if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports .suspicion to the following persons or agencies .the state licensing/certification agency .the local/state ombudsman .adult protective services .law enforcement officials .notices include .the type of abuse that is alleged .date and time the alleged incident occurred .the name(s) of all persons involved in the alleged incident .what immediate action was taken by the facility . upon receiving an allegation of abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated .the investigator notifies the ombudsman that an abuse investigation is being conducted .the ombudsman is notified of the results of the investigation .within 5 business days of the incident, the administrator will provide a follow-up investigation report . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0610 Respond appropriately to all alleged violations. 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 a thorough investigation of an allegation of physical abuse was conducted, for one of three residents (Resident G), after the facility was made aware of the allegation of abuse. Residents Affected - Few This failure had the potential to result in further abuse for Resident G, which could affect the resident's emotional and psychosocial well-being. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 28, 2025, at 10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated an allegation of abuse was discussed during a stand up meeting on January 24, 2025, that Resident G reported to the licensed nurse at around 9 p.m., on January 23, 2025, a Certified Nursing Assistant (CNA) pushed her. On January 28, 2025, at 4:15 p.m., an interview was conducted with the Director of Medical records (DOMR). The DOMR stated stand-up meetings with all department heads were being conducted daily. The DOMR stated during the stand up meeting on January 24, 2025, Resident G was discussed regarding a change of condition indicating allegations made by the resident, such as no food, and a CNA pushed her. On January 28, 2025, at 4:40 p.m., a review of Resident G's medical record was conducted. Resident G was admitted to the facility on [DATE], with diagnoses which included cerebral atherosclerosis (condition where plaque builds up in the arteries in the brain, narrowing them and reducing blood flow) and depressive disorder (a mental health condition with low moods, loss of interest or pleasure in activities, with symptoms that interfere with daily functioning). A review of Resident G's Minimum Data Set (MDS - a resident assessment tool), dated November 23, 2024, indicated Resident G had a Brief Interview of Mental Status (BIMS) score of 13 (cognitively intact). A review of Resident G's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among residents) Communication Form, dated January 23, 2025, at 9:55 p.m., indicated .behavioral symptoms .false allegations about staff .resident making false allegations, told daughter that she is being locked up, has no food and that the CNA pushed her .recommendation of primary .hospice nurse . A review of Resident G's care plan indicated Resident has been making false accusations toward staff: locking up all the food, not feeding her, not answering call light for over an hour, leaving her in the bathroom for hours, dated January 24, 2025. There was no care plan indicating Resident G's accusation that a CNA pushed her. On January 29, 2025, at 10:15 a.m., an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated she spoke with Resident G on January 27, 2025, to do a follow up about the alleged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm abuse that she had heard about during the stand-up meeting on January 24, 2025. The MDSC stated Resident G's allegations regarding no food, she was locked up, and was pushed by a CNA, were discussed during the stand up meeting. The MDSC stated she did not agree Resident G's allegation of being pushed by a CNA was a false allegation. The MDSC stated how would the facility know it was a false allegation of being pushed by a CNA unless an investigation was conducted. Residents Affected - Few On January 29, 2025, at 2:10 p.m., an interview was conducted with Resident G and her family member (FM). Resident G stated she received a shower from the hospice nurse last week, and two people she had not met before came in and grabbed her under each arm and pulled her out of bed to take a shower, and she was telling them to stop. On January 29, 2025, at 4:30 p.m., during an interview with the Directof Nursing (DON) and Administrator (ADM), the DON and the ADM stated they were not aware about the allegation of physical abuse by Resident G. The ADM and the DON stated they would have investigated the allegation of abuse by Resident G if they would have known about it. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated, .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and are thoroughly investigated by facility management. Findings .are documented and reported .if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports .suspicion to the following persons or agencies .the state licensing/certification agency .the local/state ombudsman .adult protective services .law enforcement officials .notices include .the type of abuse that is alleged .date and time the alleged incident occurred .the name(s) of all persons involved in the alleged incident .what immediate action was taken by the facility . upon receiving an allegation of abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated .the investigator notifies the ombudsman that an abuse investigation is being conducted .the ombudsman is notified of the results of the investigation .within 5 business days of the incident, the administrator will provide a follow-up investigation report . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 three (Resident D, E, and F) of 13 residents (Residents D, E, and F), received treatment and care in accordance with professional standards of practice to meet each resident's highest practicable physical, mental, and psychosocial well-being, when: Residents Affected - Some 1. Resident D did not receive antibiotic (used to treat infection) medication as ordered by the physician. In addition, the topical treatments for Resident D's moisture associated skin damage (MASD - skin inflammation that occurs when the skin is exposed to moisture for a long time); 2. Resident E's neurocheck (a series of tests to check the brain, spinal cord, and nerve function) was not conducted according to the physician's order after the resident fell; and 3. Resident F was not administered medication to address constipation according to the physician's order. These failures have the potential to result in a delay in the care and treatment for Resident D, E, and F, and could have affect their overall health condition. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit was conducted for complaints of quality of care. 1. January 30, 2025, at 10:15 a.m., a review of Resident D's medical record was conducted. Resident D was admitted on [DATE], with diagnoses which include benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) with urinary tract infections. A review of Resident D's Treatment Administration Record (TAR) for December 2024 and January 2025 indicated the following treatments for Resident D's MASD were not documented as completed: - Triad Hydrophilic (a type of medication for wounds) wound dress external paste, apply to bilateral (both) buttocks every day shift for MASD and fungal; no documentation treatment was completed on the day shift of December 8, and December 13, 2024. - Ciclopirox External Gel 0.77%, apply to sacrococcyx (area below the spine to the tailbone)/buttocks every shift for MASD with fungal dermatitis (inflammation of skin); no documentation treatment was completed on December 8, and December 13, 2024. - Sacral (triangle shaped bone under spine) coccyx (tailbone) and bilateral buttocks MASD: clean with NS (normal saline), pat dry, apply barrier cream, leave open to air every shift, no documentation treatment was completed on January 19, and January 24, 2025. A review of Resident D's Medication Administration Record (MAR) dated December 2024, indicated the following: - Bactrim DS (an antibiotic used to treat an infection) 800-160mg (milligram-a unit of measurement) every 12 hours for a urinary tract infection was ordered to start December 2, 2024. The MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 indicated the dose for Bactrim on December 2, 2024, 9 p.m. dose was not administered as not available; Level of Harm - Minimal harm or potential for actual harm - Bactrim DS 800-160mg every 12 hours, ordered to start December 24, 2024, at 8:00 a.m.; the dose was not given as the medication was unavailable. Residents Affected - Some On January 30, 2025, at 4:15 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated Resident D has several treatments that were not documented as provided, the DON confirmed they were not completed. The DON stated the treatments should not have been missed and the Bactrim was in the medication room available in the emergency kit and should be given timely. 2. On January 30, 2025, at 11:50 a.m., a review of Resident E's medical record was conducted. Resident E was admitted on [DATE], with diagnoses which included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic balance) and dementia (a group of thinking and social symptoms that interfere with daily functioning). A review of Resident E's Progress Notes, indicated the following: - dated January 1, 2025, at 10:35 a.m.; .resident is AO (alert, oriented) X 2-3 (2-3 indicates oriented to person, place and time) with forgetfulness & (and) episodes of confusion. Resident was observed laying on the floor in supine (on back) position between her bed and the bathroom, her head was positioned underneath the bed next to a bedside table .resident noted with a knot to the back of her head .resident states she was trying to get into her wheelchair .and grab food from her bedside table and she slipped and fell . - dated January 2, 2025, at 10:27 a.m.; .IDT (Interdisciplinary Team - a group of healthcare professionals) me on 1/2/25 (January 2, 2025) to discuss fall on 1/1/25 (January 1, 2025) .Bump noted at the back of bed (sic) .continue neuro checks per facility protocol . A review of Resident E's Change of Condition Evaluation, dated January 1, 2025, at 10:26 a.m., indicated, .noted resident not in bed .observed resident on floor .resident laying on back on the left side of the bed, head under roommates [sic] wheelchair, naked .brief off .resident stated she was trying to get up for breakfast but unable to answer how she got onto the floor . Further review of Resident E's record indicated there was no documented evidence a neuro check log was completed for Resident E's after the fall on January 1, 2025. On February 4, 2025, at 10:15 a.m., conducted an interview with the DON. The DON stated neuro checks were ordered for Resident E on January 1, 2025, but no documentation of the neurocheck completed could be found. 3. On January 31, 2025, at 3:30 p.m., an interview with Resident F was conducted. Resident F stated she wants to have normal bowel movements; she has been constipated for a long time. On January 31, 2025, a review of Resident F's medical record was conducted. Resident F was admitted to the facility on [DATE], with diagnoses which included Parkinson's dementia (a change in thinking and problems with memory) and psychosis (a mental disorder characterized by a disconnection from reality) with hallucinations (perceiving things that are not actually present, hearing voices, seeing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 objects). Level of Harm - Minimal harm or potential for actual harm A review of Resident F's Order Sunnary Report, included the following physician's orders to address constipation: Residents Affected - Some - .Milk of Magnesia Oral Suspension (MOM) .Give 30 ml (milliliter - unit of measurement) by mouth as needed .Give if no BM (bowel movement) x (times) 3 (three) days .; date ordered January 1, 2025; - Bisacodyl Rectal Suppository (administered via the rectum/anus) .Insert 1 suppository rectally as needed for Bowel Management if MOM (Milk of Magnesia) is ineffective after 8 (eight) hours give suppository .; date ordered January 1, 2025; and - Fleet Enema Rectal Enema (a [NAME] pe of rectal enema used to relieve constipation and prepare the bowels for medical procedures) .Insert 1 applicator rectally as needed .if suppository is ineffective after 8 hours administer Enema .; date ordered January 1, 2025. A review of Resident F's Care Plans indicated the following: - Alteration in comfort, dated January 2, 2025, Interventions included Hospice nurse to assess resident's bowel movement pattern each visit. - At risk for constipation, dated January 3, 2025, Goal: will have BM (bowel movement) every 2-3 days, interventions: Medication as ordered [Milk of Magnesia, Bisacodyl Rectal suppository, fleet enema]. Monitor for effectiveness of medication. Inform MD (medical doctor) promptly if ineffective. Monitor bowel movements for frequency, amount, and consistency. Monitor for signs of complications related to constipation. Monitor medications to see if causing constipation. A review of Resident F's Tasks: Bowel Continence, dated January 1, to January 31, 2025, indicated no bowel movement documented on January 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, and 26, 2025. A review of Resident F's Medication Administration Record (MAR), for January 2025, indicated MOM, bisacodyl, dulcolax suppository, and fleet enema were not documented as administered to Resident F when the resident did not have BM on several days in January 2025. On January 31, 2025, at 4 p.m., an interview was conducted with the DON. The DON stated Resident F should be having bowel movements every two to three days. The DON stated if Resident F would not have BM for three or more days, the nursing staff should be medicating the resident with milk of magnesia, rectal suppositories or be given an enema. A review of the facility's policy titled Change in a Resident's Condition or Status, dated February 2021, indicated, .changes in the resident's medical/mental condition and/or status .accident or incident involving the resident .significant changes in the resident's physical/emotional/mental condition .specific instruction to notify the physician of change in the resident's condition .impacts more than one area of the resident's health status .requires interdisciplinary review and/or revision to the care plan . A review of the facility's policy titled Administering Medications, dated April 2019, indicated, .medications are administered in accordance with prescriber orders, including any time frame. Medication administration times are determined by resident needs and benefit, not staff convenience. Factors (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Village Healthcare Center 2400 West Acacia Avenue Hemet, CA 92545 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that are considered include .enhancing optimal therapeutic effect of the medication .medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .as required or indicated for a medication .the date and time the medication was administered .topical medications used in treatment are recorded on the resident's treatment record (TAR) . A review of the facility's protocol titled Bowel .Disorders-Clinical Protocol, dated September 2017, indicated, .lower gastrointestinal tract conditions .alteration in bowel movements .the nurse shall assess and document/report .presence of fecal impaction .digital rectal examination .all current medications .staff and physician will identify risk factors related to bowel dysfunction .taking medications that are used to treat, or may cause or contribute to dysmotility .identify current medications that are associated with gastrointestinal side effects .antipsychotics and antidepressants .institute a regimen to prevent constipation .monitor the individual's response to interventions .frequency and consistency of bowel movements . A review of the facility's policy titled Wound Care, dated October 2010, indicated, .to provide guidelines for the care of wounds to promote healing .documentation .type of wound care given, the date and time wound care was given .all assessment data .wound bed color, size, drainage .notify supervisor if the resident refuses the wound care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure accurate skin assessments and wound care treatment were provided to promote the healing and prevention of new pressure injuries from developing, for three of 13 residents (Residents A, B, and C). Residents Affected - Some These failures have the potential to result in delayed wound healing. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate quality of care and treatment complaints. On January 28, 2025, at 2 p.m. an interview was conducted with the Treatment Nurse (TN). The TN stated if a resident develops a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), the Certified Nursing Assistants (CNA) are usually the first ones to notice and would report their findings of the wound to her. The TN stated she would conduct the following procedures when a resident was identified with a pressure ulcer/injury: - Evaluate the resident's skin; - Measure the wound; - Write a description of the wound (color, drainage, odor); - Call the provider to let them know there is a change in the resident and get an order for treatment; - Fill out a change of condition (COC) form, write the change in the communication book for the other licensed nurses to monitor the resident for 72 hours; and - Initiate or revise a care plan for the wound with interventions. The TN stated the admitting nurse does the initial skin assessment when a resident is admitted and then she would perform a secondary skin assessment as a follow up. 1. On January 28, 2025, at 2:45 p.m., a review of Resident A's medical record was conducted. Resident A was admitted on [DATE], with diagnoses which included metabolic encephalopathy (a condition where the brain does not function properly due to an imbalance in the body's metabolism) and septic shock (a widespread infection causing organ failure). A review of Resident A's Skilled Nursing admission Assessment, dated January 2, 2025, at 6:50 p.m., indicated, .skin .bilateral (both) heels discoloration .bilateral buttocks Pressure stage 1 (one) .coccyx (tailbone) pressure stage 1(one) . A review of Resident A's admission Summary, dated January 2, 2025, at 9:42 p.m., indicated, .skin assessment .non blanchable (does not fade when pressure is applied) redness to bilateral buttocks and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some coccyx .RT (right) heel red, maroon and mushy, zero open .Lt (left) heel, red, [NAME] [sic] and mushy, zero open . A review of Resident A's Treatment New admission Risk Assessment, dated January 3, 2025, at 1:10 p.m., indicated, .pressure ulcer #1 .Coccyx pressure ulcer . stage 1 (one) .treatment repositioning .pressure ulcer #2 .buttocks .stage 1 (one) .treatment repositioning .non blanchable redness noted to bilateral buttocks and coccyx. Redness to bilateral heels also noted. Discussed the importance of repositioning often while in bed . A review of Resident A's Change of Condition Evaluation, dated January 5, 2025, at 5:46 p.m., indicated, .skin wound or ulcer .requires extensive assistance for repositioning .open area .left gluteal (buttocks) fold .right gluteal fold . A review of Resident A's Health Status Note, dated January 5, 2025, at 6:20 p.m., indicated, .asked by CNA (Certified Nursing Assistant) to look at patients [sic] coccyx during AM (morning) shift .redness to coccyx area noted, open areas noted. Triad (a type of ointment for wound care) applie . A review of Resident A's Treatment Nurse Weekly Skin Assessment, indicated the following: - dated January 10, 2025, at 10:52 a.m., indicated, .seen by wound consultant .bilateral buttocks MASD (moisture-associated skin damage-a condition causing skin damage due to prolonged exposure to moisture, such as urine, sweat, or wound drainage) with open areas: has scant serous (clear watery fluid) drainage .clean with NS (normal saline-a fluid containing sodium chloride, used to irrigate wounds), apply barrier cream (a cream applied to the skin to create a protective layer) . - dated January 17, 2025, at 10:48 a.m., indicated, .seen by wound consultant .bilateral buttocks MASD and open areas: 50% slough (a type of dead tissue that forms in wounds) is present in open areas. Has light serous drainage .continue with treatment .clean with NS (normal saline), apply with barrier cream to surrounding area and Santyl (an ointment used to remove damaged tissue from skin ulcers) to open area . - dated January 24, 2025, at 12:16 p.m., indicated, .Coccyx PI (pressure injury), grade 2 (two), 0.5cm x 0.4cm x 0.1cm (centimeter-a unit of measurement) .Right buttock PI grade 3 (three), 0.5cm x 0.6cm x 0.1cm .Sacrum (triangle shaped bone at the base of the spine) PI grade 3 (three), 1.0cm x 0.4cm x 0.2cm .Left Inferior (lower) buttock PI grade 3 (three), 0.7cm x 0.6cm x 0.1cm .Left Superior (upper) buttock PI grade 3 (three), 2.0cm x 2.0cm x 0.2cm . On January 29, 2025, at 3:15 p.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN was the treatment nurse until January 23, 2025. A review of Resident A's treatment note, dated January 9, 2024, indicating non blanchable redness to bilateral buttocks, the RN stated it should have been documented as a stage one pressure injury. The RN stated she put in an order to monitor Resident A's skin, she cannot find documentation of monitoring in the progress notes or the treatment administration record (TAR). 2. On January 29, 2025, at 12 p.m., a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE]. 2024, with diagnoses which included cardiac pacemaker and urinary tract infection. A review of Resident B's Treatment Nurse New admission Risk Assessment, dated January 9, 2025, at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm 10 a.m., indicated, .is there a pressure ulcer on admission .No .narrative .non-blanchable redness noted to bilateral buttocks . A review of Resident B's Treatment Administration Record (TAR), dated January 2025, indicated the following: Residents Affected - Some - Bilateral buttocks non blanchable redness; cleanse with NS (normal saline), pat dry, apply triad, leave open to air, start date January 16, 2025. - Sacrococcyx pressure injury unstageable: cleanse with NS, pat dry, apply barrier cream to peri wound (area around the outside), and on open area apply collagen alginate and dry dressing, start date January 18, 2025. - Sacrococcyx unstageable: cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply Santyl, and dry dressing, start date January 25, 2025. A review of Resident B's Treatment Nurse Weekly Skin Assessment, indicated the following: - dated January 17, 2025, at 2:35 p.m., indicated, .open ulcer .yes .seen by wound consultant .sacrococcyx unstageable measuring 4.9cm x 4.0cm x unstageable with 90% granulation, 10% purple. Moderate serosanguinous drainage, treatment order to cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply collagen, alginate, and dry dressing . - dated January 24, 2025, at 1:24 p.m., sacrococcyx pressure area 4.5cm x 6.2cm x UTD (undetermined) with 70% granulation, 30% slough. Light Serosanguinous drainage. Treatment orders to cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply Santyl ointment, and dry dressing. On January 29, 2025, at 3:15 p.m., the RN stated Resident B's admission note for January 9. 2025, indicated there was non-blanchable redness to his bilateral buttocks, this should have been noted as a stage one pressure injury, treatment should have been started when it was initially identified (January 9, 2025), and a care plan should have been created. The RN stated there was still notable non-blanchable redness to Resident B's sacrococcyx area and a treatment was ordered on January 16, 2025 (seven days after it was initially identified). On January 31, 2025, at 2:30 p.m., an interview was conducted with the TN. The TN stated open areas to the buttocks or other pressure areas, changes the classification of a pressure injury. The TN stated open areas need to be measured, and a description, and appropriate treatment orders should be obtained. The TN stated pressure areas with non-blanchable redness is a stage one pressure injury, appropriate treatment includes repositioning, in addition to monitoring closely, to only reposition a resident is not a standard of practice. The TN stated if a stage one pressure injury has an open area, the wound needs to be recategorized to a stage two pressure injury. The TN stated once a skin concern is noted it needs to be addressed in the weekly skin notes and a wound with slough needs to be recategorized as a stage three pressure injury as a standard of practice. The TN stated when using Santyl on a wound, it must be cover with dressing to work as an autolytic (breakdown of cells and tissue by enzymes) for debridement (involved removing dead, infected, damaged tissue from a wound or ulcer), it cannot be left open to air, the medication would not be able to work properly. 3. On January 31, 2025, at 9:00 a.m., a review of Resident C's medical record was conducted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident C was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or complete paralysis of all four limbs) and pressure injury to his left buttock, stage 4 (four). A review of Resident C's Order Summary Report, indicated: - Foley Catheter (a thin flexible tube inserted into the bladder to drain urine) care every shift with Chlorhexidine Gluconate (a special soap used to clean skin and protect against germs) 2% cloth, cleanse tube from urethral meatus (the external opening where urine comes out) to inner thigh, clean downward every shift, ordered November 23, 2024. - Left buttock, skin bridge wound: cleanse with NS, pat dry, apply dry dressing every day shift, ordered November 1, 2024. - Scrotum cleanse with normal saline, pat dry, apply Nystatin (antifungal medication) cream every shift for redness, ordered December 20, 2024. A review of Resident B's Treatment Administration Record (TAR), for December 2024 and January 2025, indicated no documentation treatments were completed for: - Left buttock pressure injury stage 4 (four), clean with NS, apply triple ABT ointment with collogen powder to wound bed, pack with calcium alginate including the tunneling area, cover with dry dressing, on December 9, 2024. - Foley Catheter care every shift with chlorhexidine gluconate 2% cloth cleanse tube from urethral meatus to inner thigh, on night shift December 7, 2024, January 19, and January 24, 2025. - Scrotum cleanse with normal saline, pat dry, apply zinc cream twice daily and as needed for redness, on December 7, 2024. - Scrotum cleanse with normal saline, pat dry, apply nystatin cream, every shift for redness, started on December 20, 2024, on night shift January 19 and January 24, 2025. -Left buttocks stage 4 (four), skin graft in place, followed by xeroform, gauze, Tegaderm, then border dressing, replace outer dressing if soiled, every shift, started on January 17, 2025, on night shift January 19/2025, night shift. On January 31, 2025, at 4 p.m., the DON stated Resident B is very particular about who he allows to perform his urinary catheter care, his catheter care is important because he gets urinary tract infections often, and it is important to make sure he is receiving wound care consistently. There was no documentation in the TAR that the treatment orders were done. The DON stated the treatments need to be completed as ordered. A review of the facility's Job Description-LVN Treatment Nurse, indicated, .daily assesses the total needs of the resident and develops nursing care plans .prepares, administers, and charts medications according to the physician's order .responsible for interpretation and execution of the physician's orders .accurate observations, evaluations and reporting of resident's symptoms . A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm April 2018, indicated, .the nurse shall describe and document/report the following .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions .Guide the care plan .especially when wounds are not healing .or new wounds develop despite existing interventions . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, when: Residents Affected - Many 1. Stacks of dirty pots, pans, and dishes in the three-sections sink area, several with food on them and more dirty dishes noted on a metal shelf across from the three-section sink, one filled with an egg like mixture. 2. Food particles, crumbs, a cookie, broken eggshells, a plastic bowl, and various wrappers were under the stoves and ovens. This failure had the potential to attract further rodents in the kitchen who could transmit disease to 43 of 44 medically compromised residents by contaminating food and food contact surfaces. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding dietary services. On January 27, 2025, at 11:30 a.m., an observation and concurrent interview was conducted with the Dietary Supervisor (DS). The DS stated the kitchen crew cleans the kitchen three times a day, after each meal is completed. During the kitchen tour with the DS, the following were observed: - Stacks of dirty pots, pans, and dishes were observed in the three-compartment sink area, several with food still on them; - Multiple dirty dishes were observed on a metal shelf across the three-compartment sink; - Food particles, crumbs, a whole cookie, broken eggshells, a plastic bowl, and various wrappers were observed under the stoves and ovens. The DS looked under the ovens and stoves, and stated it was very dirty. The DS stated the kitchen staff did not have time to clean up after breakfast. The DS stated the breakfast dishes in the three-comparetment sink would be cleaned up after lunch is served as they were not able to wash the dishes yet. On January 27, 2025, at 12:30 p.m., a review of the pest control service report for the facility, dated November 2024 - January 2025 indicated the following: - November 22, 2024, .mice caught in interior traps in kitchen near exit doors. Doors need to be closed at all times. Rodent activity present .Observation .dead .mice .flies .grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves dry shelves, cooking stations .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . - December 18, 2024, .Rodent activity present .earwig (nocturnal insects that often hide in small, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 moist crevices during the day, and are active at night, feeding on a wide variety of insects and plants) activity present .observation .dead .earwigs .kitchen . grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves dry shelves, cooking stations .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . Residents Affected - Many - January 24, 2025, .Rodent activity present .gnat (a very small flying insect that bites animals and people) and earwig activity present .observation .dead .fungus gnats .kitchen .open actions .grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . A review of the facility document titled, Cooks Weekly Cleaning List, indicated no documentation cleaning was performed on December 8, 9, 10, 18, 19, 27, 28, and 29, 2024. A review of the facility document titled, Cooks Weekly Cleaning List, dated January 13 to 19, 2025, indicated, the following areas were cleaned on January 25, 2025 (six days after the dates indicated to clean): - .both plate and pellet warmers and floors underneath .; - .convection oven .; and - .Fryers inside, outside, and underneath . A review of the facility document titled, Servers Cleaning List, indicated no documentation cleaning was performed on December 12, 13, 22, 23, 24, and 25, 2024. A review of the facility document titled, Servers Cleaning List, dated January 16 to January 22, 2025, indicated no documentation the following tasks were completed: - .wash dirty plastic containers in dry storage room. (may run containers that fit in dish machine .please make sure you are checking .any loose items on the shelves the containers are on.) .; - .clean black/brown condiment containers that hold the salad dressing & jelly/butter. (run thru dish machine) make sure to put dates . ; - .clean shelf area where blue lids container sit, brown sugar container sits and under tray line shelves. Clean inside and outside of bread warmers. Clean shelves where servers' gloves are under tray line .; - .scrub servers sink, clean walls in sink area, clean trash can, wipe down paper towel and soup (sic-soap) dispenser and clean tan drain box under sink .; - .sweep and mop under cold, dry, juice machine, movable units .; and - .clean and defrost ice cream freezer inside, bottom, sides and run ice cream freezer covers in the dish machine . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555463 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2025 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 A review of the facility document titled, Dishwasher and Pot Washer Weekly Cleaning List, indicated no documentation cleaning was performed on December 10, 18, 19, 27, 28, 29, 2024. A review of the facility document titlted, Dishwasher and Pot Washer Weekly Cleaning List, indicated no documentation the following tasks were completed on the following dates: Residents Affected - Many - dated December 30, 2024, to January 5, 2025, .plastic storage/sheet pan and cup rack (with wheels) the wall behind and the floor underneath .garbage disposals . - dated January 6 to 12, 2025, .garbage disposals .all trash cans large and small, take out back and use soap, scrubbie [sic] and hose to clean theses thoroughly . On January 27, 2025, at 4:00 p.m., an interview was conducted with the DS. The DS stated the cleaning lists should represent seven (7) to ten (10) days at a time, if it states daily , it means the cleaning task should be completed every day during the week, the initials or name meant it was done every day. The DS stated she did not know why there were tasks with no names, dates, or initials on them, or if the date listed indicated it was done outside of the weekly cleaning tasks. The DS stated she understands if there was no documentation on the weekly cleaning lists, it looks as if the cleaning was not done, and daily cleaning tasks should contain initials with a date for each day the area was cleaned. The DS stated it could be confusing when looking at the cleaning lists which tasks were supposed to be done weekly and which ones were supposed to be done daily. The DS stated if the kitchen was not being cleaned on a daily and weekly basis it could increase the possibilities of rodents and insects, and may lead to food borne illnesses. A review of the facility's policy titled Sanitization, dated November 2022, indicated, .the food service area is maintained in a clean and sanitary manner .kitchens, kitchen areas .are kept clean, free from garbage and debris, and protected from rodents and insects .manual washing and sanitizing is a three-step process .scrape food particles and wash using hot water and detergent .waste is properly contained in a dumpster/compactor with lids .areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555463 If continuation sheet Page 16 of 16