Inspection·June 22, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/22/23 at 11:48 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 51, in Resident 3's room. LN 51 stated, His view is not the best. I think we could do better. Staff should advocate for the residents who can't speak for themselves. On 6/22/23 at 11:57 A.M., an interview was conducted with Manager (MGR) 51. MGR 51 stated, We want residents to feel at home and comfortable, we can do better for him. The facility was unable to provide a policy regarding a clean, homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 2 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment tool) was accurately coded for one of 18 residents (Resident 63) reviewed for accurate MDS. Residents Affected - Few This failure had the potential for Resident 63 to receive inappropriate care due to inaccurate diagnosis. Findings: A review of Resident 63's admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses to include Traumatic Brain Injury (brain dysfunction caused by an outside force). Resident 63's MDS indicated a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that can develop because of exposure to a traumatic event). During an observation and an interview on 6/20/23 at 4:32 P.M. with certified nursing assistant (CNA) 25, Resident 63 was seen up in a wheelchair, watching tv in room with a mask on. CNA 25 stated Resident 63 was cooperative and did not have any behavioral concerns. During a concurrent interview and record review on 6/22/23 at 9 A.M., with the minimum data set nurse (MDSN), the MDSN reviewed Resident 63's MDS dated [DATE] section I-16100. The MDSN stated Resident 63 did not have a diagnosis of PTSD , and the MDS was coded incorrectly. The MDSN stated MDS assessments should be accurately coded because the MDS dictated the care the resident should be receiving. A record review of the facility's Policy and Procedure Plan and Guideline dated 10/98, indicated, .D. Each individual who completes a portion of the assessment sign and certify the accuracy of that portion of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 3 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 observation, interview and record review, the facility failed to implement a care plan related to pressure ulcers (an injury to skin and tissue usually caused by pressure) for one of eight residents reviewed for pressure ulcers (Resident 59). This failure had the potential for poor communication among care providers. Findings: Resident 59 was admitted to the facility on [DATE]. Observations were conducted as follows: On 6/21/23 at 1 P.M., Resident 59 was lying in bed on her back. On 6/21/23 at 2 P.M., Resident 59 was lying in bed on her back. On 6/21/23 at 3 P.M., Resident 59 was lying in bed on her back. On 6/21/23 at 4 P.M., Resident 59 was lying in bed on her back. On 6/21/23, a record review was conducted. Resident 59's care plan indicated Resident 59 was to be turned and repositioned every one to two hours. During an interview on 6/21/23 at 10:02 A.M., with certified nursing assistant (CNA) 25, CNA 25 stated a pressure ulcer could develop if residents were not turned and repositioned at least every two hours. During an interview on 6/21/23 at 4:38 P.M., with CNA 26, CNA 26 stated Resident 59 was dependent on staff for bed mobility and should be turned every one to two hours. During an interview on 6/22/23 at 2:43 P.M., with the director of nursing (DON), the DON stated, Resident 59 should have been turned every one to two hours as indicated in the resident's care plan to ensure Resident 59 did not develop a pressure ulcer. The DON stated Resident 59's care plan should have been implemented. A review of the facility's policy on care planning did not provide guidance related to the implementation of care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 4 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise a resident care plan related to communication for one of 18 residents (Resident 63). This failure had the potential for Resident 63's specific care needs and interventions to not be communicated and addressed by healthcare professionals. Findings. A review of Resident 63's admission Record indicated that Resident 63 was admitted to the facility on [DATE] with diagnoses Status Post Motor Vehicular Accident, Subarachnoid Hemorrhage, (a bleeding in the space between the brain and the tissue covering the brain) and Traumatic Brain Injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). During a concurrent observation of Resident 63 and interview of certified nursing assistant (CNA) 26 on 6/20/23 at 4:32 P.M., Resident 63 was seen sitting up in wheelchair, watching tv in his room. CNA 26 stated, Resident 63 was non-verbal and communicated by hand gestures and by using an electronic tablet. During a concurrent interview and record review with licensed nurse (LN) 22 on 6/21/2022 at 9 A.M., LN 22 stated, Resident 63 was able to speak words in the past. LN 22 stated that currently, Resident 63 communicated by hand gestures and by using an electronic tablet. Resident 63 was speaking few months after admission, but at present Resident 63 uses hand gestures only. Speech evaluation record on 6/21/2023 indicated Resident 63 was conversant with a conversation level of 90% and verbal expression of 75%. Resident 63 continues with speech treatment. During an attempt to interview Resident 63 on 6/22/2023 at 7:59 A.M., Resident 63 gave a thumbs up when called by name. Resident 63 did not provide verbal responses when questions were asked. Resident 63 replied to all questions with thumbs up. During a concurrent interview and record review with LN 22, on 6/22/2023 at 8:35 A.M., LN 22 reviewed Resident 63's care plan. The care plan indicated Resident 63's speech was clear. LN 22 stated Resident 63's care plan should have been updated to reflect the resident's current mode of communication which was through hand gestures and with a use of an electronic tablet. LN 22 stated revising the resident's care plan was important to ensure that the current care needs and interventions were communicated to all healthcare providers. A review of the facility's policy and procedure titled, Care Plan / Interdisciplinary Care Conference, dated 1/12/2022, indicated .care plans are reviewed and revised by the interdisciplinary team (IDT- a group of professionals all working collaboratively toward a common goal) members as needed, weekly with significant changes and at least quarterly FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 5 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 observation, interview and record review, the facility failed to provide skin assessment and wound treatment to one of three residents (Resident 47) when Resident 47's eschar (dead tissue) was not assessed and treated per physician's orders. Residents Affected - Few This failure had the potential to worsen the condition of Resident 47's wound, with the potential of infection. Findings: Resident 47 was admitted to the facility on [DATE] with diagnoses to include respiratory failure (an inability to breathe independently), per the Medical Record. During an observation on 6/19/23 at 9:05 A.M., inside Resident 47's room, Resident 47's great toe appeared to be brownish/gray in color, with a scaly appearance. A follow up observation of Resident 47 and interview with Licensed Nurse (LN) 31 was conducted on 6/19/23 at 2:59 P.M. LN 31 stated Resident 47 had eschar on his right big toe. LN 31 stated Silvadene (a medication to treat wounds) was being used to treat Resident 47's eschar. On 6/19/23, a record review was conducted. Per Resident 47's wound care order, dated 5/1/23, Resident 47 was to receive daily treatment of the wound with Silvadene cream to the eschar. Per Resident 47's treatment record, no assessments or treatments were indicated as completed on 6/12/23, 6/15/23, 6/16/23, and 6/17/23. During a concurrent interview and record review with LN 31 on 6/19/23 at 3 P.M., LN 31 stated Resident 47's eschar was not assessed and treated on 6/12/23, 6/15/23, 6/16/23, and 6/17/23. LN 31 stated missing the treatments could make the eschar worse. During an interview with the Director of Nursing (DON) on 6/22/23 at 11:05 A.M., the DON stated staff should follow wound orders to treat and prevent infection. The facility was unable to provide a policy regarding following physician orders for wound treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 6 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 observation, interview and record review, the facility failed to consistently provide treatment for pressure ulcer (skin injury due to pressure) prevention to two of eight residents (Residents 17, 59). Residents Affected - Few This failure had the potential for Residents 17 and 59 to develop pressure ulcers. Findings: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses to include respiratory failure (failure to breathe on her own), per the Medical Record. On 6/20/23, a record review was conducted. Resident 17's physician order, dated 5/25/23, indicated a treatment order for the tail bone wound to be cleansed with wound cleanser, then be covered with Xeroform (a dressing that covers a wound) twice a day. During an observation of Resident 17 and interview with Licensed Nurse (LN) 32 on 6/21/23 at 8:49 A.M., the tail bone did not have a Xeroform dressing and there was no dressing anywhere in the linen or the bed. LN 32 stated she had not removed the dressing, and stated, Without finding the old dressing, there is no proof the nurse placed the Xeroform dressing. An interview conducted with LN 32 on 6/21/23 at 9 A.M. LN 32 stated Resident 17's tail bone wound should have been treated and assessed every shift and treatment provided per physician's order to prevent further damage of the skin. During a concurrent interview and record review with LN 33 on 6/21/23 at 12:10 P.M., LN 33 stated there was no skin assessment and wound treatment documented by the night shift (11 P.M. - 7 A. M.) LN. An interview was conducted with the Director of Nursing (DON) on 6/22/23 at 12:30 P.M. The DON stated LNs should follow the prescribed wound treatment to every resident to facilitate healing and prevent further damage. Per a facility policy, titled Pressure Ulcer Prevention and Management, effective May 2023, .11. The RN will monitor the impact .16. The facility will continue to follow the process to prevent and treat .pressure ulcers . 2. Resident 59 was admitted to the facility on [DATE] per the Medical Record. Observations were conducted as follows: On 6/21/23 at 1 P.M., Resident 59 was lying in bed on her back. On 6/21/23 at 2 P.M., Resident 59 was lying in bed on her back. On 6/21/23 at 3 P.M., Resident 59 was lying in bed on her back. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 7 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 On 6/21/23 at 4 P.M., Resident 59 was lying in bed on her back. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/21/23 at 10:02 A.M., with Certified Nursing Assistant (CNA) 25, CNA 25 stated a pressure ulcer could develop if residents were not turned and repositioned at least every two hours. Residents Affected - Few During an interview on 6/21/23 at 4:38 P.M., with CNA 26, CNA 26 stated Resident 59 was dependent on staff for bed mobility and should be turned every one to two hours. During an interview on 6/22/23 at 2:43 P.M., with the Director of Nursing (DON), the DON stated Resident 59 should have been turned every one to two hours to help prevent the development of pressure ulcers. A record review of the facility's policy, titled Pressure Ulcer Prevention and Management, effective May 2023, indicated, .16. The facility will continue to follow the process to prevent and treat .pressure ulcers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 8 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 observation, interview and record review, the facility failed to: 1. Ensure two of 18 sampled residents (Residents 1, 31) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: a. Non-pharmacological intervention that is specific for Resident 1's behavior was not implemented. b. Resident 31's as needed Lorazepam (medication used to treat anxiety) was administered beyond the 14 days ordered. c.There was no documentation of the rationale for extending Resident 31's as needed Lorazepam. 2. Monitor for the appropriate indication for the use of a psychotropic medication. These failures had the potential for increased risks associated with psychotropic medication use that include but are not limited to sedation, respiratory depression, falls, constipation, anxiety, weight gain, confusion, abnormal involuntary movements, memory loss, and may result in poor resident outcome. Findings: 1a. A review of Resident 1's clinical record indicated resident was recently readmitted with diabetes mellitus (A group of diseases that result in too much sugar in the blood [high blood glucose]) without complications, chronic dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified psychosis. Review of Resident 1's medication order dated 5/25/22, showed aripiprazole (an antipsychotic medication, used to treat psychosis [a severe mental disorder in which a person loses the ability to recognize reality or relate to others]) 7.5 milligrams (mg, unit of measurement) feeding tube (FT) at bedtime for unspecified psychosis manifested by continuous screaming and spitting at staff. Review of Resident 1's medication order dated 6/29/22 showed lorazepam (medication used to treat anxiety) 0.5 mg daily through FT for anxiety manifested by combativeness and hitting staff. During the survey, Resident 1 was observed on multiple occasions: on 6/20/23 at 8:53 A.M.; at 9:25 A.M.; and at 3:30 P.M. During these observations, the resident was observed to be quiet, alert, pleasant, and watching television. On one of the occasions, Resident 1 was observed talking to a certified nursing assistant in an almost inaudible voice at bedside. There was no screaming, agitation, distress, spitting, hitting, or verbal aggressiveness observed. During an interview on 6/21/23 at 8:53 A.M., Licensed Nurse 1 stated the facility implemented non-pharmacological approaches but was not able to show documentation. Review of Resident 1's medical record indicated on 6/3/23 and 6/4/23, Resident 1 did not exhibit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 9 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 any of the behaviors being monitored for psychosis and anxiety; however Resident 1 had aroma therapy on 6/3/23 and music therapy on 6/4/23. Further record review showed Resident 1 had episodes of psychosis seven times and anxiety six times on 6/9/23; however, had a music therapy that day. No Resident 1's specific intervention was documented for these episodes of psychosis and anxiety. During a concurrent interview and record review on 6/21/23 at 2:10 P.M., the Long-Term Care (LTC) Nurse Manager stated the facility provided aroma therapy and music therapy to all residents. The LTC Nurse Manager was unable find any documentation for implementation of Resident 1's specific non-pharmacological intervention for the behaviors exhibited. During an interview on 6/22/23 at 7:30 A.M., the LTC Nurse Manager stated the facility implemented several non-pharmacological interventions specific to Resident 1's behaviors but they were not documented. Review of the facility's Policy & Procedures (P&P) titled Monitoring of Antipsychotic Medications dated 5/11/22, indicated .non-pharmacological behavior modification activities and their effects, as well as the effect of pharmacological behavioral modifiers, are addressed in nursing notes in the resident's chart and in the resident care planning . Review of the facility's P&P titled Monitoring of Anxiolytic (used to reduce anxiety) Medications, dated 5/11/22, indicated .non-pharmacological behavior modification activities and their effects, as well as the effect of pharmacological behavioral modifiers, are addressed in nursing notes in the resident's chart and in the resident care planning . 1b. A review of Resident 31's clinical record indicated resident was recently readmitted with tracheostomy, respiratory distress, and past medical history of anoxic brain injury after ventricular fibrillation (A life-threatening heart rhythm that results in a rapid, inadequate heartbeat) cardiac arrest. Review of Resident 31's medication order of 5/20/23, showed lorazepam 0.5 milligrams (mg, unit of measurement) intravenous push (IVP into the blood stream) every 2 hours as needed for respiratory distress or mild restlessness for 14 days (5/20/23 to 6/3/23). Review of Resident 31's medication administration record (MAR) showed lorazepam 0.5 mg IVP was administered on 6/5/23 at 2:30 A.M. Further review of Resident 31's medication order did not show an active lorazepam order between 6/3/23 (when the previous order was completed) and 6/5/23 (when lorazepam IVP was administered). During a concurrent interview and record review on 6/22/23 at 9:05 A.M., the Subacute Nurse Manager stated her expectation for the nurses to give the right medication for the right indication to the right resident. The nurses are expected to make sure the resident is assessed and parameters checked prior to giving the medication. The Subacute Nurse Manager stated lorazepam was administered on 6/5/23 because the medication was still on the MAR. 1c. Review of Resident 31's medication order of 6/18/23, showed lorazepam 0.5 milligrams IVP every 2 hours as needed for respiratory distress or mild restlessness for 14 days (6/18/23 to 7/2/23). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 10 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 Review of the providers progress notes of did not show any rationale for extending lorazepam IVP as needed order beyond 14 days. During a concurrent interview and record review on 6/22/23 at 9:05 A.M., the Subacute Nurse Manager was unable to find any documentation in the physicians' progress notes indicating the reason or rationale for extending the lorazepam order. Review of the facility's Policy & Procedures titled Monitoring of Anxiolytic Medications, dated 5/11/22, indicated .if the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the as needed order . 2. A review of Resident 58's admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses to include Downs Syndrome with Developmental delay, and Anxiety. A review of Resident 58's physician order dated 10/25/21 indicated Abilify 5 mg per mouth daily for Psychosis and the behavior being monitored was undressing self. During a joint observation of Resident 58 and interview with certified nursing assistant (CNA) 25 on 6/19/23 at 3:31 P.M., Resident 58 was seen up in wheelchair in the hallway. CNA 25 stated Resident 58 was cooperative with care and preferred to be up in the wheelchair for most of the day. CNA 25 stated Resident 58 would get upset when taken back to bed. During an interview on 6/20/23 at 4:43 P.M., with CNA 26, CNA 26 stated Resident 58 did not have behavioral issues. During an interview on 6/21/23 at 8:53 A.M. with licensed nurse (LN) 23, LN 23 stated Resident 58 was cooperative with care and did not have behavioral issues. During an interview and joint record review on 6/22/23 at 8:14 A.M., with LN 21, LN 21 reviewed Resident 58's physicians order for Abilify. LN 21 stated the indication for the use of Abilify was for undressing. LN 21 stated the dosage of Resident 58's Abilify was decreased on 12/7/20 but was increased on 10/25/21 due to increase in agitation and hitting of staff. LN 21 stated Resident 58's behavior monitoring did not reflect Resident 58's aggressive behavior. LN 21 stated there were no documentation from licensed nurses regarding Resident 58's aggressive behavior. LN 21 stated the purpose of increasing the dosage on 10/25/21 was unclear. LN 21 stated if Resident 58's Abilify dosage was increased due to aggressive behavior/hitting staff, that behavior should have been monitored to assess the effectiveness of the medication. A review of the facility policy titled Policy/ Procedure, psychotropic drug use, revised 5/11/22, indicated, .purpose -to provide for the safe and effective use of an anti-psychotic medications. Residents will receive antipsychotic medications only when medically necessary. Antipsychotic use is monitored to facilitate residents receiving the intended benefit of the medication and to minimize the unwanted side effects . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 11 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater. An observation of 27 opportunities during the medication pass resulted in four errors when: Residents Affected - Few 1. A licensed nurse (LN) 11 did not flush a gastronomy tube (G-tube, a tube that is surgically placed into the stomach to deliver food and medication) between medications during administration. 2. A licensed nurse (LN) 12 did not ensure residual (remaining crushed medication) for three crushed medications were rinsed from the medication cups and administered to Resident 20. The calculated medication error rate was 14.81 percent. These failures placed the health and safety of all residents at risk. Findings: 1. Resident 20 was admitted to the facility on [DATE] with diagnosis of a gastrostomy (surgical opening to the stomach to supply food and medication) with a G-tube On 6/19/23 at 10:31 A.M., an observation of LN 11 administering medications through Resident 20's G-tube was conducted. LN 11 attached a syringe to Resident 20's G-tube and poured 30 milliliters (mls) of kordremul mineral oil (a medication used to treat constipation) from a medication cup into the syringe. Before the mineral oil emptied from the syringe into Resident 20's G-tube, LN 11 poured 20 milligram (mg) tablet of crushed baclofen (medication that relaxes muscles) mixed with 10 ml of sterile water into the syringe. On 6/19/23 at 2:27 P.M., an interview was conducted with LN 11. LN 11 stated Resident 20's G-tube should have been flushed with 10ml of sterile water in between medications. LN 11 stated she, Made a mistake because she should have flushed Resident 20's G-tube with 10ml of sterile water before adding the next medication into the syringe. On 6/22/23 at 9:08 A.M., an interview with the pharmacy consultant (PC) was conducted. The PC stated nurses were expected to wait until the entire medication mixture had entered the G-tube before adding the 10 ml flush to the syringe. A review of the facility's policy & procedure titled, Enteral Tube - Medication Administration, dated 5/4/23, indicated, .F. Liquid medications are to be given before solids and are to be given separately to avoid possible precipitation . M .Tube is flushed between individual liquids and solids with a minimum of 10 mls of water . 2. Resident 75 was admitted to the facility on [DATE] with diagnosis of uncontrolled hypertension (high blood pressure) and gastrostomy and G-tube. On 6/20/23 at 8:18 A.M., a concurrent mediation administration observation and interview was conducted with LN 12. LN 12 prepared three medications for administration for Resident 75 through a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 12 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 G-tube. LN 12 crushed and placed the following medications in 30ml medication cups with 10 mls of sterile water in each: Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Few One 10mg tablet of Amlodipine (a medication that lowers blood pressure), b. Two 50mg tablets of Losartan (a medication that lowers blood pressure) c. One 10mg tablet of Labetalol (a medication that lowers blood pressure and lowers heart rate) LN 12 administered the medications into a syringe attached to Resident 75's G-tube. LN 12 completed the medication administration and placed each of the 30mls medication cups on the bedside table. On observation, medication residual was seen at the bottom of the three medication cups. LN 12 stated he was finished with the medication administration. LN 12 stated he did not see the residual medication in each of the three cups. LN 12 stated if the residual medication was not given to Resident 75 she would not have received the full dose of prescribed medication. On 6/22/23 at 9:08 A.M., an interview was conducted with the PC. The PC stated it was expected medication residual would not be present after preparing and administering medications for a G-tube. The PC stated additional water should be added to the cup and administered to ensure the resident gets all the prescribed medicine. A review of the facility's policy & procedure titled, Enteral Tube - Medication Administration, dated 5/4/23, indicated, .M .Medication cups with liquids or dissolved medications in them are rinsed to assure entire administration of dose . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 13 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: 1. Sterile water for irrigation were dated when opened, 2. Discontinued medications were disposed from the medication cart. 3. Unattended medication cart was securely locked These failures had the potential for unsafe storage and administration of resident medication. Findings: 1a. Resident 42 was admitted to the facility on [DATE] with diagnoses which included respiratory failure and was on oxygen therapy, per the facility's Medical Record. On [DATE] at 10:58 A.M., an observation was conducted of Resident 42 in her room. Resident 42 had a tracheostomy (surgical procedure to create an opening through the neck into the windpipe) and was connected to oxygen with a humidifier (container of sterile water for adding moisture). There was an opened bottle of sterile water for irrigation at the bedside table. The bottle did not indicate the date and time it had been opened. On [DATE] at 12:22 P.M., a joint observation of Resident 42 and an interview was conducted with Licensed Nurse (LN) 41. LN 41 stated there was no date or time on the bottle of sterile water. LN 41 stated the sterile water was for the oxygen humidifier for Resident 42. LN 41 stated she should have written a date and time on the bottle but she did not have a pen. LN 41 stated the facility's policy was to date the bottle of the sterile water when opened because it was only good for 24 hours. On [DATE] at 10:27 A.M., an interview was conducted with the LN 44. LN 44 stated the expectation was for the LN to date the irrigation bottle when opened because it was expected to be used within 24 hours. On [DATE] at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the policy was to date the sterile water for irrigation once it was opened to ensure when to discard them because it was good for 24 hours to prevent further infection. A review of the facility's policy titled, Labeling of Medications, revised [DATE], indicated, .G. Labeling of Medications Prepared .for specific patient use .A. Medications which are not immediately administered must be labeled by the patient's care provider with at minimum the following information .3. Expiration date if administration is not completed within 24 hours . 1b. On [DATE] at 3:40 P.M., an observation of treatment cart (TC) 1 and interview were conducted with the PC. An open bottle sterile water for irrigation was found in TC 1 with an opened date of [DATE], 6:15 A.M. marked on the side of the bottle. The PC stated sterile water for irrigation needed to be disposed of within 24 hours of the marked open date on the bottle because it posed a risk of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 14 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 infection. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy & procedure titled, Medication Storage in the Long Term Care Facility, 39129, effective [DATE], indicated, I. Purpose: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier . L. outdated, contaminated, or deteriorated medications and those in containers that are cracked , soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction . Residents Affected - Some 2. On [DATE] at 3:08 P.M. a concurrent observation, record review and interview were conducted with licensed nurse (LN) 13. The following medications with expired orders were observed in Medication cart 2 in the long-term care unit: 2a. A bottle of chlorohexidine 0.12% oral rinse solution (solution that removes bacteria from the mouth) labeled with Resident 58's name indicated Resident 58 was to receive 15mls every 8 hours for two weeks. A record review of Resident 58's medication orders indicated the chlorohexidine 0.12% oral rinse solution was started on [DATE] and stopped on [DATE]. LN 13 stated the chlorohexidine 0.12% oral rinse solution should have been removed from the medication cart as soon as the medication order expired to prevent a medication error. On [DATE] at 9:09 A.M., a concurrent observation, record review and interview were conducted with LN14. Medication cart 2 in the sub-acute unit was observed. The following medications with expired orders were found: 2b. A bottle of ciprofloxacin 0.3% eye drop solution (medication to treat eye infections) was labeled with Resident 50's name. The bottle indicated Resident 50 was to receive 1 drop of ciprofloxacin 0.3% into each affected eye every 2 hours for 2 days, then every 4 hours for 5 days. A review of Resident 50's medication orders indicated the ciprofloxacin 0.3% order stop date was [DATE]. 2c. A bottle of carbamide peroxide otic solution (medication used to treat earwax buildup) was labeled with Resident 48's name. The bottle indicated Resident 48 was to receive three drops of carbamide peroxide otic solution in each ear every night for three days. A review of Resident 48's medication orders indicated the order started on [DATE] and expired on [DATE]. LN 14 stated the carbamide peroxide otic solution order was expired and should be removed from the medication cart and discarded. In an interview with the pharmacy consultant (PC) on [DATE] at 8:33 A.M., the PC stated the nurses were expected to check medication carts for medications with expired orders at the start of every shift. PC stated medications with expired orders should be discarded from the medication cart as soon as the order expires. 3. During an observation in the hallway on [DATE] at 12:28 P.M., a medication cart was unlocked and was unattended by a licensed nurse for approximately two minutes. A concurrent observation and interview with Licensed Nurse (LN) 35 was conducted on [DATE] at 12:30 P.M. LN 35 stated the medication carts should be securely locked by the assigned LN before leaving it unattended. An interview was conducted with the DON on [DATE] at 12:45 P.M. The DON stated LN should never leave the medication carts unlocked for the safe storage of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 15 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 Review of the facility's policy, Medication Storage in the Long Term Care Facility, revised [DATE], indicated, F. Except for those requiring refrigeration, medications intended for internal use are stored securely in a medication cart . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 16 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 kitchen trash cans were cleaned and sanitized. Residents Affected - Few This failure had the potential to place residents at risk for foodborne illness from cross contamination. Findings: On 6/19/23 at 8:05 A.M., a kitchen inspection was conducted with Dietary General Manager (DGM) 1. During the inspection, two large, dark gray trash cans were viewed, stored underneath work tables in the food production area. When pulled out from under the tables, the trash can handles appeared to have a thick layer of a greasy substance, with food particles and other debris adhering to them. On 6/19/23 at 8:10 A.M., an interview was conducted with DGM 1. DGM 1 stated the handles on the trash cans had not been thoroughly cleaned, and staff would touch the handles to use the trash cans. DGM 1 stated, The trash can handles should be cleaned. There is a potential for cross-contamination. Per a facility policy, revised 5/31/23 and titled Hazard Management & Prevention, Sanitation Program, .Purpose: To maintain a clean, safe and effective environment of care and to prevent the transmission of disease-carrying organisms .The Food Service Director monitors sanitizing schedules and procedures .Clean equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 17 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a medical record related to communication was accurate for one of one residents (Resident 63) reviewed for communication. This failure had the potential for Resident 63 plan of care to not be communicated amongst healthcare providers. Findings: A review of Resident 63's admission Record indicated that Resident 63 was admitted to the facility on [DATE] with diagnoses Status Post Motor Vehicular Accident, Subarachnoid Hemorrhage, (A bleeding in the space between the brain and the tissue covering the brain) and Traumatic Brain Injury (Brain dysfunction caused by an outside force, usually a violent blow to the head). During an observation on 6/20/2023 at 4:32 P.M., Resident 63 was seen sitting up in wheelchair, watching tv in room with a bedside table placed in front, Resident 63 was gesturing thumbs up with nonverbal response. During an interview on 6/20/23 at 4:33 P.M., with certified nursing assistant (CNA) 25, CNA 25 stated Resident 63 communicated by hand gestures and by the use of a tablet or communication device. During a concurrent interview and record review with licensed nurse (LN) 21 on 6/22/2023 at 8:15 A.M., LN 21 reviewed Resident 63's weekly summaries dated 6/1/2023, 6/8/2023 and 6/15/2023. LN 21 stated licensed nurses documented on the above weekly summaries that Resident 63 communicated by speech. LN 21 stated the documentation related to Resident 63's mode of communication that were documented on the weekly summaries were inaccurate. LN 21 stated accurate documentation was important to ensure that care needs of the residents are accurately communicated to all health care providers. During an interview on 6/22/2023 at 3:35 P.M., with the director of nursing (DON), the DON stated all medical records should accurately reflect the care needs of the residents to ensure that the residents needs were met. A review of the facility's policy and procedure titled, Content of the Medical Record, dated 8/12/2021, was conducted. The policy did not provide guidance related to accurate documentation in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 18 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when: Residents Affected - Some 1. Licensed Nurse (LN) 41 did not disinfect the vitals machine equipment between residents (42 and 46), 2. LN 42 did not sanitize a glucometer after used before keeping in the supply box, 3. LN 43 did not change gloves while in contact with dirty and clean equipment and supplies, and, 4. Emergency medical technicians (EMTs) did not wear personal protective equipments (PPE) during a resident transfer from gurney to bed. These failures had the potential to spread infections between residents, staff, and visitors. Findings: 1a. Resident 42 was admitted to the facility on [DATE] with diagnoses which included Methicillin-resistant Staphylococcus aureus (MRSA, staph infection that is difficult to treat because of resistance to some antibiotics), per the facility's Medical Record. 1b. Resident 46 was admitted to the facility on [DATE] with diagnoses which included MRSA, per the facility's Medical Record. On 6/19/23 at 12:22 P.M., an observation was conducted of LN 41. LN 41 took Resident 42's blood pressure (BP). After use, LN 41 did not sanitize the vitals machine equipment. On 6/19/23 at 12:29 P.M., an observation was conducted of LN 41. LN 41 used the same vitals machine equipment and took Resident 46's BP. On 6/19/23 at 12:31 P.M., an observation was conducted of LN 41. LN 41 came out from Resident 46's room without sanitizing the vitals machine equipment. On 6/19/23 at 12:50 P.M., an interview was conducted with LN 41. LN 41 stated she forgot to clean the vital machine equipment. LN 41 stated she should have cleaned the vitals machine equipment after every use to prevent contamination, especially the residents were at high risk for infection. On 6/22/23 at 10:27 A.M., an interview was conducted with LN 44. LN 44 stated the LN should have sanitized the vitals machine equipment in between residents to prevent contamination. On 6/22/23 at 11:02 A.M., a joint interview was conducted with the Infection Preventionists (IPs) 1 and 2. IP 1 stated the LNs should have cleaned the vitals machine equipment after every resident use to prevent cross contamination and further infection. On 6/22/23 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the vitals machine equipment should have been cleaned after every resident use to prevent further infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 19 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy titled, Cleaning Schedule - Patient Care Equipment, revised 4/17/23, indicated, .I. Purpose: Provide guidelines for cleaning and disinfecting equipment to prevent the spread of infection .III. Text .F. Clean and disinfect patient care equipment between patient use . 2. Resident 1 was admitted to the facility on [DATE] with diagnoses which included bacteremia (bacteria in the blood) and diabetes (high blood sugar), per the facility's Medical Record. On 6/20/23 at 11:20 A.M., an observation was conducted of LN 42. LN 42 exited Resident 1's room holding a tray with a glucometer (a small machine to check blood sugar) on it. LN 42 did not sanitize the glucometer and placed it in a clear box with diabetes supplies. On 6/20/23 at 11:22 A.M., an observation and an interview was conducted with LN 42. LN 42 stated she had not sanitized the glucometer because she ran out of sanitizing wipes. On 6/22/23 at 10:46 A.M., an interview was conducted with LN 35. LN 35 stated the expectation was for the LN to sanitize the glucometer after every resident use and before placing in the clear box. On 6/22/23 at 11:02 A.M., a joint interview was conducted with the Infection Preventionists (IPs) 1 and 2. IP 1 stated the LNs should have sanitized the glucometer after every resident use to prevent cross contamination and further infection. On 6/22/23 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the glucometer should have been disinfected after every resident use to prevent contamination and further infection. A review of the facility's policy titled, Cleaning Schedule - Patient Care Equipment, revised 4/17/23, indicated, .I. Purpose: Provide guidelines for cleaning and disinfecting equipment to prevent the spread of infection .III. Text .F. Clean and disinfect patient care equipment between patient use . 3. Resident 8 was admitted to the facility on [DATE] with diagnoses which included sepsis (bloodstream infection), per the facility's Medical Record. On 6/21/23 at 8:40 A.M., a wound treatment observation of Resident 8 was conducted with LN 43. LN 43 put on a new pair of clean gloves, prepared the wound treatment supplies, and placed them in a draped bedside table. Using the same gloves, LN 43 closed the door, grabbed the trash can, placed it near the table and moved the draped bedside table close to him. LN 43 then removed his gloves and placed them on the clean, draped bedside table. On 6/21/23 at 8:52 A.M., an interview was conducted with LN 43. LN 43 stated he draped the bedside table to create a clean work area. LN 43 stated the purpose was to keep the wound treatment supply clean and considered the draped bedside table as clean area. LN 43 stated the trash can was considered dirty. LN 43 stated he should have removed his gloves and performed hand hygiene before moving the clean bedside table near him and should have not placed the used gloves in the clean work area. LN 43 stated, I should have tossed the used gloves right away to prevent contamination and infection. On 6/22/23 at 10:27 A.M., an interview was conducted with LN 35. LN 35 stated the LN should have maintained clean and dirty area when providing wound treatment to a resident. LN 35 stated LNs should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 20 of 21 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 055074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Coronado D/P Snf 233 Prospect Place Coronado, CA 92118 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 ensure sanitizing their hands and changing gloves when providing wound treatment. Level of Harm - Minimal harm or potential for actual harm On 6/22/23 at 11:02 A.M., a joint interview was conducted with the Infection Preventionists (IPs) 1 and 2. IP 1 stated the LN should have sanitized his hands after contact with the trash can and should have kept the draped area clean to prevent cross contamination and introduction of bacteria to the resident's wound. Residents Affected - Some On 6/22/23 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LN to maintain the clean area clean and should have not touched the dirty area to prevent further infection. A review of the facility's policy titled, Enhanced Standard Precautions in the Skilled Nursing Units, revised 3/5/21, indicated, I. Purpose; to establish appropriate precautions to be used when caring for a long term care resident known or suspected to be actively infected .C. Contact Precautions. A set of precautions initiated to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment . 4. During an observation on 6/20/23 at 10:59 A.M. inside Resident 29's room, two EMT's were not wearing isolation masks, or personal protective gowns while transferring the resident from gurney to the bed. A record review was conducted on 6/20/23. Resident 29's physician's order, dated 4/30/23 indicated Enhanced Standard Precautions (ESP, approach to prevent multi drug resistant organisms transmission in skilled nursing facilities). An interview with LN 21 was conducted on 6/20/23 at 11 A.M. LN 21 stated the two EMT's should have worn the yellow gown and masks due to the ESP. LN 21 stated it was the responsibility of all nursing staff to educate and maintain infection control standards for PPE. An interview was conducted with the IP on 6/22/23 at 10:45 A.M. The IP stated EMT's should have worn PPE since they were in direct contact with residents on ESP. During an interview with the DON on 6/22/23 at 1:15 P.M., the DON stated all staff and visitors who will be in direct contact with ESP residents should wear PPE. Review of the facility's policy Standard Precautions and Transmission- Based Precautions for hospitalized Patients, dated 2023, indicated .Visitors are encouraged to wear isolation gowns and gloves when participating in direct patient care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 21 of 21