Health inspection·May 2, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 effective pain management for two of four sampled residents (Resident 81 and Resident 77) when: Residents Affected - Few 1. Resident 81 did not receive the prescribed medication order for severe pain. 2. Resident 77's severe pain was not reported to the physician. This failure had the potential for Residents 81 and 77 to have unrelieved pain. Findings: 1. Resident 81 was admitted to the facility on [DATE] with diagnoses which included coccyx (tailbone) pressure injury and paraplegia (inability to move lower extremities). On 4/29/25 at 8:18 A.M., an interview was conducted with Resident 81. Resident 81 stated that the pain medication that the facility was giving to him, did not work in the past. A review of Resident 81's physician orders indicated: Norco 5-325 mg (milligrams) give one tablet by mouth every four hours as needed for moderate 5-6 (pain level) pain . Norco 10-325 mg give one tablet by mouth every six hours as needed for severe 7-10 (pain level) pain. On 5/1/25 at 9:01 A.M., a joint interview and record review was conducted with Clinical Lead (CL) 1. Resident 81's pain assessment dated [DATE] at 8:30 P.M. indicated that Resident 81 complained of severe pain. Resident 81 received one Norco 5-355 mg tablet. CL 1 acknowledged that Resident 81 should have received Norco 10-325 mg, one tablet for severe pain, as ordered. 2. Resident 77 was admitted to the facility on [DATE] with diagnoses which included severe discitis (inflammation of the spine discs) and osteoarthritis (inflammation of the joint that causes pain). On 4/29/25 at 9:18 A.M., an interview was conducted with Resident 77. Resident 77 stated that his pain medications sometimes did not work. A review of Resident 77's physician orders indicated: Roxicodone 5 mg (milligrams) one tablet by mouth every four hours as needed for moderate 5-6 (pain level) pain. Roxicodone 10 mg one tablet by mouth every four hours as needed for severe 7-10 (pain level) pain. On 5/1/25 at 9:21 A.M., a joint interview and record review was conducted with CL 1. Resident 77's pain assessment on 4/4/25 at 2:04 P.M. indicated, Resident 77 complained of severe pain and was given Roxicodone 10 mg. A pain reassessment of Resident 77 was conducted on 4/4/25 at 2:20 P.M. and indicated Resident 77 still had severe pain. CL 1 acknowledged that the licensed nurse (LN) who reassessed Resident 77's pain level should have called the physician to report Resident 77's unrelieved severe pain. On 5/1/25 at 2:17 P.M., an interview was conducted with Clinical Manager (CM) 1. CM 1 stated that LNs should follow physician's medication order for managing resident's level of pain and that LNs should follow-up with the resident's physician if the pain was unrelieved after interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 2 of 10 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 05/02/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Patient Screening, Assessment and Management of Pain revised 5/2/24 indicated, .J. Implement pain management interventions to achieve optimal patient functional status .L. The provider will be notified if pain remains above the acceptable level of pain following pain management interventions Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 3 of 10 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 05/02/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure nursing staff competency when one licensed nurse (LN) 1 did not complete the required abuse training. Residents Affected - Few This failure had the potential to affect residents' care and treatment. Findings: During an interview with the Senior Specialist (SS) on 5/1/25 at 11:08 A.M., the SS stated that nursing personnel should complete a two-hour abuse training within the calendar year (January to December). A concurrent interview and record review with the Staffing Manager (SM) was conducted on 5/2/25 at 10:17 A.M. A review of LN 1's abuse training indicated LN 1 attended a one-hour classroom abuse training on 11/1/24. There was no indication on the employee profile, that LN 1 attended another abuse training course to complete the required two-hour abuse training. The SM acknowledged that LN 1 missed one hour of abuse training. The SM further stated that the training was conducted twice a year to reinforce the knowledge for staff to properly care for the residents. During an interview with Clinical Manager (CM) 1 on 5/2/25 at 2 P.M., CM 1 acknowledged that nursing staff should have completed abuse training as required. The facility's policy titled Elder Abuse - Identification and Reporting revised 1/10/25 indicated, .J. Special staff meetings and training will be held semi-annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 4 of 10 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 05/02/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that irregularities noted by the pharmacist on the monthly regimen review (MRR) were addressed timely and documented consistently in the medical record for 1 of 30 residents (Resident 51). This failure had the potential to affect and delay interventions necessary for the resident's care and well-being. Findings: Resident 51 was admitted to the facility on [DATE] with diagnoses which included psychosis (mental disorder characterized by a disconnection from reality) and Down Syndrome (genetic disorder causing developmental delays) per undated admission Records. A review of Resident 51's Physician orders medication orders indicated Trazodone (antidepressant medication) tablet, 50 mg, oral, every night ordered on 9/18/24; Aripiprazole (antipsychotic medication) tablet, 15 mg, oral, daily ordered on 9/18/24. A review of the facility's Monthly Regimen Review (MRR) binder dated 9/2024 to 4/2025 was conducted on 5/1/25. A list of residents reviewed for MRR was not consistently available in the binder. A review of the facility's MRR binder of written reports with pharmacist's recommendations and irregularities dated 9/2024 to 4/2025 was conducted on 5/1/25 and indicated an incomplete list of written reports. A review of Resident 51's Pharmacy Consultant's MRR written reports with pharmacist's recommendations and irregularities dated 9/2024 to 4/2025 was conducted. On 9/26/24: Consultant Pharmacist Communication to Nursing indicated, Please remind doctor to review and sing med orders via '30-day med reviews by provider', and Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh[behavior] date. On 10/20/24: Nursing Recommendation from Pharmacist indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh (behavior) date.; Consultant Pharmacist Communication to Nursing indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh date. On 11/25/2024: Nursing Recommendation from Pharmacist indicated Using trazodone for insomnia/mood is an off-label use. It must include all psych requirement and beh date. On 12/17/24: Consultant Pharmacist Communication to Nursing indicated, Patient is on routine and/or PRN (pro re nata - as needed) opioid. Please eval (evaluate) and consider taper down dose or usage, eg (exempli gratia - for example) from 2 tabs to 1 tab, freq (frequency) change to q (every) 12 h (hour) instead of q4h prn, etc . Please add to order check and hold if RR<12. Nursing Recommendation from Pharmacist indicated, Patient is on routine and/or PRN opioid. Please eval and consider taper down dose or usage, eg from 2 tab to 1 tab, freq change to q 12h instead of q4h prn, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 5 of 10 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 05/02/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/23/25: Nursing Recommendation from Pharmacist indicated, RE: Meloxicam 7.5 mg (milligrams). Please clarify the above hold order to either DC (discontinue) or restart asap (as soon as possible) to avoid confusion and error. On 2/20/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. Consultant Pharmacist Communication to Physician indicated, 30 days recap - reviewed all orders and approved for next 30 days. Provider must reviewed and approved all orders monthly for next 30 days. Please sign 30 days recap section as documentation . Consultant Pharmacist Communication to Nursing indicated, RE: wound dressing paste. Please provide us a stop date ., or Indefinitely for . or .until healed. On 3/4/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. Consultant Pharmacist Communication to Nursing indicated, RE: wound dressing paste. Please provide us a stop date ., or Indefinitely for . or .until healed. On 4/16/25: Consultant Pharmacist Communication to Physician indicated, Would you agree to have a ***TSH level soon and q6 (every six) months to monitor *** levothyroxine treatment? On 4/25/25: Nursing Recommendation from Pharmacist indicated, Trazodone Dx for insomnia - please document off-label use rationale, failure of other drug, etc. in care plan. An interview and record review were conducted on 5/1/25 at 1 P.M., with Clinical Manager (CM) 1. CM 1 stated that the MRR report and binder were not readily available and complete. CM 1 stated that Resident 51's Consultant Pharmacist's written reports communication to Physician and Nursing were either not responded and documented, responded with done, but did not clarify what was done, and was not documented in the resident's medical record. CM 1 acknowledged that the MRR report should have been readily available and complete, and the written reports of the Pharmacy Consultant should have been addressed and acted upon. A review of facility's policy and procedure titled Medication Regimen Review (MRR) Report and Nursing Documentation last reviewed on 5/4/23 indicated, I. Purpose: To facilitate the safe and effective use of medication, the pharmacist will review the medication regimen of each patient monthly and report, in writing, any irregularities . III. Text: A. The pharmacist reviews each patient's medication regimen .to determine if any irregularities exists or recommendations are needed . G. The consultant pharmacist medication regimen review and nursing documentation review reports are processed as follows: 1. Physician Report/Communication Note: a. The report or communication note is provided by the consultant pharmacist or facility to the Director of nursing or his/her designee and responsible physician, as needed within 7 working days of the review. The Report of Communication note is forwarded to Medical Director monthly . b. The physician shall provide a written or verbal response to the report slash communication to the facility within one month after the report is forwarded . If. Physician fails to provide a written or verbal response, the facility will continue to follow up on report until such time as response is noted . c. A copy of the report/communication note is kept by the facility until the nursing response or physician's response is returned . d. The physician's response is provided to the consultant pharmacist for review and then filed by the facility. e. The facility maintains copies of signed reports, communication and file for at least one year. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 6 of 10 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 05/02/2025 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 Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to facility policy and standards of practice when: 1. Kitchen Staff (KS) 1 did not perform handwashing upon entering the kitchen. 2. Kitchen Staff (KS) 2 did not clean and sanitize the thermometer probe appropriately. 3. Food items were not stored appropriately when: a. Dry storage food items were not labeled and dated. b. Canned items in the dry storage were dented and not removed from the food storage. c. Outdated/expired food items in the storage room were not discarded on or before the expiration date. These failures exposed the residents to contaminated food and unsanitary practices, which had the potential to place them at risk for developing a foodborne illness. Findings: 1. An observation was conducted on 4/29/25 at 7:47 A.M. with KS 1 in the kitchen. KS 1 entered the kitchen with a cart. KS 1 did not wash her hands upon entering the kitchen. KS 1 emptied the food tray from the cart to the dirty sink area and later touched the clean and sanitized trays and cups. A concurrent observation and interview were conducted on 4/29/25 at 7:50 A.M. with the Food and Dietary Manager (FDM). The FDM approached KS 1, reminded staff to perform hand hygiene, and placed the touched tray and cups in the dirty area. The FDM acknowledged that KS 1 did not wash her hands upon entering the kitchen area. The FDM stated that everyone should perform handwashing upon entering the kitchen area. According to the 2022 US FDA Food Code, Section 2-301.11 titled Clean Condition .The hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code . According to the 2022 US FDA Food Code, Section 2-301.14 titled When to Wash .The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after .activities . Employees must wash their hands after any activity which may result in contamination of the hands . A review of facility's policy and procedure titled, Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .C. Handwashing and Glove Use .1. Hands are washed by all FANS (Food and Nutrition Services) employees: a. When beginning work . Between handling soiled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 7 of 10 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 05/02/2025 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 dishes or equipment and handling clean food or utensils . Level of Harm - Minimal harm or potential for actual harm 2. A tray-line observation was conducted in the kitchen on 4/30/25 at 11 A.M. KS 2 removed a thermometer probe from its container and checked the temperature of the cooked fish. After checking the temperature, KS 2 dipped the tip of the thermometer probe into the red bucket (container of sanitizer used for cleaning the kitchen surfaces) and wiped the thermometer probe with a towel. Residents Affected - Some An interview was conducted on 4/30/25 at 12:15 P.M. with the Registered Dietitian Operations Manager (RDOM). The RDOM stated that the thermometer probe should be cleaned with thermometer wipes or sanitizer specifically for the thermometer probe. The RDOM stated the sanitizer in the red bucket cannot be used to clean the thermometer probe, to prevent cross contamination of food-borne pathogens. An interview was conducted on 4/30/25 at 2:30 P.M. with KS 2. KS 2 stated that he was in a hurry and later realized that he cleaned and sanitized the thermometer probe with the sanitizer in the red bucket. KS 2 stated he should have used wipes or the sanitizer specifically for the thermometer probe, to prevent cross contamination. According to the 2022 US FDA Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .E. Equipment/ Sanitation .2. All kitchen equipment, such as choppers, grinders, mixers, slicers and knives are washed and sanitized between each use . 3. A joint kitchen observation and interview were conducted on 4/29/25 at the dry storage room and the walk-in refrigerator with the Food and Dietary Manager (FDM). The following items were observed: a. An undated box of doughnuts was found on top of the storage shelf. In addition, one canned item was not labeled with a date. The FDM stated that the box of doughnuts should include a date to indicate when it was placed in the storage room. The FDM acknowledged that the items stored in the food storage room should have been labeled, with a date, but were not. The FDM stated it was important to ensure stored items included labels, date and time, for the safety of residents from foodborne illness. According to the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .G. Food Storage/Disposal . 1. All foods are labeled, covered and dated when stored .Outdated foods are discarded . b. Three (3) canned items were dented: 1 can of [NAME] Pear halves; 1 can of Diced Peaches; and 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 8 of 10 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 05/02/2025 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 unlabeled can. Level of Harm - Minimal harm or potential for actual harm The FDM acknowledged that the dented canned items should have been removed from the food storage to prevent use of contaminated food. Residents Affected - Some According to the 2022 US FDA Food Code, section 3-101.11 (Annex), .dented, pitted, and rusted cans can potentially be a serious hazard. According to the 2022 US FDA Food Code, section 3-202.15 (Annex), .damaged cans may allow the entry of bacteria or other contaminants and must be returned. c. A container of dry peppers with dates 4/14 - 5/14, and multiple vegetable containers in the refrigerator had expired dates. The FDM stated that the expired food items should have been removed prior to the expiration dates. The FDM stated it was important to ensure expired food items were removed from the food storage room and discarded, for the safety of residents from food borne illness. According to the 2022 US Food and Drug Administration (FDA) Food Code, section 3-501.17 titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Manufacturer's use-by dates, It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages. Although most use-by and sell-by dates are not enforceable by regulators, the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. According to the 2022 US FDA Food Code, section 6-404.11 titled Segregation and Location, Vegetable storage: Even if foods are held long enough, even under proper refrigeration, extended shelf life may be a problem. A study on fresh vegetables inoculated with harmful contaminants and the growth of these contaminants increased during that extended storage period . A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .G. Food Storage/Disposal .1.All foods are labeled, covered and dated when stored .Outdated foods are discarded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 9 of 10 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 05/02/2025 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 ensure infection control practices were implemented for one of 80 residents (Resident 48) when a trash can with a hanging urine container (UC) was observed on a bedside table, close to Resident 48's tumbler (drinking cup). Residents Affected - Few This failure had the potential to result in the spread of infection and cross contamination that may affect Resident 48 and/or care providers. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV- disease that can be spread to other individuals) and impaired mobility, per Resident 48's admission record. During a concurrent observation and interview with Clinical Lead (CL) 1 on 4/29/25 at 8:24 A.M., Resident 48's trash can with a hanging UC was observed on the bedside table, close to Resident 48's tumbler. CL 1 stated that urine spillage from the UC could potentially contaminate another person. CL 1 acknowledged that the trash can should not have been placed on the bedside table, and that the UC should not have been left next to Resident 48's tumbler. During an interview with Clinical Manager (CM) 1 on 5/2/25 at 2:02 P.M., CM 1 stated that trash cans should not be placed on the resident's table, and that UC and dirty materials should be kept away from resident's personal items to minimize the spread of infection. Review of Centers for Disease Control and Prevention (CDC) guideline dated 4/3/24 indicated Infection Control Basics .Make use of common-sense practices. Properly handle, clean and disinfect patient care equipment, tables FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055074 If continuation sheet Page 10 of 10