Inspection·May 6, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and concurrent interview with licensed vocational nurse A (LVN A) on [DATE], LVN A entered Resident 15's room and confirmed the resident had the above-listed medications on the bedside table. She also confirmed one bottle of Refresh Optive eye drops expired on 6/2020. LVN A stated if staff sees medications at bedside, they are supposed to take them away or keep them in a locked place. LVN A explained that if a resident wants to self-administer medications, the facility should do an assessment, obtain a physician's order and develop a care plan. LVN A stated the nurses should check to make sure medications stored at bedside are not expired. During an interview and concurrent record review with LVN A on [DATE] at 8:52 a.m., LVN A reviewed Resident 15's medical record and confirmed there was no assessment indicating it was safe for the resident to self-administer medications. She confirmed there was no physician's order for Resident 15 to self-administer medications or keep medications at bedside. LVN A also confirmed Resident 15 did not have care plans to address self-administration of medications, bedside storage of medications, or non-compliance with bedside medication storage policies. Review of the facility's policy titled Medication Storage in the Facility ID4: Bedside Medication Storage, dated 4/2008 indicated, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. A written order for the bedside storage of medication is present in the resident's medical record. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required if unlocked storage is deemed inappropriate. Review of the facility's policy titled Self-Administration of Medications, revised 2/2021 indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. The nursing staff routinely checks self-administered medications and removes expired, discontinued, or recalled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 2 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 ensure three of 18 sampled residents (Residents 227, 20 and 226) received necessary and proper care and services when: Residents Affected - Few 1. For Resident 227, licensed vocational nurse D (LVN D) did not give the medication per physician's order; 2. For Resident 20, LVN did not wear gloves during administration of insulin (used to treat high blood sugar) by subcutaneous (SC, under the skin) injection; and 3. For Resident 226, the facility failed to develop a care plan (a document which communicates and directs the care and services, including goals and interventions, required to meet residents' needs and recognizes potential needs or risks) related to resident's pain and change of condition on 1/14/2022. These failures could affect the residents' health and individualized care and services provided while in the facility. Findings: 1. Review of Resident 227's clinical record with diagnoses of Diverticulitis of intestine (infection or inflammation of pouches that can form in the intestines), encounter for surgical aftercare following surgery on the digestive system. During a medication pass observation on 5/4/2022 at 12:43 p.m., while in the resident's room, Resident 227 was sitting upright in bed. Resident 227 was eating lunch and had already consumed about 70 percent of the meal. LVN D administered Erythromycin (antibiotic) tablet 250 milligrams (mg) by mouth. Review of Resident 227's, Medication Administration Record (MAR), indicated Erythromycin tablet 250 mg and give one tablet by mouth before meals related to diverticulitis of intestine. To be administered on 0630, 1130, and 1630. During a follow up interview with LVN D on 5/4/2022 at 2:45 p.m., LVN D confirmed the above observation. She further stated that the Erythromycin should be given at least half an hour before meals. During an interview with the facility's pharmacy consultant (PC) on 5/6/2022 at 12:55 p.m., the surveyor informed PC regarding the above observation. PC stated that when administering medication before meals, it was normally given half an hour before. Review of the facility's policy, titled, Administering Medications, dated 4/2019, indicated, Interpretation and Implementation: 4) Medications are administered in accordance with prescribed orders, including any required time frame. 7) Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) 2. During an observation on 5/2/2022 at 12:30 p.m., Resident 20 was in the hallway, sitting in the wheelchair. LVN P did not wear gloves during the administration of insulin via SC injection tp (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 3 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 Resident 20. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 5/6/2022 at 9:35 a.m., DON stated that LVN P should wear gloves during injection administration. DON further stated it is in their policy and procedure. Residents Affected - Few During a review of the facility's policy with the DON on 5/6/2022 at 9:40 p.m., titled Subcutaneous Injection revised 3/2011, indicated, Steps in the Procedure: 1. Perform hand antisepsis 2. Put on gloves . 3. Review of Resident's 226's Medication Administration Record (MAR) for 11/2021, indicated the resident had physician's order for Gabapentin (medication that works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 300 mg by mouth three times a day for nerve pain; Tylenol 325 mg, give 650 mg by mouth every 4 hours as needed for mild pain; Tramadol (a specific type of narcotic medicine called an opioid that is approved to treat moderate to moderately severe pain) tablet 50 mg, give 1 tablet every 6 hours as needed for moderate to severe pain. There was no comprehensive care plan noted related to pain. Review of Resident 226's Situation, Background, Assessment and Recommendation (SBAR, a communication tool), dated 1/14/2022, indicated that Resident 226 complained of pain and was crying. Resident 226's intensity of pain was 10 (rate on scale of 1-10, with 10 being the worst). Resident 226 was sent to the emergency room (ER) for further evaluation on the same day. There was no short-term care plan noted related to Resident 226's change of condition. During a concurrent interview and record review of Resident 226's clinical record (physician's order, MAR, SBAR, Care plans) with the DON on 5/6/2022, at 9:15 a.m., DON confirmed that they did not develop a comprehensive care plan related to Resident 226's pain, and no short-term care plan when Resident 226 complained of 10/10 pain and was transferred to the ER on [DATE]. DON stated there should be care plans related to Resident 226's pain and during change of condition on 1/14/2022. Review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, indicated, A comprehensive, person-centered care plan that includes measurable objectivesand timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: include measurable objectives and timeframes; incorporate identified problem areas; incorporate risk factors associated with identified problems; reflect treatment goals, timetables and objectives in measurable outcomes; developed within seven days of the completion of the required comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 4 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 64's medical record indicated she was admitted on [DATE]. Resident 64's Minimum Data Set (MDS, an assessment tool) indicated she was cognitively intact. Further review of the record indicated Resident 64 had a physician's order, dated 2/3/20, for podiatry consult and treatment as needed. Residents Affected - Few During an observation and concurrent interview with Resident 64 on 5/2/22 at 11:23 a.m., the resident was wearing open-toed shoes and her toenails were long, jagged and thick. Resident 64 stated she had not seen a podiatrist and was not even aware there was a podiatrist who came to see the residents. During a follow-up observation and concurrent interview with Resident 64 on 5/4/22 at 10:07 a.m., Resident 64 was sitting on her bed wearing open-toed shoes. Her toenails were long, jagged and thick and unchanged from the previous observation above. During an interview with licensed vocational nurse A (LVN A) on 5/4/22 at 10:21 a.m., she stated it was not facility staff, but the podiatrist who trimmed the residents' toenails. LVN A was not sure how often the podiatrist came to the facility, but she stated the nurses could make podiatry referrals if needed. She explained the nurses could either request that a podiatrist come to the facility to see the resident, or make arrangements to have the resident go to an outside podiatrist. LVN A confirmed she has arranged podiatry appointments as needed in the past. During an observation and concurrent interview with LVN A on 5/4/22 at 10:31 a.m., LVN A entered Resident 64's room and confirmed the resident's toenails were long, jagged and thick. LVN A asked Resident 64 if the podiatrist had seen her, to which Resident 64 replied that she did not even know there was a podiatrist. LVN A stated she was never informed by direct care staff that Resident 64's toenails needed to be trimmed. LVN A acknowledged if staff saw Resident 64's toenails needed to be trimmed, they should have reported this to the nurse. During an interview and concurrent record review with the DON on 5/4/22 at 10:50 a.m., she stated the podiatrist came to the facility every 90 days, but the facility could make referrals for residents to see a podiatrist as needed. The DON reviewed the facility's ancillary services (services including, but not limited to dental, optometry and podiatry) binder. She confirmed that Resident 64's Ancillary Tracking Form indicated she had not been seen by a podiatrist. Review of the facility's policy titled Foot Care, revised 3/2018 indicated, Residents will be provided with foot care and treatment in accordance with professional standards of practice. Residents will be assisted in making transportation appointments to and from specialists (podiatrist, endocrinologist, etc.) as needed. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals. Based on observation, interview and record review, the facility failed to arrange podiatry (medical specialty concerned with the care and treatment of the foot) services for two of 18 sampled residents (Residents 43 and 64). This had the potential to affect the residents' physical and psychosocial health and well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 5 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0687 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a concurrent observation and interview on 5/5/2022 at 10:52 a.m., while in the resident's room. Resident 43 was alert and oriented and was sitting on the edge of the bed. Resident 43 stated his toenails on both feet were so long and thick that it is hard to walk comfortably. Resident 43's had long, thick and discolored toenails on both feet. Resident 43 stated he reported it to the staff (could not remember their names) about his long, thick toenails. Residents Affected - Few During an interview with the director of nursing (DON) on 5/6/2022 at 09:16 a.m., the DON stated if the resident requested podiatry services, facility staff should notify the social worker or the DON via email, then the resident would be added to their list to be seen by the podiatrist. Review of Resident 43's Ancillary Tracking Form, no podiatry appointment indicated. Review of Resident 43's Physician's order summary report, order date 3/1/2022, indicated, Podiatry consult and treatment as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 6 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 72's medical record indicated she had a physician order, dated 4/19/22, for an enteral feeding of [NAME] Farms Standard 1.4 (GT formula brand) at 40 milliliters per hour (mL/hour, formula flow rate) for 10 hours. During an observation in Resident 72's room on 5/3/22 at 9:51 a.m., there was a bag of GT feeding formula hanging on a pole next to Resident 72's bed. More than half the bag of formula had already been administered. The bag of formula was unlabeled and undated. During a follow-up observation and concurrent interview with licensed vocational nurse A (LVN A) on 5/3/22 at 9:58 a.m., LVN A confirmed Resident 72's GT feeding formula bag was unlabeled and undated. LVN A explained the bag should have been labeled with the resident's name, the name of the formula, the rate at which the formula was to be administered, and the date and time the feeding was initiated. During an interview with the director of nursing (DON) on 5/6/22 at 2:44 p.m., she confirmed GT feeding formula bags should be labeled. The DON presented an unopened GT feeding formula bag. Inside the packaging was a blank label with designated spaces for staff to fill out information, including but not limited to the resident's name, room number, name of the formula, rate of administration, name of the staff who prepared the formula, the date and time the formula was hung, and the date and time the formula expires. Review of the facility's policy titled Enteral Feedings - Safety Precautions, revised 11/2018 indicated, Preventing errors in administration: 1. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number; b. Type of formula; c. Date and time formula was prepared; d. Route of delivery; e. Access site; f. Method (pump, gravity, syringe); and g. Rate of of administration (mL/hour). 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. Based on observation, interview, and record review, the facility failed to provide the appropriate services for two of 18 sampled residents (Residents 29 and 72) who had a gastrostomy tube (GT, tube surgically placed through the abdomen and into the stomach to administer nutrition, hydration and medications) when: 1. For Resident 29, licensed vocational nurse J (LVN J) did not check the GT placement and did not raise the head of the bed during feeding, and 2. For Resident 72, staff did not label and date the GT feeding formula bag. Findings: 1. Review of Resident 29's medical record indicated with diagnoses of nontraumatic intracerebral hemorrhage (refers to bleeding into the substance of the brain in the absence of trauma or surgery), diabetes mellitus (high blood sugar), and gastro-esophageal reflux without esophagitis (when stomach contents and acids back up into the esophagus). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 7 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview with LVN J on 5/4/2022 at 2:07 p.m., while in the resident's room. Resident 29 was lying in bed, LVN J stated she will administer resident's feeding. LVN J performed hand hygiene, applied gloves, inserted a syringe into the GT, aspirated gastric residual (the amount of fluid in the stomach), and no residual noted. LVN instilled approximately 30 milliliters (ml, unit of liquid volume) of water into the tube, then instilled Glucerna (tube feeding formula) 1.5 formula into the tube. LVN did not check the GT placement or raise the head of the bed to 30 degrees to 45 degrees during feeding. During a concurrent interview with LVN J, she acknowledged the above observation and stated that she should check the GT placement with a stethoscope and raised the head of the bed to prevent regurgitation (gastric juices, sometimes undigested food, rises back up the esophagus and into the mouth). Review of facility's policy titled Enteral Feedings - Safety Precautions, revised 11/2018, indicated, Preventing Aspiration: 1) Check enteral tube placement every 4 hours and prior to feeding or administration of medication; 2) Elevate the head of the bed at least 30 degrees during tube feeding and at least 1 hour after feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 8 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident 62's Order Summary Report indicated, Oxygen at 3 LPM via NC continuously. Residents Affected - Few During an observation on 5/2/2022 at 9:10 a.m., Resident 62 was lying in bed and was receiving oxygen at 3 LPM via NC connected to an oxygen concentrator machine (a type of medical device used for delivering oxygen to individuals with breathing-related disorders). There was no Oxygen in Use sign posted at the door or in the resident's room. Review of the facility's policy titled Oxygen Administration, revised 10/2010 indicated, Place an 'Oxygen in Use' sign on the outside of the room entrance door. Based on observation, interview and record review, the facility failed to follow their oxygen administration policy for one of 18 sampled residents (Resident 54) and one non-sampled resident (Resident 62) when staff did not place an Oxygen in Use sign outside the entrance to the residents' rooms. This failure had the potential to compromise the residents' safety. Findings: 1. Review of Resident 54's medical record indicated he had a physician order, dated 3/30/22, for oxygen at 3 liters per minute (LPM, oxygen flow rate) via nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) continuously. During observations on 5/3/22 at 10:42 a.m. and 5/5/22 at 9:12 a.m., Resident 54 was lying in bed receiving oxygen via NC. There was no Oxygen in Use sign posted outside the entrance to Resident 54's room. During a follow-up observation and concurrent interview with licensed vocational nurse D (LVN D) on 5/5/22 at 9:34 a.m., LVN D visualized Resident 54 in his room receiving oxygen via nasal cannula. LVN D acknowledged there was no Oxygen in Use sign posted outside the room entrance. She stated it was her understanding that there should be an Oxygen in Use sign posted outside the room entrance. During an interview with certified nursing assistant E (CNA E) on 5/5/22 at 10:11 a.m., she stated Resident 54 used oxygen at all times. CNA E confirmed that if a resident used oxygen, there should be an Oxygen in Use sign posted outside the room entrance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 9 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure proper communication with the dialysis (a treatment that does some of the things done by healthy kidneys) Center for two of seven residents (Residents 46 and 41) who get dialysis treatments, when the dialysis communication forms were not completely filled out. This failure had the potential to result in a lack of knowledge of the residents' health status. Residents Affected - Some Findings: Resident 46 was admitted with diagnoses which included end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), chronic kidney disease (a gradual loss of kidney function) type 1 diabetes (increase blood sugar), and resident's non-compliance with renal dialysis. 1. During a review of Resident 46's dialysis communication forms, the forms indicated: a. the form dated 5/2/22 did not have a post-dialysis assessment; b. the form dated 4/20/22 did not have vital signs post-dialysis and no post-dialysis assessment; c. the form dated 4/29/22 had a blank dialysis center section, which did not include pre-dialysis weight, vital signs before or after dialysis; d. the form dated 4/12/22 did not have a post-dialysis weight; e. the form dated 4/11/22 did not have the dialysis center section filled out; f. the form dated 4/8/22 was missing Residents 46's pre-dialysis and post-dialysis weights; g. the form dated 3/28/22 did not have a pre-dialysis weight; h. the form dated 3/25/22 did not have the dialysis center section filled out; and i. the form dated 3/18/22 did not have the dialysis center section filled out. Resident 41 was admitted with diagnoses which included end stage renal disease, chronic kidney disease, congestive heart failure, and dependence on renal dialysis. 2. During a review of Resident 41's dialysis communication forms, the forms indicated: a. the form dated 4/27/22 did not have the Post Dialysis Assess section filled out and did not have a post weight; b. the form dated 4/1/22 did not have the dialysis center section filled out; c. the form dated 3/30/22 did not have the end vital signs filled out; d. the form dated 3/25/22 did not have the dialysis center section filled out; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 10 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0698 e. the form dated 2/7/22 did not have the post dialysis assess section filled out. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/04/22 at 1:47 p.m. with licensed vocational nurse D (LVN D), LVN D stated if the dialysis communication form is missing information, she would call the dialysis center, let them know and fax the form back to the dialysis center. Residents Affected - Some During an interview on 5/05/22 at 10:08 a.m. with the medical records staff member (MR), MR stated when dialysis sends back forms that were faxed to the dialysis center, the forms would be in the hard copy chart. MR stated there were no dialysis forms, from the dialysis center in the overflow. MR stated the forms in the hard copy chart are not completed. During an interview on 5/05/22 at 3:53 a.m. with registered nurse F (RN F), RN F stated We call the dialysis center to clarify, if it's not filled out, then we fax the form to them. The dialysis center fills it out and faxes it back. If the form is not back in 2-3 hrs, we follow-up by calling them. During an interview on 5/05/22 at 4:09 p.m. with RN F, RN F stated she did not see a note dated 3/25/22, nor on 4/29/22 about notifying the dialysis center. A review of the facility's policy titled Renal Dialysis, Care of Residents, revised December 2013, indicated, .Record date, time, access site conditions, patency after dialysis, and access site care in the Dialysis Communication Form. To have pertinent data available for all caregivers of dialysis residents to provide quality care. The Facility will document the following in the resident's care plan: .11. Weight: pre/post (Dialysis unit determines both pre and post dialysis weights .). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 11 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 act upon consultant pharmacist reports for two of 18 sampled residents (Residents 39 and 27). This failure had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of Resident 39's medical record indicated he was admitted on [DATE] and had the diagnosis of major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest). Further review of the record indicated Resident 39 had a physician's order dated 12/15/19, for Duloxetine (medication used to treat depression) 60 milligrams (mg, unit of dose measurement) one capsule by mouth two times a day. Review of Resident 39's Note to Attending Physician/Prescriber, dated 2/12/22, indicated for Duloxetine 60 mg BID (two times a day), Per Federal CMS guidelines, gradual psychotropic [medications that affect the mind, emotions and behavior] dose reductions should be attempted in two separate quarters within the first year (with at least one month between attempts) and then annually unless clinically contraindicated. Please review the resident's condition and assess if a gradual dose reduction (GDR) was warranted. Document as appropriate below. The portions of the note designated for the physician to provide a response were left blank. During an interview and concurrent record review with the director of nursing (DON) on 5/4/22 at 1:31 p.m., she reviewed Resident 39's Note to Attending Physician/Prescriber and confirmed the physician did not complete the portion of the document he was supposed to fill out. The DON explained that she does forward the consultant pharmacist reports to the physicians, but the physicians do not always do their part. 2. Review of Resident 27's medical record indicated she was admitted on [DATE] and had the diagnosis of hypothyroidism (thyroid gland does not produce enough of certain hormones). Further review of the record indicated Resident 27 had a physician's order, dated 6/8/19, for Levothyroxine Sodium (medication used to treat hypothyroidism) 150 micrograms (mcg, unit of dose measurement) one tablet by mouth daily. Review of Resident 27's Note to Attending Physician/Prescriber, dated 3/8/21 indicated, [Resident 27] has an order for Levothyroxine 150 mg daily. If appropriate, may we check a TSH [thyroid stimulating hormone, a test to evaluate thyroid gland function] with the next lab draw? The physician did not provide a response to this question. The portions of the note designated for the physician to provide a response were left blank. During an interview and concurrent record review with the DON on 5/6/22 at 9:00 a.m., she reviewed Resident 27's Note to Attending Physician/Prescriber and confirmed the physician did not complete the portion of the document he was supposed to fill out. The DON reviewed Resident 27's medical record and confirmed the physician did not order the TSH test as recommended. The DON stated the most recent physician's order to check Resident 27's TSH was on 7/12/2019 (almost two years and ten months prior to this interview). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 12 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 Review of the facility's policy titled Consultant Pharmacist Reports, dated 6/2021 indicated, Recommendations are acted upon and documented by the facility staff and/or the prescriber. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 13 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure that medications were stored safely and properly when: 1. Two of two medication room refrigerators in Stations A and B were not kept locked; 2. Two of two Xalatan (Latanoprost, to treat high pressure inside the eye due to glaucoma) eye drops for Resident 23, and Resident 69 did not have an open date; and 3. One opened Humalog insulin (fast acting insulin) vial for Resident 228 did not have an open date. Findings: 1.a. During an initial observation of the medication room in Station A with the infection preventionist (IP) on 5/2/2022 at 9:03 a.m., the medication room refrigerator was not locked. The medication room refrigerator had controlled medications (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction). IP stated the medication refrigerator should be locked. 1b. During another observation of the medication room in Station B, with the director of nursing (DON) on 5/2/2022 at 10:00 a.m., the medication refrigerator was not locked. There were biologicals (vaccines) and controlled medications inside the refrigerator. DON stated that it should be kept locked. Review of the facility's policy, titled, Storage Medications, dated 11/2020, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 2. During an inspection of the medication cart #1 on 5/5/2022 at 11:53 a.m., with licensed vocational nurse D (LVN D), two opened Xalatan eyedrops for Residents 23 and 69 had no open dates written on the medication label. LVN D stated there should be an opened date. The manufacturer's label indicated: Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. During a concurrent interview with LVN D she acknowledged the above observation and stated there should have been an opened date and should not be kept longer than 28 days after opening. 3.During the same inspection of medication cart 1 with LVN D, an opened Humalog 100 units (u, standard units for measurement) per milliliter (ml, unit of volume for liquids) for Resident 228 was found without an open date. Indicated on the label was to discard on the 28th day after opening. During a concurrent interview with LVN D, she acknowledged the above observation and stated that it should be dated when it was first opened. Review of facility's policy, titled, Administering Medication, dated 4/2019, indicated, .When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 14 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 opening a multi-dose container, the date opened is recorded on the container. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 15 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to ensure the planned menu was followed when: Residents Affected - Some 1. Seven of seven residents (Residents 19, 20, 30, 46, 54, 56, and 63) on a renal diet (renal diet is one that is low in sodium, phosphorous, and protein, limit potassium and calcium) did not receive rice and one received potatoes; 2. One of one resident (Resident 72) on a vegan diet did not receive planned menu items and received foods that were not on the menu including foods with milk and chicken, 3. [NAME] beans were served instead of seasoned beans as indicated on the menu during the lunch meal on 5/2/22, and, 4. Portion size was not followed for seasoned greens during the lunch meal on 5/2/22. Theses failures had the potential to result in the facility not meeting the nutritional needs of the residents and compromising their nutritional status. Seventy-six residents received meals from the kitchen. The resident census was 82. Findings: 1.a. During a review of the facility's menu titled, Therapeutic Spreadsheet dated 5/2/22, the lunch menu indicated for Liberal Renal and RCS/Liberal Renal diets one Pork Chop/Gravy SF (salt free), #8 scoop (1/2 cup) steamed rice SF, #8 scoop seasoned greens SF. During an observation of the lunch meal service on 5/2/22 starting at 11:38 a.m., Resident 20's plate included one pork chop, a #8 scoop green beans, #12 scoop greens, and no evidence of steamed rice. There was no evidence that rice was prepared or served at this meal. During an interview on 5/2/22 at 12:34 p.m. with the dietary services supervisor (DSS) N, the DSS N confirmed rice was on the menu for the renal diets and stated rice was not made or served today. During an interview on 5/03/22 at 9:18 a.m., registred dietition (RD) stated she expects staff to serve what is on the menu. She further confirmed when there are changes to the menu, there should be a substitution log that RD approves and that she did not approve any changes to the menu yesterday (5/2/22). During a review of Residents 19, 20, 30, 46, 54, 56, and 63's lunch tray cards (card containing a list of the right food, drinks, portions, assistive devices, other food preferences and diet orders of each resident) dated 5/2/22, indicated the residents' diet orders were Liberal Renal (Residents 19, 30, 54) or RCS (Reduced Concentrated Sweets)/Liberal Renal (Residents 20, 46, 56, 63) and that the noon meal included steamed rice. None of the tray cards indicated a dislike of steamed rice. b. During a review of the facility's menu titled, Therapeutic Spreadsheet dated 5/4/22, the lunch menu indicated residents on Liberal Renal diets receive steamed rice in place of the potatoes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 16 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 5/4/22 at 12:16 p.m. in the small dining room, Resident 30's lunch included potatoes (a high potassium vegetable) and no rice. During an interview on 5/4/22 at 12:20 p.m. with certified nursing assistant (CNA) G, CNA G verified she was feeding Resident 30 potatoes and the tray card indicated rice not potatoes. CNA G stated she had not noticed it was wrong and maybe instead of rice she had potatoes. During a review of Resident 30's dietary order dated 2/28/22, the dietary order indicated Resident 30's diet was Liberal Renal Diet. Review of facility diet manual for Liberal Renal Diet, dated July 2019, indicated limit vegetables high in potassium. During an interview on 5/5/22 at 10:00 a.m. with the DSS N and RD, the DSS N stated residents should be served what is on the tray card. RD verified that what foods are on the tray card and menu is what should be served. 2.a. During a review of the facility's menu titled Therapeutic Spreadsheet dated 5/2/22, the lunch menu indicated the vegan diet included oat nut patties -2 each, #8 scoop (1/2 cup) seasoned beans, #8 scoop seasoned greens, #12 scoop (1/3 cup) puree vegan bread/margarine. During an observation on 5/2/22 at 11:38 a.m. in the kitchen during tray line, Resident 72's plate included #24 scoop (2 2/3 tablespoons) refried beans, #8 scoop puree greens, and #12 scoop pureed cornbread. During a review of Resident 72's noon meal tray card dated 5/2/22, the tray card indicated under Diet order: vegan, consistency pureed, and the noon meal included 2- #8 scoops pureed oat nut patties, #8 scoop pureed seasoned beans, #8 scoop pureed seasoned greens, 1- pureed vegan bread/margarine. During an interview on 5/2/22 at 12:44 pm in the presence of DSS N, food services worker B (FSW B) stated she knows what to serve each resident based on what is on the tray card. b. During a review of Resident 72's noon meal tray card dated 5/3/22, on the serving tray in Resident 72's room, the tray card indicated Resident 72's tray contained pureed #6 scoop tofu patty, pureed #8 scoop angel hair pasta, pureed #10 scoop Italian blend vegetables, #16 scoop pureed vegan garlic bread, #10 scoop pureed mandarin oranges, 8 fl oz (fluid ounces a unit of measurement) soy milk, and 8 fl oz water. During a concurrent observation and interview on 5/3/22 at 10:56 a.m. in the kitchen with FSW B, FSW B was observed making the pureed pasta, using the ingredients from the chicken and the pasta. FSW B stated the pasta and chicken ingredients included chicken, pasta, pepper, chicken broth, Italian seasoning and a little bit of sour cream (pointing to an open container of sour cream). During an observation on 5/3/22 at 1:03 p.m. in Resident 72's room, the meal tray on the bedside table contained a plate with 3 scoops -pureed refried beans, pureed pasta, pureed vegetables, on the tray was a glass of soy milk, water, and a cup with pureed orange cake. There was no evidence of a tofu patty or mandarin oranges. During an interview on 5/3/22 at 1:10 p.m. with the RD, the RD confirmed the pureed pasta on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 17 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0803 Resident 72's tray contained chicken broth and chicken that was in the sauce used to puree the pasta. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review on 5/3/22 at 1:16 p.m. with DSS N, the recipe for the orange cake included yellow cake mix as an ingredient. Review of the yellow cake mix package ingredients indicated nonfat milk was included as an ingredient. DSS N confirmed that the yellow cake mix did include milk and should not be served on a vegan diet. Residents Affected - Some During an interview on 5/3/22 at 1:23 p.m. with DSS N and food service worker (FSW) B, DSS N confirmed that Resident 72's tray included refried beans, vegetables, and pasta with alfredo sauce puree. Resident 72 was not served tofu patties as indicated on the menu. FSW B confirmed tofu was not made, and Resident 72 received beans instead of the tofu patties on her plate. During an observation and interview on 5/3/22 at 1:32 p.m. in Resident 72's room with certified nursing assistant (CNA) H and Resident 72, CNA H confirmed Resident 72 had orange cake, not pureed oranges as listed on the tray card. Resident 72 stated she did not like the beans, CNA H confirmed none of the beans were eaten. During review of the facility's dietary Therapeutic Spreadsheet dated 5/3/22, the therapeutic spreadsheet indicated the vegan menu included tofu patty -2 each, angel hair pasta, Italian blend vegetables, vegan garlic bread, mandarin oranges, soy milk, and water. c. During an observation and interview on 5/4/22 at 12:51 p.m. in Resident 72's room, with Resident 72 and CNA I, Resident 72 was having lunch. The tray contained pureed green beans, white mashed potatoes, tofu with ketchup on top, pureed bread, water, soymilk, coffee-decaf and a cup with watery brownish liquid. CNA I indicated she was not sure what it was, stated maybe vanilla wafers. During a review of Resident 72's noon meal tray card dated 5/4/22, the tray card indicated the noon meal included 2 #6 scoops pureed tofu loaf/gravy, #8 scoop pureed O'Brien potatoes, #12 scoop pureed seasoned green beans, 1 each pureed vegan bread/margarine, #10 scoop pureed vanilla wafers, 8 fl oz soy milk and 8 fl oz water. During a review of the facility's Tofu loaf/gravy recipe, Recipe # 6683 (not dated), the recipe indicated some of the ingredients included onions, canola oil, carrots, green pepper, dill weed, soy sauce. During an interview on 5/5/22 at 9:20 a.m. with FSW B, FSW B stated tofu loaf was made with a slice of tofu cooked in margarine in a pan and served with ketchup on top. During an interview on 5/3/22 at 9:18 a.m., RD stated she expects staff to serve what is on the menu. She further confirmed when there are changes to the menu, there should be a substitution log that RD approves. During a review of Resident 72's diet order dated 3/29/22, the diet order indicated Vegan diet, Pureed. During a review of facility document titled Menu Substitution Log, undated, the log indicated When a planned menu item has to be substituted with another item (of similar nutritive value) please add to this log, RD needs to review and sign off on the substitution upon notification. There were two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 18 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0803 entries 1/21 BBQ ribs and 5/2/22 Strawberries. Level of Harm - Minimal harm or potential for actual harm 3. During an observation of the lunch meal service on 5/2/22 starting at 11:41 a.m. in the kitchen, there was no evidence that seasoned beans were prepared or served; pork chops, green beans, greens, and cornbread were served. Residents Affected - Some During review of facility's posted menu dated 5/2/22, the menu indicated the noon meal on 5/2/22 included pork chop, seasoned beans, seasoned greens, and cornbread. During a review of the facility's menu titled Therapeutic Spreadsheet dated 5/2/22, the menu indicated seasoned beans to be served to all diets except Liberal Renal and RCS Liberal Renal. During a review of residents' tray cards dated 5/2/22, the tray cards for 59 residents indicated seasoned beans for the noon meal. None indicated a dislike for beans. During an interview on 5/3/22 at 9:18 a.m., RD stated she expects staff to serve what was on the menu. She further confirmed when there are changes to the menu there should be a substitution log that RD approves and that she did not approve any changes to the menu yesterday (5/2/22). The RD stated the green beans served were nutritionally different than the seasoned beans (legumes) on the menu. During an interview on 5/3/22 at 11:00 a.m with the DSS N and RD, DSS N stated when something different is served like a vegetable, he does not notify the RD since nutrients are basically the same. DSS N stated dried beans were ordered but the facility was sent green beans. During an observation and interview on 5/3/22 at 11:05 a.m. in facility's dry storage room/DSS N office, the RD stated as she pointed to a can of baked beans, she would have substituted the seasoned beans with canned beans, not green beans, to better match the nutrition of the seasoned beans, which are higher in protein than green beans. Multiple cans of beans (black beans, baked beans) and dried beans (black and white) were observed in the room by the surveyors and acknowledged by the RD and DSS N. During a review of the facility's recipe titled SEAS BEANS dated 2002-2022, Week 4 Monday Noon Meal Recipe #: 1481, the recipe indicated Any type of bean can be used for this recipe: red (kidney), pinto, navy, white, black etc. 4. During a review of the facility's menu titled, Therapeutic Spreadsheet dated 5/2/22, the lunch menu indicated for Regular, Large portions, Fortified/High Protein, Vegetarian, Vegan, Liberal Renal, RCS/Liberal Renal diets #8 scoop (1/2 cup) Seasoned Greens. During an observation of the lunch meal service on 5/2/22 starting at 11:38 a.m., food service worker B (FSW B) served Seasoned Greens, using a #12 scoop (1/3 cup) only. During an interview and concurrent record review on 5/2/22 at 12:44 p.m. after the lunch meal service ended, DSS N and FSW B confirmed only the green scoop, which they confirmed was a #12 scoop (1/3 cup), was used to serve the seasoned greens. DSS N stated FSW B had the gray scoop (#8) out but did not use it. DSS N further confirmed that the serving size should have been #8 scoop (1/2 cup) for all the seasoned greens while looking at the therapeutic spreadsheet. Review of the lunch tray cards from 5/2/22 revealed there were 75 residents with either regular, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 19 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0803 large portions, fortified/high protein, vegetarian, vegan, liberal renal, RCS/liberal renal diets. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/3/22 at 9:18 a.m., RD stated she expects staff to serve what is on the menu. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 20 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview, and facility document review, the facility failed to provide food in a form that meets the needs of two residents (Residents 31 and 45) on either mechanical soft (texture modified diet for people with difficulty chewing or swallowing) or ground meat diets when: a. Residents 31 and 45 received whole pork chops, and b. Resident 45 received two whole bean burritos. This failure had the potential to place residents on a mechanical soft or ground meat diet at an increased risk for choking. Findings: 1. During an observation of the lunch meal service starting on 5/2/22 at 11:38 am in the presence of dietary services supervisor N (DSS N), food service worker B (FSW B) placed a whole pork chop on Resident 45's plate. food service worker C (FSW C) placed the plate on a tray and put the tray in the meal delivery cart for delivery. Once the cart was full, FSW C rolled the cart out to the hall for delivery to residents. During a concurrent observation of Resident 45's plate and tray ticket (a form placed on each resident's meal tray with diet order, foods to serve, likes and dislikes) and interview on 5/2/22 at 12:02 p.m. in the hallway outside the kitchen, DSS N confirmed Resident 45 was served a whole pork chop and should have gotten a chopped pork chop since the resident was on a mechanical soft diet. DSS N then took the plate back to the kitchen and changed the whole pork chop to chopped pork chop. During a further observation of the lunch meal service starting on 5/2/22 at 12:34 p.m. in the presence of DSS N, FSW B served Resident 31 a whole pork chop. FSW C placed the plate on a tray and into a food delivery cart for delivery to residents. During a concurrent record review at that time, the tray ticket on Resident 31's tray indicated Resident 31 was to get a Regular diet with ground meat. Review of the tray tickets for lunch 5/2/22 for Resident 31 under Diet Consistency indicated Ground meats, and the list of foods to serve included Ground pork chop/Gravy 1 each. Review of the tray ticket for lunch 5/2/22 for Resident 45 under Diet Consistency indicated Mechanical Soft, and the list of foods to serve included Ground Pork Chop/Gravy 1 each. Review of the facility menu titled {Facility name} Cycle 2 2022 Therapeutic Spreadsheet Week 4 Monday, dated 5/2/22, indicated the Mechanical Soft/Ground diet should get Ground pork chop with gravy. During an interview on 5/4/22 at 9:58 a.m. with DSS N in the presence of RD, DSS N stated ground meat is the same as mechanical soft meat. He further indicated they put ground meat on the tray ticket when a resident can eat the regular texture of other foods (vegetables, bread, dessert), but needs meat cut up. RD confirmed a pork chop should be cut up for mechical soft and ground meat diets. During an interview on 5/5/22 at 10:00 am, RD verified that what is on the tray ticket and menu was what should be served to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 21 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility diet manual for Mechanical Soft (Ground), dated July 2019, indicated all meat (such as beef, fish, poultry and pork) should be ground or chopped. It further indicated definitions of menu terms Chopped: ¼(inch - a unit of measurement) - ½ pieces and Ground: 1/8 or less - consistency of ground meat. 2. During a lunch meal observation on 5/4/22 at 12:29 p.m. in Resident 45's room, Resident #45's meal tray had two whole bean burritos with no sauce as an alternate for the main entree. Resident 45's brother confirmed Resident 45 could not eat them. Review of the tray ticket for lunch 5/4/22 for Resident 45 under Diet Consistency indicated Mechanical Soft. Review of Resident 45's diet order dated 3/9/22 indicated Regular diet, Mechanical soft texture, Moist - add gravy/sauce to all meats. During an interview on 5/5/22 at 9:33 a.m. with DSS N and RD, DSS N stated mechanical soft should be really soft and that a whole burrito should have been cut up. RD confirmed the kitchen should have cut up the burrito for a mechanical soft diet. Review of facility diet manual for Mechanical Soft (Ground), dated July 2019, indicated the diet requires a reduced amount of mastication (chewing). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 22 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 - Many 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 store, prepare, and distribute food safely when: 1. Ground beef was not submerged in water during the thawing process; 2. Cooked potatoes (a potentially hazardous food capable of supporting bacterial growth associated with foodborne illness) were not logged for proper cool down; 3. Resident refrigerator contained multiple food items beyond the discard date; and 4. Cups and mugs used to serve resident drinks were stored stacked and wet; These failures had the potential to cause food Borne illness to a highly susceptible population of 76 residents who received food from the kitchen. The facility census was 80. Findings: 1. During concurrent observation and interview on 5/2/22 at 12:36 p.m. in the kitchen with food service worker (FSW) K, three, five-pound chubs of ground beef were observed in a plastic container in the sink with cold water running over them. The chubs were not fully submerged in the water. FSW K stated she was defrosting the meat in the sink to make meatloaf for tomorrow (5/3/22). FSW K stated she will mix up the meat and bake it tomorrow, and stated it takes about three hours sometimes four to defrost frozen meat in this manner. During an observation on 5/2/22 at 3:23 p.m. in the kitchen, the three chubs of ground beef were still in a container, in the sink with cold water running, not fully submerged. During an observation and interview on 5/2/22 at 4:17 p.m. in the kitchen with FSW K. The three chubs of ground beef were in the reach in refrigerator. FSW K stated they were placed in the refrigerator about 20 minutes ago. The meat chubs were 50.2 F (Fahrenheit), and 51.4 F between the meat chubs, temperature taken by the surveyor. During a concurrent observation and interview on 5/2/22 at 4:28 p.m. in the kitchen with FSW K, three chubs of ground meat was observed in the reach in refrigerator. FSW K confirmed she does not take temperatures of the water or the meat while defrosting in the sink, just runs the water over it. At 4:34 p.m. the temperature of the reach in refrigerator was 42 F, the temperature between the ground meat chubs was 47.7 F and 46.8 F. FSW K stated they were placed in the refrigerator because she was too busy to make the meatloaf now. During an interview on 5/3/22 at 11:00 a.m. with the dietary services supervisor (DSS) N in the kitchen, the DSS N stated, meat needs to be completely submerged to thaw when using running water. During an interview on 5/5/22 at 1:12 p.m. with the registered dietitian (RD), the RD confirmed when thawing meat in the sink it should be in the appropriate sized container and be fully submerged with the cold water running. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 23 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 - Many During review of the facility's policy Food Preparation and Service date revised October 2017, the Food Preparation and Service policy indicated Thawing frozen food . Thawing procedures include: .Submerging the item in cold running water (70 F). According to Food and Drug Administration (FDA) Food Code 2017, Section 3-501.13 Thawing, when thawing temperature control for safety foods such as ground beef under running water the following steps should be adhered to: Completely submerged under running water: (1) At a water temperature of 70 F or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41 F, for more than 4 hours including: (a) The time the food is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the food temperature to 41oF. 2. During an observation on 5/3/22 at 9:26 a.m. in the kitchen there was a large metal pan of cooked potatoes (approximately 12 x 24x 4 (inches), half full, and covered in foil, dated 5/2/22 to be used 5/3/22 in the produce refrigerator. The temperature reading of the potatoes was 48 F. The refrigerator temperature readings were 45 F and 40 F on the two thermometers next to each other on the same shelf in the refrigerator. Recheck of the internal temperature of the cooked potatoes, in the presence of the dietary services supervisor (DSS) O with another thermometer reading was 48.9 F. There was no evidence of a cool down log. During an interview on 5/3/22 at 9:30 a,m. in the kitchen with the RD, the RD stated hot foods should get down to 70 F in two hours, then get below 41 F in four hours, potatoes should be on the cool down list, they are in the danger zone (temperatures between 41 F -135 F) now so not safe to eat. During an interview on 5/3/22 at 10:42 a.m. in the kitchen with the RD, RD confirmed cooked potatoes are a time and temperature-controlled food (TCS, food that requires time/temperature control for safety to limit the growth of pathogens i.e., bacterial or viral organisms capable of causing a disease or toxin formation. During a concurrent interview and record review on 5/3/22 at 11:14 a.m. in the kitchen with the DSS N reviewing the cool down log, the DSS N stated, he would expect cooked potatoes to be on the cool down log and confirmed there was no documentation. During an interview on 5/3/22 at 11:37 a.m. in the kitchen with FSW K, FSW K stated she cooked the potatoes last night (5/2/22), cooked them in the skins, peeled them, then placed them in the refrigerator covered, and went home. No temperatures were taken, or temperature log completed. During review of the facility's policy Food Preparation and Service date revised October 2017, the Food Preparation and Service policy indicated, .Potentially hazardous foods [another word commonly used to mean TCS foods] should be cooled rapidly. This is defined as cooling from 135 F to 70 F within two hours and then to a temperature of below 41 F within the next four hours. The total cooling time between 135 F and 41 F is not to exceed six hours. According to the FDA Food Code 2017 Annex section 3-501.14 Cooling, safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 24 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 factors to foodborne illness. Level of Harm - Minimal harm or potential for actual harm 3. An observation and interview were conducted on 5/2/22 at 3:27 p.m. in the medication room with licensed vocational nurse (LVN) M inspecting the Residents food refrigerator. LVN M stated food labeled with the residents' name and date is placed in the refrigerator, food is kept for 7 days or until the manufacture's expiration date. Residents' food observed in the refrigerator included leftover hummus with three areas of green/black spots dated 4/26/22 for Resident 72, cheese and crackers in a sealed package. The cheese had white fuzzy spot and dry white crust along the edges. The date written indicated placed in the refrigerator 4/26/22 for Resident 64. LVN M said she would serve the cheese and crackers because it is still within best by date of 5/9/22. That was an eight ounces package of [NAME] salami, unopened, manufacturer use by dated 4/23/22. There were oysters in jar with a sell by date of March 11, air dried sausage opened with a best by date of 3/27/22 for Resident 19, and opened pickles with a sell by date 2/2022 for Resident 33. LVN M stated she was not sure how often nurses look in the refrigerator to clean foods out, and temperatures are checked two times a day. LVN M confirmed all those foods listed were not safe for the residents. Residents Affected - Many During an interview with LVN A on 5/3/22 at 9:43 a.m. at the nursing station nearest to the resident refrigerator, LVN A stated she checks the resident refrigerator in the morning. She checks the temperature and checks that food has a name and date. Food can stay in the refrigerator 48 hours and she throws food away if over 48 hours. During an interview on 5/3/22 at 4:22 p.m with the director of staff development (DSD), the DSD stated the residents' refrigerator should have food labeled with name and the date it is put in the refrigerator. We hold food for 72 hours, the nurse that has the station closest to the refrigerator checks the temperature and tosses food older than 72 hours. During an interview on 5/5/22 at 1:12 p.m. in the DSS N office in the kitchen, with the RD and DSS N, the RD stated she was, not involved in the residents' refrigerator, it is all nursing. During a record review of the facility's policy Foods Brought by Family/Visitors revised date 12/2021, the facility policy indicated .Food brought by family/visitors that is left with the resident to consume later will be labeled and stored .nursing staff will discard perishable foods within 72 hours. The nursing staff and/or food service staff will discard any foods that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). 4. During an observation on 5/3/22 at 4:08 p.m., in the kitchen on the shelf in the dishwashing area, 11 plastic cups and six mugs were upside down on a food tray double stacked. When lifted the cups and mugs were wet inside and there was puddled water on the tray. Concurrent interview with FSW L verified cups and mugs were wet inside. During an interview on 5/4/22 at 9:58 a.m. in the kitchen with the DSS N and RD, DSS N stated they do not usually dry cups on a tray, as they usually allow them to air dry on racks. RD confirmed cups would not dry when placed upside down wet directly on a tray. During an interview on 5/5/22 at 2:10 p.m. in the kitchen with the DSS N and RD, DSS N stated staff had not been in-serviced on air drying of kitchen utensils and equipment. During a record review of the facility's policy Dishwashing Machine Use, revised March 2010, the policy indicated The following guidelines will be followed when dishwashing .after running items (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 25 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 through entire cycle, allow to air-dry. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 26 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent the overuse of antibiotics) for one of 18 sample residents (Resident 54). Resident 54 received a course of antibiotics for pneumonia (a lung infection), but did not meet all the criteria that needed to be present for antibiotic use. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Residents Affected - Few Findings: Review of Resident 54's Progress Notes, dated 4/23/22, indicated he had intermittent (no continuous or steady) coughing and the doctor ordered a chest x-ray (procedure that produces images of the internal components of the chest). Review of Resident 54's Progress Notes, dated 4/24/22 indicated, Received xray result date of service 4/22/22, with impression of left lung base infiltrate (a substance in the left lung). Review of Resident 54's medication administration record (MAR) indicated he had a physician's order dated 4/24/22, for Amoxicillin-Pot Clavulanate (an antibiotic used to treat a variety of infections) 250-125 milligrams (mg, unit of dose measurement) one tablet by mouth every 12 hours for 10 days for pneumonia. Further review of the MAR indicated Resident 54 received this antibiotic twice a day from 4/24/22 to 5/3/22. During an interview with the infection preventionist (IP) on 5/6/22 at 9:44 a.m., she stated the antibiotic stewardship program was in place to avoid the prescribing of antibiotics that were not truly needed. The IP explained if a resident was taking antibiotics but did not meet all the criteria, she should contact the resident's doctor to see whether or not the antibiotic should be continued. When asked what criteria a resident must meet to receive antibiotics for pneumonia, the IP presented a document titled Surveillance Data Collection - Infection Control. Review of the facility's undated document titled Surveillance Data Collection - Infection Control indicated for pneumonia, three criteria must be present. The third criteria on the document indicated the resident must have at least one of the following: 1. Fever (temperature above 100 degrees Fahrenheit (F, unit of temperature measurement); 2. Leukocytosis (increased number of white blood cells); 3. Acute change in mental status from baseline; and 4. Acute functional decline. During an interview and concurrent record review with the IP on 5/6/22 at approximately 10:15 a.m., the IP reviewed Resident 54's medical record and confirmed there was no documentation indicating the resident had a fever, leukocytosis, acute change in mental status from baseline, or acute functional decline before and during the time he received the above antibiotic. The IP acknowledged Resident 54 did not meet all the criteria listed on the facility's Surveillance Data Collection - Infection Control document. The IP stated she did not notify Resident 54's doctor. Review of the facility's policy titled Antibiotic Stewardship, revised 12/2016 indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 27 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition when: Residents Affected - Some 1.The produce refrigerator was not maintaining temperatures below 41 Fahrenheit (F); the oven temperature dial did not contain numbers or markings for the temperature setting; and the plate warmer handle was detached from the lid on one side. These failures had the potential to cause equipment to not be functionally safe and impact the ability of the equipment to operate as intended or cause contamination of food, leading to foodborne illnesses. Findings: 1.a. During an observation on 5/2/22 at 9:17 a.m. in the kitchen during the initial tour, the plate warmer cover handle was broken. One side of the handle was not attached making it difficult to lift the lid. 1.b. During an observation on 5/2/22 at 9:38 a.m. in the kitchen during the initial tour, the left oven temperature dial had no numbers or markings to indicate the temperature setting. During a concurrent interview with food service worker (FSW) B, FSW B confirmed there were no numbers or markings. She stated it had been like that for a while and she guesses the temperature setting by adjusting the dial similar to the other oven dial. 1.c. During an observation on 5/2/22 at 9:41 a.m. in the kitchen on the initial kitchen tour, the reach in refrigerator that contained produce, contents included whole tomatoes, bagged lettuce, margarine, and whole green peppers. The inside thermometers read 42 F and 45 F. The refrigerator contained two thermometers inside next to each other on the same shelf. During an observation on 5/3/22 at 9:00 a.m. in the kitchen, the produce refrigerator inside temperatures read 40 F and 45 F. Contents included bagged lettuce, whole tomatoes, and a tray of cooked potatoes. The internal temperature of the cooked potatoes was 48 F and they were labeled with date 5/2/22 use 5/3/22 (cross-reference F812). During an interview on 5/3/22 at 11:37 a.m. in the kitchen, with FSW K, FSW K stated she cooked the potatoes last night (5/2/22), cooked them in the skins, peeled them, then placed them in the refrigerator covered, and went home. During an observation on 5/3/22 at 9:26 a.m. in the kitchen, the produce refrigerator door did not completely close on its own. It needed to be pushed closed. The refrigerator was directly next to a freezer and the refrigerator door rubbed against the freezer as it closed. The temperatures on the two thermometers inside the produce refrigerator were 40 F and 45 F. During an observation on 5/3/22 at 10:24 a.m., the produce refrigerator temperatures were 40F and 45F on the two thermometers inside. During an observation on 5/3/22 at 10:50 a.m. in the kitchen, the produce refrigerator's internal thermometers read 40 F and 45 F and the outside digital refrigerator thermometer read 33 F. During a concurrent interview with the dietary services supervisor (DSS) O, DSS O stated staff check the interior refrigerator thermometer when recording temperatures on the log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 28 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During review of the facility's Refrigerator Temperature Monitor Log Refrigerator Location: Produce dated May 2022, the log indicated, 5/1 a.m. 5:00 Temp 33, Afternoon 1:30 Temp 34, p.m. 6:30 Temp 31. 5/2 A.M. 5:00 Temp 33, Afternoon Temp -no entry, P.M. 6:30 Temp 35. 5/3 A.M. Temp - no entry. Log provided to surveyors 5/3/22 at 11:00 A.M. During an interview on 5/3/22 at 9:26 a.m. in the kitchen, with the registered dietitian (RD), the RD stated she had not noticed the oven dial with no numbers or the broken handle on the plate warmer cover. During an interview on 5/5/22 at 10:37 A.M in DSS N's office, with DSS N and RD present, DSS N stated when something breaks, cooks or staff tell DSS N, and maintenance is notified. During concurrent review of the maintenance binder there was no evidence that an oven temperature dial, refrigerator, or the handle of a plate warmer was reported to maintenance. During review of the facility's policy Refrigerators and Freezers revised December 2014, the policy indicated, This facility will ensure safe refrigerator, freezer maintenance, and temperature. Acceptable temperature ranges are 35 F to 40 F for refrigerators. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily . According to Food and Drug Administration (FDA) Food Code 2017, section 4-501.11 Good Repair and Proper Adjustment, equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 29 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Many Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the following multi-resident rooms provided less than 80 square feet per resident. Findings: room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 3 beds, 77.7 square feet per resident room [ROOM NUMBER], 2 beds, 74 square feet per resident room [ROOM NUMBER], 3 beds, 77.7 square feet per resident room [ROOM NUMBER], 2 beds, 76 square feet per resident room [ROOM NUMBER], 2 beds, 77 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 70 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 71 square feet per resident room [ROOM NUMBER], 3 beds, 74 square feet per resident room [ROOM NUMBER], 3 beds, 74 square feet per resident room [ROOM NUMBER], 3 beds, 74 square feet per resident room [ROOM NUMBER], 2 beds, 76 square feet per resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 30 of 31 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 055240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Watsonville Nursing Center 535 Auto Center Drive Watsonville, CA 95076 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 0912 room [ROOM NUMBER], 3 beds, 78.5 square feet per resident Level of Harm - Potential for minimal harm room [ROOM NUMBER], 2 beds, 71 square feet per resident room [ROOM NUMBER], 3 beds, 72 square feet per resident Residents Affected - Many room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 3 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 3 beds, 72 square feet per resident room [ROOM NUMBER], 2 beds, 73 square feet per resident room [ROOM NUMBER], 3 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 70.8 square feet per resident room [ROOM NUMBER], 3 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 70.8 square feet per resident room [ROOM NUMBER], 3 beds, 73 square feet per resident room [ROOM NUMBER], 2 beds, 70.8 square feet per resident room [ROOM NUMBER], 3 beds, 70.5 square feet per resident room [ROOM NUMBER], 3 beds, 72.3 square feet per resident During multiple observations on 5/1/18 and 5/4/18, none of the rooms were observed to inhibit the staff providing care. The staff and the residents moved freely in the rooms. The residents and the staff stated the square footage of the rooms was not a concern. Continuance of the room waiver is recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055240 If continuation sheet Page 31 of 31