Inspection·June 26, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 25 and 44) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying them that Part A coverage is being terminated and providing information on how to file an appeal of that decision). Residents Affected - Few This failure had the potential to prevent the residents from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: A review of Resident 25's clinical record indicated he was admitted to the facility on [DATE] with a primary diagnosis of pneumonia. The facility initiated a discharge from Medicare Part A services on 4/15/19 with benefit days remaining. A NOMNC was not found in the clinical record. A review of Resident 44's clinical record indicated he was admitted to the facility on [DATE] with a primary diagnosis of chronic kidney disease. The facility initiated a discharge from Medicare Part A services on 4/17/19 with benefit days remaining. A NOMNC was not found in the clinical record. During an interview with the administrator (ADMIN) on 6/24/19 at 1:10 p.m., he stated the facility was unable to locate the NOMNC for Residents 25 and 44. He further stated that the facility should have issued the NOMNC. A review of the facility's document Denial Letter Usage (undated), indicated Notice of Medicare Provider Non-Coverage also known as 'Generic Notice' form CMS 10123-NOMNC. Give 2 calendar days prior to LCD (Last Medicare Covered Day): 1) When Part A ends and staying at the facility; 2) When DC (discharged ) to Home; 3) Part B patients ending therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 2 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide restorative nursing assistant (RNA) services (exercise program intended to improve or maintain level of function) as ordered for two of 18 sampled residents (9 and 44). This failure had the potential to result in a decline in the residents functional abilities. Findings: 1. Review of Resident 44's clinical record indicated he was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (partial or total loss of ability to move one side of the body), abnormalities of gait and mobility, unsteadiness on feet, and generalized weakness. Review of Resident 44's physician's order, dated 4/18/19, indicated he was to receive RNA treatments consisting of omnicycle (arm and leg pedal exerciser), shoulder and elbow exercises, sitting in wheelchair with ankle weights, and knee and hip exercises. Review of Resident 44's document Rehabilitation and Restorative Nursing Program dated 4/16/19, indicated he was to receive the above RNA treatments five times a week, Wednesday through Sunday, for range of motion (ROM, full movement potential of a joint) maintenance of both upper and lower extremities for three months. During an interview with RNA C on 6/26/19 at 2:00 p.m., he stated Resident 44 refused to do the exercises. He further stated if a resident refused the RNA treatment, the refusal should be documented and the nurse should be notified. During an interview with RNA D on 6/26/19 at 2:44 p.m., she stated Resident 44 refused to exercise most of the time, and stated Resident 44 did exercise on the omnicycle only a few times. She further stated the refusals should be documented. She stated she did not inform Resident 44's nurse when he refused the RNA treatments. Review of Resident 44's documentation survey report, dated April 2019, indicated he refused RNA services one time on 4/24/19. RNA documentation for 8 days of the month when RNA treatments were scheduled were left blank. Review of Resident 44's documentation survey report, dated May 2019, indicated he received RNA services on 5/11/19, 5/18/19 and 5/19/19. Documentation indicated Resident 44 refused RNA services five times during the month, and 15 days were left blank. Review of Resident 44's documentation survey report, dated June 2019, indicated he refused RNA services five times and 17 days were left blank. During an interview with the assistant director of nursing (ADON) on 6/26/19 at 10:25 a.m., she stated RNA services should be provided as ordered. She confirmed the missing signatures on Resident 44's RNA documentation records and stated RNA treatments should be documented. The ADON further stated blank documentation indicated the RNA treatment was not provided. She further stated when Resident 44 refuses the RNA treatments, the RNA should inform the licensed nurse and the physician should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 3 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0688 notified. Level of Harm - Minimal harm or potential for actual harm 2. A review of the clinical record for Resident 9, the admission Record dated 6/26/19 indicated Resident 9 was admitted on [DATE] with diagnoses of hypertension (high blood pressure), muscle weakness, anemia (a state in which hemoglobin in blood is below the reference range) and repeated falls. Residents Affected - Few A review of the clinical record for Resident 9, the Documentation Survey Report dated 6/19 indicated an order for RNA (restorative nursing assitant) PT (physical therapist) program five times a week for three months. During an interview and record review with restorative nursing assistant D (RNA D) on 6/25/19 at 2:44 p.m., she confirmed there were missing documentation related to RNA order for Resident 9 for June 2019. She also added that sometimes they don't get to finished with their RNA task because of other tasks that they have to finish. During an interview and record review with the director of nursing (DON) on 6/25/19 on 2:49 p.m., she confirmed there were missing documentations for RNA for the last three months (Apri1 2019, May 2019 and June 2019). During an interview with the rehab director (RD) on 6/26/19 at 10:37 a.m., she stated that the RNA PT Program was to prevent and maintain certain level of function. The RD also added the RNA PT Program should be followed and implemented to maintain certain level of functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 4 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were provided to prevent accidents or harm for five of 20 sampled residents, when: 1) There was no bolster (cushion for support) in Resident 39's bed and the bed level was raised. 2) A neurological assessment was not completed after seven unwitnessed falls for Resident 19 and the alarming devices were non-functional and not in place for Resident 19. 3) There were fire hazard items placed on three residents room light (Residents 23, 36 and 45). These failures had the potential to place residents at risk for accidental burns, repeated falls, injury, or even death. Findings: 1) Review of Resident 39's clinical record, Resident 39 was admitted on [DATE] with diagnoses included chronic kidney disease , hypertension (high blood pressure) and dementia (memory loss). Record Review of Resident 39 's MDS (resident tool assessment) dated 11/03/18, Resident 39 was severely cognitively impaired and required extensive assistance with two person physical assist during activities of daily living. During observations on 06/24/19 and 06/25/19 at 1:53 p.m., Resident 39 was alert, lying in bed and speaking Spanish. Resident 39's bed level was up and there was no bolster found in Resident 39's bed. Interview with CNA M on 6/25/19 at 3:50 p.m., CNA M stated the CNA on themorning shift forgot to lower the level of bed position. CNA M also stated Resident 39 had never had a bolster in her bed since her last fall several months ago. Record Review of Resident 39 IDT (interdisciplinary team) fall Investigation notes dated 1/3/19, indicated seen in side lying position on the floor beside bed. Assessed and left eyebrow has laceration .and was taken to acute hospital for further treatment. Resident slid from bed. Resident 39 returned from acute hospital with left eyebrow laceration with glue. Interventions included Keep bed in low position. On low air loss mattress with bolster, position resident in the middle of the bed. Interview with the ADON on 6/26/19 at 9:30 a.m., the ADON stated they did not revised Resident 39's fall care plan after she fell on 1/3/19 to include the bolster and keeping the bed in low position. 3) During observation on 6/23/19 at 8:16 a.m., Resident 23's cap, Resident 36's hat and Resident 45's balloon were placed on top of resident's room light that was on. During interview with CNA E on 6/24/19 at 9:36 a.m., CNA E acknowledged the above findings and stated, Those are fire hazards and should not be kept there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 5 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2) A review of Resident 19's clinical record indicated he was admitted on [DATE] with diagnoses including repeated falls, muscle weakness, altered mental status, bilateral glaucoma, and abnormalities of gait and mobility A review of Resident 19's Minimum Data Set (MDS, an assessment tool), dated 3/29/19, indicated the resident's cognition (ability to think, understand, and reason) was severely impaired and required extensive assistance (staff provide weight-bearing support) for transfers and toileting. The MDS also indicated Resident 19 was not steady and was only able to stabilize with staff assistance for surface to surface transfers. A review of Resident 19's physician orders dated 6/10/19, indicated a bed alarm and chair alarm to alert staff of unassisted transfer and to check placement every shift. During an observation on 6/23/19 at 9:00 a.m., a chair alarm, unattached to Resident 19, was on top of the pillow on resident 19's bed and a bed alarm cord was not connected to the alarm base unit. Resident 19 was walking to the bathroom unassisted and there were no alarms sounding. There was no caregiver inside the room. During an interview on 6/23/19 at 9:05 a.m. with certified nursing assistant G (CNA G), she confirmed Resident 19 was in the BR unassisted and there was no alarm sounding. CNA G examined the bed alarm and noted the cord had exposed wires and was no longer attached to the alarm unit and confirmed the alarm was not operational. CNA G stated the chair alarm located on Resident 19's pillow should be worn by the resident when he is out of the bed. During an interview on 6/23/19 at 11:00 a.m. with licensed vocational nurse K (LVN K), she stated the bed and chair alarms are checked every shift by the licensed nurse for placement and function and indicated she had not yet checked Resident 19's alarms. LVN K stated Resident 19 was a fall risk and should have the bed or chair alarm in use at all times. During an interview with the assistant director of nursing (ADON) on 6/24/19 at 10 a.m., she stated when a resident has an unwitnessed fall the licensed nurse initiates the fall protocol which includes neuro checks (assessment of level of consciousness, pupil reaction, refex activity and movements of the extremities). The ADON stated neuro checks follow the protocol which is as follows: Neuro checks 15 minutes x2, then half an hour x3, then 2 hours x2, then every 4 hours x 4, next 48 hours x 6. She stated monitoring the residents after a fall incident is important to identify any changes of condition that need medical intervention or transfer to the hospital. Review of Resident 19's clinical record indicated he had falls on 5/2/19, 5/3/19, 6/6/19, 6/8/19, 6/14/19, 6/20/19 and 6/23/19. The Fall Scene Investigation Report indicated the falls on those dates were unwitnessed. There was no documentation to indicate neurological assessments were performed and completed after the falls on the above dates. During an interview with the director of nursing (DON) on 6/25/19 at 9:40 a.m., she confirmed there was no documentation of neuro checks being performed by the licensed nurses after Resident 19's falls on 5/2/19, 5/3/19, 6/6/19, 6/8/19, 6/14/19, 6/20/19 and 6/23/19. The DON stated there should be neuro checks documented after every unwitnessed fall of any resident. A review of the facility's, Fall Management policy revised 11/2012, indicated . Un-witnessed fall for residents who are deemed to be an unreliable historian and nurse is unable to determine if a head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 6 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0689 Level of Harm - Minimal harm or potential for actual harm injury occured will have neurological checks implememnted and documented . Continued monitoring by a licensed nurse is necessary, as symptoms may present at any time, even days following the actual event. This will include assessing for injury and monitoring of vital signs every shift for a minimum of 72 hours and documented in the nursing notes. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 7 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 care of an intravenous (IV, within a vein) site dressing and accurate measurement of arm circumference and external length catheter were completed as per physician orders for one (Resident 66) of one resident reviewed with IV catheters, which had the potential to result to IV complication. Residents Affected - Few Findings: Review of Resident 66 's clinical record, Resident 66 was admitted on [DATE] with diagnoses included sepsis (serious complication of infection) disruption of external operation (surgical) wound, and muscle weakness. Review of Resident 66's MDS dated [DATE], Resident 66 was cognitively alert and required supervision during activities of daily living. During concurrent observation and interview on 06/23/19 at 9:28 a.m., Resident 66 had rashes and bruise on the right upper arm skin surrounding the transparent dressing of the IV site. Resident 66 also stated that nurses had pulled his external length catheter every time they changed the IV dressing and it had gone longer already. Review of Resident 66's IV administration record dated 5/2019 and 6/2019, indicated no licensed nurse signature was marked on the following dates to monitor IV central lines and observe for reactions during infusion such as signs & symptoms of infiltration (IV fluid or medications leak) or phlebitis (inflammation of vein) before and after medication administration: 5/24/19 (10:00 PM), 5/25/19 (10:00 PM), 5/26/19 (at 2:00 PM and 10:00 PM), 5/27/19 at 6:00 AM and 10:00 PM, 5/28/19 at 6:00 AM and 10:00 PM and 5/31/19 (at 2:00 PM and 10:00 PM). There was also no licensed nurse signature on 6/20/19 that arm circumference and external catheter length was measured. Interview with the ADON on 6/24/19 at 3:30 p.m., the ADON confirmed the above findings and stated the RN also should have assessed the rashes and bruise on Resident 66's right upper arm to inform the physician to provide treatment. Interview with registered nurse B (RN B), on 6/25/19 at 8:20 a.m., RN B stated she forgot when was the last time she measured Resident 66's right arm circumference and external length catheter. RN B also identified the length of the external catheter as its size all the way thru the extension tubing or double lumen. Interview with the ADON on 6/24/19, at 3:30 p.m., ADON stated the order of the care of the IV site was changed to do it every Saturday because RNs are busy to do it every Thursday. The ADON also stated RN was supposed to measure external catheter length from the end of the hub to the point of skin insertion that is only the thin portion of the external catheter but not all the way. Review of Resident 66's physician order dated 5/23/19, indicated IV central lines site monitoring every 8 hours and PRN. Observe for reactions during infusion. Observe for signs & symptoms of infiltration or phlebitis before and after medication administration. Review of Resident 66's physician order dated 5/30/19, indicated Right upper arm measurement for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 8 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0694 Level of Harm - Minimal harm or potential for actual harm PICC lines on admission/after dressing change & PRN (as needed). Arm circumference 17 inches. IV central lines active therapy orders #9: external catheter length: 12 centimeters (cm, unit of measure). Measure from the end of the hub to insertion into the skin. This order was revised on 6/24/19 to external catheter length: 8 cm. Measure from the end of the hub to insertion into the skin. Then it was revised again to indicate external catheter length: 10 cm. Measure from the end of the hub to insertion into the skin. Residents Affected - Few Review of Resident 66's physician order dated 6/15/19, indicated Monitor skin redness/irritation on the right upper arm. Update physician for any changes or complications. Review of Resident 66's progress notes dated 6/19/19 at 6:43 AM by RN B, indicated measurement arm circumference 43 cm, PICC length 18 cm . Interview with the ADON on 6/24/19 at 3:45 p.m., when asked about the variations of the length of external catheter, the ADON stated they could not tell if it had gone shorter or longer because they were not able to note the baseline measurement of the right arm circumference including length of external catheter from the day of admission. The ADON also stated that at present the length of external catheter was 10 cm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 9 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis (the clinical purification of blood as a substitute for normal function of the kidney) communication record were completed, for one of one resident receiving dialysis (21). This failure had a potential to put Resident 21 at risk in developing undetected, potentially life-threatening complications related to dialysis treatment. Residents Affected - Few Findings: During a review of clinical record for Resident 21, the admission Record dated 6/26/19 indicated Resident 21 was admitted on [DATE] with diagnosis of end stage renal disease (gradual loss of kidney function), acute on chronic combine systolic (congestive) and diastolic (congestive) heart failure (a progressive heart disease that affects pumping action of the heart muscle) and hypertension (high blood pressure). During a review of clinical record for Resident 21, the following Nurse's Dialysis Communication Records dated 3/8/19, 5/17/19, 6/10/19 and 6/21/19 were incomplete. During an interview with the director of nursing (DON) on 6/25/19 at 11:08 a.m., the DON confirmed above Nurse's Dialysis Communication Records were incomplete. She also stated her expectation is for all records to be completed. A review of the facility's policy, Dialysis, Coordination of Care & Assessment of Resident revised 1/2018, indicated the facility will notify the Dialysis Center by telephone or in writing via a Dialysis Communication Paper prior or at the time of treatment. It also indicated the dialysis center, by telephone or in writing, will notify the facility regarding post dialysis assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 10 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate indication, behavioral and adverse/side-effects monitoring for one of 20 sampled residents (Resident 122) related to use of Seroquel (treats mental/mood disorder), which had the potential to result to adverse drug reactions. Residents Affected - Few Findings: Review of Resident 122 's clinical record, Resident 122 was admitted on [DATE], with diagnoses included dementia (memory loss), muscle weakness, and parkinson's disease (central nervous system disorder, often including tremors). Review of Resident 122 physician's order dated 6/2019 indicated Seroquel 200 mg po OD for dementia. Review of Resident 122's care plan, medication and treatment administration record dated 6/2019, there was no targeted behavior that includes its monitoring related to the use of Seroquel. Additionally, there was no adverse or side-effects monitoring of the drug. Interview with LVN J on 6/24/19, at 9:01 a.m., LVN J confirmed lack of targeted behavioral and adverse/side-effects monitoring in the clinical record. LVN J also stated the nurse did not enter the task in the electronic medical record. Interview with CNA I on 6/24/19 at 9:25 a.m., CNA I was not aware there was behavioral issues concerning Resident 122. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 11 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure that the Alprazolam (anti-anxiety) for one of 20 sampled residents (Resident 122) was limited to 14 days, which had the potential to cause adverse drug reactions. Findings: Review of Resident 122 physician's order dated 6/15/19, indicated Alprazolam tablet Disintegrating 0.25 mg. Give 1 tablet by mouth as needed for anxiety. Interview with LVN J on 6/24/19 at 9:01 a.m., LVN J confirmed that Alprazolam as needed had no stopped date within duration of 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 12 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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: 1) resident medications were sufficiently labeled; 2) unused narcotics were disposed of; and 3) discontinued narcotics were secured. This failure had the potential to result in the accidental administration of a wrong medication to the wrong resident and/or drug diversion. Findings: 1. During an observation of medication cart TEAM 1 on 6/23/19 at 1:08 p.m., three opened boxes of Natural Balance Tears (eye drops) were in the medication cart each labeled with only a room number. During a concurrent interview with the associate director of nurses (ADON), she confirmed the observation. 2. During an observation of medication cart TEAM 2 on 6/23/19 at 1:15 p.m., the narcotic drawer contained three small plastic envelopes each containing a single tablet. One envelope was labeled with a room number and date; a second envelope was labeled with a room number, resident name, and date: and a third envelope was labeled with a resident name and a partially illegible drug name. During a concurrent interview with the ADON, she confirmed the observation. When asked why the narcotic tablets were in the medication cart, she stated those are for destruction. During a review of the electronic medication administration record (eMAR) on 6/23/19 at 1:39 p.m. with the ADON and licensed vocational nurse A (LVN A), the three narcotics were identified as Resident 31's Norco 5/325 (two tablets) and Resident 66's Percocet 10/325 (one tablet). A review of the eMAR for Resident 31 indicated she had refused her Norco on 6/12/19 and 6/18/19. A review of the eMAR for Resident 66 indicated he had refused his Percocet on 6/21/19. During a concurrent interview with the ADON, when asked what the expectation is regarding nurses turning in unused narcotics to the DON, she stated They should always give it to the RN the next day if it is not a weekend. When asked if the unused narcotics had been in the cart too long, the ADON stated yes. 3. During an observation and concurrent interview with the ADON on 6/24/19 at 8:02 a.m., she demonstrated the facility's process of securing discontinued narcotics in a locked file drawer located in the director of nursing's (DON) office. The ADON stated the narcotics are locked in a drawer with the key accessible to the ADON and the DON. The ADON is observed removing the key from an unlocked drawer located just above the drawer used to secure the narcotics. The ADON opened the narcotic drawer with the key. When asked who else (other than herself and the DON) had a key to the DON's office, she replied maintenance. A review of the facility's policy, Disposal of Medications and Medication-Related Supplies: Controlled Medication Disposal dated January 2013, indicated When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 13 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 it is not placed back in the container. It is destroyed in the presence of two licensed nurses . Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy, Medication Storage in the Facility: Controlled Medication Storage dated August 2014, indicated Schedule 11-V medications and other medications subject to abuse are stored in a separate area under double lock. Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed . Residents Affected - Few A review of the facility's policy, Disposal of Medications and Medication-Related Supplies; Controlled Medication Disposal dated January 2013, indicated The director of nursing and the consultant pharmacist are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 14 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide plateguard (stainless steel food guard to secure food spill) during lunch meal for one of seven residents (Resident 61) reviewed with adaptive devices, which had the potential to affect resident's ability to complete self-feeding task. Residents Affected - Few Findings: During dining observation on 6/23/19 at 12:15 p.m., Resident 61 had no plate guard during lunch meal which had caused some food particles to have been spilled on the table. The plateguard was left on the tray cart. CNA H did not attach the plateguard on top of the plate. During interview with CNA H on 6/23/19 at 12:16 p.m., when asked where's the plateguard of Resident 61, CNA H pointed out the silverware underneath the plate. During interview with DSD on 06/26/19 at 11:33 a.m., the DSD stated the CNA should be responsible for putting the plateguard on top of the plate. The DSD showed that the silverware underneath the plate which the CNA pointed out was not the plateguard. Review of Resident 61's meal card dated 6/23/19, indicated devices: Plate Guard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 15 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food safely when: Residents Affected - Many 1. refrigerator #1 had torn, dirty gaskets and racks with peeling coating and rust; 2. refrigerator #2 had torn, dirty gaskets; racks with rust; and a discolored pork roast; and 3. freezer #2 had torn, dirty gaskets; racks with peeling coating and rust; and poultry and salmon with freezer burn These failures had the potential to cause food borne illness to a highly susceptible population of 75 residents who received food from the kitchen. Findings: During an initial tour and observation of the kitchen on 6/23/19 at 8:58 a.m. with the dietary aide (DA), refrigerator #1 had torn, dirty gaskets and racks with peeling coating and rust; refrigerator #2 had torn, dirty gaskets; racks with rust; and a discolored (gray/green) pork roast; and freezer #2 had torn, dirty gaskets; racks with peeling coating and rust; and poultry (turkey deli meat, chicken breasts, turkey pieces) and salmon fillets with freezer burn. During a concurrent interview, the DA confirmed the observations. A review of the facilities policy, Storing Frozen Foods dated January 2013, indicated Store frozen food items in original packaging, in moisture-proof wrapping, or in approved containers to prevent freezer burn. A review of the facility's policy, Sanitation dated July 2013, indicated The Maintenance Department & Environmental Department assists Dietary Department as necessary in maintaining equipment and in doing janitorial duties which the dietary employee cannot do. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 16 of 17 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 055871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control practices when used lancets (a spring-loaded device that contains a needle) were stored in an unlocked freezer in an unlocked biohazardous waste storage area. Residents Affected - Few This failure had the potential to expose the residents to infectious disease. During an observation of the biohazardous waste storage area with the associate director of nursing (ADON) and the van driver (VD) on 6/24/19 at 8:45 a.m., the door to the storage area was unlocked. A freezer used to contain biohazardous waste was also unlocked. Thirteen lancets and caps (lancet covers) were scattered on the bottom of the freezer. During a concurrent interview, both the ADON and VD confirmed the observations. During an interview with the maintenance supervisor (MS) on 6/24/19 at 8:53 a.m., when asked if the biohazardous waste storage area should be locked, he stated it should be locked. A review of the facility's policy, Disposal of Medications and Medication-Related Supplies: Syringe and Needle Disposal dated April 2008, indicated Immediately after use, syringes and needles are placed into a puncture resistant, one-way containers specifically designed for that purpose. The policy further indicated While awaiting disposal, full containers of discarded needles are kept where residents and unauthorized staff do not have access (such as in a locked medication room). A review of the facility's policy, Medical Waste Management: Waste Minimization dated 1/10/19, indicated Sharps Waste - Any device having acute rigid corners or edges, or projections capable of cutting or piercing, including: Hypodermic needles, syringes, blades and needles, lancets. The policy further indicated Storage and Security: Storage enclosure must be clean and orderly, secured to deny any access to unauthorized persons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 17 of 17