Health inspection·July 28, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right out of it. The RCRN stated CNA G, who put it on Resident 317, also did recreation, which was pretty much the exact same thing. The RCRN stated CNA G's thought process of doing this was that Resident 317 had a habit of disrobing, and with the sheet there, she wouldn't expose her privates. The RCRN then stated the sheet was on top of (Resident 317), then tucked under her hips, with a draw sheet wrapped around her legs. There was a single loose knot which came undone easily by moving my legs. The way it was described, it was not proper procedure. During a review of Resident 317's care plan, dated 7/28/23, where staff had allegedly observed, on 1/28/23, her waist and lower legs had been wrapped in a sheet, it indicated an intervention of: if resident exposes her self cover with clothes, sheets, or blankets as needed. Draw the privacy curtain as needed and check on resident frequently. During a review of the SBAR (Situation, Background, Appearance, Review and notify) Communication Form for Resident 317, dated 1/29/23, the SBAR indicated Received report to prior day resident wrap with white linen blanket to lower extremities in a bow tie shape . During a review of Resident 317's Progress Notes dated 1/29/23, the progress notes indicated a CNA had notified the DON that on 1/28/23 at 10:45 p.m., she was passing by Resident 317's room and noticed Resident 317 taking off her gown, so she went in the room to help Resident 317 put her night gown back. The CNA noticed her bed sheets were tangled around the waist and lower legs and knotted on her lower legs just above the ankle. The CNA removed the knots on the sheets. During a review of Resident 317's Minimum Data Set (MDS, an assessment tool) dated 2/17/23, indicated Resident 317 was severely cognitively impaired with a brief interview of mental status (BIMS) of 0. A score of 13-15 indicated an individual was cognitively intact. A score of 8-12 indicated an individual was moderately cognitively impaired. A score of 0-7 indicated an individual was severely cognitively impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 2 of 26 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 07/28/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 35) had been informed about having an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about advance directive. This failure had the potential to result with inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services. Findings: Resident 35 was admitted to the facility with diagnoses which included dysphagia following unspecified cerebrovascular disease (stroke), dysphagia (swallowing difficulties), metabolic encephalopathy (a problem in the brain), adult failure to thrive, acute kidney failure, nephrogenic diabetes insipidus (kidneys do not function correctly, so too much fluid gets flushed out in the urine), and history of pulmonary embolism (a sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs). Review of Resident 35's electronic health record (EHR), there was no documentation found about advance directive. The POLST (Physician Orders for Life Sustaining Treatment) form had check boxes which would indicate: 1. if there is an advance directive, 2. if it is not available, or 3. if there is no advance directive. None of the check boxes had been checked. During an interview with the social services director (SSD) on 7/26/23 at 12:39 p.m., she stated Resident 35 did not have an Advance Directive. The SSD acknowledged section D (section regarding advance directive) of the POLST did not have a check mark. During a review of the facility's policy and procedure (P&P) titled Record Content: Physician Orders For Life Sustaining Treatment (POLST), dated 11/2017, indicated Physician Orders For Life Sustaining Treatment (POLST)-this form: a. Complements an advance directive (but does not replace it), by taking the individual's wishes regarding life-sustaining treatment, such as those set forth in the advance directive, and converting those wishes into a medical order. Review both these forms to ensure consistency and update forms appropriately to resolve any conflicts. .1. When A Complete POLST Form Is Provided On admission: .c. Obtain copies of appropriate documents, such as, advance directive and/or conservatorship/guardianship documents for the resident's health record. .2. When There Is No POLST Form Completed On admission: The admission coordinator, or social services director, or licensed nurse: .b. Health Care Professional: - .Explain the difference between an advance health care directive and the POLST form, as indicated on the POLST form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 3 of 26 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 07/28/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure 1. one of 17 sampled residents (Resident 35) or their responsible party (RP, person who is accountable in making decision on behalf of the resident) received a notice of transfer and discharged to the general acute care hospital (GACH) and 2. the State Long-Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) office was not notified about two of 17 residents (Residents 35 and 317) transfer to the GACH. These failures had the potential of not providing the residents and/or their RPs with an access to an advocate who could inform them of their rights. Findings: 1. Resident 35 was admitted to the facility with diagnoses which included Parkinson's disease, Dementia with behavioral disturbance, mild protein-calorie malnutrition, dysphagia following unspecified cerebrovascular disease (stroke), schizophrenia (a chronic brain disorder that can include symptoms of delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation.), unsteady on feet, weakness, dysphagia (swallowing difficulties), metabolic encephalopathy (a problem in the brain), long-term use of anticoagulants (blood thinners, making it harder to stop bleeding), nephrogenic diabetes insipidus (kidneys do not function correctly, so too much fluid gets flushed out in the urine), and history of pulmonary embolism (a sudden blockage in the pulmonary arteries, the blood vessels that send blood to the lungs). During a review of Resident 35's electronic health record (EHR), the EHR indicated he was sent to the GACH emergency department (ED) on 3/25/23 for decreased appetite and confusion. He was noted to be tachycardic (fast heart rate) and tachypneic (rapid shallow breathing), with an oxygen blood saturation of 74-78% on room air; which should be upper 90%. During an interview with the social services director (SSD) on 7/27/23 at 9:23 a.m., she stated I don't see the transfer form in PCC (software used for the residents' EHR). During another interview with the SSD on 7/27/23 at 1:52 p.m., she stated she did not find a transfer and discharge form given to Resident 35 or his RP and to be faxed to the Ombudsman. 2. Resident 317 was admitted with diagnoses which included Parkinson's disease, dementia with behavioral disturbance and agitation, unsteadiness on feet, age-related osteoporosis (bone mineral density and bone mass decreases, increasing risk of broken bones), pancytopenia (a decrease in all three blood cell types), dysphagia (trouble swallowing) following cerebrovascular disease, weakness, repeated falls, nutritional deficiency, acute kidney failure, intellectual disabilities, cognitive communication deficit, and history of falling. During a review of Resident 317's EHR, the EHR indicated she was sent to the GACH on 5/19/23, after having a heart attack. During an interview with the SSD on 7/27/23 at 9:16 a.m., the SSD stated she did not see a transfer form in Resident 317's EHR. She stated she would check with medical records to see if they could find it. During an interview with the SSD on 7/27/23 at 1:53 p.m.,, she stated she had a transfer and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 4 of 26 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 07/28/2023 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 0623 discharge form, but there was no verification of faxing the form to the Ombudsman. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's copy of the Notice of Transfer/Discharge form, at the top of the first page, it had blanks to fill in for the Residents' name, Notification date, person notified, relationship, effective date, and transfer/discharge to. At the top of the second page it read: Copy to: (then a check box) State LTC Ombudsman Office-Date: (a line for filling in the date). Residents Affected - Few All Facilities Letter (AFL) 17-27, dated 12/26/17 and addressed to long-term care facilities, indicated, Effective January 1, 2018, AB 940 requires a LTC facility to notify the local LTC Ombudsman at the same time notice is provided to the resident or the resident's representatives when a facility-initiated transfer or discharge occurs. The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision. AFL 17-27 further indicated, The facility is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if a resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 5 of 26 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 07/28/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 52). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions. Residents Affected - Few Findings: Review of Resident 52's medical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's Disease (brain disorder that destroys memory and thinking skills), dementia (mental disorder caused by brain disease or injury), and repeated falls. Review of Resident 52's SBAR [situation, background, assessment, recommendation] Communication Form, dated 5/9/22, indicated Resident 52 had a fall. Review of Resident 52's Fall Scene Investigation Report, dated 5/9/22 indicated, Resident was seen on the floor in her room at the left side of her bed. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 7/25/23 at 3:37 p.m., she reviewed Resident 52's medical record an confirmed the resident fell on 5/9/22. The MDSC explained this fall should have been coded on the MDS dated [DATE]. The MDSC reviewed Resident 52's MDS, dated [DATE], and confirmed section J1800 was coded No, indicating the resident did not fall during the specified time frame. The MDSC confirmed section J1800 should have been coded Yes, to indicate Resident 52 did fall during the specified time frame. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (MDS coding instructions), dated 10/2019, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 6 of 26 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 07/28/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards and facility policy and procedures for three of 17 sampled residents (Residents 7, 20, and 41), when: Residents Affected - Few 1. Licensed Vocational Nurse (LVN) C failed notify the physician when Resident 7 refused his diabetic medication 8 times in June and 12 times in July 2023; 2. For Resident 41, LVN E administered 13 units of insulin (medication to lower blood sugar) while the order indicated to give 6 units, and informed the physician after he administered it; 3. For Resident 20, 72 hour alert charting was not completed post fall. These failures had the potential to cause complications of the residents' medical conditions. Findings: 1. A review of Resident 7's clinical record indicated he was admitted to the facility with diagnoses including type 2 diabetes mellitus (disease that impairs the body's ability to regulate blood sugar [BS]) and diabetic neuropathy (nerve damage due to diabetes). His medications included two different types of insulin (injectable medication to lower BS) and metformin 1,000 milligrams (mg, unit of measurement) by mouth two times daily before meals for type 2 diabetes mellitus, dated 2/15/22. The facility scheduled metformin to be administered daily at 6:30 a.m. and 4:30 p.m. A review of Resident 7's June 2023 medication administration record (MAR) showed LVN C documented a 2 (meaning drug refused) on the MAR for the 6:30 a.m. metformin administrations on: 6/21, 6/22, 6/23, 6/24, 6/27, 6/28, 6/29 and 6/30/23 (total of 8 times). A review of Resident 7's July 2023 MAR indicated LVN C documented a 2 on the MAR for the 6:30 a.m. metformin administrations on: 7/4, 7/5, 7/6, 7/9, 7/10, 7/11, 7/12, 7/17, 7/18, 7/21, 7/22, and 7/23/23 (total of 12 times). During an interview with LVN D on 7/24/23 at 3:14 p.m., she stated Resident 7 sometimes refused his medications, especially early in the morning when he was still sleeping. He would get upset when woken up to take medications or for his BS check, that he would use bad words, or say get out of here! She also explained that if the resident did not like a particular staff member, he would refuse service from them. During a concurrent interview and record review with the director of nursing (DON) on 7/24/23 at 3:24 p.m., she verified the number of metformin refusals as stated above and said All 6:30 a.m. administration and only with her [LVN C]. She continued, They [the nurses] have to notify the doctor that the resident keeps refusing. During another interview and record review with the DON on 7/25/23 at 12:26 p.m., she stated she could not find any documented evidence LVN C called and notified the physician of Resident 7's repeated refusals of the metformin during the 8 days in June and 12 days in July. She stated, She should know to call the doctor. The DON stated LVN C worked night shift and was not available for interview. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 7 of 26 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 07/28/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 7's labs indicated he had a hemoglobin A1c reading (a test measuring your average BS level over the past 3 months) of 8.8% (high; the American Diabetes Association suggests a goal of 7% or lower A1C is a blood test for type 2 diabetes) on 3/16/23. 2. Resident 41 was admitted to the facility with diagnoses including type 2 diabetes mellitus. A review her Minimum Data Set (MDS, a care area assessment and screening tool), dated 7/19/23, indicated she had a BIMS score of 15 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15), which indicated she had intact cognition. On 7/24/23 at 12:18 p.m., LVN E was observed pricking Resident 41's left point finger and obtained a blood sample to get a BS reading. It was 217 milligrams/deciLiter (mg/dL). At this time, LVN E stated he will wait until the lunch tray came out before giving insulin to her. During a concurrent observation and interview on 7/24/23 at 12:36 p.m. at the medication cart, LVN E stated the lunch tray arrived at the resident's bedside and he was ready to administer the insulin to Resident 41. He explained the resident would determine the amount of insulin she needed, not according what the doctor ordered, but according to the BS reading and how much food she will eat; she would tell the nursing staff how much insulin she needed. He stated, Resident will complain if she doesn't get what she wants. During this observation, LVN E reached into the resident's room and asked Resident 41 what insulin dose she wanted. Resident 41 stated she wanted 13 units of insulin. On 7/24/23 at 12:40 p.m., LVN E was observed withdrawing into a syringe 13 units of insulin lispro (a short acting insulin) from the insulin lispro 100 units per milliliter (mL) vial. During an interview with Resident 41 on 7/24/23 at 12:43 p.m., while LVN E was in the room and ready to administer the insulin, Resident 41 stated she determined that the ordered sliding scale (a set of instructions for administering insulin dosages based on specific BS readings) by the physician was usually too low, and there were days she would eat more and less depending on what she liked. She stated she could calculate the amount of carbohydrates she will consume along with the BS reading and determine the insulin amount; that it has worked out well for her and helped control her BS better this way. On 7/24/23 at 12:45 p.m., LVN E was observed injecting the insulin into the resident's left abdomen. On 7/24/23 at 12:48 p.m., during an interview with LVN E, he stated the nurses were aware of the resident requesting different insulin doses different than ordered, and that new nurses were not comfortable so they would call the doctor several times a day. He stated he gave 13 units but the order called for 6 units. He stated he will call the physician later to let him know and document in the nursing progress notes the amount he administered. A review of LVN E's progress notes, written on 7/24/23 at 1:52 p.m., indicated insulin was offered and refused 3x, explained risks and benefits, MD aware given 13 units per request. A review of Resident 41's physician order, dated 8/13/22, for insulin lispro solution 100 units/ml, inject as per sliding scale: if [BS] 76 - 120 = no insulin; . 201 - 250 = 6 units . subcutaneously before meals and at bedtime related to type 2 diabetes mellitus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 8 of 26 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 07/28/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a follow-up interview with LVN E on 7/24/23 at 3:07 p.m., he stated he called the physician about 10 to 15 minutes after being observed by the surveyor. During a concurrent interview and record review with the DON on 7/24/23 at 3:38 p.m., she stated Resident 41 had kind of self-directed care but the doctor knows what's going on. When asked what the nurse should do if the resident requested the insulin amount outside of the ordered range, she stated the nurse should call the doctor first and get a one-time order. When advised LVN E administered 13 units of insulin when the order called for 6 units, and called the doctor after he administered it, the DON stated, It's not the right order. It's standard of practice that if you give outside of the prescribed order, you get an okay first. Review of the facility's policy and procedure titled Medication Administration - General Guidelines, dated 10/2017, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .and Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition . the nurse calls the provider pharmacy . or if necessary contacts the prescriber for clarification. 3. Review of Resident 20's clinical records indicated, he was admitted to the facility on [DATE], with diagnoses including hemiplegia (severe loss of strength leading to complete paralysis on one side of the body) and hemiparesis (partial muscle weakness on side of the body) following unspecified cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain) affecting left non-dominant side, type 2 diabetes mellitus (high blood sugar, adult-onset) and vascular dementia (memory loss caused by multiple strokes). Further review of Resident 20's clinical record indicated he had a fall on 6/2/23 and no alert charting and monitoring were done on these shifts: a. 6/2/23 - afternoon shift, b. 6/3/23 - night shift, c. 6/4/23 - morning shift, d. 6/4/23 - afternoon shift e. 6/4/23 - night shift and f. 6/5/23 - morning shift. During a concurrent interview and record review with licensed vocational nurse F (LVN F), on 7/27/23 at 11:18 a.m., LVN F verified there were no alert charting done on the above shifts. LVN F further stated alert charting for 72 hours should be done every shift after a fall. During a concurrent interview and record review with the DON on 7/28/23 at 12:00 p.m., the DON reviewed Resident 20's clinical record and verified Resident 20 was not monitored every shift for 72 hours after he fell on 6/2/23. The DON further stated licensed nurses should do alert charting every shift post fall. Review of the facility's policy titled, Falls Management, revised, 11/2012, indicated, . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 9 of 26 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 07/28/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm 6.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 nurses' notes. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 10 of 26 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 07/28/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities for one of 17 sampled residents (Resident 52). This failure had the potential to negatively affect the resident's overall well-being. Residents Affected - Few Findings: Review of Resident 52's medical record indicated she was admitted on [DATE] and had the diagnoses of Alzheimer's Disease (brain disorder that destroys memory and thinking skills), dementia (mental disorder caused by brain disease or injury), and major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 52's Minimum Data Set (MDS, an assessment tool), dated 9/27/22, indicated doing her favorite activities was very important to Resident 52. Review of Resident 52's care plan, revised 10/20/22 indicated, The resident is dependent on staff for activities, cognitive stimulation, social interaction. The care plan also indicated, The resident needs 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. The care plan further indicated, When the resident chooses not to participate in organized activities, turn on TV, music in room to provide sensory stimulation. During observations on 7/24/23 at 8:44 a.m., 7/24/23 at 1:02 p.m., 7/25/23 at 1:37 p.m., 7/27/23 at 11:59 a.m., and 7/28/23 at 8:28 a.m., Resident 52 was in her room lying in bed. The only items in Resident 52's room were the bed, overbed table, floor mats, and drawers. There was no TV or radio in the room. At no time during the survey was Resident 52 observed to be receiving, or being offered group or individual activities. During an interview and concurrent record review with the activities director (AD) on 7/28/23 at 9:18 a.m., the AD stated Resident 52 joined group activities at times. She stated Resident 52 also liked to walk around, watch TV, and listen to music. The AD stated Resident 52 spent most of her time in her room, so the facility would provide room visits. The AD reviewed Resident 52's medical record and confirmed there was no documentation that the resident received, or was offered activities during the survey. The AD also reviewed her own activities records and confirmed there was no documentation that Resident 52 received, or was offered activities during the survey. During a concurrent observation, interview, and record review with licensed vocational nurse A (LVN A) on 7/28/23 at 9:46 a.m., LVN A reviewed Resident 52's medical record and confirmed the care plan indicated to turn on the TV and play music in the room if the resident chose not to participate in organized activities. LVN A looked in Resident 52's room and confirmed there was no TV or radio in the room. LVN A confirmed staff would not be able to implement the intervention of turning on the TV and playing music in Resident 52's room. The facility's policy and procedure (P&P) titled Activities/Recreation Program: Categories, revised 6/2022 indicated, The Activity/Recreation Director and staff will provide for ongoing Activity/Recreation programs to meet the needs and interests of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 11 of 26 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 07/28/2023 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor, evaluate and managed residents behavior for one of 11 sampled residents (Resident 24), when Resident 24 had episodes of shaking her side rails when in bed. The failure had the potential for Resident 24, not attaining her highest well-being and caused discomforts to her roommate Resident 41. Findings: During an interview with Resident 41 on 7/24/23 at 8:53 a.m., she stated her roommate Resident 24 had episodes of banging or shaking her side rails when in bed. Resident 41 further stated, Resident 24 had this behavior going on for about a year [already] and she had been complaining to the facility but nothing had been done. During an observation and concurrent interview of Resident 24 on 7/24/23 at 12:50 p.m., Resident 24 was sitting in her wheelchair in the dining area, eating her lunch. She was confused and could not respond to questions when asked. Review of Resident 24's clinical records indicated, she was admitted to the facility on [DATE], with diagnoses including bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs), dementia (loss of memory) with agitation and schizoaffective disorder (serious mental health condition characterized primarily by symptoms of hallucinations or delusions and symptoms of a mood disorder). During an interview and concurrent record review with licensed vocational nurse F (LVN F) on 7/28/23 at 12:43 p.m., LVN F verified Resident 24 had episodes of shaking her bed rails due to anxiety and could be bothering her roommate. LVN F reviewed Resident 24's clinical record and stated Resident 24's behavior was not monitored and could not find notes that it was coordinated. LVN F further stated the doctor was not notified. During an interview with the director of nursing (DON) on 7/28/23 at 1:15 p.m., the DON stated Resident 24's behavior of shaking her bed rails should have been addressed. The DON further stated, the behavior should have been monitored and coordination notes should have been implemented. The DON added, the doctor should have been notified for Resident 24's behavior for further management. Review of the facility's policy and procedure, titled Behavior Management, revised, 11/2012, indicated, It is the policy of Windsor Healthcare to attempt to manage and reduce or eliminate dysfunctional resident behavior through the provision of behavioral interventions. Based on the assessment of precipitating factors and behavior exhibited, the interdisciplinary team formulates a plan of care to manage, reduce or eliminate the behavior. Behavioral manifestations to be monitored are recorded on the Medication Administration Record and episodes are tallied each shift using hash marks. The care plan and its effectiveness are assessed no less than quarterly and the care plan modified based on the results of the assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 12 of 26 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 07/28/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted and given according to the physician's orders for two of two sampled residents (Residents 2 and 267). Controlled medications were signed out of the Controlled Drug Record (CDR, or an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) as administered to the residents; furthermore, there were no physician's orders for the administrations. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications. Findings: During the survey, CDRs for two random residents (Residents 2 and 267) were requested for review. 1. A review of Resident 2's clinical record indicated he had a physician's order, dated 9/19/22, for hydrocodone-acetaminophen (Norco, a controlled medication for moderate to severe pain) 5-325 milligrams (mg, unit of measurement), 1 tablet by mouth every 6 hours as needed for pain. It was discontinued on 5/23/23. A review of Resident 2's Minimum Data Set (MDS, a care area assessment and screening tool), dated 5/2/23 , indicated he had a BIMS score of 13 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15), which indicated he had intact cognition. A review of Resident 2's CDR for Norco 5-325 mg and the May and June 2023 MARs indicated the nursing staff signed out 1 tablet on the following dates and times, after the order had been discontinued and without documenting the respective administration on the MARs: - 5/25/23 at 7:45 p.m. - 5/26/23 at 8 p.m. - 5/27/23 at 7:10 p.m. - 5/28/23 at 10:15 (no a.m. or p.m. indicated) - 5/29/23 at 9:45 p.m. - 5/31/23 at 9:13 p.m., and - 6/1/23 at 8:45 p.m. During a concurrent interview and record review with the director of nursing (DON) on 7/25/23 at 12:12 p.m., she reviewed Resident 2's above-mentioned records and confirmed seven Norco tablets were removed after the order had been discontinued; and they were not documented on the MARs, resulting in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 13 of 26 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 07/28/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few seven tablets unaccounted for. The DON stated it was the resident who requested to discontinue the Norco on 5/23/23. She also reviewed the nursing progress notes and stated she could not find any documented evidence they were administered to Resident 2. During an interview with Resident 2 at his bedside on 7/25/23 at 3:42 p.m., he stated he did not want the Norco and often refused it because it did not do anything for him. When asked whether he continued to receive Norco after he requested to discontinue it, Resident 2 stated he did not remember. During a follow-up interview with the DON on 7/25/23 at 4:07 p.m., she stated she had yet found out what happened to Resident 2's seven Norco tablets, and was working on getting the statements from the two nurses involved, who were on vacation and not available for interview. 2. A review of Resident 267's clinical record indicated she had a physician's order, dated 7/18/23, for alprazolam (controlled medication to treat anxiety) 0.25 mg, 1 tablet by mouth one time a day every Tuesday, Thursday, and Saturday for verbalization of anxiousness prior to dialysis related to ANXIETY DISORDER. A review of Resident 267's CDR for alprazolam and the July 2023 MAR indicated a nursing staff signed out 1 tablet on 7/19/23 at 1 a.m. (a Wednesday) but did not document the administration on the MAR. During a concurrent interview and record review with the DON on 7/25/23 at 12:06 p.m., she confirmed there was no order to give it on a Wednesday (a non-dialysis day), and there was no documentation on the MAR nor progress notes to indicate it was administered to the resident. A review of the facility's policy and procedures titled, Controlled Medications, dated 8/2014, indicated: When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4) Initials of the nurse administering the dose on the MAR after the medication is administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 14 of 26 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 07/28/2023 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 Based on interview and record review, the facility failed to ensure the medication regimen for one of 17 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 had been receiving Reglan (metoclopramide; medication to treat nausea and vomiting) exceeding 12 weeks duration, as specified by the manufacturer, without a risk/benefit (R/B) assessment. This had the potential for the resident to experience side effects, specifically tardive dyskinesia (an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs) from prolonged use. Residents Affected - Few Findings: A review of Resident 57's clinical record indicated a physician's order for metoclopramide 5 milligrams (mg) 1 tablet by mouth before meals for nausea/vomiting (N/V) since 2/24/2023 (5 months ago). The resident's July 2023 medication administration record (MAR) indicated the resident had been receiving it routinely three times daily at 8 a.m., 11 a.m., and 4 p.m. A review of Lexicomp, a nationally recognized drug information resource, indicated under Adult Dosing: To decrease the risk of tardive dyskinesia (TD), metoclopramide should not be used continuously for >=12 weeks and Metoclopramide can cause tardive dyskinesia, a serious movement disorder that is often irreversible. There is no known treatment for tardive dyskinesia. The risk of developing tardive dyskinesia increases with duration of treatment and total cumulative dose . Avoid treatment with metoclopramide for longer than 12 weeks because of the increased risk of developing tardive dyskinesia with longer-term use. During an interview with licensed vocational nurse (LVN) D on 7/27/23 at 10:08 a.m., she stated the resident still had occasional N/V, and it was the facility's nurse practitioner (NP) who prescribed it. During an interview with the NP on 7/27/23 at 11:15 a.m., she stated she did not prescribe the Reglan, but she assessed the resident earlier this month. She confirmed long-term use of Reglan could result in tardive dyskinesia for the resident. When asked whether there was a R/B assessment for Reglan being used longer than 12 weeks, the NP did not respond. She stated, Every time I asked if he has nausea/vomiting, he always says no. So although I did not put him on it, I will have it changed to 2 weeks; and if he doesn't need it, will discontinue it. During a concurrent interview and record review with the director of nursing (DON) on 7/27/23 at 11:41 a.m., she stated, historically the resident was always nauseated and he wanted something to take before he could eat. She continued, He still has some nausea/vomiting now and then. When asked whether there was a R/B assessment exceeding the 12 weeks of use as per the manufacturer's specifications, the DON reviewed Resident 57's clinical record and stated, I don't see anything. A review of the facility's policy and procedure titled Medication Administration - General Guidelines, dated 10/2017, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 15 of 26 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 07/28/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35 received Remeron (generic name: mirtazepine, an antidepressant medication) for poor appetite related to depression without staff consistently monitoring for his meal intakes. The failure resulted in inadequate monitoring for the effectiveness of the medication. Findings: A review of Lexi-comp, a nationally recognized drug information resource, indicated Remeron is used to treat various medical conditions including depression. One of its side effects included increased appetite. A review of Resident 35's clinical record indicated he was an elderly resident admitted to the facility with diagnoses including unspecified dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), failure to thrive, and depression. His height was 62 inches (5 feet 2 inches); and he weighed 115.6 pounds on 7/1/2023. Further review of Resident 35's clinical record indicated he was admitted to the hospital on [DATE] with documented chief complaint of confusion, poor oral intake. Upon returning to the facility on 3/28/23, he received a physician's order for Remeron 15 milligrams daily at bedtime, dated 3/28/23. For the use of Remeron, a review of Resident 35's medication administration record (MAR) indicated the nursing staff monitored episodes of depression m/b [manifested by] episodes of poor appetite. every shift for Mirtazepine starting 5/16/23. On 7/6/23, this behavior monitoring was changed to: Monitor episodes of depression m/b episodes of poor appetite. Document episodes of refusing meals. every shift for Mirtazepine. A review of Resident 35's care plan for depression, revised 5/10/23, indicated, The resident uses antidepressant medication Remeron r/t [related to] Failure to thrive. decrease appetite eating less than 25% . Give anti-depressant medications ordered by physician. Monitor/document side effects and effectiveness . Monitor for decrease appetite < than 25%. A review of the May and June 2023 MARs indicated the nursing staff documented 0s (zeros) every shift for the entry of Monitor episodes of depression m/b episodes of poor appetite. every shift for Mirtazepine. A review of the July 2023 MAR indicated the nursing staff documented some 50s, other times 100s, but mostly 0s for the entry of Monitor episodes of depression m/b episodes of poor appetite. Document episodes of refusing meals every shift for Mirtazepine starting on 7/6/23. It was unknown what poor appetite meant quantitatively, and whether 0 meant no poor appetite, or resident ate zero percent of his meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 16 of 26 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 07/28/2023 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 During a concurrent interview and record review with the director of nursing (DON) on 7/27/23 at 1:37 p.m., she stated Resident 35 had concerns with poor oral intake and weight, but he had been eating better. She reviewed the above-stated MARs and confirmed there was inconsistency in what the nursing staff monitored for the effectiveness of Remeron. She stated, They should monitor for meal intakes, usually less than 50% . and it should say breakfast, lunch, and dinner [instead of every shift]. She acknowledged consistency in monitoring would help the facility assess whether the medication helped improve the resident's appetite. A review of the facility's 10/14/17 policy and procedure titled Psychotropic Medication Management indicated the facility ensure residents in need of psychotropic medications receive appropriate assessment and intervention in order to achieve their highest level of functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 17 of 26 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 07/28/2023 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure the temperature (temp) in one of two medication refrigerators (Ref #2) was maintained within acceptable range from 36 to 46 degrees Fahrenheit (ºF) as per the manufacturers' and the facility's guidelines. Ref #2 had out-of-range temp readings 4 times in June 2023, and 23 out of 47 times in July 2023, without any documented action taken by the staff to correct the out-of-range temps. Exposing medications to out-of-range temps, such as too hot or cold, can cause them to become unstable and even degrade, posing a risk of negative side effects and decreasing their effectiveness. Findings: On 7/24/23 at 9:37 a.m., a visit to the medication room with the director of nursing (DON) identified two medication refrigerators: one small Immunization Refrigerator and a larger house-hold type medication refrigerator (Ref #2). A review of the thermometer inside Ref #2 with the DON indicated temp reading of 34ºF. Ref #2 was observed to contain 19 pre-filled insulin (medication to lower blood sugar) pens, 2 insulin vials, 1 bag of formoterol (for breathing problems) inhalation solution, 12 various types of eye drops (to treat eye problems such as glaucoma), a refrigerated emergency kit (a kit containing medications for immediate use during a medical emergency), 4 lorazepam (to treat anxiety) oral solution bottles, and 2 Glatopa (to treat multiple sclerosis, a disabling disease of the brain and spinal cord) syringes. During this visit, the DON stated the nursing staff monitored and documented the temp monitoring twice daily, during the day shift and NOC (or night) shift. A review of the undated temp log titled Medication Refrigerator Daily Temperature Record indicated it included the following instructions, Refrigerator temperature to be monitored and documented on day shift AND NOC shift to maintain a desired refrigerator temperature of 36º - 46ºF. At the bottom of the record, it indicated, If the temperature was outside the stated parameters, what action was taken? Please comment above. A review of the June 2023 Medication Refrigerator Daily Temperature Record for Ref #2 indicated it had out-of-range temperature on 4 days during the day shift: on 6/13, 6/19, 6/21, and 6/29/23. All had temp reading of 34ºF. There was no documented action taken when the temperature was outside of the set parameters. A review of the July 2023 Medication Refrigerator Daily Temperature Record for Ref #2 indicated it had 23 out-of-range temp readings out of 47 times documented in this month. Of the 23 times, 11 of the readings had temp reading of 32ºF (or freezing temp); the remainder (12 times) had temp reading of 34ºF. There was no documented action taken when the temp was outside of the set parameters. During a concurrent interview and record review with the DON on 7/24/23 at 3:22 p.m., she reviewed the June and July 2023 temp logs and acknowledged the above finding, and that no action was taken by the staff when the medication refrigerator had out-of-range temps. She stated, when the temp reading is out-of-range, the staff should adjust the thermostat control, document the action taken, and re-check after a short while to make sure the temp goes back in range. She acknowledged that medications should not be frozen, especially insulin, which may be ineffective for the residents. She stated, I need a new fridge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 18 of 26 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 07/28/2023 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 - Some During a re-visit to the medication room with the DON on 7/25/23 at 8:22 a.m., she stated all medications in Ref #2 were transferred to the Immunization Refrigerator the night before, and the facility re-ordered all new insulin pens and vials to replace those in Ref #2. Ref#2 was observed not in use. A review the United States' Food & Drug Administration's (FDA) online publication titled Information Regarding Insulin Storage and Switching Between Products in an Emergency, dated 9/19/2017, indicated: According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36°F to 46°F . Insulin loses some effectiveness when exposed to extreme temperatures. The longer the exposure to extreme temperatures, the less effective the insulin becomes. This can result in loss of blood glucose control over time . avoid freezing the insulin. Do not use insulin that has been frozen. A review of the product label from the manufacturer for Glatopa, dated 1/2018, indicated, Store Glatopa refrigerated at . 36°F to 46°F . If needed, the patient may store Glatopa at room temperature, 15°C to 30°C (59°F to 86°F), for up to one month, but refrigeration is preferred. Avoid exposure to higher temperatures or intense light. Do not freeze Glatopa. If a Glatopa syringe freezes, it should be discarded. A review of the facility's policy and procedure titled Medication Storage In the Facility, dated 4/2008, indicated, Medication requiring 'refrigeration' or 'temperatures between 2°C (36°F) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 19 of 26 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 07/28/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident 6's medical record indicated he was admitted on [DATE]. Resident 6's Minimum Data Set (MDS, an assessment tool), dated 5/18/23, indicated he had a BIMS score of 15. Further review of the medical record indicated Resident 6 was on a regular diet. Residents Affected - Some During an interview with Resident 6 on 7/24/23 at 11:08 a.m., he stated the food at the facility was sometimes bland. Resident 6 confirmed he did not have any dietary restrictions. During an observation and concurrent interview on 7/26/23 at 1:35 p.m., three surveyors, along with the DM, conducted a taste test of the food the facility served the residents for lunch that day. The facility's menu indicated the lunch consisted of barbecue pork, baked beans, seasoned greens, and cornbread. All three surveyors agreed the seasoned greens were bland. The DM confirmed they did not taste like seasoned greens. She stated they tasted more like collard greens. Review of the facility's policy titled Food Handling Practices, revised 1/2013 indicated, The production of attractive, palatable food is achieved through careful control of materials and equipment, organization of work, and the care, handling, and service of products. The objective of good food preparation are to: serve foods which are attractive, palatable, and in the form best tolerated/accepted by residents. Review of the facility's undated policy titled Food Tasting indicated, Sample food to verify proper preparation and seasoning. Food tasting is a very important part of the dietary department QUA (quality assessment) and A (assurance) process, as well as individual meal satisfaction for residents. Based on observation, interview and record review, the facility failed to ensure food palatability was maintained, when six of 17 sampled residents (Residents 11, 41, 12, 269, 270 and 6) complained about the taste of the food being served. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status. Findings: 1. During an interview with Resident 11 on 7/24/23 at 8:15 a.m., he stated he did not like the food in the facility because the food tasted bland. Review of Resident 11's clinical records indicated, was admitted to the facility on [DATE] and had a brief interview for mental status (BIMS, widely used tool, to screen and identify the cognitive condition of residents) score of 15 (a score 15 indicated the resident was cognitively intact). 2. During an interview with Resident 41 on 7/24/23 at 8:53 a.m., she stated she had issues with her food since the change of management about a year and a half ago. Resident 41 further stated the food sometimes tasted bland. Review of Resident 41's clinical records indicated, she was admitted to the facility on [DATE]. Resident 41 was on consistent carbohydrate diet, regular texture and thin consistency and had a BIMS score of 15. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 20 of 26 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 07/28/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. During an interview with Resident 12 on 7/24/23 at 10:15 a.m., he stated he was a resident of the facility for about two years and had issues with the food taste since last year. Resident 12 further stated the food sometimes tasted bland. Review of Resident 12's clinical records indicated, he was admitted to the facility on [DATE], with diagnoses including, cerebral infarction (most common type of stroke which occurs, when a clot of blocks a blood vessel that feeds the brain) and weakness. Resident 12 was on regular diet and had a BIMS score of 13 (a score of 13 indicated the resident was cognitively intact). 4. During an interview with Resident 269 on 7/24/23 at 11:45 a.m., he stated he did not like his food because it tasted bland. Resident 268 further stated he complained about the food about two weeks ago and nothing was done. Review of Resident 269's clinical records indicated, Resident 269 was admitted to the facility on [DATE] and had a BIMS score of 12 or his cognition was moderately impaired. 5. During an interview with Resident 270 on 7/24/23 at 12:00 p.m., he stated his food was bland and had been complaining about 2 weeks ago. Review of Resident 270's clinical records indicated, he was admitted to the facility on [DATE] and had a BIMS score of 15. During an interview with the registered dietitian (RD) on 7/26/23 at 8:55 a.m., the RD verified that the reason for the complaints of Residents 11, 41, 12, 269 and 270, could be attributed to the fact that there was a time, during the change of management last year, the RD was working remotely and could not attend to the needs and complaints of the residents personally. During an interview with the director of nursing (DON) on 7/26/23 at 11:37 a.m., she stated Residents 11, 41, 12, 269 and 270 issue about the food was because of the kitchen management transition. The DON further confirmed the RD was working remotely and did not physically see the residents during the transition. The DON stated, residents could not complain directly to the RD at that time. During an observation on 7/26/23 at 1:35 p.m., with the RD and the dietary manager (DM), two lunch meal test trays were brought for taste testing. The first tray had regular minced and moist barbecue pork, baked beans, seasoned greens and cornbread. The second tray had regular pureed barbecue pork, baked beans, seas greens and cornbread. Both the meal test trays were tested. The first meal test tray tasted bland and could not taste any seasonings. During an interview with the DM on 7/26/23 at 1:40 p.m., the DM acknowledged she could not taste any seasonings in the first meal test tray and tasted bland. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 21 of 26 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 07/28/2023 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 document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when: Residents Affected - Many 1. There was a crusty white substance on several areas of the ice machine; and 2. Kitchen staff did not follow manufacturer's instructions when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Findings: 1. During an observation on 7/26/23 at 7:45 a.m., accompanied by the dietary manager (DM), the facility's ice machine was inspected. There were streaks of a crusty white substance running along the top and down the left side of the ice machine. This crusty white substance was also found under the ice machine's lid. More of this crusty white substance was found in the area where the lid contacted the body of the ice machine. During a concurrent interview with the DM, she confirmed the presence of the crusty white substance on the ice machine. The DM acknowledged the ice machine did not look clean. The United States Food and Drug Administration's 2022 Food Code indicated ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. The Food Code further indicated food equipment shall be clean to sight and touch. 2. During an interview with the DM on 7/26/23 at 8:53 a.m., she explained the kitchen surface sanitizer was used on multiple kitchen surfaces, including in areas where food was prepared. During an observation on 7/26/23 at 8:55 a.m., accompanied by the DM, dietary aid B (DA B) was asked to demonstrate how to test the kitchen surface sanitizer. DA B located a red bucket filled with kitchen surface sanitizer in the food preparation area of the kitchen. Without checking the sanitizer's temperature, DA B took a piece of test paper, dipped it in the sanitizer, then checked to see if the test paper changed to the appropriate color as indicated on the test paper container. The printed instructions on the test paper container indicated the testing solution should be between 65-75 degrees Fahrenheit (F, unit of temperature measurement). During an observation and concurrent interview with the DM on 7/26/23 at approximately 8:57 a.m., the DM confirmed DA B did not check the temperature of the kitchen surface sanitizer before testing it. The DM reviewed the printed instructions on the test paper container and acknowledged the sanitizer was supposed to be between 65-75 degrees F during testing. DA B was asked to check the temperature of the kitchen surface sanitizer after his test demonstration. DA B dipped a thermometer in the sanitizer and the temperature reading was 77.2 degrees F. The DM confirmed the temperature was not within range. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 22 of 26 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 07/28/2023 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 During an observation and concurrent interview with the DM on 7/26/23 at approximately 8:59 a.m., there was a poster on the kitchen wall with instructions on how to test the kitchen surface sanitizer. The instructions indicated the testing solution should be between 65-75 degrees F. The DM confirmed this observation. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 23 of 26 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 07/28/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and document review, the facility failed to ensure refuse (any disposable materials, which includes recyclable and non-recyclable materials) was stored properly when one out of four dumpsters was overfilled and the lid was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility. Residents Affected - Few Findings: During an observation on 7/25/23 at 9:46 a.m., accompanied by the dietary manager (DM), there were four dumpsters in the facility's designated waste storage area. One dumpster was overfilled with cardboard. The dumpster was so full that the lid would not close, as it was propped open by the cardboard inside. There were also several large cardboard boxes stored on top of the dumpster lid. During a concurrent interview with the DM, she confirmed the above observation and confirmed the dumpster lid should have been closed. The DM stated all her staff knew the dumpster lids were supposed to be closed. The DM acknowledged, an open dumpster could attract pests. The United States Food and Drug Administration's 2022 Food Code indicated, Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. The facility's undated policy and procedure (P&P) titled Food Handling Practices indicated, Keep lids/doors to dumpsters closed when not dumping garbage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 24 of 26 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 07/28/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, licensed vocational nurse A (LVN A) failed to perform hand hygiene during wound treatment for one of two sampled residents (Resident 6). This failure had the potential to cause infection or other complications to Resident 6's wound. Residents Affected - Few Findings: Review of Resident 6's medical record indicated he was admitted on [DATE] and had a pressure ulcer (damage to the skin or underlying tissue as a result of prolonged pressure) on the left buttock. During an observation on 7/26/23 at 2:00 p.m., LVN A performed treatment on Resident 6's left buttock pressure ulcer. While wearing a pair of clean gloves, LVN A cleaned Resident 6's pressure ulcer with a piece of gauze soaked in normal saline (solution used to clean wounds). She then removed her gloves and without performing hand hygiene, she put on a new pair of gloves. LVN A then took a piece of dry gauze, dried Resident 6's pressure ulcer, and removed her gloves again. Without performing hand hygiene, LVN A put on another pair of new gloves, applied Aquacel (a type of dressing used to aid wound healing) to Resident 6's pressure ulcer, then removed her gloves again. Without performing hand hygiene, LVN A put on another pair of new gloves and applied a foam dressing to Resident 6's pressure ulcer. During an interview with LVN A on 7/26/23 at 2:12 p.m., she confirmed she changed her gloves multiple times while treating Resident 6's pressure ulcer and did not perform hand hygiene between glove changes. LVN A stated she usually performs hand hygiene before starting the wound treatment and after completing the wound treatment. During an interview with the director of nursing (DON) on 7/26/23 at 2:28 p.m., she stated nurses should perform hand hygiene every time they remove gloves and before they put on new gloves. The DON further stated nurses should perform hand hygiene after cleaning a dirty wound and before applying a clean dressing. The facility's policy and procedure (P&P) titled Hand Hygiene P&P, revised 1/10/19, indicated employees are required to wash their hands thoroughly between procedures on the same resident, after touching objects that may be soiled, and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 25 of 26 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 07/28/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure their pest control program was effective when there were several fruit flies (small flying insects that have the potential to contaminate food) in the kitchen, even though the kitchen had recently been treated for fruit flies. The presence of pests in the kitchen had the potential to result in foodborne illness (illness caused by contaminated food) for 66 out of 66 residents. Residents Affected - Many Findings: Review of the facility's pest control summary, dated 7/6/23, indicated 22 live fruit flies were found in the kitchen. The summary further indicated the pest control company applied treatment in response to the fruit flies that were found in the kitchen. During an observation on 7/26/23 at 7:54 a.m., accompanied by the dietary manager (DM), there was a white bucket on the floor near one corner of the kitchen. There were approximately 11 live, small, black, flying insects observed on this white bucket. During a concurrent interview with the DM, she confirmed the presence of the live, small, black, flying insects in the kitchen. The DM stated she was not sure how the insects got in the kitchen, and stated she would ask the pest control company to come to the facility. Review of the facility's pest control summary, dated 7/26/23, indicated the pest control company performed Service to control fruit flies in the kitchen. The United States Food and Drug Administration's 2022 Food Code indicated, The premises shall be maintained free of insects, rodents, and other pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 26 of 26