Inspection·January 26, 2024

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 policy review, the facility failed to implement infection control practices when: Residents Affected - Some 1. Certified Nursing Assistant A (CNA A) placed soiled linen and towels on the restroom floor in Resident 1's room and carried the soiled linen and towels out of Resident 1's room and in the hallway; and 2. CNA B cleansed Resident 2, then carried a bag of used incontinent brief and soiled towels with gloved hands, walked out of Resident 2 ' s room and in the hallway. These failures had the potential to spread infection in the facility. Findings: 1. During an observation in Resident 1's restroom on 1/26/24 at 2:50 p.m., the soiled linen and towels were on the restroom floor. During an observation and interview with CNA A in Resident 1 ' s restroom on 1/26/24 at 3 p.m., she stated she changed Resident 1 in the restroom per Resident 1's request, and she placed the soiled linen and towels on the restroom floor. CNA A stated she should place the soiled linen and towels in the hamper and not on the floor. Then, CNA A put on gloves, picked up the soiled linen and towels, walked out of Resident 1's room and in the hallway to place the soiled linen and towels in the hamper which was in front of Room CC. During a concurrent interview with CNA A, she stated she should have the hamper in front of Resident 1's room, so that she could place the soiled linen and towels in there and not carry the soiled linen and towels out of Resident 1's room and in the hallway. During an interview with the back-up infection preventionist (BUIP) on 1/26/24 at 3:25 p.m., she stated CNA should place the soiled linen and towels in the hamper and not on the floor. CNA should have the hamper in front of residents ' rooms, so that they could place the soiled linen and towels in there and not carry the soiled linen and towels out of residents ' rooms and in the hallway. 2. During an observation on 1/26/24 at 4:15 p.m., CNA B finished cleansing Resident 2. Then she carried the bag of used incontinent brief and soiled towels with her gloved hands, walked out of Resident 2 ' s room and in the hallway to throw the bag in the big trash bin which was in front of Room CC. During a concurrent interview with CNA B, she stated she should have the trash bin in front of Resident 2's room, so that she could throw the bag of used incontinent brief and soiled towels in there and not carry the bag out of Resident 2's room and in the hallway with gloves on. During an interview with BUIP on 1/26/24 at 4:30 p.m., she stated CNA should have the trash bin in front of residents' rooms, so that they could throw the trash in there and not carry the trash out of residents' rooms and in the hallway with gloves on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 2 of 3 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 01/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility's policy, Personal Protective Equipment - Using Gloves, dated 9/2010, indicated Discard used gloves into the waste receptacle inside the examination or treatment room. Review of the facility's policy, Soiled Linen, Handling, dated 1/10/19, indicated . 4. Place residents soiled personal clothing into the soiled linen barrel . 5. Consider all soiled linen contaminated and handle as little as possible and with minimum agitation to prevent gross microbial contamination of the air and of persons handling the linen. Hold linen away from the body and place carefully in linen barrel. As always, follow Standard Precautions during all care and procedures, even when the resident does not have an identified infection. Event ID: Facility ID: 055871 If continuation sheet Page 3 of 3