Health inspection·January 26, 2024

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. Based on observation, interview, and policy review, the facility failed to ensure that the facility environment remains free of accident hazards when the temperatures of hot water at the sinks of Room AA and Room BB were at 127 degrees Fahrenheit (F, temperature scale) and 130 F. This failure placed the residents and staff at risk for accidental burns. Findings: During an observation with the maintenance director (MD) on 1/26/24 at 12:45 p.m., the sink in the restroom of Room AA was shared by four residents, and the temperature of the sink hot water was at 127 F. The sink in the restroom of Room BB was shared by two residents, and the temperature of the sink hot water was at 130 F. During an interview with the MD on 1/26/24 at 1:05 p.m., he stated the sink hot water temperature should be maintained between 105 F to 115 F. Review of the facility ' s undated policy, TELS Masters, indicated the hot water temperature typically falls between 105 F to 115 F. For burn prevention, it advises that the facility keep domestic water temperatures below 120 F. Page 1 of 3 055871 055871 01/26/2024 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

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. 055871 Page 2 of 3 055871 01/26/2024 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 055871 Page 3 of 3