Health inspection·March 14, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for two of four sampled residents (Resident 121 and Resident 226 ) when Resident 121 and Resident 226 foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) drain bags were left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 121 and Resident 226. Findings: 1. During an observation on 3/10/25, at 10:29 a.m., in Resident 121's room. Resident 121 was observed sitting on his wheelchair with the urine bag hanging on the left side of his wheelchair uncovered and yellow colored urine was visible from the drainage bag. Review of Resident 121's clinical record indicated Resident 121 was admitted to the facility with diagnosis including benign prostatic hyperplasia (BPH, is a common condition in older men where the prostate gland, located below the bladder and surrounding the urethra, grows larger than normal). Review of Resident 121's physician's order indicated an order for Indwelling Catheter: Foley Catheter size: FR 16. dated 3/6/25. During an interview on 3/12/25, at 3:44 p.m., with the Director of Nursing (DON), the DON confirmed Resident 121's foley catheter bag was uncovered. She stated Resident 121 should have a privacy bag cover, when in bed and when resident go out of the room. 2. During an observation on 3/12/25, at 11:12 a.m., with the Physical Therapy Assistant (PTA), the PTA was observed walking with Resident 226 in front of Resident 226's room. Resident 226's foley catheter bag was hanging uncovered on the PTA cargo pants pocket. During a review of Resident 226's clinical record indicated she was admitted to the facility with the diagnosis including malignant neoplasm of vulva (cancerous tumor that develops in the external female genital organs). Review of Resident 226's physician's order indicated an order for Indwelling Catheter: Foley Catheter size: FR 16. During an interview on 3/12/25 at 4:50 p.m., with the DON, the DON confirmed there was no privacy Page 1 of 12 055871 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0550 Level of Harm - Minimal harm or potential for actual harm bag covering Resident 226's foley catheter and it was hanging on the PTA's cargo pants pocket. The DON stated, it should not be like that, staff should have unhooked the bag and put it in the walker. During an interview on 3/14/25, at 1:23 p.m., with the PTA, he confirmed he hanged the foley catheter bag of Resident 226 on his cargo pants pocket and he stated there was no cover on the foley catheter bag. Residents Affected - Few During an interview on 3/14/25, at 2:21 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was not okay to hang the foley catheter bag on the cargo pants pocket for dignity. The ADON further stated, foley catheter bag should have a cover at all times. Review of the facility's P&P titled, Quality of Life- Dignity Revised 2/2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.1. Residents are treated with dignity and respect at all times . 055871 Page 2 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review, the facility failed to protect resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment)for one of 18 residents (Resident 7) when Registered Nurse D (RN D) left the computer screen on and unattended on top of the medication storage cart. Residents Affected - Few This deficient practice had the potential to compromise the resident's privacy and confidentiality. Findings: During an observation on 3/12/25, at 2:35 p.m., Resident 7's medication orders were on the computer screen and RN D left the computer screen on and unattended. The computer that contained Resident 7's PHI was on top of the medication cart parked in the hallway facing away from resident rooms. During an interview with RN D on 3/12/25, at 2:40 p.m., RN D confirmed she left the computer screen on when she went to the other side of the facility to provide wound care to other residents. During an interview with the Director of Nursing (DON) on 3/12/25, at 3 p.m., the DON stated nurses should sign out from the computer when going to do other tasks. The DON further stated the hallway was busy with passersby like housekeepers, visitors, and other staff. A review of the facility's policy and procedure titled, Resident Rights, revision date December 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality; 2. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer. 055871 Page 3 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 the PASARR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 assessment was coded accurately for one of five sampled residents (Resident 6) reviewed for PASARR. Residents Affected - Few This failure had the potential for having residents that were not appropriate in the facility and for Resident 6 not to receive the appropriate services. Findings: Review of Resident 6's clinical record indicated Resident 6 was admitted to the facility on [DATE] with diagnosis includes depression (mental health condition characterized by a persistent low mood, loss of interest, and other symptoms that interfere with daily life) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 6's PASARR Level 1 Screening Form dated 3/24/21, showed Resident 6 had no prescribed psychotropic (substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medications for mental illness. Review of Resident 6's acute care discharged summary dated 3/24/21, showed Resident 6 had a physician's order dated 3/24/21, divalproex sodium (used to treat mania (episodes of frenzied, abnormally excited mood) in people with bipolar disorder ) 500 mg (milligram, unit of measurement), q (every) am (in the morning) and 1000 mg q pm ( in the evening) and Doxepin (medication used to treat depression and anxiety (anxiety, a mental health condition involving repeated episodes of sudden feelings of fear, dread and uneasiness) 25 mg at bedtime. Review of Resident 6's physician's order dated 3/24/21 indicated, Divalproex Sodium Tablet 500 mg give 1 tablet by mouth in the morning to bipolar disorder and Divalproex Sodium Tablet 500 mg give 2 tablet by mouth in the evening related to bipolar disorder. During a concurrent interview and record review on 3/12/25 at 3:59 p.m., with the Director of Nursing (DON), a review of Resident 6 PASARR level 1 screening form dated 3/24/21 indicated Level 1 screen no need for a PASARR level II evaluation. The DON confirmed Resident 6 was on psychotropic medication upon admission. The DON confirmed Resident 6 had PASSR level 1 screening form indicated no prescribed psychotropic medications for mental illness. The DON stated the PASARR should be corrected, the prescreening will determine the appropriate placement for resident. Review of the facility's P&P titled, PASRR Completion Policy Revision Date 9/30/2024, the P&P indicated, The Center will a make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed. 055871 Page 4 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

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 seven sampled residents (Resident 51 and 66). Controlled medications were signed out of the Controlled Drug Record (CDR, 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; Controlled medications were documented on the MAR as administered to the residents but not signed out of the CDR. 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 (Resident 51 and 66) were requested for review. 1. A review of Resident 51's clinical record indicated a physician's order, dated 1/14/25 for tramadol (controlled medication for the management of moderate to moderately severe pain) 50 milligrams (mg, unit of measurement), 1 tablet by mouth every 6 hours as needed for moderate pain. A review of Resident's 51's CDR for February and March 2025 for tramadol 50 mg, indicated two tablets of tramadol 50 mg were removed on 2/25/25 at 6:09 p.m. and 2/25/25 at 7:31 p.m. The MAR indicated tramadol 50 mg was administered on 3/1/25 at 7:31 p.m. During a concurrent interview and record review with the Director of Nursing (DON) on 3/14/25, at 4:38 p.m., the DON reviewed Resident 51's CDR and MAR and stated the nurse documented the wrong date on the CDR for the tramadol administered on 3/1/25 at 7:31 p.m. 2. A review of Resident 66's clinical record indicated a physician's order, dated 2/18/25, for hydrocodone-acetaminophen (Norco, a controlled medication for moderate to severe pain) 5-325 mg, 1 tablet by mouth every 6 hours as needed for severe pain. A review of Resident 66's February and March CDR for Norco 5-325 mg indicated the nursing staff signed out 1 tablet on the CDR on 3/10/25 at 7:13 a.m. without documenting the respective administration on the MAR on 3/10/25. During a concurrent interview and record review with the DON on 3/14/25, at 4:45 p.m., the DON reviewed Resident 66's above-mentioned records and confirmed one Norco tablet was removed and was not documented on the MAR resulting in one unaccounted Norco tablet. The DON stated there was no documented evidence the Norco was administered to Resident 66. A review of Resident 66's clinical record indicated a physician's order, dated 2/19/25 for tramadol 50 mg, 1 tablet by mouth every 12 hours for pain management. A review of Resident 66's CDR dated February and March 2025 for tramadol 50 mg indicated a nursing staff did not sign out any tablets on 3/10/25 for the evening dose of the tramadol but was 055871 Page 5 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0755 documented on the MAR on 3/10/25 at 9 p.m. as being administered to the resident. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the DON on 3/14/25 at 4:55 p.m., the DON verified there was no documentation on the CDR that the evening dose of tramadol was removed from the CDR. The DON also stated she was aware of CDR and MAR discrepancies by the nursing staff for a while. Residents Affected - Few A review of the facility's policy and procedures titled, Controlled Substances, revision date November 29022, indicated, Handling Controlled Substances: .4. An individual resident-controlled substance record is made for each resident who will be receiving a controlled substance. This record contains: a. name of the resident; b. name and strength of the medication; i. time of administration and l. signature of nurse administering medication. Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 5. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. 5c. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met. 055871 Page 6 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

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 follow their policy and procedure (P&P) for proper labeling and storage of medications when food was stored on two of four medication storage carts. This deficient practice had the potential to cause cross contamination that could affect the residents. Findings: During a concurrent observation and interview on 3/12/25 at 12:26 p.m. with Licensed Vocational Nurse E (LVN E), one opened and dated cup of applesauce was found stored inside the top drawer of medication storage cart AA together with bottles of medication. LVN E stated the opened cup of applesauce should be discarded at the end of the shift. During an observation and interview on 3/12/25 at 1 p.m. with LVN F, one unopened cup of applesauce was found stored in the top drawer of medication storage cart BB during inspection. LVN F stated the cup of applesauce was for mixing with medication for some of the residents. During an interview on 3/14/25 at 2:25 P.M. with the Director of Nursing (DON), the DON stated no food should be stored on or inside the medication cart. Review of the facility's policy and procedure titled, Medication Labeling and Storage, revision date February 2023 indicated, .6. Medications are stored separately from food and are labeled accordingly. 055871 Page 7 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

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 ensure sanitary conditions were maintained in the food and nutrition services when: Residents Affected - Many 1. One plastic spatula (a kitchen utensil with a wide, flat blade used for mixing spreading, lifting, and removing food) had burned handle and brownish color; 2. Nine pieces of large sized steel pan trays with a blackish colored substance on all the edges; 3. Several black colored dots were trapped in the bug light trap and was not clean as needed; and 4. Staff did not check the expiration date of the test strip prior to using. These failures had the potential to cause food contamination and illness for 69 out of 70 residents who received food from the kitchen. Findings: 1. During a kitchen observation and concurrent interview with the Dietary Manager (DM) on 3/11/25, at 9:34 a.m., a plastic spatula hanging in the kitchen utensil had burned on the handle. The DM verified the observation and further stated the plastic spatula should not be used. 2. During a kitchen observation and concurrent interview with the DM on 3/11/25 at 9:37 a.m., there were nine large sized steel pan trays with a blackish colored substance on all the edges. The DM confirmed the observation and stated the kitchenware were old, rusted and must not be used. Review of the facility's policy and procedure (P&P) titled, Sanitation, revised November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner. 2. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. During a kitchen observation and concurrent interview with the DM on 3/11/25 at 9:37 a.m., a bug light trap was observed with several black colored dots. The DM confirmed several black colored dots were trapped in the bug light trap. The DM further stated the trap were changed monthly and as needed. During a review of the facility's policy and procedure (P&P) titled, Sanitation, revised November 2022, the P&P indicated, The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean . 4. During an observation and concurrent interview on 3/11/25 at 11:12 a.m., Dietary Aide (DA) B tested the kitchen sanitizer, which was contained in a red bucket. DA B took a test strip, dipped it in the sanitizer for approximately one second, then checked to see if the test strip changed to the appropriate color. DA B did not check the expiration date of the test strip when performing the testing of the strip in the red bucket. 055871 Page 8 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an observation and concurrent interview on 3/12/25 at 12:32 p.m., [NAME] C was asked to demonstrate how to test the kitchen surface sanitizer. [NAME] C located a red bucket filled with kitchen surface sanitizer in the food preparation area of the kitchen. The DM handover the test strip canister and [NAME] C 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 without checking the test strip sanitizer's expiration date. During an interview with the DM on 3/13/25 at 1:46 p.m., the DM confirmed the staff should check the expiration of the strip before using since that's part of the process when using the strip. 055871 Page 9 of 12 055871 03/14/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures when: Residents Affected - Some 1. Resident 26's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen [a colorless and odorless gas that people need to breathe] was hanging and expose on the resident side rails; 2. Staff did not perform handwashing/hand hygiene before and after gloving; 3a. Enhanced barrier precautions signage was not posted on the door for one resident; b. One staff member did not disinfect cap of medication bottle appropriately; and 4. The Physical Therapy Assistant (PTA) hanged the foley catheter bag on his cargo pants pocket. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. During an observation on 3/10/25 at 11:14 a.m., Resident 26's nasal cannula tubing was hanging and was exposed on the resident's side rails. During a concurrent observation and interview with Registered Nurse (RN) A on 3/10/25 at 12 p.m., RN A verified the observation that Resident 26's nasal cannula tubing was hanging and was exposed. RN A stated nasal cannula tubing should be stored in a plastic bag when not in use. A review of World Health Organization (WHO) checklist 2 of the title Care, cleaning and disinfection high flow nasal cannula, indicated 13. Sore clean ventilator and disinfect before use. Ensure cleaned high flow nasal cannula device is stored in an area where there is low risk of contamination between uses . 2. During a concurrent observation and interview with the Maintenance Director (MD) on 3/12/25, at 11:32 a.m., the MD did not wash or sanitize his hands before and after wearing gloves. During an interview with the MD on 3/14/25 at 11:11 a.m., the MD confirmed the above observation and further stated he should have sanitized his hands before and after every task. Review of the facility's policy and procedure (P&P), titled Handwashing/Hand Hygiene revised 9/18/23, the P&P indicated, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare -associated infections. 3a. Review of Resident 62's clinical record indicated Resident 62 was admitted on [DATE] with diagnoses including infection and inflammatory reaction due to internal left hip prosthesis, broken internal left hip prosthesis and generalized muscle weakness. 055871 Page 10 of 12 055871 03/14/2025 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 During a concurrent observation and interview with the director of nursing (DON) on 3/10/2025, at 10:30 a.m., outside Resident 62's room, gowns and boxes of gloves were observed hanging on the door of Resident 62. The DON stated Resident 62 was on wound precautions and a sign should have been posted on the door indicating enhanced barrier precautions (EBP) for the resident. During an interview on 3/13/25 at 10:08 a.m. with the infection preventionist (IP), the IP stated Resident 62 was admitted to the facility with an E. coli (disease causing bacteria) skin infection, community acquired. The IP stated Resident 62 was receiving an antibiotic treatment for the infection and currently on EBP and an EBP sign should be posted outside the resident's door along with personal protective equipment (PPE [gown and gloves]) for anyone providing care for the resident. Review of the Center for Disease Control's (CDC) recommendation dated April 2024, When implementing Contact Precautions or Enhanced Barrier Precautions it is critical to ensure that staff have awareness of the facility's expectations. The facility should post clear signage on doors or walls outside resident rooms to indicate the type of precautions and required PPE and to specify high-contact care activities requiring their use. 3b. During a medication pass observation on 3/11/25 at 10 a.m., Licensed Vocational Nurse (LVN E) was observed cleaning the cap of a bottle of artificial tears (medication used to relieve dry, irritated eyes) with a facial tissue after the cap fell on the floor of the resident's room. LVN E then placed the capped bottle on the top of the medication storage cart. During an interview on 3/11/25 at 10:06 a.m. with LVN E, LVN E stated the tissue was used because the antiseptic wipes and alcohol swabs contain chemicals and was not sure if they were safe to use for cleaning surfaces of medication bottles or the caps. During an interview on 3/11/25 at 12 p.m., with the DON, the DON stated all medical equipment, and supplies should be disinfected with antimicrobial wipes according to the manufacturer's instructions after use or after becoming contaminated. The DON stated the bottle of artificial tears should have been thrown away and replaced with a new bottle. 4. During an observation on 3/12/25 at 11:12 a.m., with the Physical Therapy Assistant (PTA). The PTA was observed walking with Resident 226 in front of Resident 226 room. Resident 226's foley catheter (a flexible tube inserted to the bladder that is also connected to a drain bag) bag was observed hanging on the PTA's cargo pants pocket. During an interview on 3/12/25 at 4:50 p.m., with the DON, the DON confirmed the observation and stated, the catheter drain bag should have been unhooked and put it in the walker. During an interview on 3/14/25 at 1:23 p.m., with the PTA, he confirmed he hanged the foley catheter bag of Resident 226 on his cargo pants pocket. During an interview on 3/14/25 at 2:21 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was not okay to hang the foley catheter bag on the cargo pants pocket for dignity and infection control. The ADON further stated it might spread infection or bacteria. During a review of facility's P&P titled, Infection Prevention and Control Program dated 09/18/2023, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and 055871 Page 11 of 12 055871 03/14/2025 Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906

F 0880 transmission of communicable diseases and infections .11. Prevention of infection: .(3).educating staff and ensuring that they adhere to proper techniques and procedures; . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055871 Page 12 of 12