Inspection·April 9, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3) 13 residents who are at risk for elopement were monitored by the LN for episodes of exit seeking behavior every shift and documented in the Medication Administration Record (MAR, a record of prescribed medications). 4) Licensed Vocational Nurse (LVN), Registered Nurse (RN), CNA and staff from other departments including but not limited to therapy, activities, admissions, payroll, dietary, housekeeping/laundry, maintenance, health information manager (HIM), social services and MDS departments who did not attend the in-service will be provided education at the beginning of their next scheduled shift by the DON, DSD or ADON. 5) The facility's ADON initiated an in-service to LVN and RN on the policy and procedures (P&P) titled Elopements Resident Behavior and Facility Practice including but not limited to how to locate a missing resident, completion of elopement assessment for new admission and resident who exhibits wandering behavior, residents who are considered an elopement risk and their interventions, how to initiate an elopement care plan, and if resident is deemed at risk for elopement notify Medical Doctor (MD) and if indicated obtain orders/consent for wander guard (a device worn by residents that would alert caregivers when a resident approached a monitored door) device and monitor resident for episodes of exit seeking behavior every shift. 6) The facility's ADM initiated an in-service to the Social Services, ADON, MDS nurse, Activities Director, Central Supply, Admissions Assistant/receptionist, Accounts payable, occupational therapist on steps to take when a resident is newly admitted or current resident exhibit newly wandering/exit seeking behaviors but not limited to elopement risk assessment, if deemed at risk for elopement notify MD and if indicated obtain orders/consent for wander guard device and monitor for episodes of exit seeking behavior every shift, initiate elopement care plan, and monitoring and managing residents at risk of elopement including but not limited to every 2 hour visual checks, in addition to wander guard placement if applicable. 7) The facility ADM and DON reviewed facility elopement P&P, related to a recent incident with Medical Director. 8) The facility's RCRN provided an education to the DON and ADM on what is considered elopement and the reporting requirements. 9) 13 residents who are a risk for elopement were monitored by the LN for episodes of exit seeking behavior every shift and documented in the MAR. 10) The facility's LN initiated the completion of the head count rounds at the beginning of the shift and document on the census sheet for the other residents who are not identified as at risk for elopement. 11) The facility's ADON, DON and RN supervisor initiated the validation of the completion of the daily head count monitoring by LN. Any needed corrections will be communicated to the assigned LN. 12) The facility's maintenance supervisor/designee checked the operation of door monitors and resident wandering system (Wander Guard System) was checked on [DATE] and [DATE] and found to be functional and will continue to check weekly. 13) A new measure was put in place when the Maintenance Director installed exit door alarms on 3 of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 2 of 7 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 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety the 4 exit doors. When the doors are opened an alarm will sound which will allow staff to check if a resident is exiting the building unauthorized. 14) The facility's Social Services Director (SSD), Maintenance Director and DON initiated the in-service to the LN and CNA regarding the new alarm doors with an emphasis to respond when the exit door alarm to check the exit and that staff is to use only the main entrance to enter and exit the building. Residents Affected - Few 15) The facility's IDT initiated the daily review of new admission and residents that show new wandering/elopement behavior to ensure the new behavior is addressed, care plan is updated and interventions such as monitor for exit seeking behaviors, increased visual checks, individualized activity plan, and wander guard are implemented. 16) The facility's HIM initiated the admission audits and change conditions audit when current residents exhibit new wandering or exit seeking behaviors including but not limited if applicable completion of elopement risk assessment, IDT note when resident is identified for elopement risk, orders for wander guard, consent for wander guard, care plan for risk of elopement and wander guard, monitor for episodes for exit seeking behaviors were put in place every shift, the elopement binder was updated with residents' picture and person identification information, and visual checks in place. Any missing items from this audit will be reported to DON/designee for further review and follow up. 17) The facility's HIM will present elopement related audits weekly for 4 weeks then monthly Quality Assurance Performance Improvement (QAPI) committee for review with Medical Director, evaluation trending and tracking every month for 3 months until compliance has been reached. 18) The corrective actions began on [DATE] and completed on [DATE]. As stated, this failure resulted in Resident 1 leaving the facility premises without facility's knowledge. Resident 1 was found face down and unresponsive at a bus stop and died in an acute care hospital that same day on [DATE]. Furthermore, this failure had the potential to likely put the other 13 residents who were at risk to leave the premises without staff supervision. Findings: Review of Resident 1's admission record indicated he was an elderly resident admitted to the facility on [DATE] with diagnoses including disorder of bone density and structure (occurs when bones become weak and brittle due to loss of bone mass), low back pain, bilateral primary osteoarthritis (breakdown of cartilage in the joints leading to pain, stiffness and reduced mobility) of hip, and generalized muscle weakness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) Section GG Functional Abilities, dated [DATE], indicated Resident 1 needed supervision or touching assistance to walk 150 feet once standing, and as well as to walk at least 150 feet in a corridor or similar space. Review of Resident 1's initial Elopement Evaluation, dated [DATE], did not indicate risk level for elopement. Review of Resident 1's Activity Care Plan, dated [DATE], indicated Resident 1 enjoyed independent activity such as walking around the facility or patio. The care plan further indicated interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 3 of 7 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 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few which included that it was important for Resident 1 to go outside when the weather was good, sit down and relax. The care plan also indicated that Resident 1 liked to use his walker to go around the building and sit at the patio. Review of Resident 1's Nursing Alert Note, dated [DATE], indicated Resident 1 was seen walking towards the front door to the parking lot and was assisted back to the facility. Resident 1 expresses his desire of walking outside. During an interview on [DATE], at 3:04 p.m., with LVN B, she stated on [DATE], the previous Director of Staff Development (DSD) saw Resident 1 walk through the door, enter the parking lot and that the DSD brought Resident 1 back inside the facility. LVN B stated she accompanied Resident 1 back to his room and informed Resident 1 that if he would go outside, he had to inform staff and that he just cannot leave on his own. When LVN B was asked if she would do an elopement evaluation when a situation like this happened, LVN B stated she would not, because it was the first time Resident 1 went through the facility's door without informing staff. During an interview with the ADM on [DATE] at 3:20 p.m., the ADM stated the previous DSD who was working on [DATE] was no longer working in the facility. Surveyor was unable to interview the previous DSD. During an interview on [DATE], at 1:55 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated the MDS assessment on [DATE] indicated Resident 1 required supervision or touching assistance with most activities of daily living. The MDSC stated supervision means when somebody stands beside the resident and provides verbal or visual cues when the resident is doing tasks. The MDSC stated touching assistance means to guide Resident 1 with no weight bearing from the staff. The MDSC stated Resident 1 was able to walk over 150 feet using the front wheel walker (FWW, a type of mobility aid with wheels on the front two legs). Review of Resident 1's of Social Service Progress Note, dated [DATE], indicated Resident 1 left the facility again without informing the facility staff. The Social Service Progress Note further indicated that, the SSD interviewed Resident 1 due to the incident of leaving the facility. Resident 1 stated, I just walked to the bus stop by firefighters and went home to pick up some items I needed. Review of Resident 1's MDS Section GG Functional Abilities, dated [DATE], indicated Resident 1 needed supervision or touching assistance to walk 150 feet once standing, and as well as to walk at least 150 feet in a corridor or similar space. Review of Resident 1's clinical record indicated there was no SBAR (Situation, Background, Assessment, Recommendation; a communication tool) for the incident on [DATE] when Resident 1 left the facility a second time and went to his old apartment to get a jacket without informing facility staff. During a concurrent interview and record review on [DATE] at 2:29 p.m., with the DON, she reviewed Resident 1's clinical record and confirmed there was no SBAR done on [DATE]. Review of Resident 1's Elopement Evaluation, dated [DATE], did not indicate Resident 1's elopement risk level. Review of Resident 1's care plans indicated there was no care plan initiated to address Resident 1's incident on [DATE] when Resident 1 left the facility without informing facility staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 4 of 7 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 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE], at 3:28 p.m., the SSD stated on [DATE] Resident 1 left the facility and went to his old apartment and was gone for about an hour. The SSD stated she was made aware by a CNA that Resident 1 was not in the facility. The SSD stated she could not remember the time or who was the CNA at that time. During a concurrent interview and record review on [DATE], at 2:29 p.m., with the DON, she stated that the incident on [DATE] when Resident 1 left the facility and went to his old apartment was not considered an elopement because Resident 1 came back to the facility. The DON stated she did the elopement reevaluation and based on the evaluation Resident 1 was not at risk for elopement. The DON further stated that a care plan was not initiated for Resident 1, and it could have been the best practice to initiate a care plan for elopement when Resident 1 left the facility. When the DON was asked what was considered as an elopement, the DON stated elopement was when a resident leaves the facility without authorization. The DON further stated that when Resident 1 left the faciity on [DATE], it was not considered as an elopement because he had a purpose to go to his apartment and came back to the facility. During an interview on [DATE], at 3:07 p.m., with CNA C, she stated there was an episode when Resident 1 was in the hallway and asked where the bus stop and taxi was. CNA C stated Resident 1 verbalized he wants to go to the bus stop. CNA C stated another CNA, and a nurse heard the resident but could not remember who the CNA and the nurse were. CNA C could not remember the date when Resident 1 was asking where to find the bus stop and taxi. During an interview on [DATE], at 12:46 p.m., the DON stated the IDT (Interdisciplinary Team, a group of healthcare professionals from different fields that work together towards a common goal for a patient) decides if a resident was high risk of elopement or not. The DON stated the incident on [DATE] when Resident 1 left the facility and went to his old apartment was discussed by the IDT but determined Resident 1 was not a high risk for elopement. The DON acknowledged that the IDT discussion was not documented. Review of Resident 1's clinical record indicated there was no IDT note documented for the incident of [DATE] when Resident 1 went to his apartment to get a jacket. During a telephone interview on [DATE], at 1:01 p.m., with LVN E, the nurse assigned to Resident 1 on [DATE], LVN E stated that around 7:15 a.m. he saw Resident 1 in his room and the CNA informed LVN E around 9 a.m. that Resident 1 was not in the room. LVN E stated Resident 1 came back around 11 a.m. to the facility. LVN E stated Resident 1 mentioned he took the bus to go to his house to get his jacket. LVN E stated management team were informed because they had to search for Resident 1. LVN E stated he did not think he did an elopement evaluation after the incident. Review of Resident 1's Nurses Progress Note, dated [DATE], indicated Resident was seen in his room, at the start of the shift around 0720 [7:20 a.m.]. Resident was laying in bed, resting .Resident was seen by other staff during the morning rounds. Resident's walker noted in the from by reception, however, resident was not in the building. During an interview on [DATE], at 1:12 p.m., with LVN A, she stated on [DATE], around 7:20 a.m., Resident 1 was lying in bed. LVN A stated she saw Resident 1 an hour after when she gave the medications to Resident 1's roommate. LVN A stated around 8:30 a.m. is when she last saw Resident 1. LVN A stated she realized Resident 1 was not in the facility around lunch time between 12:00 noon to 12:30 p.m. when a CNA informed her that Resident 1 was not in the dining room. LVN A went to Resident 1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 5 of 7 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 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few room and bathroom and checked the sign out binder. LVN A instructed the CNA to look at the rest of the facility's bathrooms. LVN A added, someone called the Code Orange (a code for a resident missing in the facility). During a concurrent interview on [DATE], at 11:05 a.m., with CNA D, she stated she was the assigned CNA to Resident 1 on [DATE]. CNA D stated, she saw Resident 1 around 8:35 a.m. walking around the facility after breakfast. CNA D stated a CNA informed her around 12 p.m. that Resident 1 was not in the dining room. CNA D went to Resident 1's room and restroom and did not find the resident. CNA D stated she informed the nurse and checked other rooms and outside the facility. Review of the facility's report to the department (CDPH, California Department of Public Health), received on [DATE], indicated Resident 1 was last seen around 9:00 a.m. on [DATE]. The report further indicated that a CNA noticed that Resident 1 was not in his room. The facility was made aware that Resident 1 was not in the facility around 12:40 p.m. that prompted the search for Resident 1. The report also indicated the facility received a call at 12:58 p.m. informing the facility that Resident 1 was at the acute care hospital's Emergency Department (specific area within a hospital that provides immediate medical care). During an interview on [DATE], at 12:17 p.m., with the Maintenance Director (MTD), he stated the patio gate was wide open before the breakable lock was placed about two weeks ago. The MTD stated residents could go through the gate at the patio before [DATE]. The MTD further stated the breakable lock was a lock that could be broken in case of emergency and does not need a key to unlock. During an interview on [DATE], at 1:40 p.m., with the Receptionist (RECPST), she stated she was working at the front desk on [DATE]. The RECPST stated she was at the reception desk all day and did not see Resident 1 leave the facility. The RECPST stated she paged the Code Orange which means missing resident. The RECPST stated she checked residents sign out book (a record keeping tool) and found out neither Resident 1 nor Resident 1's family member signed him out. During an interview on [DATE], at 2:21 p.m., with the Physical Therapist Assistant (PTA), the PTA stated Resident 1 was able to walk on his own independently using the FWW. During an interview on [DATE] at 4:55 p.m., with the Administrator (ADM), the ADM stated there was nothing that could have been done differently to prevent the incident. Review of Resident 1's ambulance provider record, dated [DATE], indicated EMS (Emergency Medical Services, a system that provides emergency medical care) was dispatched (send off to a destination) at 9:26 a.m. and was on scene at 9:30 a.m. at North Main Street/Iris Drive. At 9:52 a.m., Resident 1 was transferred to the acute care hospital. According to googlemaps.com, the facility's distance from the nearest bus stop located at North Main Street/iris Drive was approximately 0.4 miles by foot or walking. According to weather.com. on [DATE] the weather forecast in [NAME], CA, indicated that the temperature record high was 80 degrees Fahrenheit (temperature scale) and the record low was 25 F. Review of Resident 1's History and Physical from the acute care hospital, dated [DATE], indicated he was found down from an unwitnessed fall while at a bus stop. He was found in prone [face down] position by a bystander who then called 911 at 9:30. EMS expressed concern for assault [a violent or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 6 of 7 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 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Skyline Care Center 348 Iris Drive Salinas, CA 93906 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sudden attack] given patient's abrasion on forehead and cracked rib prior to starting CPR [Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating}. Patient was in ventricular fibrillation [a serious heart rhythm problem where the heart's lower chambers (ventricles) beat too fast, often over 100 beats per minute] and started CPR at 9:32. He was shocked twice with 3 rounds of epinephrine [a medication to treat many life-threatening conditions] along with amiodarone [a medication to keep the heart rhythm normal.]. He was transferred to the ED [Emergency Department] .CPR was continued in the ED starting 9:51 and stopped at 9:54 after ROSC [return of spontaneous circulation, return of heartbeat and breathing without needing external assistance] was achieved. He was admitted to the ICU [Intensive Care Unit, a specialized hospital department providing critical care to severely ill or injured patients]. Review of Resident 1's Death Summary from acute hospital dated [DATE], indicated Resident 1 passed away at 5:36 p.m. Review of the facility's policy and procedure (P&P), titled Elopements Resident Behavior and Facility Practices, dated [DATE], indicated Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The interdisciplinary team will further evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, and care plan discussions, as applicable. Review of Resident 1's Certificate of Death, issued on [DATE], indicated the cause of death was ventricular fibrillation (fast and irregular heartbeat), undifferentiated shock (unknown cause of the body not getting enough oxygen), and respiratory failure (a serious condition that makes it difficult to breathe on our own). The Certificate of Death further indicated the date of death was [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055871 If continuation sheet Page 7 of 7