Health inspection·March 28, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Residents 27 and 60). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Residents Affected - Some Findings: Review of Resident 27's medical record indicated she was admitted to the facility under Medicare Part A on 6/30/2021. The medical record further indicated Resident 27 came off Medicare Part A on 7/8/2021 and continued living in the facility. Review of Resident 27's SNF Beneficiary Protection Notification Review, filled out by the facility on 3/24/2022, indicated the facility initiated Resident 27's discharge from Medicare Part A services when benefit days were not exhausted (the resident still had Medicare Part A days remaining). The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 27. Review of Resident 60's medical record indicated she was admitted to the facility under Medicare Part A on 2/6/2021. The medical record further indicated Resident 27 came off Medicare Part A on 3/23/2021 and continued living in the facility. Review of Resident 60's SNF Beneficiary Protection Notification Review, filled out by the facility on 3/24/2022, indicated the facility initiated Resident 60's discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 60. During an interview with the administrator (ADM) on 3/25/2022 at 9:51 a.m., he stated social services was responsible for issuing notices when residents came off Medicare Part A services. During an interview with the social services director (SSD) on 3/25/2022 at 10:00 a.m., she confirmed the facility did not provide a SNF ABN to Residents 27 and 60 when they came off Medicare Part A services. The SSD explained she was not familiar with the SNF ABN and was not aware the facility was supposed to provide them when residents came off Medicare Part A. The Department of Health and Human Services and Centers for Medicare & Medicaid Services Form CMS-20052, dated 2/2017, indicates the facility must provide a SNF ABN when residents are discharged from Medicare Part A services, with skilled benefit days remaining, and continue to live in the facility. According to the Centers for Medicare & Medicaid Services (CMS, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN-), the facility must provide a SNF ABN prior to providing custodial care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 2 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 perform re-evaluation restraint assessments in a timely manner for three of five residents (Residents 62, 63, and 27), when restraint assessments were not performed on at least a quarterly basis. This failure had the potential of residents being physically restrained when not medically indicated. Residents Affected - Some Findings: 1. During an observation on 3/21/22 at 12:37 p.m. in Resident 62's room, Resident 62 was observed sitting in her wheelchair with a seatbelt around her waist. During a review of Resident 62's electronic records, no quarterly restraint assessments were found. Resident 62 had cognitive impairment. During an interview on 3/25/22 at 9:54 a.m., with the director of nursing (DON), DON stated she did not see any quarterly restraint assessments for Resident 62. 2. During an observation on 3/21/22 at 12:08 p.m., Resident 63 was wheeling herself in the hallway seated in a wheelchair with a seatbelt around her waist. During a review of Resident 63's electronic record indicated one restraint assessment was performed on 9/20/2020, but no other restraint assessment was located. Resident 63 had cognitive impairment. During an interview with DON on 3/25/22 at 9:48 a.m., DON stated Resident 63 has one restraint assessment performed on 9/29/2020. DON stated Resident 63 was not receiving quarterly restraint assessments. During a review of the facility's policy and procedure titled Use of Restraints, revised April 2017, the policy indicated .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.the ongoing re-evaluation for the need for restraints will be documented.Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 3. Review of Resident 27's clinical record indicated she was admitted on [DATE], with diagnosis of Alzheimers Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), Parkinson's disease (a progressive nervous system disorder that affects movement), difficulty in walking and muscle weakness. Review of Resident 27's Physician's Order, dated 6/30/2021, indicated Self-release belt while up in chair due to consistent leaning forward in her wheelchair. Release and reposition for 10 min. every 2 hours. Review of Resident 27's Initial assessment for use of physical restraint, dated 7/29/20, indicated self-release belt while up in wheelchair (resident unable to unbuckle on command). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 3 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/22/2022 at 11:47 a.m., with certified nursing assistant AA (CNA AA) while in Resident 27's room, the resident's wheelchair had a self-release belt attached to it. CNA AA stated that Resident 27 uses the self-release belt when in the wheelchair. CNA AA also stated that Resident 27 was unable to unfasten her self-release belt. During a concurrent interview and record review of Resident 27's clinical record with Minimum Data Set Coordinator (MDSC), on 3/25/2022 at 11:40 a.m., MDSC confirmed that Resident 27's self-release belt restraint did not have follow-up quarterly reviews or assessments since the initial assessment on 7/29/2020. MDSC also confirmed that there was no resident or resident representative consent prior to the use of physical restraint. Review of the facility's policy dated 4/2017 titled Use of Restraints, indicated, Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative .Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive method of restraints, or total restraint elimination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 4 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide physician ordered nutrition supplements (products that are used to complement a resident's dietary needs, a high calorie drink in this case) to one resident (Resident 71) with a history of weight loss and pressure injury. This failure had the potential to cause further weight loss and decline in health status. Residents Affected - Few Findings: A review of Resident 71's clinical record, indicated Resident 71 was admitted with diagnoses including cerebral infarction (a stroke caused by narrowing of the blood vessel in the brain), and right sided weakness caused by the stroke, dysphagia (difficulty swallowing caused by stroke), and Alzheimer's disease, unspecified (a progressive disease that destroys memory and other important mental functions). A review of Resident 71's Admission's Minimum Data Set (MDS, an overall assessment of resident's status) assessment, dated 7/12/21, indicated the Brief Interview for Mental Status (BIMS) score was 99 (with severe cognitive impact), requiring extensive assistance with eating and weight was 102 pounds (lbs.). A review of Resident 71's Weights and Vitals Summary, dated 1/20/22, indicated Resident 71's weight was 82 lbs., which indicated an 18% weight loss from her weight of 100 lbs. on 7/27/21. A review of the facility document titled, Order Summary Report for Resident 71, dated 3/25/2022, indicated under Other, house supplement 4 oz (ounce) at breakfast and dinner with an order date of 11/01/2021, and high calorie supplement po (per os - by mouth) 60ml (milliliter - volume of measurement) three times a day with an order and start date of 08/05/2021. During lunch observation on 3/22/22 at 1:25 p.m., inside Resident 71's room, Resident 71 was sitting in a wheelchair, and holding onto a cup of high calorie supplement using her left hand. Certified nursing assistant W (CNA W) was sitting beside Resident 71 and assisted her with feeding. Resident 71 was observed slow in eating and with an empty cup of milk on the overbed table. During a concurrent interview and a facility document review with food service worker BB (FSW BB) on 3/24/22 at 9:10 a.m., the FSW BB reviewed the list of the printout labels for the ordered snacks for each resident. The FSW BB confirmed Resident 71 was not on the list of the printout labels. The FSW BB stated they only prepared ordered snacks based on the list in the printout labels. During a concurrent interview and a facility document review with the dietary service supervisor (DSS) on 3/25/22 at 10:12 a.m., the DSS reviewed Resident 71's meal ticket for breakfast and dinner. The DSS also reviewed the Standing Order List for snacks. The DSS confirmed the house supplement ordered for breakfast and dinner was not listed on Resident 71's meal ticket and Resident 71 was not listed in the printout labels. The DSS stated dietary staff would prepare the meals and snacks based on the meal ticket and list in the printout labels. The DSS confirmed Resident 71 did not get the house supplement ordered because it was not listed on both meal tickets and printout labels. During a phone interview with Resident 71's nurse practitioner (NP) on 3/25/22 at 3:00 p.m., the NP stated she was always in contact with Resident 71's daughter and their wish was not to prolong Resident 71's life by doing an aggressive treatment. The NP further stated, She is not declining because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 5 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0692 Level of Harm - Minimal harm or potential for actual harm she's not eating, but in reality, she's not eating because she's declining. When informed the house supplement ordered since 11/01/2021 was not given to Resident 71, the NP stated, I'm sorry we were not able to carry out that order. The NP further stated the house supplement could only make a little affect to Resident 71's weight. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 6 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure a licensed nurse and student nursing assistant (SNA) had the specific competencies necessary to care for two of 19 sampled residents (Residents 11 and 60) when licensed vocational nurse A (LVN A) did not correctly demonstrate the proper use of insulin syringe, and when SNA turned off Resident 60's oxygen without informing the charge nurse. These failures had the potential for Resident 11 and 60 to not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings: 1. During an observation on 3/22/22 at 12:08 p.m., Resident 60 was up in her wheelchair with her oxygen on via nasal cannula. She was heard requesting SNA to turn off her oxygen. The SNA turned if off herself without informing her charge nurse. During the concurrent interview with the DSD and licensed vocational nurse A (LVN A), charge nurse and infection preventionist (IP), the DSD stated SNA was doing her clinical hours in the facility as a student nursing assistant and should not have turned off the oxygen as this was beyond her scope of practice. LVN A denied being asked to turn off Resident 60's oxygen. 2. During a medication pass observation with licensed vocational nurse C (LVN C) on 3/23/22 at 7:35 a.m., LVN C did not cap the insulin syringes after she prepared Resident 11's Lantus and Novolog (medications to lower blood sugar) injections. LVN held both syringes with exposed needles when she entered resident's room. She did not cap and locked the syringe after she administered the injections. During the concurrent interview, LVN C validated the observation and acknowledged that she did not properly lock the insulin syringe. She also stated that she put herself and others for possible needle prick injury. During an interview with the director of staff development (DSD) on 3/23/22 at 3:06 p.m., he confirmed he had not in-serviced staff regarding Needle Safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 7 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to ensure licensed nurses (incoming shift nurse and outgoing shift nurse) consistently signed off the Correct Count Verification sheet/form for controlled medications that indicated they acknowledged accuracy and accountability of controlled drugs for two of four medication carts. This failure had the potential for inaccurate recording and accounting of controlled medications. Findings: During an inspection of Nursing Station 1's Carmel and Monterey medication carts on 3/21/22 at 3:40 p.m., with licensed vocational nurse A (LVN A), LVN A confirmed there were multiple missing signatures found in the Correct Count Verification sheet for February and March 2022 for both carts. During the concurrent interview with LVN A, she stated both nurses who were coming in for the shift and going off shift should sign the form every shift. During an interview with the pharmacy consultant (PC) on 03/24/22 at 9:50 a.m., the PC concurred two nurses (incoming and outgoing shift nurses) should have signed the correct count sheet every shift. A review of the facility's revised 5/15/2018 policy and procedure, Preparation and General GuidelinesControlled Substances, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Accurate accountability of the inventory of all controlled drugs is maintained at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 8 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 properly store medications in four of four medication carts and in one of two medication refrigerators when: 1. Multi-dose vials and liquid medications were not dated when opened and discarded when expired (beyond due date). 2. Expired medications were not disposed accordingly. 3. Multiple eyedrops/ointment opened and not dated, expired eyedrops not discarded and disposed. 4. Internal medications (oral medications) were mixed with external medications. These failures had the potential for administration of wrong and expired medications which could placed residents at risk for adverse drug reactions and possible complications. Findings: During an inspection of Station 2 medication refrigerator on 3/21/222 at 9:50 a.m., with licensed vocational nurse D (LVN D), there was a multidose tuberculin vial opened not dated. LVN D stated the vial should have been dated when opened. During an inspection of Station 1 Monterey medication cart on 3/21/22 at 3:40 p.m., with licensed vocational nurse A (LVN A), there were two bottles of eyedrops, three tubes of eye ointment opened and not dated; one antibiotic eyedrops opened and expired on 12/13/21. During an inspection of Station 1 Carmel medication cart on 3/21/22 at 3:58 p.m., with registered nurse G (RN G), there were two bottles of eyedrops opened and erased open dates, one expired bottle of eyedrops, and insulin Lantus expired 3/18/22. RN G stated the erased open dates were too confusing. During an inspection of Station 2 Pebble Beach medication cart with LVN D on 3/21/22 at 4:20 p.m., there were three bottles of liquid Tylenol (medications for pain/fever) expired on 2/1/22, a bottle of milk of magnesia (MOM, medication for constipation) opened and not dated, a bottle of Ultratussin (cough medication) opened and not dated and was leaking, a bottle of Gerilanta (antacid, house supply) opened and undated. A menthol camphor lotion mixed and stored with the liquid medications. A bottle of opened lactulose liquid and undated, GNP tussin liquid bottle opened and undated. During the concurrent interview with LVN D she stated these medications should be disposed accordingly. A review of the facility's undated policy and procedure, Medication Storage in the Facility, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Orally administered medications are kept separate from externally used medications and treatments Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 9 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 disposed according to procedures for medication disposal. Level of Harm - Minimal harm or potential for actual harm Multi-dose injectable vial or pen device, medication vials, ophthalmic medications once opened, will be good to use until the expiry date on the pharmacy label. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 10 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observations, interviews, and facility document review, the facility failed to ensure the Registered Dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services as evidenced by: Lapses in the delivery of services associated with: staff competency (cross-reference F802), following the menu (cross-reference F803), providing physician prescribed diet orders (cross-reference 808), food safety and sanitation (cross-reference F812), providing physician prescribed nutrition supplements (cross-reference F692), physical environment of the kitchen (cross-reference 908). Failure to ensure dietetic services systems are accurately and effectively delivered may result in compromising the nutritional status of the residents by not assessing their nutritional needs, the potential transmission of foodborne illness, and/or a decreased nutritional intake due to not receiving the correct foods. Findings: During the annual recertification survey conducted from 3/21/22 to 3/28/22 there were multiple issues identified with respect to the functions of food and nutrition services (cross-reference F802, F803, F808,

F812, F692, F908). 1. Issues with staff competency were identified when one kitchen staff, Foodservice Worker M (FSW M), did not properly prepare puree foods and did not follow recipes, and two kitchen staff, Foodservice Worker O (FSW O) and Foodservice Worker P (FSW P) did not know how to test the sanitizer level in the dish machine and sanitizer bucket, and kitchen staff were not routinely monitoring the sanitizer concentration in the dish machine (cross-reference F802). 2. Issues with following the menu were identified when FSW M served a smaller meat portion (1/4 cup instead of 3/8 cup) and a larger portion of vegetables (1/2 cup instead of ¼ cup) to puree diets, and a half portion of sweet potatoes to Carbohydrate Controlled diets instead of a full portion as indicated on the menu. Also Foodservice Worker N (FSW N) did not serve milk as indicated on the menu (cross-reference

F803). 3. Issues with consistently providing the fortified diet were identified when FSW M either did not add a fortified food to two residents' plates or added a minimal amount of calories to fortified diets (cross-reference F808). 4. Issues with food stored, prepared, distributed, and served in accordance with professional standards for food safety were identified when an ice machine was not kept in a sanitary condition, meat was thawed improperly, sanitizer was stored on food production surface, sanitizer had an inconsistent strength, a nutrition supplement was held above 41 degrees Fahrenheit for extended period of time, multiple food service equipment were stored wet, and floors and equipment were not kept clean (cross-reference F812). 5. Issues with providing a physician ordered nutrition supplement were identified when the supplement was not available and the resident never received the supplement (cross-reference 692). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 11 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6. Issues with maintenance of the physical environment in the kitchen were identified when the screen door did not stay closed, floors and coving were not maintained, food trays were worn and cracked, and floor drains were not kept clean (cross-reference F908). Review of the kitchen training binder indicated the most recent and only, kitchen staff training done by Registered Dietitian (RD) was on 4/17/20 and the topic was Sanitation: Use of bleach solution, and high touch areas. The sign-in sheet indicated FSW M attended the training, but FSW O and FSW P did not attend. Further review of the binder indicated a training on Diets and Food Consistencies that was undated and taught by Foodservice Worker Q (FSW Q) and FSW M was in attendance. There were no in-service sign-in sheets since 4/17/20. During an interview on 3/24/22 at 4:40 p.m., Dietary Services Supervisor (DSS) confirmed all the training and in-services that had been done for the Food and Nutrition Services Department were in the binder. During an interview on 3/24/22 at 4:40 p.m., DSS stated RD will send over documentation of her visits to DSS by email. He further confirmed he did not have copies of her reports onsite. The facility provided the following documents titled Food and Nutrition- RDN Monthly Inspection Checklist, dated 4/23/21, 9/11/21, and 10/19/21 as documentation of RD visits. Review of the facility document titled Food and Nutrition - RDN Monthly Inspection Checklist, dated 4/23/21 indicated some of the issues identified by the RD included: sanitizer strip logs with a handwritten note missing data, documentation of sanitizer concentration with a handwritten note missing some days, and other handwritten comments included: scoop sizes incorrect, does not read/use spreadsheet, puree fish and puree veg (vegetable) very thin. Review of facility document titled Food and Nutrition - RDN Monthly Inspection Checklist, dated 9/11/21 indicated some of the issues identified by RD included Monthly signed in-services was not checked with handwritten note (0 (no) inservice Augu [August] 2021 competency done, Daily supervisor inspection checklist for past four weeks was not checked, and under comments handwritten notes sanitizer bucket at cook's area not registering ppm [parts per million, used to determine the strength and effectiveness of the sanitizing solution] on strip. Review of facility document titled Food and Nutrition - RDN Monthly Inspection Checklist, dated 10/19/21 indicated some of the issues identified by RD included Sanitizer test strip logs with handwritten note dish area missing, Monthly signed in-services was not checked, and Daily supervisor inspection checklist for past four weeks was not checked. Although RD identified some of the same issues identified during the survey, there was no indication on the reports what actions were taken to fix the issues. During a phone interview on 3/24/22 starting at 10:08 a.m., RD indicated that her role at the facility is to do the nutrition assessments, monitor weights, do all nutrition related charting, and once a month she tries to do kitchen inspection and that inservices in the kitchen were being done in the past. She further stated that she works at an acute hospital where there are COVID cases so she limits her time in this facility as she does not want to cross contaminate. She stated she usually comes in once a week and pops in and out when she has time; she is contracted to work eight hours per week in this facility. RD confirmed since January 2022 she has not done in depth rounds at this facility because of the outbreak of COVID in the hospital. She stated she tells the administrator and DSS about what findings she has from her kitchen inspections and they work to fix the issues. RD indicated that DSS has been the supervisor of kitchen for less than a year. Her role in training him was training on Title 22 (State of California requirements) and food safety. She indicated DSS has been working in the kitchen as dishwasher or cook four days a week to fill in, and they are trying to do his training, but it is difficult to keep their heads (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 12 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many above water. She stated she gave him foodservice training videos to watch, but that there was no documentation. She confirmed that she has not done any formal training with DSS because when they try to he has to cook, wash dishes, or fill in as a diet aide. During an interview on 3/24/22 at 4:40 p.m., DSS stated he has been the kitchen supervisor for about seven months. DSS confirmed he has watched all the foodservice training videos provided by RD, but was not evaluated on them by RD and did not take the quizzes that go with the videos. DSS stated RD was last was here in person about two to three weeks ago and that she is available by email. During an interview on 3/23/22 at 12:49 p.m., DSS stated he was oriented to his new position by the administrator (Admin) and that RD did some training on portion sizes of scoops and how to order foods. Review of the facility document titled 'Dietetic Consultancy Agreement', dated 8/1/15, indicated the following: Under Engagement and Services: The Company shall provide sufficient consultation hours per month necessary for the Consultant to perform exemplary professional service and meet federal and state regulations, as well as the needs of the company and its clients. Under Services provided: Oversight of the food service department. Focus on food safety and sanitation, quality food selection and preparation, storage and proper service of therapeutic diets, Provide a written report of consultation visits, including recommendations to the Director of Nursing, Administrator and Director of Dietary at the completion of each visit, and In-service education to food service staff and nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 13 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document record review, the facility failed to ensure staff competency when: 1. The staff members were unable to properly test the dish machine's sanitizer and were not routinely testing the concentration of the dish machine's sanitizer and wash and rinse temperature. 2. Two of three staff members were unable to test the red bucket's sanitizer correctly and two red buckets' sanitizer concentration was not consistently tested for the month of March. 3. The FSW M did not follow the pureed preparation for vegetables. 4. The FSW M did not follow the recipes for the honey glazed pork and the fresh baked sweet potatoes served for lunch on 3/21/22. These failures had the potential to result in compromising the health and safety of the 71 residents in the facility. Finding: 1. During a concurrent observation and interview with food service worker O (FSW O) on 3/22/22 at 9:30 a.m., inside the dish room, FSW O was unable to verbalize the process on how to check if the dish machine was working well without a fair amount of prompting. The FSW O pulled out the quat strips (measures the concentrations of quaternary ammonia (a common sanitizer in foodservice) in solution in parts per million) to test the chlorine-based machine. The FSW O stated the quat strip was the one he would usually use to test the concentration of the dish machine's sanitizer. The FSW O further stated the result of the test was 200 parts per million (ppm,a measurement of concentration). The FSW O took the chlorine test strip when prompted and started to test the dish machine sanitizer. The result was 50 ppm, which indicated the right sanitizer concentration. The FSW O confirmed he had not done the testing of the dish machine's sanitizer frequently. During a concurrent observation and interview with FSW Y on 3/23/22 at 12:15 p.m., inside the dish room, the FSW Y stated they never tested the dish machine's sanitizer. FSW Y further stated the sanitizer dispenser in the dish machine was digital and when it dispensed the pellet, the monitor would indicate, dispensed sanitizer. The FSW Y confirmed she never tested the sanitizer of the dish machine since the new dish machine was delivered. During a concurrent interview and facility document review with FSW Q on 3/24/22 at 9:05 a.m., the FSW Q reviewed the missing signatures and the missing data in the low temperature dish machine monitoring log on 3/6, 3/7, 3/8,3/9, 3/13, 3/14, 3/15, 3/16, 3/20 and 3/21/22. The FSW Q stated whoever checked the temperature and the sanitizer concentration of the dish machine should log the result and sign it. During a review of the facility's undated job description for Dishwasher position, it indicated, Maintain quality controls on equipment and proper functioning of equipment. 2. During a concurrent observation and interview on 3/23/22 at 12:13 p.m., food service worker P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 14 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0802 Level of Harm - Minimal harm or potential for actual harm (FSW P) checked the concentration of sanitizer in the red bucket located to her station. The FSW P dipped the yellow quat strip and swirled it in the bucket for approximately 20 seconds while she counted very slowly to 10. The quat strip turned green and the FSW P compared the color to the container. The FSW P stated it is 400 parts per million (ppm, a measurement of concentration). The FSW P further stated the normal range was from 400-800 ppm. Residents Affected - Many During a concurrent observation and interview on 3/23/22 at 12:30 p.m., FSW Y stated the buckets on three compartment sinks were just filled within the last half hour. FSW Y tested the bucket, the same bucket that FSW P had just tested, and the result was 100 ppm. The FSW Y filled up a new bucket with water and with solid quat broad range sanitizer. The FSW Y tested the sanitizer concentration with water temperature of 136 degrees F, and the result was [PHONE NUMBER] ppm. It was determined the quat strip used were expired. During a concurrent interview and facility document review with FSW Q on 3/24/22 at 9:05 a.m., FSW Q reviewed the two logs titled, Sanitizer Concentration Log for RED BUCKETS, dated March 2022: one log from the dish room indicated, nobody tested the sanitizer since March 1 through March 22 and the other log from FSW P's station indicated some missing testing on 3/5, 3/6, 3/12, 3/13, 3/19, 3/20 and nobody did the testing at dinner time. The FSW Q stated whoever checked the sanitizer concentration of the red buckets should log the result and sign it. 3. During a concurrent observation and interview with FSW M on 3/21/22 at 10:30 a.m., FSW M was making pureed zucchini by adding half pouch of the liquid thickener in the blender. FSW M stated they ran out of the powder thickener and used the liquid thickener instead. During an observation on 3/21/22 starting at 12:09 p.m. during the lunch meal service, the pureed zucchini squash was runny, spread across the plate, and did not hold its shape. A review of the facility's document titled, REGULAR PUREED DIET, indicated, The texture of the food should be of a smooth and moist consistency and able to hold it's shape. 4. A review of the facility's week 3 diet spreadsheet, indicated honey glazed pork chop and fresh baked sweet potatoes were included for lunch. During a concurrent observation and interview with FSW M on 3/21/22 at 10:18 a.m., some pork chops were laid out in a pan with some salt and pepper. The FSW M stated the pork chops have salt, pepper, and dried rosemary sprinkles. During a tray line observation on 3/21/22 at 12:09 p.m., the pork served had rosemary on them but did not appear honey glazed, and the baked sweet potatoes did not look fresh, but appeared purchased in a can. The baked sweet potatoes were in a syrup and FSW M had to pour off the syrup after scooping the sweet potato onto a plate. During an interview with FSW M on 3/22/22 at 11:28 a.m., the FSW M confirmed the sweet potatoes served for lunch on 3/21/22 were from a can. The FSW M stated he just warmed up the potatoes and served them. During a review of the facility's recipe, titled, HONEY GLAZED PORK CHOP OZ (OUNCE), dated 2/15/2020, indicated the ingredients were soy sauce, honey pure clover, applesauce in juice, salt, granulated sugar, and pork chop. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 15 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0802 During a review of the facility's recipe, titled,BAKED SWEET POTATOES FRSH, dated 2/15/2020, indicated the ingredient was only the fresh sweet potatoes and to bake for an hour or until done. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 16 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed and the nutrient needs were met when: Residents Affected - Some 1. Milk was not served according to the menu for a random sample of 16 residents (Residents 61, 274, 275, 54, 19, 3, 53, 27, 276, 9, 10, 7, 42, 51, 22, 2); 2. Fourteen of 14 residents (Residents 22, 10, 17, 5, 61, 64, 38, 73, 40, 48, 25, 54, 34, 41) on CCHO regular texture diet (carbohydrate controlled diets, diets designed for people with diabetes that evenly spread carbohydrates throughout the meals) when they were served the wrong portion size for sweet potatoes; 3. Seven of seven residents (Residents 33, 45, 29, 27, 71, 63, 15) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for pork chop and zucchini, 4. Two residents (Residents 72 and 18) with a preference for no meat did not receive a good source of protein for lunch. These failures had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of the 32 residents. Findings: 1. Review of the facility menu titled Diet Spreadsheet for cycle day 15 Lunch (3/21/22) indicated for the Regular diet and the CCHO Regular texture diets: 1 each Baked Sweet Potatoes, fresh. During an observation of the lunch meal service on 3/21/22 starting at 12:05 p.m., Foodservice Worker M placed one piece of sweet potato (approximately ½ of a whole sweet potato) on the CCHO regular texture diet plates and two pieces of sweet potato (approximately one whole sweet potato) on each of the Regular diet plates. During a concurrent interview at that time, FSW M stated he gives a half portion of sweet potato or 1 piece to the CCHO diets, and two pieces of sweet potato to the Regular diets. During an interview with Dietary Services Supervisor (DSS) on 3/24/22 at 11:39 a.m., DSS stated staff should follow the menus. 2. Review of the facility menu titled Diet Spreadsheet for cycle day 15 Lunch (3/21/22) indicated Milk ½ cup for all diet types except Renal which was to get Lemonade. During an observation of the lunch meal service on 3/21/22 starting at 12:05 pm, many trays did not have milk. Review of the facility menu titled Diet Spreadsheet for cycle day 17 Lunch (3/23/22) indicated Milk ½ cup for all diet types except Renal. During an observation of the meal service on 3/23/22 starting at 12:15 p.m., Foodservice Worker N (FSW N) placed drinks on meal trays. He put milk on the trays if the standing order on meal tray ticket (papers on the tray that indicate residents' diet order and preferences and dislikes) requested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 17 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some milk. Some residents did not get any drinks with lunch (Residents 61, 274 and 275), while other residents did not get any milk (Residents 54, 19, 3, 53, 27, 276, 9, 10, 7, 42, 51, 22, and 2). A review of the meal tray tickets at that time, indicated the following for Residents 61, 274, 275, 54, 19, 3, 53, 27, 276, 9, 10, 7, 42, 51, 22, and 2: none were on Renal diets and none of them had milk or dairy listed as a dislike. During an interview on 3/23/22 at 1:09 p.m. the meal trays had left the kitchen, FSW N stated residents who have milk as a preference are the only ones who get milk on their meal tray. He further stated drinks are determined by their preferences (standing order) on the meal tray ticket so whatever they have for preference is what they get to drink. During an interview on 3/24/22 at 11:39 a.m., DSS confirmed the residents should have gotten milk on their meal trays as long as they do not have no dairy or no milk as a dislike on their meal tray ticket. He further confirmed that staff should follow the menu for serving milk. 3. Review of the facility menu titled Diet Spreadsheet for cycle day 15 Lunch (3/21/22) indicated for the Puree diets, the following items: #10 scoop (3/8 cup) Honey Glazed Pork Chop puree, ½ cup mashed sweet potato, and #16 scoop (¼ cup) Basil Zucchini puree. During an observation of the lunch meal service on 3/21/22 starting at 12:05 p.m., Foodservice Worker M (FSW M) placed a #16 scoop (1/4 cup) puree pork chop and two #16 scoops (1/2 cup total) Basil Zucchini puree on each of the puree diet plates. During a concurrent interview at that time, FSW M confirmed he served one #16 scoop of puree pork chop and two #16 scoops of puree zucchini to the puree diets. Review of the facility document titled Diet Type Report, dated 3/23/22, indicated under Diet Texture: Pureed for the following residents: Residents 33, 45, 29, 27, 71, 63, and 15. 4. Review of the facility menu titled Diet Spreadsheet for the L3/Advanced (mechanical soft) diets, showed the following items: a. for cycle day 15 Lunch (3/21/22): 2 oz (ounce) Honey Glazed Pork Chop ground, ½ cup mashed sweet potato, ½ cup basil zucchini saute, ½ mandarin oranges, ½ cup milk. b. for cycle day 16 Lunch (3/22/22: 4 oz (ounce) Meatloaf ground, 2 oz gravy, ½ cup steamed cabbage, ½ cup glazed carrots, one wheat roll with margarine, ½ cup milk, ½ cup chocolate cream pudding. During an observation on 3/21/22 at 12:20 p.m. of the lunch meal service, Resident 72 had rice, zucchini, and peaches on her tray. During an observation on 3/22/22 at 11:45 a.m. of the lunch meal service, Resident 18 had two bowls of chicken noodle soup, juice, hot water, and milk on her tray. During an observation on 3/22/22 at 12:49 p.m. of residents' meal trays in the meal delivery cart in the hallway, Resident 72 had a large portion of steamed cabbage, one roll, one packet of blue cheese dressing, pudding, and no drinks on her tray. Review of Resident 72's meal tray ticket indicated Resident 72 was on a Mechanical soft diet (diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 18 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with altered texture for people with chewing or swallowing difficulties), and under dislikes: carrots, peas, Meat: All (NO ALT MEATS), green beans, corn, beans, potatoes (give baked instead of fries/mashed), sweet potatoes (give real instead of canned). Review of Resident 18's meal tray ticket indicated Resident 18 is on a Mechanical soft diet and under Notes stated Standing order is meal, Standing orders: six fluid ounces chicken noodle soup, six fluid ounces cranberry juice (no raspberry), 6 packet sugar, 2 eight ounces tea, and under dislikes: fish/seafood, mushrooms, raspberries, sandwiches, meat: all, squash, carrots, desserts: all. During an interview on 3/23/22 at 12:00 p.m. with Foodservice Worker M (FSW M) regarding residents who request no meat, he stated he would only give them the vegetables and starch. He further stated he would rely on the diet aide to add protein such as cottage cheese to the tray. He confirmed there is no vegetarian menu to follow and that the cook decides what to prepare. He stated they need to serve them three ounces of protein and they used to have vegetarian burgers but the residents did not like them. During a telephone interview on 3/24/22 starting at 9:30 am with Registered Dietitian (RD), RD stated for vegetarians the facility has to provide them with vegetarian choices and that there are vegetarian friendly items available for purchase from their vendor or the cook can make their own and be creative. She recognized there are a lot of vegetarians. She further indicated that they have a spreadsheet for a vegetarian diet and thinks she has approved a vegetarian menu. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 19 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, staff interview, and facility document review, the facility failed to assure residents consistently received a fortified diet as prescribed by a physician when two out of 33 residents on a fortified diet did not receive any fortified foods, and six out of 33 residents on fortified diets received minimal extra calories at one meal. These failures had the potential to result in not meeting the nutritional needs and further compromising the nutritional status of the 33 residents on fortified diets. Findings: Review of facility document titled Fortified Diet from the facility's diet manual, dated 2012, indicated The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. It further indicated The amount of calorie and protein increase will vary depending on the facilities current Fortification of Food policy and the individual residents needs and preferences. No other fortified diet policy was provided when requested. During an interview on 3/21/22 at 12:05 p.m., Foodservice Worker M (FSW M) stated the brown gravy is made from powder and is used for fortified diets. He stated fortified diets get gravy on the meat. Review of the facility menu titled Diet Spreadsheet for cycle day 15 Lunch (3/21/22), indicated for Regular diet: Honey Glazed Pork Chop 2 ounce, Baked Sweet potatoes, fresh 1 each, Basil Zucchini Saute fresh ½ cup. There was no indication of what to serve a fortified diet. During an observation of the lunch meal service on 3/21/22 at 12:20 p.m., FSW M placed one #16 scoop (1/4 cup) of gravy on the pork chops for Residents 39, 55, 58, 7, 27, and 29 and did not put any gravy on the pork chops for Residents 17 and 30. Review of the meal tray tickets for Residents 39, 55, 58, 7, 27, 29, 17, and 30 (papers on each mealtray that indicate resident's diet orders and preferences and dislikes) indicated each resident was to receive a fortified diet. Review of the Nutrition Facts label (information on food labels with the nutrients listed in that food) from the Low Sodium [NAME] Gravy Mix indicated each ¼ cup prepared gravy provided 25 calories. During an interview with FSW M on 3/23/22 at 12:03 p.m., when asked how he knows what to serve the fortified diets, FSW M said he adds two ounces of meat above what Regular diet gets, also he puts gravy on the meat, and today he would also put butter on the vegetable or the roll. He further stated he adds an extra one ounce of vegetables above what the regular diet gets. Review of the facility menu titled Diet Spreadsheet for cycle day 17 Lunch (3/23/22), indicated for Regular diet: Apple Stuffed Chicken Breast five ounces, Country Chicken Gravy five ounces, Ancients [NAME] ½ cup. There was no indication of what to serve a fortified diet. During an observation of the lunch meal service on 3/23/22 starting at 12:15 p.m., Foodservice Worker N (FSW N) called out four regular fortified diets to FSW M. FSW M served one chicken breast to fortified diets, the same size as previous regular plates. He put one plastic teaspoon of butter on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 20 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0808 the vegetables of the fortified diet plates. Level of Harm - Minimal harm or potential for actual harm During an interview with Dietary Services Supervisor (DSS) on 3/24/22 at 8:35 a.m., DSS stated fortification would depend on the item being served, as an example chili would get extra cheese, and vegetables would get butter and other items would get gravy. He was unsure of how many additional calories per day fortification would give. Residents Affected - Some During a phone interview on 3/24/22 starting at 9:30 a.m. with Registered Dietitian (RD), RD stated the fortified diet is described on a fortified foods chart posted in the kitchen. She further stated things like butter and brown sugar may be added to oatmeal at breakfast, and butter and gravy may be added to foods at lunch and dinner. She said the fortified diet should provide about an extra 100 calories per meal and about 300 extra calories a day. During a phone interview on 3/25/22 starting at 12:00 p.m., RD further stated the fortified diets get one of the additional items listed on the fortified foods chart per meal. Review of facility undated document titled Fortified Diet Chart, which was posted in the kitchen, indicated for Breakfast the options for fortified foods are: one extra tablespoon of butter/cheese on eggs, one extra tablespoon of butter on toast, one extra tablespoon of butter on hot cereal, or two ounces (1/4 cup) of sauce/gravy on meat. For Lunch/Dinner, the chart indicated one extra tablespoon of butter/cheese on vegetables, one extra tablespoon of butter/cheese on starch (pasta, potatoes, rice), one extra slice of cheese on sandwich, or two ounces (1/4 cup) of sauce/gravy on meat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 21 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition; 2. Thawed meat was kept in the refrigerator for an extended period of time; 3. A red bucket with sanitizer was left on a food production surface; 4. A food contact surface sanitizer had inconsistent strength; 5. A protein based nutritional supplement was held above 41 degrees Fahrenheit (F, a temperature scale) for an extended period of time; 6. Food containers were stacked wet; 7. Kitchen floors had some black build up to corners of each storage area leading to the back door; 8. Spills of rice were found at the cart beside the rice container; 9. The lid of a flour container had a crack; 10. Storage rack had some brownish and blackish build up; and 11. Personal belongings were found hanging inside the dry storage area. These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 71 residents eating at the facility. Findings: 1. During a concurrent observation and interview with the environmental services director (EVSD) on 3/22/22 at 9:30 a.m., inside the utility room in Station 2, in the presence of the dietary services supervisor (DSS), EVSD stated the ice machine cleaning was being done by an outside company, Brand A. The exterior part of the ice chute had some whitish build up and the interior part had some brownish and whitish buildup. The EVSD stated they had very hard water, and water softener was expensive. The ice machine air filter had some buildup of grayish material. The interior of part of the ice machine had some buildup of cloth fibers, with a cotton ball type appearance and bunched up to what appeared like a red yarn. The clear water supply tubing had some black material buildup. The EVSD acknowledged all the buildup inside the ice machine. There was no air gap observed and this was confirmed by the EVSD. The ice machine drain was connected to the sink drain beside the machine. During an interview on 3/22/22 at 10:30 a.m., the DSS stated the ice machine was brand new and it was delivered to the facility on [DATE]. The DSS further stated the ice machine was never cleaned by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 22 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 Brand A refrigeration ever since it was delivered. Level of Harm - Minimal harm or potential for actual harm A review of the facility provided document titled, Brand A Refrigeration Inc Invoice, dated 10/06/2021, indicated, 10/04/21 - Delivered unit. Residents Affected - Many 2. During an observation on 3/21/22 at 10:05 a.m., inside the walk-in refrigerator, the following meats were observed fully thawed: five pounds beef strips dated placed in the refrigerator on 3/21/22, and 3 large plastic bins of chicken thighs approximately 30 pounds, dated placed in the refrigerator on 3/21/22. In comparison, the following meats, with similar thaw dates, were only partially thawed, but mostly frozen: approximately five pounds of cooked chicken dated on 3/20/22; diced raw chicken in a box dated 3/21/22; and four five-pound chubs of ground beef dated 3/21/22. The top part of a diced raw chicken was thawed while the bottom part was partially frozen. The diced raw chicken had a yellow sticker on top of the box indicated delivery date was on 3/17/22. In the refrigerator a pound of ground beef, stew meat, and steaks may thaw within a day. Bone-in parts and whole roasts and large quantities of meat may take 2 days or longer (ASkUSDA.gov) During a concurrent observation and interview on 3/21/22 at 10:10 a.m. with food service worker M (FSW M), a fully thawed raw diced chicken in a plastic bin, approximately 3 pounds, was found in a cart outside the walk-in refrigerator. The FSW M stated the diced chicken was placed inside the refrigerator on 3/20/22 at around 11:00 p.m. and would use it as an alternate lunch. During an observation on 3/24/22 at 9:01 a.m. inside the walk-in refrigerator, one of the plastic bins of chicken thighs, approximately 20 pounds remaining, and the box of diced chicken thigh meat, both labeled with date placed in the refrigerator of 3/21/22 and use by date of 3/23/22, were still in the refrigerator. During an interview with DSS on 3/21/22 at 3:46 p.m., the DSS stated all delivery on this date was only produce. The DSS further stated all the meat in the refrigerator was delivered on 3/17/22, chilled and have been stored in the refrigerator since then. The DSS stated they used the FDA U.S. Food and Drug Administration: Refrigerator and Freezer Storage chart, which was observed posted outside the storage area. During a review of the FDA U.S. Food and Drug Administration, titled, REFRIGERATOR & FREEZER STORAGE CHART, dated March 2018, it indicated, Fresh Poultry: Chicken or turkey, parts - storage in refrigerator should be 1-2 days. 3. During an observation on 3/21/22 at 11:26 a.m. inside the kitchen, food service worker P (FSW P) was cutting some cantaloupe and honeydew right next to the red bucket number 1 (#1) with sanitizer. During an observation on 3/21/22 at 11:31 a.m., the red bucket #2 with sanitizer was observed located in between the coffee maker and the cook's food preparation table. During an observation on 3/22/22 at 8:52 a.m., the red bucket #1 with sanitizer was still on the food preparation table next to the sink. During a review of the facility's undated policy and procedure titled, Dry Storage Areas, indicated, 11. Poisonous and toxic material will be stored outside the food storage and preparation area or in cabinets used for no other purpose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 23 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 Residents Affected - Many 4. During a concurrent observation and interview on 3/23/22 at 12:13 p.m., food service worker P (FSW P) checked the concentration of sanitizer in the red bucket located to her station. The FSW P dipped the yellow quat strip and swirled it in the bucket for approximately 20 seconds while she counted very slowly to 10. The quat strip turned green and the FSW P compared the color to the container. The FSW P stated it is 400 parts per million (ppm - a measurement of concentration). The FSW P further stated the normal range was from 400-800 ppm. During a concurrent observation and interview on 3/23/22 at 12:30 p.m., FSW Y stated the buckets on three compartment sinks were just filled within the last half hour. FSW Y tested the bucket the same bucket that FSW P had just tested, and the result was 100 ppm. FSW Y filled up a new bucket with water and with solid quat broad range sanitizer. FSW Y tested the sanitizer concentration with water temperature of 136 degrees F, and the result was [PHONE NUMBER] ppm. It was determined the quat strip used were expired. During a review of the poster on the wall, it indicated to test the sanitizer with water temperature at 65-75 degrees F. During a review of the posted facility document titled, Sanitizer Concentration Log for RED BUCKETS, indicated, PPM should read at 200-400. 5. During a concurrent observation and interview on 3/22/22 at 9:55 a.m. with licensed vocational nurse A (LVN A), a carton of protein based nutritional supplement, dated 03/22/22 was on top of the medication cart. LVN A stated dietary staff would drop off three of the protein based nutritional supplement at the nurse station at around 6:00 a.m. LVN A further stated nurses would open one protein based nutritional supplement at around 7:30 a.m. and left it on cart until about 3:00 p.m. LVN A stated evening shift nurses would open a new carton of protein based nutritional supplement . The surveyor marked the side of the carton with an x. During another concurrent observation and interview on 3/22/22 at 12:39 p.m. with LVN A, the marked protein based nutritional supplement was still on the medication cart. LVN A poured the marked protein based nutritional supplement in a cup and the surveyor tested the temperature. LVN A confirmed the protein based nutritional supplement temperature was 71.1 degrees F. During an observation on 3/22/22 at 5:03 p.m., the marked protein based nutritional supplement was still on top of the medication cart. During a review of an unopened protein based nutritional supplement packaging, it indicated, STORAGE AND HANDLING: Store at room temperature. Do not freeze. Refrigerate after opening and use within 3 days. If not refrigerated after opening, use within 4 hours. 6. During a concurrent observation and interview on 3/21/22 at 9:50 a.m. with FSW M, more than 10 plastic bins and 2 large bins were stacked upside down in the storage area and were still wet. The storage rack was also damp. FSW M stated they stored the plastic bins in the storage area once air dried. During an observation on 3/22/22 at 11:15 a.m. inside the kitchen, there were four wet plastic containers stacked on the drying rack. During an observation on 3/22/22 at 11:32 a.m., the food processor was stored wet with its lid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 24 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 sealed on in an upright position. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/23/22 at 12:15 p.m. with FSW Y, there was half a tray of wet 8-ounce bowls inverted, on a tray without drying mats. There was also half a tray of 4-ounce tulip bowls stacked, still damp inside. FSW Y acknowledged the bowls were still wet and they should be air dried. FSW Y confirmed food processor should be stored upright when dry and inverted when wet. Residents Affected - Many During a concurrent observation and interview on 3/23/22 at 4:18 p.m. with DSS, there were still wet plastic containers stacked in the storage room. The DSS acknowledged the plastic containers should be air dried first prior to storage. During a review of the facility's undated policy and procedure titled, Dishwashing policy, indicated, 4. after dishes are done, let air dry. 7. During an observation on 3/22/22 at 11:15 a.m., inside the kitchen, there were some black build up on the floors at the corner of each storage area, bottom edge entrance in walk in refrigerator and freezer and along the walls leading to the back door. During an interview on 3/23/22 at 12:49 p.m., the DSS stated the kitchen floors were cleaned by the evening dietary staff. During an interview on 3/23/22 at 2:56 p.m., the DSS stated kitchen floors were not included in the monthly cleaning list. The DSS further stated deep cleaning in the kitchen should be scheduled. During a review of the facility's undated policy and procedure, titled General Sanitation of Kitchen, it indicated, Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During a review of the facility's undated policy and procedure titled, Dry Storage Areas, indicated, Floors, walls, shelves and other storage areas will be kept clean. 8. During the initial kitchen observation on 3/21/22 at 9:45 a.m., there was rice spilled all over the cart beside the rice bin. During an observation on 3/23/22 at 12:03 p.m., there was still rice spilled on a cart beside the rice bin. During a concurrent observation and interview with the DSS on 3/23/22 at 4:18 p.m., the rice was still all over the cart next to the rice bin. The DSS took a picture and acknowledged the rice spills should be cleaned. According to FDA Food Code Annex 4-602.13, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2017 4-601.11). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 25 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 9. During an initial kitchen observation on 3/21/22 at 9:45 a.m., there was a cracked lid on a flour bin. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview with DSS on 3/23/22 at 4:18 p.m., the DSS took a picture of the cracked lid on a flour bin and acknowledged it should be changed. Residents Affected - Many During a review of the facility's undated policy and procedure titled, Dry Storage Areas, indicated, 10. Grain products, dried vegetables and broken lots of bulk food will be stored in labeled containers with tight-fitting covers. 10. During an observation inside the kitchen on 3/22/22 at 8:58 a.m., the drying/storage rack for clean pots and pans had some buildup of black, brown particles and with some debris at the bottom rack and wheels. During an interview with the DSS on 3/23/22 at 12:49 p.m., the DSS stated the cleaning schedule at the kitchen was limited to tabletop surfaces, oven, and stove. The DSS further stated the items such as dome rack and other areas are not assigned to be cleaned. During a concurrent observation and interview with the DSS on 3/23/22 at 2:56 p.m., the DSS confirmed the storage cart for pots, pans and food processor was dirty and needed to be cleaned. The DSS further stated he tried to replace some carts but did not have the budget for it. A review of the Food and Drug Administration (FDA) Food Code 2017, 4-602.13 indicated Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 11. During an observation on 3/22/22 at 11:26 a.m., an employee coat was stored in a small dry storage area with cleaned equipment, containers, and foods like potatoes, sweet potatoes, and onions. During another observation on 3/23/22 at 12:05 p.m., an employee jacket was observed hanging at the corner of the door in the small dry storage room. During a concurrent observation and interview with the DSS on 3/23/22 at 4:18 p.m., a staff personal belonging, a purse, was hanging at the corner of the door in the small dry storage room where the cleaned containers and other equipment were stored. The DSS confirmed there should be no personal items inside the storage room. It is the standard of practice to not store personal belongings such as purses, coats, shoes, and personal medications with food, food equipment, and food-contact surfaces because of the possibility of cross-contamination (FDA Food Code and Annex 2017 6-305.11) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 26 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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, the facility failed to implement infection control measures when: Residents Affected - Many 1. The facility's screening process for Coronavirus disease (COVID-19, a disease caused by a contagious virus) was not in accordance with Centers for Disease Control and Prevention (CDC) guidelines; 2. The receptionist did not follow the facility's Screening Checklist when screening a visitor for COVID-19; 3. One dietary staff member was not screened for COVID-19 prior to entering the facility; 4. There were no receptacles (containers) inside the residents' rooms to dispose of used gowns in the yellow zone (area designated for resident with known or possible exposure to COVID-19); 5. One CNA did not use and dispose of personal protective equipment (PPE, mask, gown, gloves, eye protection) appropriately when providing care to Resident 3; 6. A receptacle designated for soiled adult diapers was left uncovered in the hallway; 7. The infection preventionist (IP) did not change her gown when performing COVID-19 testing for Residents 70, 46, 33, 14, 64, 71, 20 and 63; 8. One housekeeper did not use an isolation gown while in the yellow zone; 9. One CNA did not remove the isolation gown before leaving the yellow zone; and 10. One LVN did not perform hand hygiene after removing and disposing PPE. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. During an observation on 3/21/2022 at 9:10 a.m., receptionist U (REC U) performed COVID-19 screening on the survey team. REC U asked the team members, Are you having any COVID symptoms? He then asked the team members if they worked in a facility with recognized COVID-19 cases. REC U did not list specific COVID-19 symptoms during the screening process. He did not ask if the survey team members had close contact with anyone who had confirmed COVID-19. He also did not ask the survey team members if they had a positive COVID-19 test. During an interview with REC V on 3/22/2022 at 8:43 a.m., she stated anyone who enters the facility must be screened for COVID-19. She explained that when the screener asks about COVID-19 symptoms, he or she must list each symptom individually. During observations on 3/22/2022 from 8:52 a.m. to 8:55 a.m., REC V screened three individuals for COVID-19. She did not ask any of the three individuals if they had close contact with someone with confirmed COVID-19. She also did not ask if any of the three individuals had a positive COVID-19 test. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 27 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 Review of the facility's undated Screening Checklist indicated specific COVID-19 symptoms were listed with a blank box next to each symptom for the screener to check as he/she completed the screening. Several possible COVID-19 symptoms such as fatigue, headache, congestion, runny nose, nausea, vomiting and diarrhea were not listed on the Screening Checklist. There were no questions regarding a positive COVID-19 test or close contact with someone who had confirmed COVID-19. Residents Affected - Many During an interview with the IP on 3/22/2022 at 4:22 p.m., she confirmed that when screening individuals for COVID-19 symptoms, the screener must list each symptom individually instead of just asking if they are having any symptoms of COVID. The IP reviewed the facility's Screening Checklist and confirmed there were no questions regarding a positive COVID-19 test or close contact with someone who had confirmed COVID-19. She also confirmed several possible COVID-19 symptoms that should have been included in the Screening Checklist were not listed. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022 indicated, Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: 1) a positive viral test for SARS-CoV-2 [COVID-19], 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). Review of the CDC's Symptoms of COVID-19, updated 3/22/2022 indicated, People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. 2. Review of the facility's undated Screening Checklist indicated, 4. If allowed access, remind the individual to: Wash their hands or use ABHR [alcohol based hand rub] throughout their time [in the] building. Not shake hands with, or touch or hug individuals during their visit. Visitors permitted for compassionate care situation must wear a facemask while in the building and restrict their visit to the resident's room, as designated by the facility. During an observation on 3/22/2022 at 8:55 a.m., RECV screened a visitor for COVID-19. She did not provide the visitor with the above reminders as indicated on the facility's Screening Checklist. During an interview with the IP on 3/22/2022 at 4:22 p.m., she confirmed that when screening visitors, the screener should provide the reminders as indicated on the Screening Checklist. 3. During an observation on 3/22/2022 at 8:37 a.m., food service worker M (FSW M) was inside the kitchen. During a concurrent interview, FSW M stated he came in to work at 6:30 a.m. During an interview and concurrent record review with REC V on 3/22/2022 at 8:43 a.m., she stated anyone who enters the facility must be screened for COVID-19. REC V reviewed the facility's employee screening log and confirmed there was no documentation that FSW M was screened before he entered the facility on 3/22/2022. Review of the facility's policy titled Employee Screening/Facemasks, dated 3/17/2020 indicated, [Name of facility] is responsible for preventing the introduction of COVID-19 into the facility. Visitors and healthcare personnel (HCP) are the most likely sources of introduction. Employees will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 28 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 - Many screened each shift with questions regarding symptoms, exposure, travel and have their temperature checked. 4. During an observation of the facility's yellow zone on 3/21/2022 at 9:41 a.m., there were signs posted on the walls that indicated, 1. Remove Gloves, 2. Remove Gown, 3. Perform Hand Hygiene & Exit Isolation Room. There were receptacles designated for soiled isolation gowns spread throughout the hallways. Some resident rooms did not have a receptacle close by, so staff would have to carry their soiled isolation gowns across the halls in order to dispose of them. During an observation of the facility's yellow zone on 3/22/2022 at 8:27 a.m., the receptacles for soiled gowns were still spread throughout the hallways. There were no receptacles for soiled gowns inside the residents' rooms. During an interview with certified nursing assistant W (CNA W) on 3/22/2022 at 10:49 a.m., she confirmed that in the yellow zone, staff had to bring their soiled gowns into the hallway in order to discard them. During an interview with the IP on 3/22/2022 at 4:22 p.m., she explained the reason for removing a soiled gown prior to exiting a resident's room was to make sure the pathogens (organisms that can cause disease) on the gown remain in the resident's room. The IP acknowledged if staff had to carry their soiled gowns into the hallway to discard them, they could spread pathogens into the hallway. 5. Review of Resident 3's medical record indicated she had contact with and suspected exposure to COVID-19. During an observation on 3/21/2022 at 9:41 a.m., CNA X was inside Resident 3's room providing hands-on assistance with repositioning. There was a sign on the wall next to Resident 3's room that indicated, You are in a yellow zone, full PPE is required. CNA X was wearing a gown, gloves and an N95 mask, but he was not wearing any eye protection. After providing care, CNA X exited Resident 3's room without removing his gown and gloves. He walked through the hallway, removed his gloves and disposed of them in a trash receptacle. He did not remove his gown. During an interview with CNA X on 3/21/2022 at 9:49 a.m., he was still wearing the same gown he used while providing hands-on care to Resident 3. CNA X confirmed he was aware he needed to wear eye protection when providing care, but stated he could not find one. He also confirmed he knew he was supposed to remove his gown and gloves before exiting the resident's room, but stated he forgot. During an interview with the IP on 3/21/2022 at 10:31 a.m., she confirmed staff must wear eye protection when providing care to residents in the yellow zone. She also confirmed staff should remove their gown and gloves before exiting the resident's room. Review of the CDC's undated document titled How to Safely Remove Personal Protective Equipment (PPE) indicated, Remove all PPE before exiting the patient room except a respirator, if worn. 6. During an observation on 3/22/2022 at 10:42 a.m., there was a receptacle labeled Trash only, adult briefs [diapers] only located in a facility hallway. The receptacle was near the entrance to the kitchen. The receptacle's lid was open and the contents were exposed. During an interview with CNA W on 3/22/2022 at 10:49 a.m., she confirmed that lids to trash (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 29 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 receptacles should be closed. Level of Harm - Minimal harm or potential for actual harm During an interview with the IP on 3/22/2022 at 4:22 p.m., she confirmed the trash receptacle with the open lid was not acceptable. The IP explained the lid should have been closed to ensure pathogens were contained inside the receptacle. Residents Affected - Many Review of the facility's policy titled Medical Waste Container, revised 5/2012 indicated, Medical waste containers shall be located throughout the facility and treatment areas and must be kept covered at all times. 7. During an observation on 3/21/2022 at 9:51 a.m., there were signs posted on the walls in the yellow zone that indicated, Yellow isolation room, if you are not providing direct patient/prolonged care (example, dropping off food tray, picking up a tv remote, etc.), then 1.Perform hand hygiene, 2. Put on a mask, 3. put on gloves. Upon leaving room: Follow doffing procedures, hand hygiene. During an observation on 3/21/2022 at 12:00 p.m., there were signs posted in the yellow zone that indicated, You are in a Yellow zone, full PPE (personal protective equipment) required. During an observation on 3/21/2022 at 12:04 p.m., IP entered Resident 13's room wearing a gown, face shield and N95 mask. IP put on gloves, opened a swab package and test tube container, placed the swab into Resident 13's nose, rotated ten times and then placed the swab in the test tube container. Resident 13's call light was on and IP asked if any help was needed. Resident 13 requested certain items be moved and IP completed the request. IP removed her gloves and gown, placed the gown in a bin located in the hallway and then performed hand hygiene with alcohol based hand rub. (ABHR). IP then put on a new gown and gloves. During an observation on 3/21/2022 at 12:12 p.m., IP entered Resident 70's room with same gloves and gown she put on earlier. The IP swabbed Resident 70's nose, removed her gloves, then performed hand hygiene with ABHR. Wearing the same gown used to collect the nasal specimen from Resident 70, the IP entered Resident 46's room and swabbed the resident's nose. Wearing the same gown used to collect nasal specimens from Resident 70 and Resident 46, IP entered Resident 33's room and swabbed the resident's nose. IP's gown was observed touching Residents 33's wheelchair. Wearing the same gown, IP then approached Resident 14, who was sitting in a wheelchair in the hallway, and asked the resident about COVID-19 testing. IP donned gloves and swabbed Resident 14's nose in the hallway. No gown changes were observed, creating potential for cross contamination, between COVID-19 testing for Residents 70, 46, 33 and 14. The IP then entered Resident 64's room with same gown. During an observation on 3/21/2022 at 12:23 p.m., IP exited Resident 71's room. Wearing the same gown, IP entered Resident 20's room and swabbed the resident's nose. IP then swabbed Resident 63's nose. No gown changes were observed, creating potential for cross contamination, between COVID testing for Residents 71, 20 and 63. During an interview with CNA Z on 3/21/2022 at 12:30 p.m., she stated all residents in this hall were on COVID-19 precautions and staff do not wear the same gown and gloves when caring for more than one resident. During an interview with IP on 3/22/2022 at 4:22 p.m., she confirmed that Resident 33 tested positive for COVID-19 that morning and was transferred to the COVID-19 unit. IP confirmed she used the same gown to conduct COVID-19 testing for multiple residents the previous day, including Resident 33. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 30 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 - Many IP stated residents were in the yellow zone due to COVID-19 exposure and there was the possibility of COVID-19 infection, so PPE should be worn. IP stated she has received mixed guidance on use of PPE in the yellow zone. She stated her understanding was that if everyone was cohorted in the yellow zone, as long as you are not coming in contact with the resident and their belongings and it is less than 15 minutes (i.e. taking vitals, taking pulse oximetry, screening temperature), you don't have to wear an isolation gown. But if you are getting down and dirty, such as hoisting up resident, a gown is needed. IP further stated if you are not physically touching the resident, a gown is not needed. IP stated that during COVID-19 testing, she changed her gown when a resident sneezed on her or when a resident asked her to move something. IP acknowledged that residents in the yellow zone could have COVID-19 and be asymptomatic, and that would not be known until COVID-19 test results were available. IP stated that was the case for Resident 33, who was tested with multiple other residents the previous day using the same gown, but today Resident 33 tested positive for COVID. During an interview with the director of nursing (DON) on 3/23/2022 at approximately 12:30 p.m., she confirmed that residents in the yellow zone were persons under investigation for COVID-19 due to exposure to and therefore, staff should not be wearing the same gown between residents during COVID-19 testing. Review of the CDC's Strategies for Optimizing the Supply of Isolation Gowns, updated 1/21/2021 indicated, If used for isolation purposes, the gown should be changed between patients and must be removed and changed if it becomes soiled . 8. During observations on 3/21/2022 at 9:39 a.m., in the yellow zone, the housekeeper (HK) was mopping the floor in room [ROOM NUMBER]. She was wearing N95, face shield and gloves but was not wearing an isolation gown. During another observation at 9:47 a.m., HK went to room [ROOM NUMBER] to mop the floor and did not wear an isolation gown. During an interview with HK on 3/22/2022 at 10:00 a.m., she said that she should have worn an isolation gown while in the yellow zone. Review of the CDC's website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/22/2022, HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 9. During an observation and concurrent interview on 3/21/2022 at 9:57 a.m., while in yellow zone, certified nursing assistant E (CNA E) came out of room [ROOM NUMBER], removed the isolation gown in the hallway, then placed it inside the trash bin located in the hallway. CNA E said there were trash bins inside the resident's room and that they are all outside in the hallway. Review of the CDC's website, Implementation of Personal Protective Equipment (PPE) in Nursing Homes indicated Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 10. During an observation and concurrent interview on 3/21/2022 at 10:04 a.m., licensed vocational nurse CC (LVN CC) came out of room [ROOM NUMBER], and placed clipboard and blood pressure cuff on top of the chair. LVN CC removed her gown in the hallway, then placed the isolation gown inside the trash bin located in the hallway. LVN CC cleaned the blood pressure cuff with antibacterial wipes but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 31 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete did not remove gloves or perform hand hygiene prior to doing other tasks. LVN CC acknowledged the observation and said she should have performed hand hygiene after leaving the yellow zone area and performing another task. Review of the facility's policy, dated 8/2019, titled Handwashing/Hand Hygiene indicated, Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for: before and after entering isolation precaution settings. Event ID: Facility ID: 056055 If continuation sheet Page 32 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0881 Implement a program that monitors antibiotic use. 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 follow its antibiotic stewardship program (program intended to prevent the overuse of antibiotics) when antibiotics were prescribed for one of one sampled residents (Resident 8) without the use of the protocols outlining clinical symptoms to confirm the presence of an infection. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Residents Affected - Few Findings: Review of Resident 8's medical record indicated she was admitted on [DATE] and did not have an indwelling catheter (flexible tube inserted and left in the bladder to drain urine). Review of Resident 8's medication administration record (MAR) indicated she received the following antibiotics: 1. Ceftriaxone 1 gram (gm, unit of dose measurement) intramuscularly (IM, injected into a muscle) for urinary tract infection (UTI) from 6/23/2021 to 6/25/2021; and 2. Augmentin 500-125 milligrams (mg, unit of dose measurement) by mouth every 12 hours for UTI from 12/26/2021 to 1/2/2022. Review of the facility's antibiotic stewardship binder indicated there were multiple documents that outlined which clinical symptoms a resident needed to exhibit in order to meet the criteria for antibiotics. Review of the facility's undated document titled Infection Control Tracker-Monthly Line Listing indicated for a resident without an indwelling catheter, criteria are met to initiate antibiotics for UTI if one of the following are met: 1. Any one of the following two: Acute dysuria (pain or burning while urinating) or acute pain, swelling or tenderness of the scrotal area. 2. Single temperature of 100 degrees Fahrenheit (F, unit of temperature measurement) or 2 degrees F above baseline, or repeated temperatures of 99 degrees F and at least one of the following new or worsening symptoms: urgency (increased urge to urinate), gross hematuria (blood in the urine), suprapubic pain (pain above the pubic area), back or flank pain, frequency (increase in how often one needs to urinate), urinary incontinence (loss of bladder control). 3. No fever, but two or more of the following new or worsening symptoms: urgency, gross hematuria, suprapubic pain, urinary incontinence, frequency. Review of the facility's undated document titled Criteria for Defining UTI Events in NHSN LTCF Component indicated for a resident without an indwelling catheter, criteria are met to initiate antibiotics for UTI if one of the following are met: 1. Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate (parts of the male reproductive system). 2. Fever or leukocytosis (increased white blood cells) and one or more of the following: costovertebral angle pain or tenderness (pain in the back at the bottom of the ribcage), new or marked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 33 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0881 Level of Harm - Minimal harm or potential for actual harm increase in suprapubic tenderness, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. 3. Two or more of the following: costovertebral angle pain or tenderness, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. Residents Affected - Few Review of the facility's document titled Infection Management Guidelines, Urinary Tract Infection WITHOUT Indwelling Catheter, dated 12/31/2017, indicated criteria are met to initiate antibiotics for UTI if at least one of the following are met: 1. New or increased burning upon urination. 2. Temperature greater than 100 degrees F or lower than 97 degrees F, white blood cell count greater than 11,000 or less than 4,000. 3. New flank or suprapubic pain or tenderness. 4. Gross hematuria. 5. New or worsening incontinence or urgency or frequency. Review of Resident 8's medical record indicated there was no documentation that she was experiencing any symptoms from the above documents before or during her antibiotic treatments for UTI from 6/23/2021 to 6/25/2021 and from 12/26/2021 to 1/2/2022. Review of the facility's 24-Hour Report of Resident's Condition and Nursing Unit Activities, dated 6/23/2021, indicated Resident 8 had an order for a urine test to be done for chills and generalized pain. These symptoms are not included in the facility's documents outlining the criteria for antibiotic treatment. Review of Resident 8's nurse's note, dated 6/25/2022, indicated the nurse practitioner even discontinued antibiotic treatment due to negative urinalysis results (urine test indicated the resident did not have a UTI). Review of Resident 8's nurses note, dated 12/23/2021 indicated, UA [urinalysis] collected for hallucinations, trying to get out of bed, anxiety, confusion. These symptoms were not included in the facility's documents outlining the criteria for antibiotic treatment. Review of Resident 8's Physician's Progress Notes, dated 12/28/2021 indicated, Pt [patient] is more confused than usual but in no pain/distress. Increased confusion was not included in the facility's documents outlining the criteria for antibiotic treatment. During an interview and concurrent record review with the infection preventionist (IP) on 3/23/2022 at 4:20 p.m., she confirmed the facility was supposed to use the guidance in the antibiotic stewardship binder to determine if a resident meets the criteria for antibiotic treatment. The IP reviewed Resident 8's medical record and confirmed she did not see any documentation indicating the resident experienced symptoms that met the criteria for antibiotic treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 34 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0881 The facility's policy titled Antibiotic Stewardship - Orders for Antibiotics, revised 12/2016, indicated appropriate indications for use of antibiotics include criteria met for clinical definition of active infection. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 35 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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: Residents Affected - Some 1. Track, offer and administer pneumococcal vaccines (vaccines intended to prevent lung infection) according to Centers for Disease Control and Prevention (CDC) guidelines for three of five sampled residents (Residents 20, 26 and 27); and 2. Perform screening prior to administering the influenza (respiratory infection) vaccine for one of five sampled residents (Resident 43). These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. Review of the CDC's guidance titled Vaccines and Preventable Diseases (https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html), last reviewed 1/24/2022, indicated there are two types of pneumococcal vaccines available in the United States; pneumococcal conjugate vaccines (PCV13, PCV15, and PCV20) and pneumococcal polysaccharide vaccine (PPSV23). For adults ages 19 to 64 who have risk factors, such as chronic renal failure (a kidney disease), the guidance indicates the following: For those who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV15 or PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. If PCV20 is used, a dose of PPSV23 is not indicated. For those who have only received PPSV23, CDC recommends you may give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 with or without PPSV23, CDC recommends you give PPSV23 as previously recommended. Review of the same CDC guidance indicates the following: For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV15 or PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. If PCV20 is used, a dose of PPSV23 is not indicated. For adults 65 years or older who have only received PPSV23, CDC recommends you may give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete. Review of Resident 20's medical record indicated she was [AGE] years old and had the diagnosis of chronic kidney disease. The medical record indicated Resident 20 received Pneumovax [pneumococcal vaccine] Dose 1 on 10/27/2017. There was no documentation indicating which specific pneumococcal vaccine Resident 20 received. There was no documentation indicating whether or not the facility offered and administered another pneumococcal vaccine. Review of Resident 26's medical record indicated she was [AGE] years old and was Not Eligible for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 36 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0883 Pneumovax Dose 1. Level of Harm - Minimal harm or potential for actual harm Resident 26's Pneumococcal Vaccine Consent Form, dated 7/8/2016, had a check mark next to the option that indicated, I hereby GIVE the facility permission to administer a pneumococcal vaccine, unless medically contraindicated. Written on the right side of the consent was, Not eligible already received. There was no documentation in Resident 26's record indicating which specific pneumococcal vaccine she already received. There was no documentation indicating how many pneumococcal vaccines Resident 26 received and whether the facility offered another vaccine, if indicated. Residents Affected - Some Review of Resident 27's medical record indicated she was [AGE] years old. The record indicated Consent Refused for Pneumovax Dose 1. Review of Resident 27's Pneumococcal Vaccine Consent Form, dated 2/5/2018 indicated, Reason for declination: had it. There was no documentation in Resident 27's record indicating which specific pneumococcal vaccine she had. There was no documentation indicating how many pneumococcal vaccines Resident 27 received and whether the facility offered another vaccine, if indicated. During an interview with the infection preventionist (IP) on 3/24/2022 at 4:47 p.m., she stated she was not familiar with the CDC recommendations regarding pneumococcal vaccines. IP acknowledged for the above residents, the facility should have determined which pneumococcal vaccines they already received and whether they needed to offer them another vaccine. During an interview with registered nurse T (RN T) on 3/25/2022 at 1:57 p.m., she stated the facility offered the PPSV23 to residents upon admission. RN T stated she had been working in the facility for seven years and had not offered or administered other pneumococcal vaccines aside from the PPSV23. Review of the facility's policy titled Pneumococcal Vaccine, revised 8/2016 indicated, Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 2. During an interview with IP on 3/24/2022 at 8:17 a.m., she explained that prior to administering the influenza vaccine to a resident, staff need to obtain consent and complete a screening questionnaire. Review of Resident 43's Consent to Influenza Vaccination, dated 10/28/2021, indicated Resident 43's responsible party (person designated to make decisions for the resident) requested that the influenza vaccine be given to Resident 43. Review of Resident 43's influenza vaccine screening and administration form, dated 10/29/2021, indicated facility staff administered the influenza vaccine into the resident's right deltoid (shoulder muscle). The top half of the form contained five screening questions with boxes designated for the staff member to check either Yes or No in response to the questions. The questions on the form were as follows: 1. Have you had a severe allergic reaction to eggs, chicken products, latex or thimerosal? 2. Do you have a fever or other symptoms of acute illness? 3. Have you ever had Guillain-Barre' syndrome (a neurological disorder)? 4. Have you ever had a serious reaction to a flu vaccine? 5. Are you starting or currently receiving radiation or chemotherapy? This portion of Resident 43's form was left blank. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 37 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0883 Level of Harm - Minimal harm or potential for actual harm During a follow-up interview with the IP on 3/24/2022 at 4:47 p.m., she reviewed Resident 43's influenza vaccine screening and administration form and confirmed the screening questions were not answered. IP acknowledged staff should have completed the screening questions prior to administering the vaccine. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 38 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0888 Ensure staff are vaccinated for COVID-19 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 develop and implement policies and procedures that were in accordance with the Centers for Disease Control and Prevention (CDC) recommendations when it allowed medical exemptions and deferments from Coronavirus disease (COVID-19, a disease caused by a contagious virus) vaccinations for two of two staff members who were pregnant. Both staff members worked in the facility under this exemption. As a result, the facility's staff vaccination rate was 98.2% on [DATE]. In addition, the facility failed to ensure staff who were not fully vaccinated adhered to appropriate precautions to mitigate risk for COVID-19 spread. These failures increased the risk for COVID-19 exposure and infection to residents and staff. Residents Affected - Few Findings: Review of the facility's Appendix B, Physician's Verification of Request for Medical Exemption or Pregnancy Deferral from COVID-19 Vaccination, dated [DATE], indicated staff member R (SM R) requested a pregnancy deferral from COVID-19 vaccination. Review of a document addressed Dear Physician on facility letter head, signed and dated by a physician on [DATE] indicated, COVID-19 vaccination has been shown to be effective in protecting recipients. [Name of facility] permits medical exemptions from COVID-19 vaccination only for FDA-recognized medical contraindications, and while not a contraindication, deferment of vaccination for pregnant employees. A check mark was placed in the box for Pregnancy deferment request: Note: Pregnancy and lactation are not contraindications to COVID-19 vaccination; however, deferment accommodation will be allowed for pregnant women with validation of pregnancy from the individual's healthcare provider. The employee must be fully vaccinated by the end of the maternity leave of absence prior to return to work unless approved under a different medical exemption. Review of a letter from an outside medical group, dated [DATE], indicated a physician discussed the risks and benefits of the COVID-19 vaccine with staff member S (SM S). The letter further indicated, I recommended the vaccine, however, [SM S] desires to wait until after her pregnancy to receive the vaccine. Please allow [SM S] to have an exemption secondary to pregnancy. Her due date is [DATE]. During an interview with the director of nursing (DON) on [DATE] at 12:06 p.m., she stated SM S had her baby in early [DATE] and worked in the facility in February 2022. The DON stated the director of staff development (DSD) would have the specific dates. During an interview with the DSD on [DATE] at 12:09 p.m., he stated SM S started her maternity leave in [DATE], then worked in the office for a few days in February 2022. SM S helped with staff scheduling and personal protective equipment inventory. The DSD reviewed his calendar and stated SM S worked in the building on [DATE], [DATE] and [DATE]. The DSD stated SM S primarily stayed in the office and wore a surgical face mask, not an N95 (mask that filters 95% of airborne particles). The DSD stated most of SM S interactions were with him and a few staff members who would come into the office. The DSD stated that to his knowledge, SM S had not received the COVID vaccine. During an interview with the DON on [DATE] at 12:36 p.m., she stated the facility followed CDC guidelines for contraindications for COVID-19 vaccination. A joint review of the CDC's Media Statement New CDC Data: COVID-19 Vaccination Safe for Pregnant People (https://www.cdc.gov/media/releases/2021/s0811-vaccine-safe-pregnant.html), released on [DATE] indicated, CDC has released new data on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 39 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few safety of the COVID-19 vaccines in pregnant people and is recommending all people [AGE] years of age and older get vaccinated against COVID-19. CDC encourages all pregnant people or people who are thinking about becoming pregnant and those breastfeeding to get vaccinated to protect themselves from COVID-19 Previously, data from three safety monitoring systems did not find any safety concerns for pregnant people who were vaccinated late in pregnancy or for their babies. Combined, these data and the known severe risks of COVID-19 during pregnancy demonstrate that the benefits of receiving a COVID-19 vaccine for pregnant people outweigh any known or potential risks. A joint review of the CDC's Summary Document for Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized or Approved in the United States also indicated COVID-19 vaccines were recommended during pregnancy. The DON stated she was aware of this and stated the decision to allow pregnancy exemption/deferment was made by the Administrator (ADM). During an interview with the ADM on [DATE] at 1:10 p.m., he stated that when the healthcare staff COVID-19 vaccination policy was written, he heard on calls with the California Department of Public Health (CDPH) and the California Association of Health Facilities (CAHF) that pregnant or lactating women were not supposed to get the vaccine. The ADM explained when staff have a pregnancy deferral, before they return to work and enter the facility, they need to have received the first dose or booster, whichever one is applicable. They also have to do twice-a-week testing and wear N95 masks. When informed that SM S returned to work after pregnancy deferment was no longer applicable, was not vaccinated, did not wear N95 masks, and there was no evidence of COVID-19 testing in the facility's testing logs, the ADM stated the policy was not followed and staff should have been vaccinated before returning to work after her pregnancy deferral expired. The ADM further stated the policy about exemption/deferring COVID-19 vaccinations for pregnancy will change and will include information about when deferrals end and what needs to happen before staff returns to work. During an interview with the infection preventionist (IP) on [DATE] at 1:48 p.m., she stated SM S might have received COVID-19 testing outside the facility and may have shown the results to the DSD. IP confirmed SM S worked in the facility, did not receive COVID-19 vaccination, and did not have a medical exemption/deferral for when she was no longer pregnant. During a concurrent interview, the DON stated SM R and SM S did not have qualifying medical exemptions/deferments and should be placed in the category of staff who were not vaccinated without exemption or delay. This means the facility's staff vaccination rate was 98.2% and less than the required 100%. During an interview with the DON on [DATE] at 1:54 p.m. she stated SM S was being tested outside the facility and just showing the results to the DSD. The DON confirmed no copies of the results were kept in the facility, but the facility would obtain the copies. During an interview and concurrent record review with the IP on [DATE] at 5:24 p.m., an email from SM S to the IP, dated [DATE], indicated SM S had a COVID-19 test with indeterminate results on [DATE], which was the last day she worked in the facility. When asked what indeterminate meant, the IP stated she followed up with the lab and it meant it was unclear if SM S had COVID-19 or not. IP stated re-testing should have been done the next day, but was not. SM S had a positive COVID-19 test on [DATE]. Review of the facility's COVID-19 outbreak log showed the facility had an active COVID-19 outbreak. Since [DATE], there had been 14 COVID-19 positive staff and 11 COVID-19 positive residents. The first COVID-19 positive staff was on [DATE] and the first COVID-19 positive resident was on [DATE]. The COVID-19 outbreak was ongoing with two additional residents having COVID-19 positive test results and being transferred to the facility's designated COVID-19 unit on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 40 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the CDC's cases and deaths by county (https://data.cms.gov/covid-19/covid-19-nursing-home-data) report, accessed [DATE], showed the county where the facility was located had a 32.71 COVID-19 case rate per 100k and had a moderate level of community transmission. Review of National Health Care Safety Network (NHSN) data, dated [DATE], indicated resident vaccination rate was 97.3%. Review of the facility's policy titled Healthcare Worker Vaccine Requirement, dated [DATE] indicated, [Name of facility] is qualified as a health care facility whose employees and workers provide services as a skilled nursing facility and therefore must be fully vaccinated against COVID-19 by [DATE]. The policy further indicated, Any employee or worker qualifying for an exemption to the COVID-19 vaccination must meet the following requirements when entering the facility: 1. Test twice-weekly for COVID-19 with a PCR test that has Emergency Use Authorization by the FDA. 2. Wear an N95 mask at all times while in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 41 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the kitchen's physical environment was free from accident hazards and equipment was in good working condition when: Residents Affected - Some 1. The magnetic mesh screen at the kitchen's back door was not fully closed, the kitchen floor had a tear, and the floor coving was completely detached from the bottom part of the wall; 2. The floor drains were not emptied and cleaned; and, 3. Residents' food trays were broken exposing the metal parts at the edge. These failures had the potential to affect the health and safety of staff and 71 residents at the facility by possible exposure to disease carrying pests, hazards and injuries. Findings: 1a. During an observation on 3/21/22 at 11:31 a.m., the magnetic mesh screen located at the back of the kitchen was halfway opened. During an observation on 3/22/22 at 11:25 a.m., the magnetic mesh screen had some holes, and the bottom part was not sealed. According to Food and Drug Administration [FDA]-Food Code 2017 Section 6-202.15, it is the standard of practice to ensure the outer opening of a food establishment shall be protected against the entry of insects and rodents by a solid, self-closing, tight fitting doors. 1b. During an observation on 3/22/22 at 8:52 a.m. inside the kitchen, food service worker N (FSW N) tripped as he walked by the tear on the floor in front of the food preparation table and sink. During another observation on 3/22/22 at 12:19 p.m., the dietary services supervisor (DSS) also tripped as he walked by the tear on the floor in front of the food preparation table and sink. According to the FDA Food Code 2017 Section 6-101.11, it is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces are smooth, durable, and easily cleanable for areas where food establishment operations are conducted. 1c. During an observation on 3/22/22 at 11:15 a.m., an approximately six-inch piece of floor coving was detached from the bottom part of the wall outside the dry storage room. During a concurrent interview with the DSS and the environmental services director (EVSD) on 3/22/22 at 11:40 a.m., both managers confirmed they never did any individual environmental rounds, especially in the kitchen. The EVSD stated if there were some maintenance issues, staff would write them down in a binder and he would work on it. The DSS acknowledged the problems on the floor and back door screen needed to be addressed. According to the 2017 FDA Food Code Section 4-202.11, physical facilities shall be maintained in good repair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 42 of 43 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 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During an observation on 3/22/22 at 9:30 a.m. inside the dishwashing room, the screens on both floor sinks had food residue. The dishwasher floor sink had lettuce, red diced item resembling like red peppers or tomatoes and white particles like rice. The floor sink by three compartment sinks had a tan colored sludge type material, resembling to hot cereals. During an interview on 3/23/22 at 12:49 p.m., the DSS stated he relied on staff to inform him for any issues regarding safety and sanitation. According to FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13). 3. During a concurrent observation and interview with the DSS on 3/23/22 at 1:00 p.m., residents' trays above the dishwashing room area were discolored and some had broken corners exposing the metal part of the rim. The DSS acknowledged the trays are broken and discolored. The DSS stated he would do something about it. During an interview with food service worker Q (FSW Q) on 3/23/22 at 2:52 p.m., FSW Q stated she would report any maintenance issues in the kitchen or broken items to her supervisor or to maintenance. According to the 2017 Food and Drug Administration (FDA) Food Code Section 4-202.11, multi-use food contact surfaces shall be: smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 43 of 43