Health inspection·July 29, 2022

F 0656 Review of Resident 8's fall care plan indicated it was not updated with the new interventions. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the director of staff development (DSD) on 7/28/22 at 2:35 p.m., she confirmed Resident 8's fall care plan was not updated with the new interventions from the Fall IDT Follow-Up dated 4/29/22. The DSD stated the fall care plan should have been updated with the new interventions. Residents Affected - Few Review of Resident 8's Follow Up question Reports indicated Visual Checks - Every 15 Minutes were documented the visual checks were performed by the certified nurse assistants (CNAs) during their 30 minutes lunch breaks. During an interview and concurrent record review with the DSD on 7/28/22 at 10:46 a.m., she confirmed CNAs documented the visual checks were performed during their lunch breaks. The DSD confirmed the CNAs were not able to perform the visual checks during their lunch breaks. During an interview and concurrent record review with CNA E on 7/28/22 at 2:05 p.m., she confirmed she was assigned to Resident 8 on 4/29/22 and 4/30/22. CNA E confirmed she documented she performed the visual checks during her lunch break, but she did not perform the visual checks during her lunch breaks. During an interview and concurrent record review with CNA F on 7/28/22 at 2:59 p.m., she confirmed she was assigned to Resident 8 on 4/29/22 and documented she performed the visual checks during her lunch break, but she did not perform the visual checks during her lunch break. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manresa Healthcare Center 919 Freedom Blvd Watsonville, CA 95076 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Review of Resident 6's admission record indicated he was admitted to the facility with a diagnosis of urinary tract infection (UTI). Residents Affected - Few Review of Resident 6's minimum data set (MDS, an assessment tool) dated 7/3/22, indicated he had a BIMS ( Brief Interview for Mental Status) of 2 (0-7 severe cognitive impairment ) and he was total dependent with personal hygiene. During an observation and concurrent interview with registered nurse B (RN B) on 7/28/22 at 2:52 p.m., Resident 6's nails have black residue under his long fingernails. RN B stated Resident 6 was not diabetic and acknowledged his fingernails were dirty and need to be cleaned and trimmed . During an interview with the certified nursing assistant C (CNA C) on 7/28/22 at 3:00 p.m., she stated she was assigned for Resident 6 on 7/28/22 and she checked his nails. CNA C stated she can clean the nails but she needed to ask his nurse. Review of the facility's undated policy ,Nail Hygiene Policy and Procedure, indicated this policy is to ensure that all residents receive nail hygiene in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manresa Healthcare Center 919 Freedom Blvd Watsonville, CA 95076 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food and utensils were stored and prepared in accordance with professional standards for safety, when pans (metal container) were not air dried before storing, storage rack for the knives was uncleaned and floor inside the pantry was left wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) and cross contamination of food that could affect the 54 residents residing and consuming food at the facility. Findings: During the initial kitchen tour observation on 7/25/2022 at 1:15 p.m., there were four wet one third size pans stored in the shelf inside the pantry (dry storage room) and uncleaned storage rack for knives where five knives were placed. During the interview on 7/25/2022 at 1:31 p.m. with the dietary manager (DM), he acknowledged that pans should be air dried first after washing before storing them in the storage shelf inside the pantry. He also stated that the knives should be stored in a clean storage rack at all times. During a pantry observation and concurrent interview with the DM on 7/25/2022 at 2:00 p.m., the floor underneath the shelf where the wet pans were stored was also wet. DM verified that pantry floors should be dried and cleaned all the time. During an interview with the dietician (DT) on 7/29/2022 at 10:35 a.m., she verified that pans should be air dried before they are stored in the pantry shelves, storage rack for knives should always be cleaned or replaced with a new storage rack if needed and kitchen floors should always be cleaned and dried. Review of the facility's policy and procedure, Food and Nutrition Services, RDs for Healthcare, Inc.; Dishwashing, dated 2018, indicated, Dishes are to be air dried in racks before stacking and storing. Review of the facility's procedure, Food and Nutrition Services, RDs for Healthcare, Inc.; Sanitation, dated 2018, indicated, All utensils, counters, shelves and equipment shall be kept clean; maintained in good repair. Review of the facility's policy and procedure, Food and Nutrition Services, RDs for Healthcare, Inc.; Storeroom, dated 2018, indicated, The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. The floor, shelves and equipment must be kept clean by setting up, maintaining and monitoring a regular cleaning schedule. Routine inspection must be made to ensure cleanliness and high standards of sanitation. Review of the facility's policy and procedure, Food and Nutrition Services, RDs for Healthcare, Inc.; General Appearance of Food and Nutrition Department: Floors, dated 2018, indicated, Wipe up all spills as they occur. Use caution signs on wet floors. The wet floor should not be walked on until it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manresa Healthcare Center 919 Freedom Blvd Watsonville, CA 95076 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 is thoroughly dry. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manresa Healthcare Center 919 Freedom Blvd Watsonville, CA 95076 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 Based on observation, interview and record review, the facility failed to implement infection control practices when : Residents Affected - Some 1. Staffs were double masking using an N95 mask (disposable filtering facepiece respirator); 2. For Resident 38, her enteral feeding bag did not have a label and was left open; 3. A kitchen staff was not wearing proper N95 mask; and 4. A staff did not perform hand hygiene in between task during medication pass observation. These failures had the potential to spread infections, and compromise resident's health and safety especially when the facility had on-going Covid -19 outbreak (a new strain of virus that can cause mild to severe respiratory illness). Findings : 1. During an observation and concurrent interview with activity assistant (AA) on 7/25/22 at 1:51 p.m., AA was in the dining area with residents. AA had face shield and two masks on, a white mask covering a blue mask . AA stated she was wearing an N95 (white mask) and was fit tested . During a follow up interview with AA on 7/28/22 at 8:31 a.m., she stated she knew she did not have to wear another mask with an N95 mask but she thought two masks would give her more protection . During an observation and concurrent interview with licensed vocational nurse A (LVN A ) on 7/25/22 at 2:15 p.m., LVN A was wearing a face shield and two masks on , a white mask covering a blue mask. LVN A stated she had an N95 mask (white mask) and another mask on because N95 irritates her . During an interview with the infection preventionist (IP) on 7/28/22 at 11:32 a.m., she stated staffs were fit tested for N95 and the process did not include wearing another mask. The IP also stated the AA tested positive for Covid-19 on 7/28/22. 2. Review of Resident 38's physician order dated 6/21/22, indicated enteral feeding at 55 Jevity 1.0 x 20 hours, 918 millimeter (ml,a type of unit measurement) free water . During an observation on 7/27/22 at 8:33 a.m., Resident 38's enteral feeding pump (a device used to deliver nutrition to the stomach using a tube) was running at 55cc/ hr. The enteral feeding bag with the feeding formula had no label and left open on top. During a follow-up observation and interview with registered nurse B (RN B) on 7/27/22, RN B confirmed the above observation . RN B stated she went for her nursing rounds but did not notice the missing label and the enteral feeding bag was left open. RN B stated the enteral feeding was running since the evening shift . 3. During a kitchen observation and concurrent interview with cook D (CD) on 7/27/2022 at 8:55 a.m.,CD's N95 mask kept falling below his nose. CD verified that his N95 mask did not fit him properly and he needed to change it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manresa Healthcare Center 919 Freedom Blvd Watsonville, CA 95076 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 During an interview with the dietary manager (DM) on 7/27/2022 at 9:05 a.m., he verified that CD's N95 mask did not fit him properly and needed to be changed. During an interview with the IP on 7/29/2022 at 11:09 a.m., the IP verified that staffs including cooks should wear a properly fitted N95 masks and should be changed if it did not fit them well. Residents Affected - Some During an interview with the director of nursing (DON) on 7/29/2022 at 11:12 a.m., the DON verified that staffs should be wearing well fitted N95 masks and they should replace their N95 masks if they did not fit them properly. 4. During a medication administration observation on 7/26/2022 at 8:34 A.M., in Resident 34's room, RN B was observed administering eight oral medications to Resident 34 with her gloved hands. Then, using left gloved hand, she touched Resident's lower eyelids to instill the Systane (medication for dry eye) eye drop into each eye with her right hand. Next, using the same gloved hands, RN B opened an alcohol prep pad, took the alcohol swab to clean the resident's left upper arm site, and injected insulin (medication to lower blood sugar) into the site with an insulin pen. During an interview with RN B on 7/26/2022 at 8:38 A.M., she stated she used the same gloves during the entire medication administration, and acknowledged she should have changed gloves before administering the eye drops and before injecting the insulin. During an interview with the IP on 7/29/2022 at 11:05 A.M., she stated the nurses should change their gloves and wash their hands between each task when performing multitasks. Review of the facility's undated Hand Hygiene Policy and Procedures, indicated effective hand hygiene reduces the incidence of healthcare-associated infections. Change gloves during patient care if moving from a contaminated body site to a clean body site, remove gloves promptly after use .Decontaminate hands after removing gloves . Review of the facility's undated policy and procedure, N95 Fit Testing , indicated the purpose of this policy is to ensure staffs have the proper N95 face mask in the case of a facility outbreak requiring an N95 mask to prevent the spread of respiratory virus . The IP will ensure staffs are using the N95 mask they were using were fit tested to use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056178 If continuation sheet Page 7 of 7