Other·March 13, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 2/28/18. The facility was licensed for 51 beds. The census at the time of the survey was 43. The sample size was 12. For Complaint CA00575142 and Entity Reported Incident CA00573748 regarding Quality of Care/Treatment/Resident Safety, a federal deficiency was identified (see F689) with a scope and severity of "G". A Class "B" Citation was also issued. Representing the California Department of Public Health: 34432, Health Facilities Evaluator Nurse; 38174, Health Facilities Evaluator Nurse; 35302, Health Facilities Evaluator Nurse; and 39238, Health Facilities Evaluator Nurse.

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 03/30/2018 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 1 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect residents' rights to confidentiality of protected health information (PHI) for multiple residents in nursing station A when staff exposed and left unattended multiple pages of the medication administration record (MAR) in medication cart A. This failure had the potential to compromise resident rights. Findings: 1. During a medication administration observation on 2/27/18, at 9:19 a.m., the MAR binder was on top of medication cart A. Multiple pages were visible on the left side of the MAR binder and multiple resident information such as name, diagnoses, and medication were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 2 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE visible to anyone who was passing by the hallway. 2. During a concurrent observation and interview with the director of nursing (DON) on 2/27/18, at 12:03 p.m., the MAR binder was on top of medication cart A. Multiple pages were visible on the left side of the MAR binder and multiple resident information such as name, diagnoses, and medication were visible to anyone who was passing by the hallway. The DON stated the information of the residents should be covered. A review of the facility's undated Policy and Procedure "Preparation and General Guidelines" indicated for residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged with tags, colored plastic strips, drinking straws, or paper clips.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/30/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 3 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review , the facility failed to develop care plan for one of 12 sampled residents (Resident 10 ) when Resident 10's care plan for the use of oxygen (a colorless and odorless gas that people need to breathe) was not developed. This failure had the potential to result in the inability to identify the resident's individualized care issues and implement a person-centered care plan to address identified needs. Findings: Review of Resident 10's clinical record on 2/27/18, indicated she was admitted to the facility on 6/1/17 with diagnoses including pneumonia (PNA, an infection of the lungs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 4 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE caused by fungi, bacteria, or viruses ). Review of Resident 10's January 2018 Physician Order Sheet dated 6/29/17, indicated oxygen (O2) at 2 liters per minute (L/m) via nasal cannula (a device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help) if O2 saturation was below 90% (normal oxygen saturation level is between 95 -100 percent ) on room air (RA) as needed. During an interview with the director of nursing (DON), on 2/27/18 at 10:01 a.m., she indicated a care plan for O2 was not developed since 6/29/17. She stated Resident 10 should have had a care plan for O2. According to the facility's undated "Nursing Care Plan" policy, it indicated the nursing process was a deliberated, problem solving approach in meeting the health care and nursing needs of patients.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 03/30/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to meet professional standards for two of 12 sampled residents (3 and 10). 1. For Resident 10, the facility failed to follow the physician's order and monitor oxygen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 5 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE therapy. 2. For Resident 3, the facility failed to administer a nutritional supplement as ordered by the physician. These failures could potentially affect the quality of care provided to residents. Findings: 1. Review of Resident 10's clinical record on 2/27/18, indicated she was admitted to the facility on 6/1/17 with diagnoses including pneumonia (PNA, an infection of the lungs caused by fungi, bacteria, or viruses). Review of Resident 10's 1/2018 Physician Order Sheet indicated an order for oxygen at 2 liters/minute (L/m) via nasal cannula (a device used to deliver supplemental oxygen or airflow to a patient in need of respiratory help) if O2 saturation was below 90% (blood oxygen measurement) on room air (RA) as needed. Review of Resident 10's Treatment Administration Record (TAR) for January 2018, indicated missing O2 saturation readings for O2 below 90%. During an observation on 2/26/18, at 8:47 a.m., Resident 10 was observed with a nasal cannula connected to an oxygen concentrator at 3.5 L/m. During an observation on 2/27/18, at 9:05 a.m., Resident 10 was observed with a nasal cannula connected to an oxygen at 3 L/m . During an observation with the DON, on 2/27/18 at 9:51 a.m., she confirmed Resident 10 was on O2 at 3 L/m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 6 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and record review with the DON, on 2/27/18 , at 10:01 a.m., she stated the order for O2 at 2L/m was not followed and confirmed nurses were not documenting O2 saturation readings below 90% . During an interview with RN D, on 2/28/18 at 10:05 a.m., she indicated Resident 10's order for O2 was not followed as ordered. A review of facility's 2017 "Respiratory Care;Oxygen Administration" policy indicated oxygen is administered per physician order. Oxygen saturations are obtained and documented as ordered by the physician. 2. During a medication pass observation with licensed vocational B (LVN B) on 2/26/18, at 4:11 p.m., LVN B prepared and administered 60 cubic centimeters (cc, unit of measurement) of Cal dense med pass (a nutritional supplement drink) to Resident 3. A review of Resident 3's physician order, dated 1/2/18, indicated an order for cal dense med pass 120 cc three times a day for abnormal weight loss. During an interview with LVN B on 2/26/18, at 4:43 p.m., she stated she administered 60 cc of med pass instead of 120 cc to Resident 3.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/30/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 7 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to monitor the warm compress applied on Resident 12's abdominal area. This failure resulted in Resident 12 sustaining a second degree burn (an injury to the outer and middle layers of the skin) on his abdomen. Findings: Review of Resident 12's clinical record on 2/26/18, indicated he was readmitted to the facility on 12/31/17 with diagnoses including paraplegia (an impairment in motor or sensory function of the lower extremities). His brief interview of mental status (BIMS, cognitive performance) dated 12/13/17, indicated Resident 12 was cognitively intact. Review of Resident 12's Situation, Background, Appearance, and Review (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem), indicated on 2/11/18, at 11:30 p.m., Resident 12 complained of pain to his right abdominal area. Licensed vocational nurse E (LVN E) administered pain medication and applied a warm compress on the affected area. Review of the SBAR dated 2/13/18, indicated two blisters (bubble on the skin filled with serum and caused by friction, burning, or other damage) measuring 3.0 centimeters x 2.0 centimeters (cm, a unit of measurement) and 1.0 cm x 2.0 cm on the right lower abdominal area with redness on the surrounding areas. Treatment order included application of silver sulfadiazine (a topical antibiotic used in partial thickness and full thickness burns to prevent infection) daily and cover with sterile dressing for 14 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 8 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Interdisciplinary Progress Notes dated 2/13/18, indicated Resident 12 sustained a second degree burn to the right lower side of his abdomen. The clinical record also indicated that when Resident 12 complained of discomfort, the charge nurse heated a sheet in a plastic bag and placed it on Resident 12's abdomen. Resident 12 was half asleep and did not feel discomfort. The bag was not removed until the following morning. Review of Physician's Progress Notes dated 2/12/18, indicated Resident 12 had a second degree burn to the right abdominal area. During an observation on 2/26/18, at 9:34 a.m., Resident 12 was noted to have light brown scabs surrounded by pinkish discoloration in the abdominal area. During an interview with Resident 12, on 2/26/18, at 9:59 a.m., he stated he was having pain on his right abdomen. LVN E told him he would be given a heating pad. He acknowledged he was half asleep and did not feel the heat when LVN E applied the warm compress on his stomach. Resident 12 stated LVN E did not check him until the next morning. He also stated "one of the certified nursing assistants (CNA) found something on my abdomen the following morning" and when Resident 12 looked at it, he saw blisters on his stomach. During an interview with the director of nursing (DON), on 2/26/18, at 12:31 p.m., she indicated there was no facility policy and procedure for applying a heating pad or warm compress. The DON acknowledged LVN E should not have applied a warm compress on Resident 12. During a telephone interview with LVN E, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 9 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/27/18, at 7:48 a.m., she stated on 2/12/18, Resident 12 complained of abdominal pain. She administered pain medication and offered a warm compress. LVN E asked CNA F to heat up a towel and put it in a Ziploc bag. LVN E stated she placed the heat pack on Resident 12's abdomen but did not return to check back on the resident. On 2/12/18, at 5:30 a.m., LVN E met Resident 12 in the hallway and he told her he was feeling better. She also confirmed she did not call the attending physician (AP) prior to applying the warm compress. LVN E stated she later found out that the facility did not have a policy and procedure for application of a warm compress. During a telephone interview with CNA F, on 2/27/18, at 10:09 a.m., she acknowledged she worked the night of 2/11/18 with LVN E. She stated when LVN E asked her to make a heat pack, she took a wet wash cloth and put it in the microwave before placing it in a Ziploc bag. CNA F confirmed the facility did not have a heating pad. During an interview with the AP, on 2/28/18, at 9:41 a.m., she indicated Resident 12 developed a second degree burn to the abdominal wall after application of a warm compress.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 03/30/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 10 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to assure the accurate acquiring and administration of medication for one non-sampled resident (92) when the pharmacy delivered the wrong dosage of an extended release medication (ER, a medication that has a prolonged period of delivery in the body after administration) and licensed staff administered an ER medication by cutting it in half. This failure resulted in Resident 92 receiving medication not consistent with the physician orders. Findings: A review of Resident 92's clinical record indicated Resident 92 was admitted on 2/19/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 11 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 92's admission physician orders dated 2/19/18 indicated an order of Morphine Sulfate (a controlled medication for pain) 15 milligrams (mg, a unit of mass or weight) by mouth every eight hours for pain. A review of the facility form titled "Consultant Pharmacist Medication Regimen Review Summary" for Resident 92, dated 2/25/18, indicated Resident 92 had Morphine Sulfate 15 mg every eight hours for pain and no irregularities were noted. A review of the facility form titled "Drug Disposition" indicated the pharmacy delivered 42 tablets of Morphine Sulfate 30 mg ER for Resident 92 on 2/21/18. It indicated half tablets were wasted with two nurses signing for the destruction of the medication. During an observation of medication cart B with LVN A on 2/26/18, at 11:06 a.m., an unlabeled maroon half of a pill was found in a medication cup on the top drawer of medication cart B with other regular medications. The medication cup was unlabeled. During a concurrent review and interview with the consultant pharmacist (CP) on 2/26/18, at 11:10 a.m., he stated the maroon half pill was a Morphine Sulfate ER. He stated it should not be cut because it was an extended release tablet. A review of the blister pack for Morphine Sulfate ER in medication cart B indicated in pen an order change. He stated he was not aware of who added or changed the label. During an interview with LVN C on 2/26/18, at 1:36 p.m., LVN C stated she administered the half pill of the Morphine Sulfate ER to Resident 92 and was waiting for another nurse to co-sign the destruction of the remaining half of the pill. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 12 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN C stated the pharmacy sent out the wrong dose of the medication. According to the Lexicomp website regarding Morphine Sulfate, "cutting, breaking, crushing, chewing, or dissolving ER formulations may result in uncontrolled delivery of morphine, leading to overdose and death." (http://online.lexi.com/lco/action/doc/retrieve/do cid/patch_f/1799128#f_administration-andstorage-issues)

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 03/30/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility had a 17.24% medication error rate when five medication errors out of 29 opportunities were observed during medication passes for two sampled residents (3 and 14) and one non-sampled resident (38). These failures had the potential to compromise the residents' medical health. Findings: 1. During a medication pass observation on 2/27/18, at 9:20 a.m., RN D was observed preparing nine medications for Resident 38 including a Spriva (an inhaler to prevent and control symptoms of chronic obstructive pulmonary disease, (COPD), lung diseases that can cause difficulty in breathing) 18 micrograms (mcg, unit of measurement) one capsule via an inhalation device and BreoFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 13 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Ellipta (an inhaler to prevent and control symptoms of COPD) 100 mcg -25 mcg per dose. At the resident's bedside, RN D gave the Spiriva inhaler to Resident 38 and instructed the resident to inhale, waited ten seconds and then instructed resident to inhale the BreoEllipta. During an interview on 2/27/18, at 12:28 p.m., with RN D she stated she was not sure how long she had to wait to give the Breo-Ellipta after she gave the Spiriva to Resident 38. A review of the undated facility Policy and Procedure "Specific medication administration procedures" indicated wait one to two minutes before administering the next inhaled medication. 2. During medication administration pass observation on 2/27/18, at 9:20 a.m., with registered nurse D (RN D) for Resident 38, RN D prepared and administered one tablet of Vitamin D (a supplement) 400 international unit (IU, unit of measurement) for Resident 38. The bottle indicated 400 IU on the label but the cap of the bottle was labeled with a black marker indicating Vitamin D 1000 IU. During an observation and interview with RN D on 2/27/18, at 1:06 p.m., she stated the bottle of Vitamin D 400 IU was marked in error on the cap of the bottle as Vitamin D 1000 IU. She stated Resident 38 received Vitamin D 400 IU instead of 1000 IU as ordered. A review of Resident 38's physician order dated 2/15/17 indicated Vitamin D3 (a supplement) 1000 IU 1 cap by mouth daily for vitamin deficiency. 3. During a medication administration observation for Resident 3 with licensed vocational nurse B (LVN B) on 2/26/18, at 4:11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 14 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., LVN B prepared and administered two tablets of Gerikot (senna, a laxative medication for constipation) 8.6 milligrams (mg, a unit of measurement) to Resident 3. A review of Resident 3's physician orders dated 7/11/14 indicated an order for Senna S (senna with docusate sodium, a laxative with stool softener) 8.6 mg one tablet by mouth twice a day for constipation. During an interview with LVN B on 2/26/18, at 4:43 p.m., she stated she gave two tablets of Gerikot instead of one tablet of Senna S as ordered by the physician. 4. During a medication administration observation for Resident 14 with registered nurse D (RN D) on 2/27/18, at 9:56 a.m., RN D prepared and administered artificial tears (eye drop medication for dry eyes) one drop to the left eye of Resident 14. A review of Resident 14's physician order dated 5/19/17 indicated to administer one drop Theratears (eye drop medications for dry eyes) 0.25 percent to the left eye three times per day for eye disorder. A review of the Artificial Tears label for Resident 14 indicated the active ingredients included two percent of glycerin (a type of lubricant in eye drop medication), two percent of hypromellose (an ingredient in eye drops that soothes irritation in the eye), and 1 percent of polyethylene glycol (a type of lubricant in eye drop medication). According to the Lexicomp website, Theratears contained 0.25 percent carboxymethylcellulose (an eye drop medication ingredient). (http://online.lexi.com/lco/action/doc/retrieve/do cid/patch_f/6539) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 15 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the director of nursing (DON) on 2/27/18, at 11:10 a.m., she stated the artificial tears eye drops and the Theratears eye drops were not the same medication. A review of the undated facility policy and procedure titled "Medication Administration General Guidelines" indicated, prior to administration of medication, staff will compare the medication and dosage schedule on the MAR with the medication label. If the label and the MAR were different or if there was any other reason to question the dosage or directions, then the physician's orders were to be checked for correct dosage.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/30/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 16 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Expired narcotic medications were found in medication cart A. 2. Medication cart A was found unlocked and unattended by the nursing station next to the elevator. 3. A bottle of Vitamin D (supplement) 400 international units (IU, a unit of measurement) was labeled as Vitamin D 1000 IU on the cap in medication cart A. 4. An unlabeled maroon halved pill in a medication cup in the top drawer of medication cart B was found and the labeling on the original blister pack was marked. 5. Two unlabeled round white pills were found in medication cart B. 6. A bottle of Dilantin (medication that prevents seizures) had orange sticky substance on the lid and the bottle in medication cart B. 7. An expired Lantus (insulin, a medication that lowers blood sugar) pen and two unlabeled white pills were found in medication cart C. 8. A box containing 10 blister packets of ranitidine (Zantac, medication for heartburn) was found expired in medication cart B. 9. Humalog (medication that lowers blood sugar level) kwik 100 milliliter (ml, unit of measurement) insulin pen was found in medication cart A which was discontinued on 2/25/18 . These failures could result in the accidental administration of discontinued, expired, or contaminated medications to residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 17 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. During an observation of medication cart A with licensed vocation nurse C (LVN C) on 2/26/18, at 2:45 p.m., a bottle of morphine sulfate (a strong medication for pain) with an expiration date of 7/2017 was found in the separate locked compartment in medication cart A. A blister pack of hydrocodoneacetaminophen (a strong medication for pain) with an expiration of 1/2/18 was also found in the same locked compartment in medication cart A. LVN C stated both medications were expired. The bottle of morphine was for a resident who already expired. 2. During an observation of medication cart A on 2/26/18, at 2:42 p.m., medication cart A was found unlocked and unattended in front of nursing station A by the elevator. No nurse was noted within the area and other staff and residents passed by the medication cart. LVN C was observed walking towards nursing station A and went in the nursing station without locking the medication cart. The surveyor informed LVN C the medication cart was unlocked and unattended. LVN C then locked medication cart A and stated thank you for letting her know. 3. During medication administration pass observation on 2/27/18, at 9:20 a.m., with registered nurse A (RN A) for Resident 38, RN A prepared and administered one tablet of Vitamin D 400 IU for Resident 38. The bottle indicated 400 IU on the label but the cap of the bottle was labeled with a black marker indicating Vitamin D 1000 IU. During an observation and interview with RN A on 2/27/18, at 1:06 p.m., she stated the bottle of Vitamin D 400 IU was marked in error on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 18 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cap of the bottle as Vitamin D 1000 IU. A review of Resident 38's physician orders dated 2/15/17 indicated an order for one capsule of Vitamin D3 1000 IU once a day for vitamin deficiency. A review of the undated facility policy and procedure titled "Medication AdministrationGeneral Guidelines" indicated, before administering a medication, the medication on the resident's medication administration record (MAR) is compared with the medication label. 4. During an observation of medication cart B with LVN A on 2/26/18, at 11:06 a.m., an unlabeled maroon half of a pill was found in a medication cup in the top drawer of medication cart B with other regular medications. The medication cup was unlabeled. During an interview with the consultant pharmacist (CP) on 2/26/18, at 11:10 a.m., he stated the maroon half pill was a morphine sulfate tablet (an extended release form of morphine sulfate). He stated it should not be stored with the other medications and should be stored in the separate locked compartment with the other narcotics. During an interview with LVN C on 2/26/18, at 1:36 p.m., she stated she stored the half pill of morphine sulfate in the top drawer with the other medication while she waited for another nurse to co-sign to dispose of the medication. A review of the undated facility policy and procedure titled "Medication storage in the facility" indicated "all controlled medication and other medications subject to abuse are restored in a permanently affixed compartment separate from all other medications." The consultant pharmacist or designee should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 19 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE routinely monitor controlled medication storage, records, and expiration dates during routine medication storage inspection. 5. During a concurrent observation of medication Cart B and interview with LVN A on 2/26/18, at 10:48 a.m., two round white pills was found unlabeled and out of their original packaging in the middle drawer of the cart. LVN A confirmed the pills were unlabeled and out of their original packaging. 6. During a concurrent observation of medication Cart B and interview with LVN A on 2/26/18, at 11:06 a.m., a bottle of Dilantin had orange sticky substance on the lid. LVN A stated it should be cleaned. 7. During a concurrent observation of medication Cart C and interview with LVN A on 2/26/18, at 10:48 a.m., one expired Lantus pen and two unlabeled white pills were found. The Lantus pen label indicated an expiration date of 2/25/18. LVN A confirmed the Lantus was expired and there were two white pills unlabeled. 8. During an observation of medication Cart B with LVN A on 2/26/18, at 11:06 a.m., a box containing ten blister packets of ranitidine (Zantac, medication for heartburn) was found expired on 07/2017. LVN A stated the medication was expired. 9. During a concurrent observation of medication cart A with LVN C on 2/26/18, at 2:49 a.m., one discontinued Humalog kwik pen was found. LVN C stated it was discontinued on 2/25/18. Review of the undated facility policy and procedure titled "Discontinued medications" indicated medications awaiting disposal were supposed to be stored in a locked secure area FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 20 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE designated for that purpose until destroyed. Medications were to be removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration.

F812 SS=D Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 03/30/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when: 1. A fan with grey particles was on in the kitchen during breakfast tray line; and 2. Five plastic spatulas with rough uneven edges were found in the kitchen. These failures had the potential to cause foodFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 21 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE borne illness for residents. Findings: 1. During an observation of the breakfast trayline preparation on 2/27/18, at 7:35 a.m., in the kitchen, a stand fan on the corner of the kitchen was on and blowing air towards the window of the sink area. The fan had grey particles. During an interview with the dietary manager (DM) on 2/27/18, at 3:50 p.m., he stated maintenance was in charge of cleaning the fans. He confirmed the fan in the kitchen had grey particles and will need to be taken out. 2. During the initial kitchen tour observation with the DM on 2/26/18, at 7:41 a.m., five plastic spatulas with rough uneven edges were found in the kitchen utensil bin. He stated the plastic spatulas with the uneven surfaces should be thrown away. A review of the facility policy and procedure titled "Sanitation," dated 7/2008, indicated utensils were to be kept in good repair and free from breaks, cracks and chipped areas. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 22 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F814 Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 03/30/2018

F842 03/30/2018 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to dispose of garbage properly when one of the two dumpsters was full and staff was unable to close the dumpster lid. This failure had the potential to result in unsanitary environment for the residents. Findings: During a concurrent observation and interview with the dietary manager (DM) on 2/26/18, at 8:11 a.m., one of the two dumpsters in the back of the building for kitchen and facility use had a lid that was unable to close because it was full. He stated it was full and was unable to close the lid. He stated the dumpster was picked up once a week. A review of the facility policy and procedure titled "Garbage and Rubbish Disposal," dated 7/2008, indicated the facility's outside dumpsters provided by the garbage pick-up service are kept closed. "Garbage and rubbish containing food wastes are stored in a manner which make it inaccessible to vermin."

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5) §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 23 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 24 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure clinical records were complete and accurately documented for two sampled residents (3 and 14) and one non-sampled resident (18) when : 1. Resident 18's physician's recapitulation (recap, summary) order and medication administration record (MAR) for Glipizide (medication to treat high blood sugar) did not match the original order of the medication. 2. Resident 3 physician's recap order and MAR did not have the correct strength of Dorzolamide (eye drop medication for eye disease). 3. Resident 14's stoma (opening) site documentation was not done. These failures could potentially result in incomplete or inaccurate data necessary to assess and meet the residents' needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 25 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. During a medication pass observation on 2/26/18, at 8:31 a.m., with licensed vocational nurse A (LVN A), she prepared and administered Glipizide immediate release 2.5 milligrams (mg, unit of measurement) by mouth to Resident 18. A review of Resident 18's original physician's order dated 1/18/18 indicated an order of Glipizide 2.5 mg 1 tab by mouth daily for diabetes mellitus (DM, blood sugar level is higher than normal). A review of Resident 18's physician recap orders for 2/2018 indicated an order dated 1/18/18 for Glipizide extended release (ER, delivers a drug with a delay after administration) 2.5 mg 1 tab by mouth daily for DM. During a concurrent observation, record review and interview on 2/26/18, at 9:29 a.m. with the consultant pharmacist (CP) and LVN A, both confirmed no Glipizide 2.5 mg ER in the medication cart and stated it was a clerical error with the recap order and MAR. During an interview with LVN C on 2/26/18, at 1:46 p.m., she stated she usually compares MAR to MAR but did not catch the Glipizide error. She stated she did the recap. 2. During a medication observation on 2/26/18, at 4:11 p.m., with LVN B she administered Dorzolamide 2% 1 drop to both eyes to Resident 3. During a concurrent interview and record review with LVN C on 2/26/18, at 4:43 p.m., the physician order recap for Resident 3 indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 26 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE an order of Dorzolamide 100% 1 drop to both eyes twice daily for Glaucoma (group of eye conditions that can cause blindness). LVN C stated the medication in the cart was Dorzolamide 2% and not Dorzolamide 100%. She further stated it could be a typo. During an interview with the director of nursing (DON) on 2/27/18, at 11:09 a.m., she stated nurses should do three processes for recap. She further stated the Dorzolamide 100% medication was a typo error. According to the Lexicomp website regarding Dorzolamide, it indicated Dorzolamide only comes in 2% dosage. (http://online.lexi.com/lco/action/doc/retrieve/do cid/patch_f/6785#f_dosages) A review of July 2014 the facility's Policy and Procedure "Physician Order Recaps" indicated "The Health Information Department prints and distributes monthly physician orders with medication, treatment, and other flowsheets to the nursing department for review and revision." "Newly printed physician orders are reviewed against the most current monthly physician orders as well as any telephone order while reviewing for tracking purposes." "After review of physician orders, the licensed nurse (LN) completing the review signs and places a date on the last page under nurse review section on the MAR and/or TAR." 3. Review of Resident 14's clinical record, on 2/27/18, indicated he was admitted to the facility on 1/3/17 with diagnoses including dysphagia (unable to swallow) and a gastrostomy tube (GT, a feeding tube that is inserted through the abdomen or mouth into the stomach wall to feed patients who cannot eat normally). Review of Resident 14's February 2018 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 27 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Physician Order Sheet, indicated an order to cleanse enteral tube stoma with soap and water daily starting 3/30/17. Review of Resident 14's Enteral Feeding Physician Orders Flowsheet for cleansing the stoma site indicated missing licensed nurses' signatures for the month of January 2018. During an interview and record review with registered nurse D (RN D), on 2/27/18, at 2:55 p.m., she confirmed nurses were not signing on the flowsheet and she was not sure why it was missed. She stated the cleansing for stoma should be documented as nurses were also changing the GT site with a dry dressing daily.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 03/30/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 28 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 29 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure staff implemented infection control procedures for one sampled resident (3) and one non-sampled resident (38). For Resident 3, staff did not perform hand washing or hand hygiene after taking off gloves multiple times during medication administration. For Resident 38, staff touched and handled a capsule medication directly without gloves. These failures had the potential to result in transmission of infection in the facility. Findings: 1. During medication administration observation with licensed vocation nurse B (LVN B) on 2/26/18, at 4:11 p.m., in Resident 3's room, she gloved and de-gloved while preparing the medication for Resident 3. She also gloved and de-gloved again during administration of eye drops and during administration of a nebulizer treatment (drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for Resident 3. No handwashing or hand hygiene was performed in between gloving. During an interview with LVN B on 2/26/18, at 4:43 p.m., she stated she should have performed hand washing or hand hygiene in between gloving. She stated there was hand gel in the medication cart for her to use. The facility policy and procedure titled "Handwashing/Hand Hygiene," dated 3/2016, indicated the staff use an alcohol-based hand rub or soap and water after removing gloves. 2. During medication administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 30 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observation with registered nurse D (RN D) on 2/27/18, at 9:20 a.m., RN D performed hand hygiene before starting medication preparation for Resident 38. She then touched with her bare hands three different drawers in medication cart A and five different other medications. On the sixth medication, she prepared Spiriva (medication to help open up the airways in the lungs to make it easier to breathe) with a Handihaler (inhaler to put in the Spiriva capsule). She took out the Spiriva capsule from the blister packet and with her bare hands placed it inside the Handihaler device. RN D did not perform hand hygiene, handwashing, or gloving before touching the capsule directly. During an interview with RN D on 2/27/18, at 12:25 p.m., she stated she should use gloves when handling pills directly like Spiriva. The undated facility policy and procedure titled "Medication Administration-General Guidelines" indicated staff are to wash hands with soap and water or alcohol gel prior to handling medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 31 of 32 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055311 (X3) DATE SURVEY COMPLETED 02/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE KATHERINE HEALTHCARE 315 Alameda Ave Salinas, CA 93901 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/30/2018 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the following multi-resident rooms provided less than 80 square feet per resident, which had the potential to compromise the residents' care. Findings: Room numbers and measurements per resident were as follows: Room No. 3 10 23 No. of beds 2 2 2 Sq. foot per Res. 74.25 78.48 76.30 None of the rooms were observed to inhibit the staff to provide care to the residents and the residents received adequate care. The staff and the residents moved freely in the rooms. Wheelchairs and recliner chairs were easily accommodated. The residents and the staff stated the square footage of the rooms was not a concern. Recommend the waiver remain in effect. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MG1X11 Facility ID: CA070000066 If continuation sheet 32 of 32