Health inspection·May 5, 2023

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 sanitary conditions were maintained for one of three ice machines when an ice machine had a brown-yellow substance in an interior part of the machine was exposed to ice. This failure had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins). The ice machine was used to provide ice for the residents. Findings: During an observation and concurrent interview, with Engineering Services Technician C (EST C) on 5/3/23 at 10:25 A.M., at nurses' station AA's clean utility room, the rim of an ice chute (a dispensing tube of the interior bucket of the ice machine) was wiped with a clean white paper towel to check for residuals. The wiping yielded a brown-yellow substance onto the clean paper towel. EST C acknowledge this observation and stated he was unsure what the substance was. During an observation and concurrent interview with EST D and the Director of Nursing (DON) on 5/3/23 at 11:43 A.M., EST D and the DON acknowledged the brown-yellow substance from the ice machine. EST D confirmed the last preventive maintenance on the ice machine was in 4/2023 and stated, I may have missed that part. During an interview and concurrent record review, with EST E on 5/5/23 at 2:24 P.M., the preventive maintenance (PM) logs indicated the last PM for the ice machine was completed 12/9/22. EST E confirmed the sticker on the side of the machine, dated 4/2023, was an additional cleaning. The Nursing Station AA ice machine log lacked a PM entry on 4/2023. Review of the facility's policy Environment of Care: Inspecting, Testing and Maintenance, dated 2021, indicated, The Engineering Services technicians perform assigned activities and return completed documentation to managers . All documentation of the maintenance activity will be completed by the Engineering Services technicians, reviewed by the appropriate supervisor, and filed or the information entered into the work order system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555143 If continuation sheet Page 2 of 4 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 555143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westland House 100 Barnet Segal Lane 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure garbage was disposed of properly in the outside garbage area when a dumpster lid was left open, garbage and linen bags were left outside the dumpsters, and garbage was on the ground. This failure had the potential to attract vermin (pests or animals that spread diseases). Residents Affected - Few Findings: During an observation and interview at the facility's garbage area with the Dietetic Technician, Registered (DTR) on 5/3/23 at 9:59 A.M., two plastic containers, one small white plastic container, two plastic utensils, cardboard, multiple blue gloves, a water bottle, and a cardboard box lay on the ground outside of the trash dumpsters. A clear bag filled with contents was on top of a trash bin, and a blue bag filled with contents was on the ground between dirty linen containers. A dumpster containing cardboard had an open lid. During a concurrent interview with the DTR, the DTR confirmed the observation and stated, It should not look like this. During an observation and concurrent interview on 5/3/23 at 4:00 P.M. with Environmental Services F (EVS F) at the facility's designated garbage area, EVS F stated, It is dirty . trash should not be on the ground. During an observation and interview at the facility's garbage area with the Infection Preventionist (IP) on 5/4/23 at 8:21 A.M., a garbage dumpster was propped open with overflowing garbage bags. Three black garbage bags sat outside of the dumpster. Surgical masks and multiple gloves were on the ground outside of the trash bins. Flies were present. The IP confirmed the situation could attract vermin. During an observation and interview at the facility's garbage area with EVS G on 5/5/23 at 11:48 A.M., there were multiple gloves, a water bottle, a large rusted can labeled diced pears, cardboard, and two small containers on the ground near the trash bins. Flies were present. EVS G confirmed the observation. Review of The U.S. Food and Drug Administration's 2022 Food Code section 5-501.116 indicated, Cleaning Receptacles: Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555143 If continuation sheet Page 3 of 4 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 555143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westland House 100 Barnet Segal Lane 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 Based on observation, interview, and record review, the facility failed to implement infection prevention and control strategies when a certified nursing assistant with long fingernails took care of residents. This failure resulted in increased risk of disease transmission to residents via long fingernails, which provide more area(s) where microbes may harbor compared to short fingernails. Residents Affected - Few Findings: During an observation at station AA (ST AA) on 5/4/23 at 8:35 a.m., certified nursing assistant B (CNA B) was in a hallway with long fingernails going to a resident's room. During an interview with the infection preventionist (IP) on 5/4/23 at 9:25 a.m., the IP confirmed that certified nursing assistants should maintain short nails for infection control purposes. During an interview with CNA B on 5/4/23 at 9:54 a.m., she confirmed that she should have maintained her fingernails trimmed short for infection control purposes, but forgot to. Review of the facility's policy and procedure Professional Appearance and Grooming Standards: Nails, effective December 2022, indicated, All employees must be properly groomed . Maximum nail length of natural nail tips is 1/4 inch (unit of length). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555143 If continuation sheet Page 4 of 4