Health inspection·August 5, 2022

F 0552 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy and procedure titled, Antipsychotic and Other Psychotherapeutic Medication Usage: Verification of Informed Consent, indicated, verification of informed consent should have been completed before treatment was initiated with physician restraint, psychotherapeutic drugs, or the prolonged use of a device that may lead to the inability of a resident to regain use of normal bodily functions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 2 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Residents 9 and 67) received the appropriate care and services when: Residents Affected - Few 1. For Resident 9, facility staff did not perform resident's HgbA1c test (hemoglobin (protein in red blood cells that carries oxygen) A1C test, a simple blood test that measures your average blood sugar levels over the past 3 months) as ordered; and 2. For Resident 67, nursing staff did not remove resident's lidocaine patch (used to help relieve pain) as ordered. These failures had the potential to affect the health and well-being of the residents in the facility. Findings: 1. Review of Resident 9's clinical record indicated, resident had diagnoses including Type 2 diabetes mellitus (high blood sugar (glucose) with diabetic polyneuropathy (a type of nerve damage that can occur if you have diabetes). Review of Nutrition Reccomendation, dated 7/7/2022, indicated, Reccomendation: Suggest order HgbA1c. Reason: Would like to see if HgbA1c has normalized due to weight loss. Physician's response: Approved Signature was marked and signed by the physician. Also indicated, 4/4/22: 159.2 lbs. (pounds, measure of weight) -27 lbs. x three months, signifciant weight loss; 6/2/22: 142 lbs., -9.8 lbs x one month, significant weight loss.; 6/27/22: 134 lbs., -1.8 lbs. x one week ; 7/4/22: 132.2 lbs. During a concurrent interview and record review with Registered Nurse E (RN E) on 8/3/2022 at 9:30 a.m., RN E reviewed Resident 9's chart and confirmed there was no record HgbA1c was completed. During an interview with the Registered Dietitian (RD) on 8/3/2022 at 2:18 p.m., RD stated HgbA1c was not completed as previously ordered. RD further stated it was not in the chart. RD also stated she suggested HgbA1c for Resident 9 to see if it has normalized, then she can request to discontinue Metformin (drug used to treat diabetes mellitus), because Metformin can cause weight loss. 2) A review of Resident 67's clinical record she was admitted to the facility with diagnoses including malignant neoplasm (cancer) of right female breast, type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) and low back pain, unspecified. A review of Resident 67's physician order sheet, dated August 2022, indicated, lidocaine 5 percent topical patch (a medicated patch for pain relief) (1 patch) ADHESIVE PATCH, MEDICATED Topical, Day-ON/ SITE, with order date 7/23/2022, and lidocaine 5% topical patch (1 patch) ADHESIVE PATCH, MEDICATED Topical, EVE-OFF, with order date 7/23/2022. During a concurrent observation and interview on 8/2/2022 at 8:44 a.m., the Licensed Vocational Nurse A (LVN A) held the application of a new medicated patch to Resident 67's lower back. The LVN A stated the old patch was still on Resident 67's lower back. The LVN A removed the old patch from Resident 67's back and showed to this surveyor, dated with a permanent marker 8/1/22. The LVN A stated the patch should have been removed on 8/1/2022 at 9:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 3 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review on 8/4/2022 at 9:36 a.m. with the Director of Nursing (DON), the DON reviewed Resident 67's medication administration record (MAR, a record of medications given). The DON stated the patch should have been removed on 8/1/2022 at 9:00 p.m. as ordered by the physician. During a review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 09/2018, indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Event ID: Facility ID: 555867 If continuation sheet Page 4 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet resident's needs when: Residents Affected - Few 1) License vocational nurse A (LVN A) provided an expired protein supplement to Resident 67; 2) Medications were not given to Resident 15 and Resident 9 due to unavailability; 3) The emergency kit (e-kit, a box containing the emergency supplies and medications needed to provide treatment) were not replaced in a timely manner. These failures had the potential to result in not being able to meet resident's needs especially in times of emergency. Findings: 1. A review of Resident 67's clinical record titled, August 2022 Physician Order Sheet, indicated, Pro-Stat AWC (Protein supplement for wound care) 17 gm (gram - unit of measurement)-100kcal (kilocalories - unit of energy)/30ml (milliliters - unit of volume) oral liquid (30 ml) LIQUID (ML) Oral (by mouth), and two times daily for fourteen days starting 07/27/2022. During a concurrent observation and medication label review on 8/2/2022 at 8:35 a.m., the licensed vocational nurse prepared and provided 30 ml of Pro-Stat AWC to Resident 67. The Pro-Stat AWC's label indicated, expired on 7/15/2022. During an interview with LVN A on 8/2/2022 at 9:35 a.m., the LVN A confirmed the Pro-Stat AWC given to Resident 67 was expired. During an interview with the director of nursing (DON) on 8/4/2022 at 9:28 a.m., the DON stated staff should have a scheduled weekly check of the cart to monitor the medication for any expiration date. During a review of the facility's policy and procedure titled, Medication Administration: General Guidelines, dated 09/2018, indicated, Medication Administration: 8. Check expiration date on package/container. No expired medication will be administered to a resident. 2a. A review of Resident 15's clinical record titled, August 2022 Physician Order Sheet, indicated, CranRx with Vit C-Mannose 250 mg-30 mg- (Cranberry supplement) 1 TABLET, CHEWABLE Oral for URINARY TRACT INFECTION, SITE NOT SPECIFIED (UTI - infection involving the bladder) One time Daily Starting 07/08/2022. Further record review, indicated, Nexium 40 mg (milligram-unit of measurement) capsule, delayed release (1) CAPSULE, DELAYED RELEASE (ENTERIC COATED) [a coating applied to medication to prevent the drug from stomach's acid or to protect the patient from the direct effect of the drug] for GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (GERD - happens when the stomach contents come back up into the esophagus) once daily starting 07/08/2022. During a concurrent observation and interview on 8/2/2022 at 8:15 a.m., the LVN A did not administer both CranRx and Nexium to Resident 15. The LVN A stated both CranRx and Nexium were not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 5 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm A review of Resident 15's medication administration record (MAR, a record of medications given) for the month of July and August 2022, indicated the CranRx were not available and not administered to Resident 15 on the following dates: 7/9, 7/10, 7/11, 7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/19, 7/21, 7/22, 7/23, 7/24, 7/25, 7/26, 7/28, 7/29, 7/30, 7/31, 8/1, 8/2/2022. Further record review indicated, Nexium were not available and not administered to Resident 15 on the following dates: 7/9, 7/10, 7/13, 7/14, 8/1, 8/2/2022. Residents Affected - Few During a concurrent interview and record review with the director of staff development (DSD) on 8/3/2022 at 9:28 a.m., the DSD confirmed both CranRx and Nexium were not administered to Resident 15 as written above. The DSD further stated they (nurses) should follow up with the pharmacy. 2b. A review of Resident 9's clinical record titled, August 2022 Physician Order Sheet, indicated, Vitamin D3 10 mcg [microgram-unit of measurement] (400 unit) tablet (2 tablet) TABLET Oral for IRON DEFICIENCY ANEMIA, UNSPECIFIED (lack of iron caused by blood loss, poor dietary intake, or poor absorption of iron from food) Every Morning Starting 07/08/2022. During a concurrent observation and interview on 8/2/2022 at 8:25 a.m., the LVN A did not administer the Vitamin D3 to Resident 9. The LVN A stated the Vitamin D3 tablets were not available. A review of Resident 9's MAR for the month of July and August 2022 indicated, the Vitamin D3 tablets were not available and not administered to Resident 9 on the following dates: 7/9, 7/10, 7/14, 7/21, 7/23, 7/26, 8/1, 8/2/2022. During an interview with LVN A on 8/2/2022 at 9:03 a.m., the LVN A stated nurses should have notified the pharmacy to order medications five days before they ran out. The LVN A further stated over the counter medications (medications available without prescription) were provided by the facility's pharmacy. During an interview with the DON on 8/4/2022 at 9:15 a.m., the DON confirmed nurses should have followed up missing medications with the pharmacy. During a review of the facility's policy and procedure titled, Medication Orders, Non-Controlled Medication Orders (California Specific), dated 12/2012, indicated, 4. The prescriber should have contacted by nursing for direction when delivery of a medication will be delayed or the medication was not available. 3. During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 8/1/2022 at 1:03 p.m., both e-kit containing oral antibiotics (medications used to fight bacteria) and the other e-kit containing controlled substances (drugs or other substances that may be abused or cause addiction) were locked using red zip ties. The LVN B stated they used red zip ties when medications were taken out from the e-kit. A review of the Emergency Drug Kit Usage Report dated 7/28, four capsules of Keflex (antibiotic)were taken out at 5:20 p.m. and one capsule of Azithromycin 250 mg were taken out at 9:09 a.m from the e-kit. Further record review of the controlled substance e-kit's Emergency Drug Kit Usage Report dated 7/29/2022, indicated one tablet of Lorazepam (a sedative used to treat anxiety and sleeping problems related to anxiety) 0.5 mg and two tablets of Norco (a narcotic use to relieve pain) 5/325 mg were taken out from the e-kit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 6 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the DON on 8/4/2022 at 9:18 a.m., the DON confirmed the controlled substance e-kit was replaced on 8/2/2022 and the antibiotic e-kit was replaced on 8/3/2022. The DON stated the opened e-kit should have been replaced the following delivery day of medications. During a review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 01/2020, indicated, Emergency medications and supplies are provided by the pharmacy in compliance with applicable state and federal regulations .11. Before reporting off duty, the charge nurse indicates the opened or sealed status of the emergency kit at the shift change report, and transfers the new medication orders to oncoming staff. 12. When the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy. In states that allow replacing used doses of medication, the nurse replaces the medication in the appropriate area of the kit within 24 hours of opening or next scheduled delivery, or as required by state regulation. Event ID: Facility ID: 555867 If continuation sheet Page 7 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 5.41 percent (%, unit of measurement) medication error rate when two medication errors out of 37 opportunities were identified during medication pass for two of six residents (Resident 15 and 9). These failures had the potential to result in an ineffective drug therapy. Residents Affected - Few Findings: 1. A review of Resident 15's clinical record titled, August 2022 Physician Order Sheet, indicated, indicated, Nexium 40 mg (milligram-unit of measurement) capsule, delayed release (1) CAPSULE, DELAYED RELEASE (ENTERIC COATED) [a coating applied to medication to prevent the drug from stomach's acid or to protect the patient from the direct effect of the drug] for GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (GERD - happens when the stomach contents come back up into the esophagus) once daily starting on 07/08/2022. During a medication administration observation and interview on 8/2/2022 at 8:15 a.m., the licensed vocational nurse A (LVN A) prepared a total of nine tablets for Resident 15. The LVN A stated, the scheduled Nexium was not available for administration to Resident 15. 2. A review of Resident 9's clinical record titled, August 2022 Physician Order Sheet, indicated, Vitamin D3 10 mcg [microgram-unit of measurement] (400 unit) tablet (2 tablet) TABLET Oral for IRON DEFICIENCY ANEMIA, UNSPECIFIED (lack of iron caused by blood loss, poor dietary intake, or poor absorption of iron from food) Every Morning Starting 07/08/2022. During a concurrent observation and interview on 8/2/2022 at 8:25 a.m., the LVN A prepared a total of three tablets for Resident 9. Vitamin D3 was not administered to Resident 9. The LVN A stated the Vitamin D3 tablets were not available. During an interview with LVN A on 8/2/2022 at 9:03 a.m., the LVN A stated nurses should have notified the pharmacy to order medications five days before they ran out. The LVN A further stated over the counter medications (medications available without prescription) were provided by the facility's pharmacy. During an interview with the DON on 8/4/2022 at 9:15 a.m., the DON confirmed nurses should have followed up missing medications with the pharmacy. During a review of the facility's policy and procedure titled, Medication Orders, Non-Controlled Medication Orders (California Specific), dated 12/2012, indicated, 4. The prescriber should have been contacted by nursing for direction when delivery of a medication would be delayed or the medication was not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 8 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when: 1. Improper storage of an emergency kit (e-kit, a box containing medication needed for immediate administration) containing C-II medications (Classification by the Drug Enforcement Agency: C-II or Schedule II substance is considered to have a high potential for abuse); 2. Controlled medication for one discharge resident was found inside the medication refrigerator. These failures had the potential for drug diversion. Findings: 1. During an observation inside the facility's medication room on 8/1/2022 at 12:59 p.m. with licensed vocational nurse B (LVN B), there were three e-kits found in a locked cabinet. The e-kit containing C-II medications was located on top of the locked cabinet. Inside the cabinet were other house supply medications like vitamins, supplements, and pain relievers. During the medication room observation and interview with the medical staffing coordinator (MSC) on 8/1/2022 at 1:19 p.m., the MSC's office was located behind the medication room. The only way to get into the MSC's office was going through the medication room. The MSC stated she had a key to unlock the medication room. The MSC further stated she also shared her office with another non-licensed staff during lunch break. During an interview with the director of nursing (DON) on 8/4/2022 at 12:39 p.m., the DON confirmed the e-kit containing the C-II medications was not stored in a double lock area especially the MSC could access the medication room. During an interview with the pharmacy consultant (PC) on 8/4/2022 at 2:48 p.m., the PC confirmed the e-kit with C-II medications should have been stored in a double lock area. During a review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 01/2020, indicated, a. Schedule II medications that are part of the emergency medication supply must be double locked and should have been stored in a locked cabinet or locked drawer separate from non-controlled medications. 2. During a concurrent observation of the medication refrigerator and interview with LVN B on 8/1/2022 at 1:11 p.m. inside the facility's medication room, a bubble pack of Dronabinol (a man-made form of marijuana used to treat loss of appetite) 10 mg (unit of measurement), 13 capsules total was on the top shelf inside the refrigerator. LVN B stated nurses should have handed off the discharged resident's-controlled medication to the DON. During an interview with the DON on 8/4/2022 at 9:19 a.m., the DON stated the discontinued or discharged resident's-controlled medications should have been given to her and would have been stored inside the DON's locked drawer. The DON further stated the controlled medications would be destroyed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 9 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 with the PC. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Controlled Medication Storage, dated 11/2017, indicated, Controlled medications remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 10 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review, the facility failed to provide the chosen foods indicated on resident's lunch meal ticket for three of 8 residents (Residents 3, 216, and 217) and the facility staff did not puree (very smooth, crushed or blended food) foods with fluids which provided flavor and/or nutritional value for one of 8 residents (Resident 2). These failures had the potential to affect the physical health and well-being of residents in the facility. Findings: 1. Review of Resident 3's clinical record indicated, resident had diagnoses including Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), pressure ulcer (an injury to the skin caused by prolonged and constant pressure) of sacral region (located below the lumbar spine and above the tailbone), cellulitis (common bacterial infection) of buttock. During a meal observation and interview on 08/1/2022, at 12:43 PM, while at resident's room. Resident was slowly eating the penne sausage casserole. Surveyor noticed on Resident 3's lunch meal ticket indicated, Dessert: chocolate peanut butter brownies. There were no chocolate peanut butter brownies on Resident 3's meal tray. Resident 3 stated chocolate peanut butter brownies sounded good and would want some for dessert. During an interview with certified nursing assistant G (CNA G) on 8/1/2022 at 12:53 p.m., while in the hallway, surveyor informed CNA G of the above observation. CNA G stated Resident 3 should have received the chocolate peanut butter brownies. 2. Review of Resident 216's clinical record indicated, resident had diagnoses including Parkinson's Disease, Chronic Kidney Disease (also called chronic kidney failure, involves a gradual loss of kidney function). During a concurrent meal observation and interview on 8/1/2022 at 12:35 p.m., while at resident's room. Resident 216 was eating a turkey sandwich. Surveyor noticed on Resident 216's lunch ticket, cranberry juice was circled. There was apple juice on her tray, but no cranberry juice. Resident 216 was made aware of surveyor's observation, and stated she likes cranberry juice, but apple juice is okay for now. 3. Review of Resident 217's clinical record indicated, resident had diagnoses including unspecified macular degeneration (an eye disease that can blur your central vision), blindness right and left eye, tinnitus (ringing in the ears). During an observation and interview with Resident 217 on 8/1/2022, at 11:21 a.m., while at resident's room. Resident 217 stated her right eye was blind and left eye was not good. Resident 217 also stated she's hard of hearing. During a meal observation and interview on 8/1/2022 at 12:32 p.m., while in resident's room. Resident 217 was sitting in the wheelchair, CNA G placed the meal tray on the overbed table in front of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 11 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 217. Resident 217 started eating the chicken noodle soup, then CNA G stepped out of the room. Surveyor asked permission to checked Resident 217's lunch meal ticket and noticed for dessert the chocolate peanut butter brownies were circled. Surveyor observed there were no peanut butter brownies on resident's meal tray. Surveyor informed Resident 217's food choices on the meal ticket and the chocolate peanut butter brownies were not included in her meal tray. Resident 217 stated, I don't know what food I have on my tray, but I would want some chocolate brownies. During an interview with CNA G on 8/1/2022, at 1:05 p.m., while in the hallway, surveyor informed CNA G of the above observation. CNA G stated Resident 217 should have been informed of what food she had on her tray, and should have been served the chocolate peanut butter brownies. During an interview with the Dietary Supervisor (DS) on 8/4/2022, at 10:33 a.m., DS stated meal tickets were given at the beginning of the week and filled out by residents. She further stated she expects the resident's food choices on the meal ticket to be followed and included in their meal tray. Review of the facility's policy, Diets and Menus: Food Preferences, dated 10/1/2017, indicated, Resident food and beverage preferences will be obtained upon admission and periodically as needed to assist the Food and nutrition Services department in providing preferred foods to enhance/maintain quality of life and nutritional status. 4. A review of Resident 2's clinical record indicated, Resident 2 was admitted to the facility with diagnoses including Parkinson's disease (a neurologic disease that significantly affects mobility), paroxysmal atrial fibrillation (abnormal heart rhythm), and unspecified dementia (a condition characterized by memory loss), unspecified severity. A review of Resident 2's August 2022 Physician Order Sheet, indicated, Dysphagia (difficulty in swallowing), Puree, Regular, Thicken Liquids. Notes: Pureed diet, Thicken liquids pudding Consistency. During a concurrent observation and interview on 8/3/2022 at 11:00 a.m., waitstaff C (WS C) was preparing pureed food for Resident 2 and was being supervised by the dietary supervisor (DS). The food prepared for lunch was an eggplant parmesan sandwich. The WS C placed a whole eggplant parmesan sandwich onto the food processor and turned it on. The WS C poured at least six scoops of hot water onto the food processor to puree the eggplant parmesan sandwich. The WS C stated he used hot water to pureed food and there was no measurement followed. The WS C further stated if he saw the consistency of the food was already pureed, he would stop the food processor. During an interview with the food and beverage manager (FBM) on 8/4/2022 at 1:41 p.m., the FBM stated they did not have a specific recipe of how to thicken liquids or how to puree food. The FBM confirmed the WS C should have used a broth to puree the eggplant parmesan sandwich. The FBM further stated the hot water used to pureed food could have lessened the nutritive value of the food. During a review of the facility's policy and procedure titled, Section 7: Meal Service: Texture Modified Diets-Pureed, dated, 1/2016, indicated, Pureed Diets will be modified to meet the nutritional and chewing/swallowing status of the resident .2. Puree the item in a food processor and if needed, add liquids from the original recipe to soften the food (i.e. [Latin id est 'that is'] meat with gravy, pizza with extra sauce, etc.). 3. Milk, broth, juice, or supplements may be used when there are no liquids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 12 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 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 was stored, prepared, distributed, and served in accordance with professional standards for food safety when: Residents Affected - Some 1. Store bought salad dressings, pickle relish and yogurt were opened and not labeled; 2. Refrigerator in the skilled nursing facilities (SNF) prep kitchen had drinks unlabeled. 3. An ice machine was not kept in a sanitary condition. 4. Frying station had some black, brown, and white sticky build up on its sides and kitchen flooring was not well maintained; 5. The microwave oven located in the skilled nursing facility (SNF) prep kitchen was not kept in a sanitary condition; 6. SNF waitstaff did not practice proper hand hygiene; 7. Canned food and oatmeal containers were dented and stored in a ready to use storage; 8. Food containers were stacked up wet; 9. Carton of milk from resident's refrigerator not labeled. These failures had the potential to cause cross contamination of food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 18 residents eating at the facility. Findings: 1. During an initial tour at the facility's main kitchen and interview with the food and beverage manager (FBM) on 8/1/2022 at 9:40 a.m., the FBM showed the refrigerator designated for SNF food storage. The SNF refrigerator had some store bought food that were opened and not labeled, located at the bottom rack: One gallon of buttermilk ranch dressing, almost empty, with date received on 7/1/22; one gallon of fat free Italian dressing, with date received on 6/15/22; one gallon of Tuscan Caesar dressing, with date received on 4/29/22; one gallon of premium sweet pickle relish, no date received; sesame ginger dressing, with date received on 2/4/22; maraschino cherries with stem, with date received on 6/7/22; plain yogurt, with date received on 6/15/22; jellied cranberry sauce, with date received on 11/5/2021; and mint jelly, with date received on 6/23/22. There was also one gallon of thousand island dressing, with permanent marker writing at the lid indicated, 5/10/22, 5/16/22, and one gallon of creamy French dressing, with permanent writing on the lid indicated, 5/9/22, 5/14/22. The FBM stated staff should have labeled each gallon of dressings and food on the date they were opened. The FBM was not able to answer the question of when to discard them once opened. 2. During an initial tour at the SNF prep kitchen and interview with the waitstaff D (WS D) on 8/1/22 at 10:56 a.m., the refrigerator holding refreshments for the residents had a facility made milkshake unlabeled, and store-bought thickened orange juice, thickened lemon water and cranberry cocktail (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 13 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 from concentrate had no opened date label. The WS D confirmed anything stored and opened inside the SNF refrigerator should be labeled and dated. During an interview with the dietary supervisor (DS) on 8/1/2022 at 11:28 a.m., the DS stated any food or drinks inside the refrigerator should have been labeled and dated. Residents Affected - Some During a review of the facility's policy and procedure titled, Section 11: Sanitation & Infection Control Labeling & Dating, dated 1/2016, indicated, All foods are labeled, dated, and securely covered and use-by dates are monitored and followed. 3. During a concurrent observation and interview with the FBM on 8/1/2022 at 10:05 a.m., the facility's ice machine was located at the left side entrance of the main kitchen. The metal screen at the back part and the right-side vent of the ice machine had some grayish substance build-up. The FBM stated the cleaning and sanitation of the ice machine was assigned to their dishwasher every month. The FBM further stated the last time the ice machine was cleaned and sanitized was on 7/27/2022. During a follow up interview with the FBM on 8/3/2022 at 9:03 a.m., the FBM confirmed the grayish substance build-up in the external part of the ice machine. The FBM further stated the external part of the ice machine should have been cleaned at least once a week. During a review of the facility's policy and procedure titled, Section 11: Sanitation & Infection Control Cleaning Schedules, dated 1/2016, indicated, The daily cleaning schedule delineates how often equipment must be cleaned and whose responsibility it is to clean each specific piece of equipment or area. ITEM/AREA Ice Machine, external, WHEN Daily, PERSON/POSITION Dishwashers. 4. During the main kitchen observation on 8/1/2022 at 10:04 a.m., the frying station especially the left side had some black, brown, white, and sticky build up. Additional observation was some black and sticky area on the kitchen floor where the oven, frying station and prep station were located. During an interview with the FBM on 8/1/2022 at 11:26 a.m., the FBM stated they did not have any deep cleaning schedule at the kitchen. The FBM further stated they have a daily schedule for kitchen cleaning by their dishwashers. During a review of the facility's policy and procedure titled, Section 11: Sanitation & Infection Control Cleaning Schedules, dated 1/2016, indicated, Heavy cleaning such as under equipment, walls and floors and major equipment can be planned on a weekly basis. 5. During an observation in the SNF prep kitchen on 8/1/2022 at 10:10 a.m., the microwave was observed to have some food crumbs, black build up at the base, brown colored build-up at the top area and some brown, black build-up at the metal mesh of the microwave door. During an interview with the WS D on 8/1/2022 at 10:56 a.m., the WS D stated all food servers should have clean the microwave. The WS D further stated they did not have a cleaning log for the microwave oven. During an interview with the DS on 8/1/2022 at 11:28 a.m., the DS stated they did not have a cleaning schedule for the microwave. The DS stated the plan was to clean the microwave twice a week. During a review of the facility's policy and procedure titled, Section 11: Sanitation & Infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 14 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 Control Cleaning Schedules, dated 1/2016, indicated, Cleaning schedules are used to maintain high levels of sanitation in the Food & Nutrition Services department and serve to assign cleaning tasks to various kitchen staff members. 6. During an observation on 8/1/2022 at 11:35 a.m., the WS D entered the SNF prep kitchen with some boxes of lunch for staff and went out to the SNF to deliver the boxes of lunch to the staff. The WS D came back to the SNF prep kitchen and started preparing resident's trays for lunch by placing some condiments. The WS D did not wash hands upon entry to the SNF prep kitchen and prior to preparation of resident's lunch trays. During another observation on 8/1/2022 at 11:43 a.m., both WS C and WS D entered back to the SNF prep kitchen to deliver resident's food. The WS C started to remove the lunch trays from the food warmer and placed them to the steam table while WS D started placing some desserts to resident's lunch trays. Both waitstaff did not wash hands upon entry to the SNF prep kitchen or prior to handling resident's food. During an interview with the WS C on 8/1/2022 at 12:25 p.m., the WS C confirmed hand washing was not performed upon entry to the SNF prep kitchen. The WS C stated he should have washed hands when he entered the SNF prep kitchen or prior to taking the food out of the food warmer. During an interview with the WS D on 8/1/2022 at 12:31 p.m., the WS D confirmed hand washing was not performed on both times she entered back to the SNF prep kitchen. The WS D stated she should have washed hands every time she entered the SNF prep kitchen or prior to preparation of resident's trays. During a review of the facility's policy and procedure, titled, Food Safety Management System - B-4 Handwashing Policy .Hands must be washed frequently and correctly .During food preparation, as often as necessary to remove soil and contamination when changing tasks .After engaging in other activities that contaminate the hands. 7. During a concurrent observation and interview with FBM on 8/2/2022 at 1:05 p.m. inside the facility's dry storage room located at the basement of the main kitchen, there was a dented can of slice ripe olives and three 42 ounces of quaker oats dented on each side of the cardboard containers. The upper part of the other quaker oats was also dented and when inspected, the inner seal was already broken. The FBM stated, we placed all dented cans for return outside the storage room. During an interview with the DS on 8/2/2022 at 1:20 p.m., the DS stated dented cans should not be used and should not be stored where the ready to use storage area. The DS further stated there was a designated area for the dented cans for staff to avoid using them. A review of the Food and Drug Administration (FDA) Food Code 2017, 3-101.11, it indicated, The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard. 8. During a concurrent observation and interview on 8/2/2022 at 1:12 p.m. with the FBM, inside the main kitchen, food containers were found stacked upside down still wet in the storage area: two of 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 15 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 liters and two of the large ones. The FBM stated the food containers should be air dried prior to storage. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's undated policy and procedure titled, Dishwashing Policy & Procedure, indicated, Dishes will always be AIR DRIED! Residents Affected - Some 9. During a concurrent inspection and interview with the infection preventionist (IP) on 8/2/2022 at 3:40 p.m., an opened carton of resident's milk was found inside the designated refrigerator for SNF residents. The opened carton of milk did not have a label indicating resident's name, room number and date opened. The IP stated the dietary staff were responsible for checking the resident's refrigerator. During an interview with the DS on 8/4/2022 at 1:45 p.m., the DS stated the refrigerator for the resident's food from home or any opened food or drinks could stay inside the refrigerator for 72 hours. The DS further stated the opened milk should have been dated and the name of the resident should have been written on it. During a review of the facility's policy and procedure, titled, Section 7: Meal Service Food from Outside Sources, dated 08/2021, indicated, 6 .Food must be labeled with resident name, date it was brought to the facility and be stored in SNF resident refrigerator. It must be stored separate or distinguishable from facility food .8. Unconsumed food will be disposed of consistent with manufacturer guidelines, food labels or upon evidence of spoilage. Disposal shall be consistent with center policies related to food safety. Leftover/opened food shall be discarded within 3 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 16 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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. The licensed vocational nurse A (LVN A) did not perform hand hygiene before preparation of medications and before donning (putting on) and after removal of gloves during medication administration for residents 167, 67, and 217. 2. The licensed vocational nurse B (LVN B) did not perform hand hygiene during wound and supra pubic catheter (SPC- a device that is inserted into bladder to drain urine) care for Resident 15. These failures had the potential for residents, staff, and visitors at risk of possible spread of infection. Findings: 1a. During a medication administration observation on 8/2/2022 at 8:06 a.m., the LVN A did not perform hand hygiene prior to Resident 167's medication preparation. The LVN A went inside Resident 167, donned a pair of gloves, repositioned Resident 167, administered her medication and removed the used gloves. The LVN A was not observed performing hand hygiene before donning a new pair of gloves and after removal of used gloves. 1b. During a medication administration observation on 8/2/2022 at 8:44 a.m., the LVN A donned a new pair of gloves to apply Lidocaine patch (a patch used to relieve pain) to Resident 67's lower back. The LVN A removed the old patch from Resident 67's lower back, held the application of a new Lidocaine patch and removed the used gloves. The LVN A did not perform hand hygiene prior to donning a new pair of gloves and after removal of the used gloves. 1c. During another medication administration observation on 8/2/2022 at 8:52 a.m., the LVN A donned a new pair of gloves, administered the Timolol Maleate (medicated eyedrops used to treat high pressure inside the eye due to eye diseases) eyedrops to Resident 217's eyes, and removed the used gloves. The LVN A did not perform hand hygiene prior to donning a new pair of gloves and after removal of the used gloves. During an interview with LVN A on 8/2/2022 at 9:35 a.m., the LVN A confirmed observations above. The LVN A stated she should have performed hand hygiene before medication preparation, prior to donning a new pair of gloves and after removal of the used gloves. During an interview with the infection preventionist (IP) on 8/4/2022 at 9:42 a.m., the IP stated nurses should have perform hand hygiene prior to popping out medications from the package, prior to entrance of each resident's rooms, and after coming out of resident's rooms. The IP further stated nurses should have also perform hand hygiene before wearing a new pair of gloves and after removal of used gloves. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised date August 2019, it indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 17 of 18 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 555867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Forest Hill Manor Health Center 551 Gibson Avenue Pacific Grove, CA 93950 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 preparing or handling medications; .f. Before donning sterile gloves; .m. After removing gloves; Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 8/3/22 at 4:54 p.m., after removal of the dressing at SPC site, the LVN B doffed (removed) gloves, donned (put on) new gloves without hand hygiene. The LVN B cleaned the SPC site with soap and water, applied new dressing, went to the bathroom, discarded soiled soap and water in sink, doffed gloves, and came out of the bathroom without performing hand hygiene.The LVN B was also observed using the bed remote control to adjust Resident 15's bed height, and pillows, donned new gloves without hand hygiene after touching surfaces. The LVN B sprayed Puracyn (wound and skin cleanser) to sacrum (between lower back and tailbone area), and left Ischium (lower back side of the hip bone area) wound areas, then doffed gloves and donned a new gloves without hand hygiene. The LVN wiped sacrum wound with gauze sponge (thin medical fabric uses in wound care), applied new silicone foam dressing (absorbent wound dressing), doffed gloves and donned a new gloves without hand hygiene. After wiping left ischium wound with gauze sponge, the LVN B packed the area with Nu-Gauze (Cotton packing strips are intended to absorb excess drainage from wounds), covered with silicone foam dressing, doffed gloves and donned new gloves without hand hygiene. The LVN B changed Resident 15's position, and fixed pillows for resident's comfort level, doffed gloves, and did not perform hand hygiene. Residents Affected - Some During an interview with Infection Preventionist (IP) on 8/4/22 at 9:30 a.m., the IP stated, Licensed staff been trained on hand hygiene. They should perform hand hygiene after doffing gloves, touching surfaces, and resident. During an interview with LVN B on 8/4/22 at 11:40 a.m., the LVN B stated, I missed washing hands several times during the treatments yesterday. I should have washed my hands each time after I removed gloves and touched surfaces. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised date August 2019, it indicated, 7. Use an alcohol-base hand rub containing at least 62% alcohol; or, alternatively, soap (anti-microbial or non-antimicrobial) and water for the following situations: . e. Before and after handling an invasive device (e.g. [stands for exempli gratia in Latin, which means for example.] urinary catheters, IV [intravenous - thru veins] access sites}; .g. Before handling clean or soiled dressings, gauze pads, etc. [Et Cetera - used at the end of a sentence when listing example]; .k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; . 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 18 of 18