Health inspection·January 23, 2024

F 0578 three options were left blank, and not completed. Level of Harm - Minimal harm or potential for actual harm Review of Resident 181's face sheet indicated, Resident 181 was admitted to the facility on [DATE]. Review of Resident 181's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 181. Residents Affected - Few Review of Resident 181's POLST form dated 12/30/23 indicated, section D for advance directive all three options were left blank, and not completed. Review of Resident 184's face sheet indicated, Resident 184 was admitted to the facility on [DATE]. Review of Resident 184's clinical record indicated, there was no advance directive. Review of social services notes indicated there was no documentation that the facility verified, or offered, or assisted, and or obtained advance directive for Resident 184. Review of Resident 184's undated POLST form indicated, section D for advance directive all three options, and physician's signature were left blank, and not completed. During a concurrent interview and record review of the advance directive for Residents 8, 178, 179, 181, and 184 with the facility's social service director (SSD) on 1/19/24 at 11 a.m., the SSD confirmed there were no documentation of advance directive for the above five residents. The SSD stated she should have verified, offered, assisted, and or obtained advance directive for the residents. During an interview with the director of nursing (DON) on 1/19/24 at 11:30 a.m., the DON stated the SSD should have verified, and assisted residents to obtain advance directive. The DON also stated the SSD should have documented the efforts to obtain advance directive as needed. The DON further stated staff should have completed POLST form for residents without blanks and obtained physician's signature. Review of the facility's P&P titled, Advance Directive, revised December 2016, the P&P indicated, Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of the facility's P&P titled, Do not Resuscitate Order, revised April 2017, the P&P indicated, A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law) and placed in the front of the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 2 of 29 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 01/23/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pre-admission screening and resident review (PASRR- screening for residents with a mental disorder [MD, a wide range of conditions that affect mood, thinking, and behavior] and residents with intellectual disability [ID, when there are limits to a resident's ability to learn at an expected level and function in daily life] or related disorders [RD]) screening was completed for one out of two residents. This failure had the potential for Resident 8 not to receive the required care and services. Residents Affected - Few Findings: Review of Resident 8's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD, a psychiatric disorder that may occur in residents who have experienced or witnessed a traumatic event or set of circumstances). Review of Resident 8's history and physical document from acute hospital (where residents receive immediate and short-term treatment for any critical or life-threatening injury, illness, and diseases) dated 10/9/23, indicated Resident 8's diagnosis of PTSD. Review of Resident 8's minimum data set (MDS, resident clinical, and functional assessment tool) assessment dated [DATE] indicated PTSD under psychiatric/mood disorder for resident's primary medical condition. Review of Resident 8's clinical record indicated there was no document for PASRR. During an interview with the director of nursing (DON) on 1/19/24 at 11:51 a.m., the DON acknowledged Resident 8 had diagnosis of PTSD. The DON also acknowledged that Resident 8's PASRR was not done. The DON stated facility should complete PASRR and refer residents as needed. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, the P&P indicated, All new admissions and readmissions are screed for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid (joint federal and state program that provides health coverage to certain group of individuals) Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level 1 PASARR screen for all potential admissions, regardless of payor source, to determine if the individual meets the criteria for MD, ID, or RD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 3 of 29 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 01/23/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan for two out of 12 sampled residents (Residents 4 and 20) within 48 hours of the resident's admission when: 1. For Resident 4, there was no care plan to address oxygen use; 2. For Resident 20, there was no care plan for bowel and bladder incontinence; 3. For Resident 20, there was no care plan to manage blood sugar to prevent hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). These deficient practices had the potential for delayed administration of necessary care and services. Findings: 1. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). Review of Resident 4's physician's order summary indicated administer oxygen 2 l/min (l/min, liter per minute) as needed, starting on 12/26/23. During an observation in Resident 4's room on 1/16/24 at 11 a.m., Resident 4 was lying in her bed with oxygen at 2 l/min via nasal cannula (NC, a plastic tubing used to deliver supplemental oxygen). During an observation in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with oxygen at 2 l/min via NC. During a concurrent interview and record review with the infection preventionist (IP) on 1/23/24 at 9 a.m., the IP reviewed Resident 4's care plan and confirmed that there was no care plan to address the oxygen care. The IP stated the licensed nurses should have completed the baseline care plan to address the oxygen use within 48 hours of the resident's admission. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON acknowledged the licensed nurses should have developed the baseline care plans for oxygen use within 48 hours of the resident's admission. 2. During a concurrent interview and record review with the IP on 1/19/24 at 12:11 a.m., the IP reviewed Resident 20's care plan and confirmed that there was no care plan for bowel and bladder incontinence. The IP stated that Resident 20 was mixed for continence and incontinence and sometimes incontinent for both bowel and bladder. The IP stated licensed nurses should have developed the baseline care plan to address the bowel and bladder issue within 48 hours of admission. 3.Review of Resident 20's clinical record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (high blood sugar) without complications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 4 of 29 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 01/23/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the IP on 1/19/24 at 12:13 a.m., the IP reviewed Resident 20's care plan and confirmed that there was no care plan for blood sugar management to monitor hyperglycemia and hypoglycemia. The IP stated that Resident 20 kept receiving insulin to control his blood sugar, and licensed nurses should have developed the baseline care plan to manage his blood sugar level to prevent hyperglycemia and hypoglycemia within 48 hours of admission. Residents Affected - Few During an interview with the DON on 1/23/24 at 10:05 a.m., the DON acknowledged the licensed nurses should have developed the baseline care plans for Resident 20 to address the bowel bladder issue and blood sugar management within 48 hours of the resident's admission. Review of the facility's policy and procedure (P&P) titled Care Plans-Baseline, revised in December 2016, indicated To assure that the resident's immediate care needs and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 5 of 29 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 01/23/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure to follow physician's order for oxygen (colorless, odorless, and tasteless gas supports life) rate administration for one of three sampled residents (Resident 181). This failure had the potential to compromise Resident 181's health, and well-being. Residents Affected - Few Findings: Review of Resident 181's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 181 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when lungs are unable to pass enough oxygen to the blood, or when fail to remove carbon dioxide [colorless and odorless gas humans breathed out] from the blood), acute pulmonary edema (fluid build up in the lungs), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and obstructive sleep apnea (intermittent airflow blockage during sleep). Review of Resident 181's physician's order dated 1/7/24 indicated, Oxygen: At 2 Liters/Min (l/min, oxygen measured in liters per minute) via Nasal Cannula (NC, a medical device to provide supplemental oxygen to residents) Every Shift. During an observation on 1/16/24 at 11:53 a.m., noted Resident 181's room air concentrator (RAC, a medical device that take in air from the room and filter out nitrogen to provides higher amounts of oxygen) oxygen rate was set at 4 l/min via NC. During an interview with registered nurse A (RN A) on 11/16/24 at 11:56 a.m., RN A acknowledged Resident 181's RAC was set at 4l/min oxygen via NC. During a second observation on 1/19/24 at 8:32 a.m., noted Resident 181's RAC oxygen rate was set at 4l/min via NC. During a concurrent review of Resident 181's physician's order for oxygen and interview with licensed vocational nurse B (LVN B) on 1/19/24 at 8:35 a.m., LVN B confirmed Resident 181's RAC oxygen rate was set at 4l/min. LVN B also confirmed Resident 181 had an order for oxygen 2l/min. LVN B adjusted Resident 181's RAC oxygen rate to 2l/min and stated staff should have verified and followed Resident 181's physician's order for oxygen use. During an interview with the director of nursing (DON) on 1/19/24 at 11:38 a.m., the DON stated staff should have set Resident 181's RAC at 2l/min. Review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised July 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 6 of 29 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 01/23/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation on 1/16/24 at 10 a.m., the beds of Residents 132,4,128,129,24,20, 130,7,13,131 and 6 were inspected. All 11 beds had partial bed rails bilaterally. Review of Resident 132's physician's order, dated 1/6/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 132's bed rails observation/assessment, dated 1/6/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to the use of bed rails. Review of Resident 132's MDS assessment, dated 1/8/24, indicated Resident 132 had a BIMS score of 12. During an interview with Resident 132 on 1/16/24 at 10 a.m., Resident 132 stated the side rails were already in placed since her admission to the facility. Review of Resident 4's physician's order, dated 12/20/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 4's bed rails observation/assessment, dated 12/20/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 128's physician's order, dated 1/8/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 128's bed rails observation/assessment, dated 1/8/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 129's physician's order, dated 1/10/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 129's bed rails observation/assessment, dated 1/10/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 24's physician's order, dated 12/19/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 24's bed rails observation/assessment, dated 12/19/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 20's physician's order, dated 12/23/23, indicated to put bilateral upper grab (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 7 of 29 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 01/23/2024 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 0700 rails for bed mobility, positioning and transfer. Level of Harm - Minimal harm or potential for actual harm Review of Resident 20's bed rails observation/assessment, dated 12/23/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Residents Affected - Many Review of Resident 130's physician's order, dated 1/15/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 130's bed rails observation/assessment, dated 1/15/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 7's physician's order, dated 10/24/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 7's bed rails observation/assessment, dated 10/24/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 13's physician's order, dated 12/15/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 13's bed rails observation/assessment, dated 12/15/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 131's physician's order, dated 1/12/24, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 131's bed rails observation/assessment, dated 1/12/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. Review of Resident 6's physician's order, dated 12/24/23, indicated to put bilateral upper grab rails for bed mobility, positioning and transfer. Review of Resident 6's bed rails observation/assessment, dated 12/24/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. During an interview with the DON on 1/18/24 5:47 p.m., the DON confirmed the facility did not provide alternatives to the 25 residents prior to the use of bed rails. During an interview with licensed vocational nurse B (LVN B) on 1/23/24 at 8:47 a.m., LVN B confirmed that all the beds rails were installed before residents were admitted to the facility and the facility did not attempt alternatives prior to the use of bed rails. During a concurrent interview and record review with the infection preventionist (IP) on 1/23/23 at 9:06 a.m., the IP reviewed the bed rails observation and assessment of Residents 132,128,129,24,20,7,131, 6 and confirmed that the eight residents did not have an informed consent prior to the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 8 of 29 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 01/23/2024 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 0700 bed rails. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, revised December 2016, the P&P indicated, Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. Consent for side rails use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Residents Affected - Many Based on observation, interview, and record review, the facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for 12 of 12 sampled residents (Residents 8,178, 179, 184, 181, 12, 132, 4, 20, 7, 13, and 6). The survey team expanded the sample and identified that a total of 25 resident had the bed rails. The facility failed to follow their bed rails policy when: 1.There was no documentation that alternatives for bed rails were attempted prior to installing bed rails for 25 of 25 residents; 2.There was no informed consent (the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or interventions) from residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to installing bed rails for 16 of 25 residents (Residents 183, 181, 8, 187, 186, 182, 180, 3, 132, 128, 129, 24, 20, 7, 131, and 6). These failures resulted in the residents and resident's RPs not being fully informed on the risks of the use of bed rails and had the potential to place the residents at risk of serious injury. Findings: During an observation on 1/16/24 at 10:55 a.m., Resident 8's bed had partial bed rails up on both sides. Review of Resident 8's face sheet (a document that gives resident's information at a quick glance) indicated Resident 8 was readmitted to the facility on [DATE]. The face sheet also indicated Resident 8 was self-responsible. Review of Resident 8's minimum data set (MDS, resident's clinical and functional assessment tool) assessment, dated 11/29/23, indicated Resident 8's had a brief interview for mental status (BIMS, an assessment used in nursing homes to monitor cognition) score of 14 (score of 13-15 indicates an intact cognition). Review of Resident 8's physician's order, dated 11/23/23, indicated Resident 8 had an order for bilateral (both sides) upper grab rails for bed mobility/positioning and/or transfer. Review of Resident 8's bed rail observation/assessment, dated 10/30/23, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to installing bed rails. During an interview with Resident 8 on 1/18/24 at 1:30 p.m., Resident 8 confirmed the facility did not provide alternatives for bed rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 9 of 29 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 01/23/2024 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 0700 During an observation on 1/16/24 at 11:05 a.m., Resident 178's bed had bilateral, partial bed rails up. Level of Harm - Minimal harm or potential for actual harm Review of Resident 178's face sheet indicated Resident 178 was admitted to facility on 1/12/24. The face sheet also indicated Resident 178 had an assigned RP. Residents Affected - Many Review of Resident 178's MDS assessment, dated 01/18/24, indicated Resident 178 had a BIMS score of 12, (score of 8-12 indicates moderately impaired cognition). Review of Resident's 178's physician's order, dated 1/12/24, indicated Resident 178 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Resident 178 also had an order, dated 1/12/24, indicated Resident 178 was capable of understanding rights, responsibilities, and informed consent. Review of Resident 178's bed rail observation/assessment, dated 1/12/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 178 on 1/16/24 at 11:22 a.m., Resident 178 confirmed the facility did not use alternatives prior to use of bed rails. During an observation on 1/16/24 at 11:22 a.m., Resident 179's bed had partial bed rails up on both sides. Review of Resident 179's face sheet indicated Resident 179 was admitted to the facility on [DATE]. The face sheet also indicated Resident 179 was self-responsible. Review of Resident 179's MDS assessment, dated 12/29/23, indicated Resident 179 had a BIMS score of 9. Review of Resident179's physician's order, dated 1/7/24, indicated Resident 179 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 179's bed rail observation/assessment, dated 12/16/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 179 on 1/16/24 at 11:22 a.m., Resident 179 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:45 a.m., Resident 184's bed had partial bed rails up on both sides. Review of Resident 184's face sheet indicated Resident 184 was admitted to the facility on [DATE]. The face sheet also indicated Resident 184 was self-responsible. Review of Resident 184's MDS assessment, dated 1/20/24, indicated Resident 184 had a BIMS score of 13. Review of Resident184's physician's order, dated 1/14/24, indicated Resident 184 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 10 of 29 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 01/23/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Review of Resident 184's bed rail observation/assessment, dated 1/14/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 184 on 1/16/24 at 11:45 a.m., Resident 184 confirmed the facility did not use alternatives prior to the use of bed rails. Residents Affected - Many During an observation on 1/16/24 at 11:53 a.m., Resident 181's bed had partial bed rails up on both sides. Review of Resident 181's face sheet indicated Resident 181 was admitted to the facility on [DATE]. The face sheet also indicated Resident 181 was self-responsible. Review of Resident 181's MDS assessment, dated 01/13/24, indicated Resident 181 had a BIMS score of 14. Review of Resident 181's physician's order, dated 1/7/24, indicated there was no order for bed rails. Review of Resident 181's bed rail observation/assessment, dated 01/07/24, indicated there was no documentation that the facility attempted alternatives, and obtained informed consent prior to the installation of bed rails. During an interview with Resident 181 on 1/16/24 at 11:53 a.m., Resident 181 confirmed the facility did not provide alternatives for bed rails. During an observation on 1/16/24 at 12:15 p.m., Resident 12's bed had bilateral partial bed rails up. Review of Resident 12's face sheet indicated Resident 12 was admitted to the facility on [DATE]. The face sheet also indicated Resident 12 had assigned RP. Review of Resident 12's MDS assessment, dated 12/17/23, indicated Resident 12 had a BIMS score of 9. Review of Resident 12's physician's order, dated 12/11/23, indicated Resident 12 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Resident 12 also had an order, dated 12/11/23 indicated Resident 12 was capable of understanding rights, responsibilities, and informed consent. Review of Resident 12's bed rail observation/assessment, dated 12/11/23, indicated there was no documentation that the facility attempted alternatives prior to the use of bed rails. During an interview with Resident 12 on 1/16/24 at 12:15 p.m., Resident 12 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 11:48 a.m., Resident 182's bed had bilateral partial bed rails up. Review of Resident 182's face sheet indicated Resident 182 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 11 of 29 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 01/23/2024 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 0700 The face sheet also indicated Resident 182 had an assigned RP. Level of Harm - Minimal harm or potential for actual harm Review of Resident 182's MDS assessment, dated 1/16/24, indicated Resident 182 had a BIMS score of 14. Residents Affected - Many Review of Resident 182's physician's order, dated 1/10/24, indicated Resident 182 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 182's bed rail observation/assessment, dated 1/10/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 182 on 1/16/24 at 11:48 a.m., Resident 182 confirmed the facility did not use alternatives prior to the use of bed rails. During an observation on 1/16/24 at 12:10 p.m., Resident 187's bed had bilateral partial bed rails up. Review of Resident 187's face sheet indicated Resident 187 was admitted to the facility on [DATE]. The face sheet also indicated Resident 187 had an assigned RP. Review of Resident 187's MDS assessment, dated 11/30/23, indicated Resident 187 had a BIMS score of 4 (score of 0-7 indicates severe cognitive impairment). Review of Resident 187's physician's order, dated 11/24/23, indicated Resident 187 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 187's bed rail observation/assessment, dated 11/24/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview on 1/18/24 at 3:30 p.m., with Resident 187's RP, the RP stated Resident 187 had bed rails since the resident was admitted to the facility. During an observation on 1/16/24 at 11:59 a.m., Resident 3's bed had bilateral partial bed rails up. Review of Resident 3's face sheet indicated Resident 3 was admitted to the facility on [DATE]. The face sheet also indicated Resident 3 was self-responsible. Review of Resident 3's MDS assessment dated [DATE], indicated Resident 3 had a BIMS score of 12. Review of Resident's 3's physician's order, dated 12/5/23, indicated Resident 3 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 3's bed rail observation/assessment, dated 12/5/23, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Resident 3 on 1/16/24 at 11:59 a.m., Resident 3 acknowledged that the facility did not provide alternatives prior to the use of bed rails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 12 of 29 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 01/23/2024 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 0700 During an observation on 1/16/24 at 11:38 a.m., Resident 186's bed had bilateral partial bed rails up. Level of Harm - Minimal harm or potential for actual harm Review of Resident 186's face sheet indicated Resident 186 was admitted to the facility on [DATE]. The face sheet also indicated Resident 186 had an assigned RP. Residents Affected - Many Review of Resident 186's MDS assessment, dated 1/12/24 indicated Resident186 had a BIMS score of 15. Review of Resident 186's physician's order, dated 1/9/2024, indicated there was no order for the use of bed rails. Review of Resident 186's bed rail observation/assessment, dated 1/9/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 186 on 1/1/6/24 at 11:38 a.m., Resident 186 acknowledged there were no alternatives tried prior to the use of bed rails. During an observation on 1/16/24 at 11:42 a.m., Resident 180's bed had bilateral partial bed rails up. Review of Resident 180's face sheet indicated Resident 180 was admitted to the facility on [DATE]. The face sheet also indicated Resident 180 had an assigned RP. Review of Resident 180's MDS assessment, dated 1/7/24 indicated Resident 180 had a BIMS score of 0 (score of 0 indicates severely impaired cognition). Review of Resident 180's physician's order, dated 1/4/24, indicated there was no order for the use of bed rails. Review of Resident 180's bed rail observation/assessment, dated 1/4/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails and there was no informed consent. During an interview with Resident 180's RP on 1/16/24 at 11:42 a.m., Resident 180's RP confirmed there were no alternatives provided prior to the use of bed rails. During an observation on 1/16/24 at 11:30 a.m., Resident 183's bed had bilateral partial bed rails up. Review of Resident 183's face sheet indicated Resident 183 was admitted to the facility on [DATE]. The face sheet also indicated Resident 183 had an assigned RP. Review of Resident 183's MDS assessment, dated 1/17/24, indicated Resident 183 had a BIMS score of 13. Review of Resident 183's physician's order, dated 1/11/24, indicated Resident 183 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 13 of 29 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 01/23/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Review of Resident 183's bed rail observation/assessment, dated 1/11/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During a telephone interview with Resident 183's RP on 1/18/24 at 2:10 p.m., Resident 183's RP stated Resident 183's bed had side rails since the resident was admitted to the facility. Residents Affected - Many During an observation on 1/16/24 at 12:40 p.m., Resident 185's bed had bilateral partial bed rails up. Review of Resident 185's face sheet indicated Resident 185 was admitted to the facility on [DATE]. The face sheet also indicated Resident 185 was self- responsible. Review of Resident 185's MDS assessment, dated 1/7/24 indicated, Resident 185 had a BIMS score of 12. Review of Resident 185's physician's order, dated 1/1/24, indicated there was no order for the use of bed rails. Review of Resident 185's bed rail observation/assessment, dated 1/1/24, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. During an interview with Resident 185 on 1/16/24 at 12:40 p.m., Resident 185 stated there were no alternatives provided by the facility prior to the use of bed rails. During an observation on 1/16/24 at 11:15 a.m., Resident 14's bed had bilateral partial bed rails up. Review of Resident 14's face sheet indicated Resident 14 was admitted to the facility on [DATE]. The face sheet also indicated Resident 14 had an assigned RP. Review of Resident 14's MDS assessment, dated 11/15/23, indicated Resident 14 had a BIMS score of 5. Review of Resident 14's physician's order, dated 11/17/23, indicated Resident 14 had an order for bilateral upper grab rails for bed mobility/positioning and /or transfer. Review of Resident 14's bed rail observation/assessment, dated 9/17/22, indicated there was no documentation that the facility attempted alternatives prior to installing bed rails. Review of Resident 182's bed rail observation/assessment, dated 1/10/24 indicated there was no informed consent for the use of side rails. Review of Resident 183's bed rail observation/assessment, dated 1/11/24, indicated there was no informed consent for the use of side rails. Review of Resident 186's bed rail observation/assessment, dated 1/9/24, indicated there was no informed consent for the use of side rails. Review of Resident 187's bed rail observation/assessment, dated 11/24/23, indicated there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 14 of 29 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 01/23/2024 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 0700 informed consent for the use of side rails. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review with the director of nursing (DON) on 1/18/24 5:47 p.m., the DON reviewed the bed rails assessments of the 25 residents and confirmed the facility did not have alternatives and there was no documentation for unsuccessful attempts to use alternatives prior to the use of bed rails. The DON further stated the facility should have tried alternatives and staff should have followed the facility's policy to document unsuccessful attempts of alternatives prior to use of bed rails. Residents Affected - Many During an interview with the DON on 1/19/24 at 12:15 p.m., the DON confirmed informed consent was not obtained prior to the use of bed rails for Residents 8, 181, 183, 187, 186, 182, 180, and 3. The DON also confirmed there was no physician's order for the use of bed rails for Residents 180, 181, 185, and 186. The DON stated the staff should obtain a physician's order then obtain informed consent from the resident/RP prior to the use of bed rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 15 of 29 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 01/23/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days of use and failed to obtain an informed consent for one of 12 sampled residents (Resident 4). These failures had could lead to the administration of unnecessary medication to the resident. Findings: Review of Resident 4's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and unspecified depression. Further review of Resident 4's clinical record indicated a physician's order, dated 12/20/23, for Diazepam 10 milligrams (mg., a unit of measurement) every 8 hours as needed (PRN) for anxiety. The order did not have a stop date. During a concurrent interview and record review with the infection preventionist (IP) on 1/18/24 at 2:35 p.m., the IP reviewed the physician's order and stated that PRN psychotropic medication orders should be limited to 14 days. During a concurrent interview and record review with the IP on 1/23/24 at 9:15 a.m., the IP confirmed that no documentation indicated that Resident 4 signed the informed consent to take Diazepam PRN for anxiety. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON stated that there should be a 14-day limit for PRN psychotropic medication and that the facility should have obtained informed consent upon starting the medication to prevent administering unnecessary medication to the resident. Review of the facility's policy and procedure dated 2007 titled, Medication Monitoring, Medication Management, indicated .Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; PRN orders for psychotroic drugs are limited to 14 days .A resident and /or representative has the right to be informed about the resident's condition, treatment options, relative risks, and benefits of treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 16 of 29 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 01/23/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility had a 10.53 percent (%, unit of measurement) medication error rate, when 4 medication errors occurred out of 38 opportunities during the medication administration, for three out of nine residents (Residents 12, 4 and 185). Residents Affected - Some These failures resulted in the medications, not given in accordance with the prescriber's orders, manufacturer's specifications and medication administration's instructions, which resulted in residents, not receiving the full therapeutic effect of the medications or the proper administration of the medication and may cause preventable side effects for the residents. Findings: 1. During the medication pass observation of Resident 12 with licensed vocational nurse C (LVN C), on 1/16/24 at 12:30 p.m., there was no available hydralazine hydrochloride (used to treat or control high blood pressure) tablet and LVN C was not able to administer the hydralazine hydrochloride oral tablet medication to Resident 12 because it was not available. Review of Resident 12's clinical records indicated, Resident 12 was admitted to the facility on [DATE], with diagnoses including acute (rapid onset) on chronic (condition that gradually worsens over time) combined systolic (the heart muscle is weak and the ventricle can't contract normally) and diastolic (the heart muscle is stiff and the left ventricle can't relax normally) congestive heart failure (CHF, long-term condition affecting the left ventricle in which the heart can't pump blood well enough to meet the body's demands), type 2 diabetes mellitus (adult onset, high levels of sugar in the blood) and unspecified pulmonary hypertension (high blood pressure affecting the arteries in the lungs and in the heart). Review of Resident 12's physician's order indicated, Resident 12 had an order of hydralazine hydrochloride, 10 milligram (mg, a unit of measurement of mass) tablet by mouth, three times a day for hypertension (high blood pressure). During an interview with LVN C on 1/16/24 at 12:38 p.m., LVN C verified that the hydralazine hydrochloride tablet of Resident 12 was not available, that was the reason she missed giving the medication to Resident 12. LVN C further verified that the medication should have been available for the medication pass administration and should not be missed. LVN C then reordered to the pharmacy, the hydralazine hydrochloride medication of Resident 12. During an interview with the director of nursing (DON) on 1/17/24 at 10 a.m., the DON verified that residents' medications should be administered one hour before or one hour after the scheduled administration. The DON further verified that licensed nurses were responsible for the availability of the medication of the residents. The DON then stated that Resident 12 should not have missed her hydralazine hydrochloride. Residents should have at least 3-7 days' supply of their medications and nurses should refill their residents' medications immediately, if they noticed that the resident had less than 3-7 days' supply of the medication. 2. During the concurrent medication pass observation of Resident 4 and interview with licensed vocational nurse B (LVN B), on 1/18/24 at 8:15 a.m., LVN B administered 10 total tablets of medications to Resident 4. LVN B verified that there were only ten tablets of medications administered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 17 of 29 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 01/23/2024 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 Resident 4. Level of Harm - Minimal harm or potential for actual harm Review of Resident 4's clinical records indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses including unspecified peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), essential primary hypertension (occurs, when having an abnormally high blood pressure, that's not the result of a medical condition) and unspecified hyperlipidemia (high levels of fat particles in the blood). Residents Affected - Some Review of Resident 4's physician's order indicated, the following medications were scheduled to be administered to Resident 4 during the medication pass administration on 1/18/24 at 8:15 a.m.: a. carvedilol 12.5 mg tablet, 1 tablet by mouth, twice per day for coronary artery disease (CAD, is a narrowing or blockage of the coronary arteries), b. duloxetine hydrochloride 30 mg tablet, 1 tablet by mouth, twice per day for depression (persistent feeling of sadness or loss of interest), c. chewable aspirin, 81 mg tablet, 1 tablet by mouth, twice per day for prevention of stroke (brain attack), d. atorvastatin 20 mg tablet, 1 tablet by mouth, daily for hyperlipidemia (high cholesterol), e. folic acid, 1 mg tablet, 1 tablet by mouth, daily for supplement, f. furosemide 40 mg tablet, 1 tablet by mouth, daily for CHF, g. hydroxyzine 25 mg tablet, 1 tablet by mouth, three times per day for anxiety (feeling of fear), h. lisinopril 2.5 mg tablet, 1 tablet by mouth, daily for essential primary hypertension, i. multivitamins with minerals, 1 tablet by mouth, daily for supplement, j. potassium chloride, 1 tablet by mouth, daily for CHF and k. vitamin C 250 mg tablet, 1 tablet by mouth, daily for supplement. A total of 11 tablets of medications, scheduled to be administered during the medication pass administration on 1/18/24 at 8:15 a.m During an interview with LVN B on 1/18/24 at 2:05 p.m., LVN B verified that the atorvastatin tablet of Resident 4 was not available, that was the reason she missed giving the medication to Resident 4 and that's the reason, only 10 tablets, instead of 11 tablets were given, during the medication pass administration this morning. LVN B further verified that the medication should have been available for the medication pass administration and should not be missed. LVN B also stated that the medication should have been refilled already by the nurses. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that Resident 4 should not miss her atorvastatin tablet. The DON further verified that residents should have at least 3-7 days' supply of their medications and nurses should refill the medications right away if they don't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 18 of 29 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 01/23/2024 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 have 3-7 days' supply of their medications. Level of Harm - Minimal harm or potential for actual harm 3. During the medication pass observation of Resident 185 with LVN B, on 1/18/24 at 8:39 a.m., there was no available biotin (one of the B complex vitamins that supports the skin, hair and eye health) supplement tablet and LVN B was not able to administer the biotin supplement oral tablet medication to Resident 185 because it was not available. Residents Affected - Some Review of Resident 185's clinical records indicated, Resident 185 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, type 2 diabetes mellitus (adult onset, high levels of sugar in the blood) and hypokalemia (low levels of potassium in the blood). Review of Resident 185's physician's order indicated, Resident 185 had an order of biotin extra strength oral disintegrating (breaking into small particles) tablet, 5000 microgram (mcg, unit of mass) tablet, give 1 tablet by mouth, one time a day for supplement. During an interview with LVN B on 1/18/24 at 8:50 a.m., LVN B verified that the biotin supplement tablet of Resident 185 was not available, that was the reason she missed giving the medication to Resident 185 during the medication pass administration. LVN B further verified that the medication should have been available for the medication pass administration and should not be missed. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that Resident 185 should not miss her biotin supplement. The DON further verified that residents should have at least 3-7 days supply of their medications and nurses should refill the medications right away if they don't have 3-7 days' supply of their medications. Review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 4. During the medication administration observation of Resident 185 with LVN B on 1/18/24 at 8:45 a.m., LVN B was observed administering restasis eye drops (used for long-lasting dry eyes) to Resident 185. LVN B administered the eye drop in Resident 185's left eye first, while her head was tilted back, then administered another drop to Resident 185's right eye without instructing Resident 185 to close eyes after each drop, then applying gentle pressure in the inner corner of the eyes. Review of Resident 185's physician orders indicated, Resident 185 had an order of restasis ophthalmic (pertaining to the eye) emulsion (a mixture of two or more liquids that are normally unmixable) 0.05 percent (%), instill 1 drop in both eyes, two times a day for dry eyes. During an interview with LVN B on 1/18/24 at 2:00 p.m., LVN B verified that the restasis eye drops were not properly administered to Resident 185. LVN B further verified that she did not give instruction to Resident 185 after administering restasis eye drops, for Resident 185, to close her eyes after each drop, then applying gentle pressure in the inner corner of the eyes, which she should have done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 19 of 29 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 01/23/2024 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 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified LVN should have administered the restasis eye drops to Resident 185 properly. The DON further verified that the LVN should have instructed Resident 185, after the first drop in the left eye while Resident 185's head was tilted back, to close the eyes, apply gentle pressure in the inner corner of the eye, before administering the second drop in the right eye. Residents Affected - Some Review of the facility's policy and procedure titled, Installation of Eye Drops: Steps in the Procedure, revised January 2014, indicated, . If the resident is sitting up, tilt his/her head backward slightly . Drop the medication into the mid lower eyelid . Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. Instruct the resident not to blink or squeeze the eyelids shut, which forces the medicine out of the eye . Gently dry the eyelid with cotton ball if dripping occurs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 20 of 29 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 01/23/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, discontinued medications were properly discarded and not kept in the medication cart when: 1. For Resident 2, discontinued 30 tablets of montelukast sodium (medication used to prevent breathing difficulties) 10 milligram (mg, unit of measurement), and 53 tablets of hydrocodone-acetaminophen 5-325 (controlled medication for pain) mg, were kept in medication cart 2; and 2. For Resident 78, discontinued 26 tablets of oxycodone hydrochloride (controlled medication for pain) 5 mg, and 23 capsules of pregabalin (controlled medication that can treat nerve and muscle pain), 25 mg, were still in medication cart 2. These failures had the potential for residents to receive discontinued medications and controlled medication diversion. Findings: During an observation and inspection of medication cart 2 with the minimum data set coordinator (MDSC), on 1/17/24, at 2:35 p.m., noted discontinued 30 tablets of montelukast sodium 10 mg, and 53 tablets of hydrocodone-acetaminophen 5-325 mg were kept in the medication cart 2. Review of Resident 2's clinical records indicated, Resident 2 was initially admitted to the facility on [DATE] and was discharged from the facility on 1/10/24. During the continued observation and inspection of medication cart 2 with the MDSC, on 1/17/24 at 2:35 p.m., noted discontinued 26 tablets of oxycodone hydrochloride 5 mg, and 23 capsules of pregabalin 25 mg, were still in the medication cart 2. Review of Resident 78's clinical records indicated, Resident 78 was admitted to the facility on [DATE] and was discharged from the facility on 12/28/23. During an interview with the MDSC, on 1/17/24 at 2:45 p.m., the MDSC verified the above observation and stated the discontinued medications should have been removed in the medication cart. The MDSC further stated the montelukast medication should have been placed in the bin for discontinued medications and the controlled medications should have been placed in the locked cabinet in the director of nursing's (DON) office. During an interview with the DON, on 1/19/24 at 4:45 p.m., the DON verified that the discontinued medications should have been removed in the medication cart. The DON further stated that the controlled medications should have been placed in the locked cabinet in the DON's office. Review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised April 2019, indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . Disposal of controlled substances must take place immediately, no longer than three (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 21 of 29 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 01/23/2024 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 days, after discontinuation of use by the resident. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure titled, Discontinued Medications, revised April 2007, indicated, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. The nurse receiving the order to discontinue a medication is responsible for notifying the dispensing pharmacy of the discontinuation. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 22 of 29 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 01/23/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time personnel to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food-borne illness for 25 residents eating facility-prepared foods. Findings: During an interview with the registered dietitian (RD)on 1/16/24 at 11:56 a.m., the RD stated that he was a part-time employee of the skilled nursing facility (SNF). The RD further stated the kitchen belongs to the Assistant Living(AL), under a different company and all the kitchen staff, including the dietary service director were under the AL. During an interview with the dietary service director (DSD) on 1/17/24 at 11:56 a.m., the DSD stated that he worked as a full-time DSD for the AL since January 2023. The DSD further stated the AL and the SNF belongs to two different companies and he was not a SNF employee. Review of the facility's documents indicated there was no written policy and procedure for kitchen management. During an interview with the administrator (ADM) on 1/22/24 at 12:44 p.m., the ADM confirmed there was no written kitchen management policy and procedure. The ADM stated that the SNF did not have a kitchen to cook and all kitchen staff were AL employees. The ADM further stated that the SNF had a part-time RD and did not have a full-time DSD. Review of the California Code, Health, and Safety Code - HSC § 1265.4 indicated that a licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 23 of 29 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 01/23/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). During an interview with Resident 4 on 1/16/24 at 11 a.m., Resident 4 stated that she was allergic to egg whites but had eggs in her breakfast tray on 1/8/24. Resident 4 stated she reported this to her nurse, who took a picture and took the tray away. During an interview with Resident 4 on 1/18/24 at 9:15 a.m., Resident 4 stated that she was allergic to egg whites, but she had scrambled eggs in her breakfast tray on 1/17/24, and certified nursing assistant D (CNA D) removed the scrambled eggs. During an interview with CNA D on 1/18/24 at 9:20 a.m., CNA D stated that Resident 4 had a scrambled eggs in her breakfast tray, and he removed the scrambled eggs before Resident 4 started to eat. During an interview with licensed vocational nurse (LVN) C on 1/19/24 at 9:45 a.m., LVN C stated that Resident 4 was allergic to egg whites, and she checked Resident 4's meal by herself during her shift. She confirmed that Resident 4 had a scrambled eggs in her breakfast tray on 1/8/24, and she took a picture and removed the scrambled eggs before Resident 4 started to eat. During an interview with the registered dietitian (RD) on 1/19/24 at 03:18 p.m., The RD confirmed that Resident 4 was allergic to egg whites and stated that all kinds of food made with eggs should not be on the resident meal plates. During an interview with the director of nursing (DON) on 1/23/24 at 10 a.m., the DON stated that eggs should not be served to Resident 4 because it might cause rashes, hives (a rash with raised red patches), stomach cramps, vomiting and anaphylaxis (a severe allergic reaction that can be life-threatening and requires immediate medical attention). Review of Resident 4's Nutritional Risk Assessment -V 2 dated 12/30/23 indicated that Resident 4 had Food Allergies/Intolerance: egg whites and shrimp (both give swelling/edema. Review of the facility's undated policy and procedure titled, Food Allergies and Intolerances indicated .Food allergies are immune system responses to allergens(foods), [NAME] antibodies to food attach to mast cells in body tissue (e.g., skin, nose, throat, lungs and gastrointestinal tract) and basophils in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, and inflammatory compound .Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat . Based on observation, interview, and record review, the facility failed to accommodate food preferences, and food allergies for two out of seven sampled residents (Resident 7, and 4), when: 1. For Resident 7, milk was not provided in her lunch tray, and; 2. For Resident 4, she was allergic to egg whites and had eggs in her breakfast tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 24 of 29 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 01/23/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few This failure had the potential for decreased meal intake, adverse effects from food allergies, and negative effect on health and well-being for sampled residents. Findings: During lunch observation in the facility's dining room on 1/16/24 at 12:18 p.m., noted Resident 7 had only one glass of water with ice next to her lunch plate. During an interview with Resident 7 on 1/16/24 at 12:24 p.m., Resident 7 stated there was no milk served for lunch and prefers milk during lunch every day. During a concurrent interview, and record review of Resident 7's lunch tray card with the activity director/restorative nursing assistant (RNA, interact with residents, provide, maintian physical functioning, and prevent further impairment) (AD/RNA) on 1/16/24 at 12:30 p.m., the AD/RNA acknowledged Resident 7 prefers milk, and there was no milk served. The AD/RNA stated dietary staff should have provided skim milk (milk made when all the milkfat removed from whole milk) to Resident 7 to follow her preference for skim milk during lunch. Review of Resident 7's lunch tray card for 1/16/24 indicated, Standing Orders: 8 fl oz (fl oz-fluid ounce: unit used to measure fluid volume) Beverage, 8 fl oz Milk Skim. Review of Resident 7's minimum data set (MDS, resident clinical and functional assessment tool) dated 10/30/23 indicated Resident 7 had a brief interview for mental status (BIMS) score of 15 (score of 13-15: intact cognition). During a concurrent interview and record review of Resident 7's lunch tray card with the facility's registered dietitian (RD) on 1/17/24 at 2:30 p. m., the RD confirmed Resident 7 prefers skim milk during lunch and confirmed resident's food preferences documented in the lunch tray cards. The RD also stated dietary staff should have served skim milk to Resident 7 during lunch to accommodate her food/liquid preferences. Review of facility's policy and procedure (P&P) titled, Resident Food Preferences, revised July 2017, the P&P indicated, The food service department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 25 of 29 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 01/23/2024 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 - Many 1. The convection oven (a cooking device that heats food) located in the skilled nursing facility (SNF) pantry area was not kept in a sanitary condition; 2. No thermometer inside the freezer designated for the SNF residents; 3. The freezer temperature log was not completed, and multiple times, the temperature was 1-2 degrees above 0 Fahrenheit (F, a scale of temperature) degree; 4. The freezer designated for the SNF residents had multiple items unlabeled; 5. An opened bag of pasta was not labeled in the dry storage area; 6. The ice machine was not kept in a sanitary condition; 7. One faucet of the main kitchen was not well maintained; 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 25 residents who receives food from the facility. Findings: 1. During an initial kitchen tour observation and concurrent interview with the facility's registered dietitian (RD) on 1/17/24 at 10 a.m., the convection oven located in the skilled nursing facility (SNF) pantry area had dried brownish particles on the inside top part of the oven and the inner side of the oven door. The RD stated that the kitchen staff should keep it clean. 2. During an initial kitchen tour observation and concurrent interview with the RD and dietary service director (DSD) on 1/17/24 at 11 a.m., there was no thermometer inside the freezer designated to SNF residents, the DSD confirmed the observation. The RD stated that there should be a thermometer inside the freezer. 3. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on 1/17/24 at 11:08 a.m., the temperature log of the freezer designated for SNF residents was not completed, and multiple times, the temperature was 1-2 degrees above 0 Fahrenheit degree in the log. During a concurrent interview and record review with the RD on 1/23/24 at 9:10 a.m., the RD reviewed the freezer temperature log and confirmed that it was not completed. The RD stated that two staff did not initial the temperature log, and the kitchen staff should have kept the freezer temperature below 0 Fahrenheit degree. 4. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 26 of 29 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 01/23/2024 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 1/17/24 at 11:10 a.m., the DSD inspected the freezer designated for SNF food storage and identified the following: Level of Harm - Minimal harm or potential for actual harm a) One bag of shredded cheese with no expiration date. Residents Affected - Many b) One bag of fried potato strips with no expiration date. c) One box of 24 packages of puree breakfast with no open and expiration date. d) 14 packages of puree-linked shaped cooked sausages expired on 10/24/23 e) A bag of vegetable burger patty with no expiration date The RD stated all the food items in the freezer should have been dated and labeled. 5. During an initial kitchen tour observation and concurrent interview with the RD and the DSD on 1/17/24 at 11:30 a.m., the DSD inspected the dry storage room in the main kitchen's basement and identified an opened bag of pasta without a label indicating the open and expiration dates. The RD stated that it should be labeled with open and expiration dates. 6. During an initial kitchen observation and concurrent interview with the RD and the DSD on 1/17/24 at 4 p.m., the ice machine lid had dark brownish particles. The RD stated that the kitchen staff should have kept it clean. 7. During an initial kitchen tour observation and concurrent interview with with the RD on 1/17/24 at 4:30 p.m., the faucer in the main kitchen had a leak (dripping with water). The RD confirmed the observation and stated the kitchen staff needed a new faucet. During a review of the facility's policy and procedure (P&P) titled Food Receiving and Storage, revised October 2017, the P&P indicated, Dry foods that are stored .labeled and dated (use by date) all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements . Refrigerators must have a working thermometer and be monitored for temperature according to state-specific guidelines . During a review of the facility's policy and procedure (P&P) titled Sanitization, revised October 2008, the P&P indicated, All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks .Ice machine and ice storage container will be drained, cleaned, and sanitized per manufacturer's instruction and facility policy . During a review of the facility's policy and procedure (P&P) titled Sanitization, revised October 2008, the P&P indicated, All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks . During a review of the facility's Freezer Temperature Logv(FTL) of 2023, the FTL indicated, temperature must be recorded at least twice during 24 hours period . must be 0 Fahrenheit degree (-18 celsius degrees) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 27 of 29 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 01/23/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, infection control practices were implemented when: Residents Affected - Some 1. Licensed vocational nurse C (LVN C) did not sanitize the blood pressure cuff and pulse oximeter, before she used them on Resident 12; 2. There was a personal food, placed on top of the medication cart 2; and 3. Resident 4's oxygen tubing had no label and was found on the floor. These failures could result in the spread of infection and cross-contamination that could affect the 25 residents residing in the facility. Findings: 1. During the medication pass observation with licensed vocational nurse C (LVN C) on 1/16/24 at 12:25 p.m., LVN C took Resident 12's blood pressure (measure of how forcefully, the blood goes through the arteries) and heart rate (frequency of heartbeat) prior to the administration of hydralazine hydrochloride (used to treat or control high blood pressure) and isosorbide dinitrate (used to treat heart failure) oral medications. LVN C did not sanitize (disinfect) the blood pressure cuff (device used to measure blood pressure) and the pulse oximeter (device used to monitor the amount of oxygen carried in the body) before using them on Resident 12. During an interview with LVN C on 1/16/24 at 12:35 p.m., LVN C verified that she did not sanitize the blood pressure cuff and pulse oximeter, and should have sanitized the equipments before using them on Resident 12. LVN C further verified that she would make sure to sanitize the blood pressure cuff and the pulse oximeter, before and after using them on residents, next time. During an interview with the director of nursing (DON) on 1/17/24 at 10:15 a.m., the DON verified that the blood pressure cuff and pulse oximeter should be sanitized before and after use with residents. The DON further verified that LVN C should have sanitized the blood pressure cuff and pulse oximeter before she used them on Resident 12. During an interview with the infection preventionist (IP), on 1/23/24 at 9:20 a.m., the IP verified that the blood pressure cuff and pulse oximeter should be sanitized, before and after use. Review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised September 2022, indicated, Resident-care equipment, including reusable items . will be cleaned and disinfected according to current Centers for Disease Control (CDC, national public health federal agency, for the protection of public health and safety through the control and prevention of disease, injury and disability) recommendations for disinfection . Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 2. During the medication pass observation with LVN B on 1/18/24 at 8:15 a.m., noted that there was a food placed on top of the medication cart 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 28 of 29 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 01/23/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with LVN B on 1/18/24 at 8:20 a.m., LVN B verified that it was her personal food, on top of medication cart 2. LVN B further verified that personal food should not be in the medication cart for infection control practices. During an interview with the DON on 1/19/24 at 4:45 p.m., the DON verified that nurses should not put their personal food in the medication cart for infection control. Review of Resident 4's clinical record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including acute diastolic heart failure (the left ventricle muscle becomes stiff or thickened and shortness of breath with exertion or when lying down). Review of Resident 4's minimum data set (MDS, an assessment tool) dated 12/21/23 indicated her brief interview for mental status (BIMS, cognition level) score was 15(13 to 15 points suggests that cognition is intact). Review of Resident 4's physician's order summary indicated to administer oxygen 2L/min (l/min, liter per minute) as needed, starting on 12/26/23. During a concurrent observation and interview with certified nursing assistant (CNA) E in Resident 4's room on 1/16/24 at 11 a.m., Resident 4 was lying in her bed with a nasal cannula (NC, a plastic tubing that delivers supplemental oxygen) tubing, and part of the oxygen tubing was on the floor. The NC did not have a label indicating when it was first used or when it need to be changed. CNA E confirmed the above observation and stated the oxygen tubing should not be on the floor. During a concurrent observation and interview in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with a nasal cannula oxygen tubing, and part of the oxygen tubing was on the floor. Resident 4 stated the oxygen tubing had mucus (a sticky slippery substance) and was moist. During a concurrent observation and interview with the minimum data set coordinator (MDSC) in Resident 4's room on 1/18/24 at 9:14 a.m., Resident 4 was lying in her bed with a nasal cannula oxygen tubing, and part of the oxygen tubing was on the floor. Resident 4 stated the oxygen tubing had mucus and was moist. The MDSC stated that the oxygen tubing should not be on the floor and needed to be changed to a new one because the oxygen tubing was moist with mucus inside. During an interview with the infection preventionist (IP) on 1/23/24 at 9 a.m., the IP stated the oxygen tubing should not be on the floor, which might cause infection, and the oxygen tubing required to be labeled with an open date and changed every seven days and as needed. Review of the facility's undated policy and procedure titled Departmental (Respiratory Therapy)- prevention of infection indicated .change the oxygen cannulae and tubing every(7) days, or as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555867 If continuation sheet Page 29 of 29