Other·December 6, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 11/21/18. The facility was licensed for 26 beds. The census at the time of the survey was 20. The sample size was 12. A "G" level deficiency was identified (see

F656). A Class "B" citation was also issued. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse; 38174, Health Facilities Evaluator Nurse; and 34383, Health Facilities Evaluator Nurse.

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 12/12/2018 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 1 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to properly obtain informed consent (permission granted in the knowledge of the possible consequences) for psychotropic medications (medications capable of affecting the mind, emotions and behavior) for five of twelve residents (Residents 4, 10, 14, 18, and 69). This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment in order to make health care decisions. Findings: 1. Review of Resident 4's clinical record indicated he had a physician's order, dated 8/23/18, for Lorazepam (medication used to treat anxiety) 0.5 milligrams (mg, unit of dose measurement) to be administered every two hours as needed (PRN). There was no informed consent document in Resident 4's record for the use of Lorazepam. During an interview with the director of nursing (DON) on 11/20/18 at 10:30 a.m., she reviewed Resident 4's record and confirmed there was no informed consent for the use of Lorazepam. 2. Review of Resident 10's clinical record indicated she had a physician's order, dated 10/31/18, for Citalopram (medication used to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 2 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treat depression) 20 mg to be administered once a day. Review of Resident 10's record indicated she had a "Consent for treatment with Antidepressants" form, dated 1/12/18 for the use of Citalopram. The form did not specify the dose of the medication. During an interview with the DON on 11/20/18 at 2:57 p.m., she reviewed Resident 10's record and confirmed the informed consent for Citalopram did not specify the dose of the medication. 3. Review of Resident 14's clinical record indicated he had a physician's order, dated 10/21/18, for Duloxetine (medication used to treat depression) 60 mg to be administered once a day. There was no informed consent document in Resident 14's record for the use of Duloxetine. During an interview with the DON on 11/20/18 at 3:18 p.m., she reviewed Resident 14's record and confirmed there was no informed consent for the use of Duloxetine. 4. Review of Resident 18's clinical record indicated she had a physician's order, dated 11/12/18, for Lorazepam 0.5 mg to be administered every hour PRN. She also had a physician's order, dated 11/12/18, for Diazepam (medication used to treat anxiety) 10 mg to be administered PRN. There were no informed consent documents in Resident 18's record for the use of Lorazepam and Diazepam. During an interview with the DON on 11/20/18 at 3:56 p.m., she reviewed Resident 18's record and confirmed there were no informed consents for the use of Lorazepam and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 3 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Diazepam. 5. Review of Resident 69's clinical record indicated she had a physician's order, dated 11/6/18, for Lorazepam 1 mg to be administered every 6 hours PRN. She also had a physician's order, dated 11/6/18, for Olanzapine (medication used to treat psychotic symptoms) 5 mg to be administered once a day at bed time. Resident 69 also had a physician's order, dated 11/6/18, for Fluoxetine (medication used to treat depression) 20 mg to be administered once a day at bed time. Review of Resident 69's record indicated she had a "Consent for treatment with an AntiAnxiety Agent" form, dated 11/8/18, for the use of Lorazepam. She also had a "Consent for treatment with Antipsychotic" form for the use of Olanzapine. Resident 69 also had a "Consent for treatment with Antidepressants" form for the use of Fluoxetine. These three consent forms did not specify the doses of the medications. During an interview with the DON on 11/20/18 at 4:20 p.m., she reviewed Resident 69's record and confirmed the informed consents for the above medications did not specify the doses. During an interview with the pharmacy consultant (PC) on 11/21/18 at 10:48 a.m., she stated all psychotropic medications require informed consent and the consent should be filed in the clinical record. The PC confirmed the dose of the medication should be indicated on the informed consent. The facility's undated policy, "Antipsychotic and Other Psychotherapeutic Medication Usage: Verification of Informed Consent", indicated informed consent is to be completed before FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 4 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment is initiated with psychotherapeutic drugs.

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

F583 12/12/2018 §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 5 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and record review, the facility failed to ensure the confidential protected health information (PHI, information in a medical record that can be used to identify an individual, that was created, used, or disclosed in the course of providing a health care service, such as a diagnosis or treatment) of discharged residents was in a secured area when the access key was hanging on the kitchen wall. This failure had the potential to allow access to the confidential PHI of residents who have been discharged from the facility. Findings: During an initial kitchen tour with the dietary manager (DM) on 11/19/18 at 10:14 a.m., the storage area with emergency food supply had confidential PHI of the discharged residents. During a concurrent interview with the DM, she stated the key for the storage area was hanged at the kitchen wall. DM confirmed the discharged residents' confidential PHI was maintained in the storage area and accessible to kitchen staff. During kitchen observation and a concurrent interview with DM 1 on 11/20/18 8:15 a.m., the storage key was hanged on the wall in the kitchen. DM 1 acknowledged the storage key for confidential PHI was hanged on the wall. During an interview with the administrator (ADM) on 11/20/18 at 11:01 a.m., she stated the confidential PHI of all the discharged residents in the facility was maintained in a storage area. She confirmed the confidential PHI key was accessible to kitchen staff. ADM stated the confidential PHI of discharged residents should have been protected with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 6 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited access to the facility staff. Review of the facility's 8/15/14 policy, "Policies and Procedures for Health Information Privacy", indicated the facility will work with its workforce members to ensure that there are no unnecessary or extraneous communication that will violate the rights of its residents to have the confidentiality of their protected PHI. The maintained paper medical records and other protected health information that was in a hard copy form in a separate, identified, secure area where access was limited to work force members with a need for the information.

F656 SS=G Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 12/12/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 7 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to do a fall risk assessment after two falls, failed to develop a fall intervention based on the resident's mental status, and failed to implement the bowel and bladder program care plan for one of 12 residents (Resident 4). These failures resulted in Resident 4's fall with right femoral neck fracture (broken right hip), occipital abrasion (wound on the back of the head caused by rubbing or scraping), and left elbow skin tear. Findings: Review of Resident 4's clinical record indicated he was admitted on 6/28/18 and had the diagnoses of muscle weakness, unspecified fall, unsteadiness on feet, and abnormal posture. Review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 9/6/18, indicated he had a BIMS (Brief Interview for Mental Status) score of 4 (a score of 0 to 7 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 8 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicates severe cognitive impairment) and required extensive assistance (staff provide weight-bearing support) for bed mobility, transfers and toileting. The MDS also indicated Resident 4 wandered (moved aimlessly from place to place), and the wandering placed him "at significant risk of getting to a potentially dangerous place." Review of Resident 4's admission fall risk assessment, dated 6/28/18, indicated Resident 4 had a total score of 50 (a score of 51 or greater indicates high risk for falls). There was no documented quarterly fall risk assessment in Resident 4's clinical record. The quarterly fall risk assessment should have been completed in 9/2018. Review of Resident 4's nurse's note, dated 7/19/18, indicated he had an unwitnessed fall in his bathroom. The note indicated Resident 4 was non-compliant with using his call bell and asking for assistance. Review of Resident 4's "Incident/Accident Report," dated 7/19/18, indicated Resident 4 took off his tab alarm (device attached to the resident that makes noise when the resident attempts to get up without assistance), went to the bathroom and fell. The report further indicated to prevent fall recurrence, the facility implemented the intervention of placing Resident 4's tab alarm in a location where it was more difficult for him to deactivate it. Review of Resident 4's clinical record indicated the facility did not complete a fall risk assessment after he fell on 7/19/18. Review of Resident 4's nurse's note, dated 8/18/18, indicated a licensed nurse "Heard patients tab alarm at 8:00 a.m. and as I was going into his room to assist he slid off edge of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 9 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed to floor onto his bottom..." Review of Resident 4's "Incident/Accident Report," dated 8/18/18, indicated after Resident 4 fell, the intervention implemented to prevent fall recurrence was, "Reminded patient no to get up by himself. Forgetful & needs freq [frequent] reminders." There were no other interventions documented on the report. Review of Resident 4's clinical record indicated the facility did not complete a fall risk assessment after he fell on 8/18/18. Review of Resident 4's record indicated he had a care plan, dated 10/9/18, that indicated, "Bowel and bladder program to assist with getting resident to the restroom safely." There was no documentation in the clinical record to show the facility had been implementing a bowel and bladder program. Review of Resident 4's nurse's note, dated 11/18/18 at 2:55 p.m., indicated a certified nursing assistant (CNA) went to check on Resident 4 and saw him fall backward. According to the note, Resident 4 was noted to have an abrasion to the lower occipital area and the nurse obtained a steri-strip (small bandage used to close or stabilize wounds) for his elbow. There was no documentation in Resident 4's clinical record indicating the facility implemented any new interventions after this fall. Review of Resident 4's nurse's note, dated 11/18/18 at 10:32 p.m., indicated he was being monitored for the fall he experienced during the previous shift. The note indicated, "Noted to have an abrasion and skin tear to left elbow and abrasion to back of head..." Review of Resident 4's nurse's note, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 10 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/19/18, indicated he "screamed out" when the licensed nurse attempted to examine his right hip. Review of Resident 4's X-ray (image of the internal components of the body) report, dated 11/20/18, indicated he had an acute right femoral neck fracture with mild superior displacement (bone was out of normal alignment). During an interview with CNA H on 11/20/18 at 2:38 p.m., she confirmed she was the CNA for Resident 4 when he fell on 11/18/18. CNA H stated on the day of the fall, she assisted Resident 4 back to bed after lunch. She stated she heard things falling and heard "a thud," so she ran to Resident 4's room and saw him lying on his back with his head against his cabinet. CNA H stated this incident occurred "a little bit after 2:30 p.m." During an interview with licensed vocational nurse G (LVN G) on 11/21/18 at 7:37 a.m., she stated Resident 4 was confused and would try to get up without assistance. According to LVN G, no matter how many times staff reminded him, Resident 4 would still try to get up. LVN G explained when staff provided reminders to Resident 4, he would retain the information "for about 5 minutes" and then forget. During an interview with registered nurse A (RN A) on 11/21/18 at 7:51 a.m., she stated Resident 4 was forgetful and would not remember to use his call light even if staff reminded him. She stated if staff reminded Resident 4 not to get up without assistance, he would not remember. RN A stated reminding Resident 4 not to get up was not an appropriate intervention for him. During an interview with the director of nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 11 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (DON) on 11/21/18 at 8:32 a.m., she reviewed Resident 4's clinical record and confirmed that after he fell on 8/18/18, the only new intervention implemented was to remind him not to get up by himself. She confirmed there was no documentation that a bowel and bladder program had been implemented for Resident 4. She also confirmed there was no documentation in Resident 4's record of any new fall prevention interventions after he fell on 11/18/18. The DON stated she had not had a chance to work on Resident 4's most recent fall and no new interventions had been put in place. The DON stated fall risk assessments should be done upon admission and quarterly, but she was not aware they needed to be completed after fall incidents. She confirmed the facility did not complete Resident 4's quarterly fall risk assessment in 9/2018 and did not complete fall risk assessments after he fell on 7/19/18 and 8/18/18. The facility's policy, "Falls and Fall Risk, Managing" revised 3/2018, indicated "The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls." The policy further indicated, "If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. According to the policy, "The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling." The facility's policy, "Assessing Falls and Their Causes" revised 3/22018 indicated, "Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly." The policy further indicated when a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 12 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident falls, completion of a fall risk assessment and appropriate interventions taken to prevent future falls should be documented in the medical record.

F684 SS=D Quality of Care CFR(s): 483.25

F684 12/12/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 12 residents (Residents 69 and 15) when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 13 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. For Resident 69, a physician order for calcium (Ca, a mineral important for bone health) 600 milligrams (mg, unit of measurement), D3 (D3, a hormone that has an important role in calcium and phosphorus metabolism) 800 mg, and magnesium (Mg, mineral important for bone structure) 50 mg was not followed as ordered by the physician. 2. For Resident 15, the facility failed to implement neurological checks (neuro checks, assessment of neurological functions and level of consciousness) and alert charting (licensed nurses on each shift monitor the resident and document their observations in the clinical record) after she fell. These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. During a medication pass observation with registered nurse A (RN A) on 11/19/18 at 10:35 a.m., RN A administered Centrum Silver one tablet for Resident 69. During an interview and record review with RN A on 11/19/18 at 2:20 p.m., she stated Resident 69's physician order was Ca/D3/Mag 600/800/50 mg one tablet once a day but Centrum Silver did not meet the dosage as ordered by the physician. RN A stated the physician order for Ca/D3/Mag 600/800/50 mg was not followed as ordered by the physician. Review of the facility's 7/2016 policy, "Medication and Treatment Orders", indicated the orders for medications and treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 14 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the California Nursing Practice Act, Scope of Regulation, Business and Professions Code, Division 2, Chapter 6, Article 2 Section 2725, Subsection (b)(2), enacted 1/1/2013, indicated direct patient care services, including but not limited to, the administration of medication and therapeutic agents, necessary to implement a treatment, disease prevention or rehabilitative regimen is carried out by a nurse when ordered by and within the scope of licensure of a physician. 2. Review of Resident 15's nurse's note, dated 9/8/18, indicated, "Resident slid out of her chair this morning." There was no documentation in Resident 15's clinical record that staff implemented neuro checks after this fall. During an interview with the director of nursing (DON) on 11/20/18 at 12:29 p.m., she stated neuro checks should be implemented if a resident had a fall that was unwitnessed. The DON confirmed Resident 15's fall on 9/8/18 was unwitnessed. She reviewed the clinical record and confirmed there was no documentation of neuro checks for Resident 15 after she fell on 9/8/18. During the interview, the DON reviewed her "Incident/Accident Report" binder and stated Resident 15 also had a fall on 8/4/18. Review of Resident 15's clinical record indicated there was no documentation that nurses were monitoring her for complications after she fell on 8/4/18. During a follow-up interview with the DON on 11/21/18 at 8:24 a.m., she stated if a resident had a fall, licensed nurses should do alert charting for 72 hours. She reviewed Resident 15's record and confirmed there was no documentation of alert charting for her fall on 8/4/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 15 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility's policy, "Assessing Falls and Their Causes" revised 3/2018, indicated, "Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record."

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 12/12/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 16 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview, record review, the facility failed to ensure one resident (Resident 13) who was admitted to the facility with an indwelling urinary catheter (foley catheter, tube inserted into the bladder to drain urine), and who had a history of urinary tract infection (UTI ) had a physician order for it, received the necessary care and services as indicated in the facility's policy and procedure. These deficient practices had the potential for Resident 13 to have increase recurrent UTI's and could cause actual harm. Findings: Review of Resident 13's medical record indicated Resident 13 was admitted to the facility on 8/14/18 and readmitted on 9/23/18, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), bladder obstruction, indwelling urinary catheter, UTI. Her Minimum Data Set (MDS, an assessment tool) dated 8/20/18 indicated she was cognitively intact . Review of Resident 13's Discharge Summary from general acute hospital (GACH) dated 9/23/18, indicated Resident 13 was treated for UTI, and her indwelling urinary catheter can be discontinued at the facility and will need followup care with her urologist. Review of Resident 13's laboratory test results for urinalysis, culture and sensitivity (C&S, culture is a test to find germs [such as bacteria or a fungus] that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic [a medicine that inhibits the growth of or destroys bacteria or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 17 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE germs] will work best to treat the illness or infection.) dated 10/9/11, 10/11/18 ,10/25/18, 11/6/18, and 11/8/18 indicated positive Escherichia coli (E.Coli, a type of bacteria that can cause UTI). Resident 13 was treated with antibiotics such as Cipro on 10/11/18, Macrobid 10/26/18 and Bactrim 11/9/18. Review of Resident 13's Physician Order Sheet dated 8/30/18 indicated to change Foley catheter once monthly starting 9/10/18 and check patency every shift and dated 8/14/18. Review of Resident 13's Physician Order Sheet dated October 2018 did not indicate Foley catheter order and management . Review of Resident 13's treatment administration record (TAR) found no documentation of Foley catheter was changed on 10/10/18 and 11/10/18. Further review of Resident 13's medical record revealed the lack of evidence that an assessment was conducted to determine whether the discharge summary from GACH was followed and attempt to change the indwelling urinary catheter based on recurrent UTI's. During an interview with Resident 13 on 11/20/18 at 11:44 a.m., Resident 13 stated "as far as I remember, they have not change my Foley catheter, maybe once". During an interview with the director of nursing (DON) on 11/20/18 at 11:46 a.m., she was asked to review medical records of Resident 13. The DON confirmed Resident 13 did not have order for indwelling catheter, the indwelling catheter was not changed since 9/10/18, and there was no evidence to support that assessment was done to determine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 18 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE attempts to remove the indwelling catheter as per discharge summary from GACH and related to Resident 13's recurrent UTI's. Review of the facility's revised 9/14 policy, "Catheter Care, Urinary", indicated the purpose of this procedure was to prevent catheterassociated urinary tract infections. It was suggested that changing catheter and drainage bag based on clinical indications such as infection etc. The following should be recorded in the resident's medical record: all assessment data obtained when giving catheter care.

F691 SS=D Colostomy, Urostomy, or Ileostomy Care CFR(s): 483.25(f)

F691 12/12/2018 §483.25(f) Colostomy, urostomy,, or ileostomy care. The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one resident (Resident 13) who required an ileostomy (a surgical operation in which the lower part of the small intestine [ileum] is made into an opening in the abdomen wall for the stool to pass into a bag) received the necessary care and treatments when the facility failed to get a physician order, and treatments documented on the resident's treatment administration record (TAR). This failure had the potential to place the resident at risk for complications such as dislodgement and infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 19 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 13's clinical record indicated Resident 13 was admitted to the facility on 8/14/18 and readmitted on 9/23/18, with diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), intestinal obstruction (a blockage that keeps food or liquid from passing through your small intestine or large intestine), ileostomy. Review of Resident 13's Physician Order Sheet dated 8/18/18 indicated to change ileostomy bag when seal is open as needed by shift. Her care plan dated 8/14/18 indicated provide care to site every shift during routine care. Review of Resident 13's Physician Order Sheet dated October 2018 did not indicate the care for ileostomy. Review of Resident 13's TAR dated October 2018 found no documentation that included ileostomy care had been performed. During an interview with licensed vocational nurse B (LVN B) on 11/20/18 at 10:00 a.m., LVN B was asked to review Resident 13's physician order and TAR. LVN B confirmed that from 10/1/18 to 11/20/18, there was no order for ileostomy care. LVN B stated licensed nurses should document on the TAR that care was rendered on their shift and it was not done. During an interview with the director of nursing (DON) on 11/20/18 at 10:15 a.m., she stated the ileostomy care order was "missed" from 10/1/18 to 11/20/18. DON further stated that the treatments should be documented. Review of the facility's revised 10/10 policy, "Colostomy/Ileostomy", indicated the purpose of this procedure was to provide guidelines that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 20 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would aid in preventing exposure of the resident's skin to fecal matter. The following should be recorded in the resident's medical record: the date and time the colostomy/ileostomy care was provided.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 12/12/2018 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 21 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure four of 12 residents (Residents 4, 14, 18, and 69) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 4, the facility did not monitor for target behaviors and side effects of Lorazepam (medication used to treat anxiety) and did not develop a care plan for the use of Lorazepam; 2. For Resident 14, the facility failed to ensure an order for as needed (PRN) Ativan (medication used to treat anxiety) was limited to 14 days, did not develop a care plan for the use of Ativan, and did not monitor for side effects of Duloxetine (medication used to treat depression); 3. For Resident 18, the facility did not develop care plans for the use of Lorazepam and Diazepam (medication used to treat anxiety); and 4. For Resident 69, the facility failed to ensure there was a documented diagnosis for the use of Olanzapine (medication used to treat psychotic symptoms) and did not develop a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 22 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan for the use of Olanzapine. These failures had the potential to negatively affect the residents' physical, mental, and psychosocial well-being. Findings: 1. Review of Resident 4's clinical record indicated he had a physician's order, dated 8/23/18, for Lorazepam 0.5 milligrams (mg, unit of dose measurement) to be administered every two hours PRN. There was no care plan in Resident 4's record to address the use of Lorazepam. Review of Resident 4's 11/2018 medication administration record (MAR) indicated the Lorazepam was for anxiety manifested by restlessness. There was no documentation of behavior monitoring or side effects monitoring on the MAR. During an interview with the director of nursing (DON) on 11/20/18 at 10:30 a.m., she reviewed Resident 4's record and confirmed there was no documentation of behavior monitoring or side effects monitoring for the use of Lorazepam. During an interview with licensed vocational nurse B (LVN B) on 11/21/18 at 10:24 a.m., he reviewed Resident 4's record and confirmed there was no care plan for the use of Lorazepam. During an interview with the pharmacy consultant (PC) on 11/21/18 at 10:30 a.m., she stated monitoring for side effects of psychotropic medications must be in place. 2. Resident 14's clinical record was reviewed on 11/20/18. The record indicated he had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 23 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physician's order, dated 10/22/18, for Ativan 0.5 mg to be administered every six hours PRN. There was no documented rationale from Resident 14's physician for extending the PRN Ativan order beyond 14 days. There was no care plan in Resident 14's record to address the use of Ativan. During an interview with the DON on 11/20/18 at 3:18 p. m., she confirmed PRN orders for psychotropic medication should be limited to 14 days and upon reassessment, the physician can decide to continue to the order. The DON reviewed Resident 14's record and confirmed there was no documented rationale from the physician for continuing the PRN Ativan order beyond 14 days. During an interview with LVN B on 11/21/18 at 10:18 a.m., he reviewed Resident 14's record and confirmed there was no care plan for the use of Ativan. During an interview with the pharmacy consultant (PC) on 11/21/18 at 10:30 a.m., she stated PRN psychotropic medications were subject to a 14 day duration. The PC explained if PRN psychotropic medication needed to be extended beyond 14 days, the physician must document a rationale and specify a duration for treatment. Review of Resident 14's clinical record indicated he had a physician's order, dated 10/21/18, for Duloxetine 60 mg to be administered once a day. There was no documentation indicating licensed nurses had been monitoring Resident 14 for side effects of Duloxetine. During an interview with the DON on 11/20/18 at 3:18 p.m., she reviewed Resident 14's clinical record and confirmed there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 24 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE documented side effects monitoring for Duloxetine. The DON acknowledged licensed nurses should be monitoring for side effects of Duloxetine During an interview with the PC on 11/21/18 at 10:30 a.m., she stated monitoring side effects of psychotropic medications must be in place. 3. Review of Resident 18's clinical record indicated she had a physician's order, dated 11/11/18, for Lorazepam 0.5 mg to be administered as needed. She also had a physician's order, dated 11/11/18, for Diazepam 10 mg to be administered as needed. There were no care plans in Resident 18's record to address the use of Lorazepam and Diazepam. During an interview with LVN B on 11/21/18 at 10:18 a.m., he reviewed Resident 18's clinical record and confirmed there were no care plans in place for the use of Lorazepam and Diazepam. 4. Review of Resident 69's clinical record indicated she was admitted on 11/6/18 and had the diagnoses of fibromyalgia (musculoskeletal pain, fatigue, and tenderness in localized areas), chronic pain, anxiety disorder, major depressive disorder (persistent feeling of sadness and loss of interest), aortic aneurysm (enlargement of the aorta), kidney failure and pyothorax (infection in the chest cavity). Review of Resident 69's physician's order, dated 11/6/18, indicated Resident 69 was to receive Olanzapine 5 mg once a day at bed time. There was no documented diagnosis in Resident 69's record for the use of Olanzapine. There was no care plan in the record to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 25 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE address the use of Olanzapine. During an interview with the DON on 11/20/18 at 4:20 p.m., she reviewed Resident 69's record and confirmed there was no documented diagnosis for the use of Olanzapine. The DON acknowledged there should have been a diagnosis. During an interview with LVN G on 11/21/18 at 6:56 a.m., she reviewed Resident 69's clinical record and confirmed there was no care plan in place to address the use of Olanzapine. LVN G confirmed there should have been a care plan in place. During an interview with the PC on 11/21/18 at 10:30 a.m., she stated there should be a diagnosis or indication in place for psychotropic medication. The facility's 11/2016 policy, "Medication Monitoring; Medication Management", indicated "The prescriber and the care planning team reassess the continued need for the ordered medication. Effects of the medications are documented as part of the care planning process." The policy also indicated, "The medical necessity is documented in the resident's medical record and in the care planning process."

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

F761 12/12/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 26 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator temperature was checked twice daily for the proper ranges. This failure had the potential to compromise the therapeutic effectiveness of the stored medication. Findings: During an interview and record review with the director of nursing (DON) on 11/19/18 at 3:43 p.m., the medication refrigerator had three vials of influenza vaccine (are made to protect against three flu viruses) and three vials of purified protein derivative (PPD, a test that determines if you have tuberculosis (an airborne bacterial infection caused by the organism). She stated the medication refrigerator temperature log was checked once a day on 11/1/18, 11/2/18, 11/7/18, 11/9/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 27 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/12/18, 11/13/18, 11/16/18, 11/17/18, 11/18/18, and 11/19/18. During an interview with the pharmacy consultant (PC) on 11/20/18 at 9:40 a.m., she stated the medication refrigerator temperature should have been checked twice daily for proper ranges. Review of the facility's undated policy, "Refrigerator temperature log", indicated temperature must be recorded a minimum of twice daily during 24 hour period.

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

F812 12/12/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure foods were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 28 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stored, prepared, and served under sanitary condition when: 1. Walk-in refrigerator a bag of fresh thyme and sage leaves were undated and unlabelled; an opened bag of mint leaves with brown in color, a honeydew with brown color spots, a bin of sugar and a bin of panko crust with opened lid. 2. Dry storage an opened bag of pasta and an opened bag of graham. 3. Walk-in freezer an opened bag of green peas undated. 4. Juice dispenser with gray particles on the vent. 5. dishwasher with no air gap . These failures had the potential to cause foodborne illness in residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour with the dietary manager (DM) on 11/19/18 at 8:40 a.m., in the walk-in refrigerator observed an opened bag of fresh thyme leaves unlabeled and undated, an opened bag of fresh sage leaves unlabeled and undated, an opened bag of fresh mint leaves with brown in color unlabeled and undated, a honeydew with brown color spots unlabeled and undated. Under the kitchen table a bin of sugar and a bin of panko crust with opened lid. During a concurrent interview with the DM, she stated the food should have been dated and labeled the day it was received. DM stated the food that has been discolored should have been thrown. She also stated the lids for a bin of sugar and panko crust should have been closed. Review of the facility's undated policy, "Food Rotation And Receiving In Service", indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 29 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when the produce delivered, check for quality bruises, discoloration, texture, and please reject for credit. To store foods labeled use the date gun with month day and year if the label gun not available use label tape to include month day and year. Review of the facility's undated policy, "Receiving and Storing Food", indicated all items with lids must be closed when not in use. 2. During an observation and concurrent interview with the DM on 11/19/18 at 9:30 a.m., the dry storage with opened bag of graham and opened bag of pasta. DM stated the opened bag of graham and open bag of pasta should have been transferred into a container. Review of the facility's undated policy, "Receiving and Storing food", indicated when the product was opened, transferred into food grade containers labeled with opened date and expiration dated. 3. During an observation and concurrent interview with the DM on 11/19/18 at 9:53 a.m., the walk-in freezer observed an opened bag of green peas with no date. The DM stated the opened bag of green peas should have been dated. 4. During an observation and concurrent interview with the DM on 11/19/18 at 9:19 a.m., the juice machine observed with gray particles on the right side vent. The DM stated the juice machine was dirty and it should have been cleaned. Review of the facility's undated policy,"Cleaning Procedure for Juice Machine", indicated to wipe down all outside surfaces of juice machine including vents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 30 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. During an observation and concurrent interview with the DM on 11/19/18 at 9:12 a.m., the dishwasher pipe was on the floor and did not have air gap. The DM stated the dishwasher pipe should have an air gap to prevent backflow. Review of the Food Code dated 2013, "Backflow Prevention, Air Gap", indicated an air gap between water supply inlet and the flood level rim of the plumbing fixture, equipment, or non food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one (1) inch.

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

F880 12/12/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 31 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 32 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to observe infection control measures for one residents (Resident 12) when registered nurse A (RN A) did not wash her hands before applying and removing gloves. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: During a medication pass observation and interview with registered nurse A (RN A) on 11/19/18 at 10:56 a.m., RN A was wearing gloves on both hands when she administered an eye drop to Resident 12. She removed her gloves and put on a new set of gloves without washing her hands. RN A confirmed she did not wash her hands before she put on a new set of gloves. During an interview with director of nursing (DON) on 11/20/18 at 9:15 a.m., she stated the licensed nurse should have washed her hands before and after gloving. Review of the facility's revised 8/15 policy, "Handwashing/ Hand Hygiene", indicated to perform hand hygiene before applying and removing gloves.

F881 SS=D Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 12/12/2018 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 33 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow the Infection Management Guidelines of their antibiotic stewardship program for one resident (Resident 13). This had the potential for unmonitored and unnecessary use of antibiotics for residents. Findings: Review of Resident 13's medical record indicated Resident 13 was admitted to the facility on 8/14/18 and readmitted on 9/23/18, with diagnoses that included bladder obstruction, history of urinary tract infection (UTI) and had an indwelling urinary catheter. Review of Resident 13's laboratory test results for urinalysis and, culture and sensitivity (C&S, culture is a test to find germs [such as bacteria or a fungus] that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic [a medicine that inhibits the growth of or destroys bacteria or germs] will work best to treat the illness or infection) dated 10/9/18, 10/11/18, 10/25/18, 11/6/18, and 11/8/18 indicated positive Escherichia coli (E.Coli, a type of bacteria that can cause UTI ). Resident 13 was treated with antibiotics such as Cipro on 10/11/18, Macrobid on 10/26/18 and Bactrim on 11/9/18. Review of Resident 13's Clinical Notes Report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 34 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 11/9/18 indicated the C&S result showed Resident 13 became resistant to antibiotic Macrobid, and on 11/9/18, Resident 13 was started on Bactrim. During an interview and record review with the director of nursing (DON) and Infection Preventionist (IP) on 11/21/18 at 9:43 a.m., she stated Resident 13 was admitted to the facility with recurrent UTI's, had indwelling catheter in place, and on antibiotic medication. The DON said the facility utilized the Infection Management Guidelines in which under Resident Assessment Algorithm criteria for UTI with indwelling catheter, everytime that the urinary tests were ordered, Resident 13 did not have symptoms such as fever, urinary pain, abnormal discharges. The guidelines also indicated under Diagnostic Testing Algorithm to change indwelling catheter first if resident had indwelling catheter for more than two weeks. The DON confirmed there was no attempt to change the indwelling urinary catheter since 9/10/18 and in between each urinalysis test. The DON said there was no documentation that the physician was educated on the potential harm of the antibiotics not meeting the criteria because Resident 13 was known to have recurrent UTI's. During an interview and record review with the director of staff development (DSD) and an IP on 11/21/18 at 10:14 a.m., the Line Listing of Resident infections form dated 10/11/18 and 10/26/18 indicated Resident 13 did not meet infection criteria for UTI. The DSD stated the DON was made aware of her findings. According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 35 of 36 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555867 (X3) DATE SURVEY COMPLETED 11/21/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOREST HILL MANOR HEALTH CENTER 551 Gibson Ave Pacific Grove, CA 93950 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. Review of the facility's revised 12/16 policy, "Antibiotic Stewardship", indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OUMD11 Facility ID: CA630012059 If continuation sheet 36 of 36