Health inspection·May 9, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete her regarding the incident. The DON stated I expect staff to treat residents with kindness, consideration, and appropriateness. Per the facility's policy titled, Quality of Life - Dignity, revised August 2009, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .2.resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 7. Staff shall speak respectfully to residents at all times . Event ID: Facility ID: 055488 If continuation sheet Page 2 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 did not ensure 3 out of 3 residents were clinically appropriate for self-administration of medications. This deficient practice put Residents 22, 54 and 74 at risk for unsafe medication administration. Residents Affected - Few Findings: 1) Per the facility's Resident Face Sheet, Resident 54 was admitted on [DATE] with diagnoses including dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). On 5/6/19 at 9 A.M., Resident 54 was observed sitting on the side of her bed. Resident 54's bedside table was in front of her. On the bedside table, there was a medicine cup containing 5 pills, another medicine cup with applesauce, and a cup of apple juice. Resident 54 was observed scooping the applesauce with a spoon into the cup with the pills. She put the spoon of pills and applesauce in her mouth and sipped apple juice to swallow them. There were no staff observed in the room or outside of the room. On 5/6/19 at 9:08 A.M., during an interview, Resident 54 stated, they let me take my own meds (medicine). When Resident 54 was asked if she knew what each pill was for, she stated, I have so many, I forgot what they are. On 5/6/19 at 9:10 A.M., an observation of the medication nurse assigned to Resident 54 was conducted. LN 47 was assigned to Resident 54, and was observed four rooms down the hall from Resident 54's room. LN 47 was attending to another resident. On 5/6/19 Resident 54's medical records were reviewed. There was no record of an IDT meeting regarding an assessment to determine if Resident 54 was appropriate to self-administer medications. In addition, there was no order for self-administration of medications. On 5/8/19 at 3 P.M., during an interview with the DON. The DON stated LN 47 should not have allowed Resident 54 to take her own medications. 2) Per the facility's Resident Face Sheet, Resident 74 was admitted on [DATE] with diagnoses which included, history of falling and cognitive impairment. On 5/6/19 at 10:50 A.M., an observation was conducted at Resident 74's bedside. On Resident 74's bedside table, there was a tube labeled, Max Strength [brand name] pain cream (skin ointment) and a bottle labeled, [brand name] with Lidocaine (a medicated skin ointment). During an interview on 5/6/19 at 10:50 A.M., Resident 74 stated, I have bad knees, my son brought me the pain medications for my knees. I put the medication my son brings in on my knees whenever I need it and it helps with the pain. On 5/6/19 Resident 74's records were reviewed. There were no records of an IDT meeting regarding an assessment to determine if Resident 74 was appropriate to self-administer medications. In addition, there was no order for self-administration of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 3 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0554 Level of Harm - Minimal harm or potential for actual harm On 5/8/19 at 7:45 A.M., a joint observation and interview was conducted with LN 52 at Resident 74's bedside. LN 52 was observed picking up the tube of pain cream (skin ointment) and the bottle of medicated skin ointment from Resident 74's bedside table. LN 52 stated, He has pain meds at his bedside. I'll have to check for an order. On 5/8/19 at 8 A.M. LN 2 said, This should not be at his bedside without a doctor's order. Residents Affected - Few 3. Resident 22 was admitted to the facility on [DATE] with diagnoses which included gastrostomy (surgical opening created into the stomach from the abdominal wall, for the introduction of food), per the facility's Resident Face Sheet. On 5/6/19 at 10:34 A.M., an interview was conducted with Resident 22. Resident 22 stated he self-administered his own g-tube feedings (food formula administered through a tube that goes into the stomach) and medications through his g-tube. Resident 22 stated he had been self-administering medications for months. A record review was conducted on 5/6/19. Resident 22's physician's orders, dated 2/19/19, indicated, Able to self administer medication through g-tube . On 5/9/19 at 10:08 A.M., a joint interview and record review was conducted with LN 52. LN 52 stated residents who had a physician's order to self-administer medications were required to be educated and then assessed as competent and capable to self-administer. LN 52 stated the assessment and education had to be conducted and documented prior to the resident starting self-administration of medications. LN 52 reviewed Resident 22's clinical record and stated there was no documentation a self-administration assessment had been performed. On 5/9/19 at 10:19 A.M., an interview was conducted with LN 53. LN 53 stated Resident 22 had self-administered his own medication for the past couple of months. On 5/9/19 at 1:36 P.M., a joint interview and record review was conducted with LN 51. LN 51 stated she reviewed Resident 22's medical record and found no documentation the resident had been assessed capable to self-administer his own medications prior to beginning self-administration. LN 51 stated it was important for residents who planned to self-administer medication through a g-tube to be thoroughly assessed as the procedure was complicated. LN 51 stated there was no documentation Resident 22 did a return demonstration, or was deemed safe to self-administer medications through his g-tube prior to starting self-administration of medications. LN 51 stated a return demonstration and assessment documentation should have been completed prior to Resident 22 self-administration of medications. On 5/9/19 at 2:07 P.M., an interview was conducted with the DON. The DON stated residents who wanted to self-administer medications had to be assessed and determined safe and competent prior to starting self-administration. The DON stated residents were required to do a return demonstration of self-administration and the results of the demonstration should be documented. The DON stated there was no documentation Resident 22 was fully assessed prior to starting self-administration. The DON stated a complete assessment should have been done prior to Resident 22 self-administration of medications. Per the facility's policy titled Self-Administration of Medications, revised December 2016, .1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical capabilities to determine whether self-administering medications is clinically appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 4 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0554 for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment . 5. The staff and practitioner will document their findings . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 5 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate and support the residents right for self-determination for one of 18 residents reviewed for choices (175). The facility failed to promote Resident 175's right to choose their pain medication. Findings: Per the Resident Face Sheet, Resident 175 was admitted to the facility on [DATE] with a diagnosis which included muscle weakness and difficulty in walking. On 5/6/19 during an interview at 10:10 A.M., Resident 175 stated he was admitted to the facility for physical therapy after having undergone a hip replacement. Resident 175 stated, I'm getting better but I would like to stop taking the Oxycodone (narcotic pain medication) and just take Tylenol (acetaminophen) for pain. Resident 175 further stated, I would like to go home with just Tylenol and not the strong pain medications. On 5/7/19 at 12:55 P.M., LN 53 and Resident 175 were observed during Medication administration. LN 53 was observed entering Resident 175's room. LN 53 asked Resident 175, What is your pain level? Resident 175 stated, My pain level is 6 (moderate pain), but I want to stop taking the narcotic. I'd like to take Tylenol for my pain. LN 53 stated, You don't have an order for Tylenol, I'll give you the narcotic, that's what you had last time. On 5/7/19 at 1 P.M., LN 53 was observed administering 1 tablet of Oxycodone to Resident 175. Review of Resident 175's Physician Order Report indicated, Acetaminophen tablet; 500mg; amt: 2 tabs; oral Special Instructions: pain management .Ordered on 5/5/19. On 5/7/19 at 3:30 P.M. LN 53 stated she reviewed Resident 175's orders and saw that he had an order for acetaminophen. LN 53 stated she should have given Resident 175 acetaminophen instead of the Oxycodone. According to the facility's policy titled, Resident Rights, revised August 2009, . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. Choose a physician and treatment and participate in decisions and care planning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 6 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility did not provide a clean, comfortable and homelike environment when a resident bathroom sink was clogged. This deficient practice created unsanitary conditions for 5 residents (17, 34, 58, 65, 68) who used the sink. Findings: On 5/6/19 at 9:30 A.M., Resident 65's family members (FM 1 and FM 2) were interviewed. FM 1 stated, My mom's sink has been clogged for a long time. It drains very slowly and sometimes the sink is filled with dirty water and we can't wash our hands or wet a wash cloth because we're afraid it will overflow. FM 2 stated, We've been having problems with the sink for about 4 months now. On 5/6/19 at 9:35 A.M., The sink in Resident 65's room was observed. The sink had about 3 inches of standing water in the bowl. Upon observation, there was no plug or any other object blocking the drain in the bowl of the sink. There was a clear glass vase which contained 2 inches of gray water positioned under the sink's drain pipe below the sink's counter. On 5/06/19 at 10 A.M., a concurrent observation and interview was conducted with CNA 1. CNA 1 stated, I am usually assigned to these residents and I work four days a week, the sink has been clogged off and on for a long time. CNA 1 further stated, . this bathroom is connected to 2 rooms. CNA 1 stated she used the sink to care for five dependent residents (17, 34, 58, 65, 68). CNA 1 stated it was difficult when the sink was clogged because no one can use the sink until the water has drained. CNA 1 stated she had to leave the patient care area and wash her hands at the nurse's station. On 5/6/19 at 10:20 A.M., an interview was conducted with the charge nurse. LN 50 stated, I had not heard anything about a clogged sink in Resident 65's room, when something needs fixing, we call the maintenance supervisor (MS) and write the problem in the log book. On 5/6/19 at 10:30 A.M., MS was observed in Resident 65's bathroom, under the sink. MS stated, I've known about the problem with the sink for a long time, it gets fixed then it gets clogged again. On 5/6/19, a joint record review was conducted with LN 50. The maintenance log book was reviewed, LN 50 stated there was no record the clogged sink was reported to MS. Per the facility's policy, titled Quality of Life- Homelike Environment, revised May 2017, . 2. The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 7 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of the facility's bed hold policy (a policy of reserving a resident's bed while a resident was out of the facility for hospitalization or therapeutic leave) prior to, or within 24 hours of the resident's transfer to the acute hospital for one of three residents (276) reviewed for bed hold notices. This failure resulted in the potential for Resident 276 and/or the resident's responsible party to be unaware of their right to reserve a bed in the facility during the resident's first seven days of being admitted to the acute hospital. Findings: On 5/9/19, Resident 276's medical record was reviewed. Resident 276 was admitted to the facility on [DATE] with the diagnoses of hepatic (liver) failure and diabetes (body's ability to produce or respond to the hormone insulin), per the Resident Face Sheet. A nurses note, dated 3/12/19 at 8:50 P.M., indicated Resident 276 was transferred to the acute care hospital emergency room. There was no documentation in Resident 276's record that the facility provided Resident 276, or Resident 276's responsible party written information regarding the facility's bed hold policies at the time of transfer or within 24 hours. The Bed Hold Policy and Notification form was not signed by Resident 276 or Resident 276's representative. On 5/9/19 at 10:55 A.M., an interview and record review was conducted with the MR assistant. The MR assistant noted Resident 276's record did not contain the Bed Hold Policy and Notification form signed. The MR assistant stated the form should have been signed so the resident was aware of her right to hold her bed. Per the facility's policy titled, Bed-holds and Returns, dated March 2017, .Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 8 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the MDS assessment section for nutrition was accurately coded for one of four tube fed residents (Resident 38) reviewed for tube feeding. This failure had the potential to affect the nutritional plan of care and ultimately the overall quality of life for Resident 38. Findings: Resident 38 was readmitted to the facility on [DATE] with the diagnoses of dysphagia (difficulty swallowing) and new gastrostomy (GT a tube inserted through the abdomen that delivers liquid nutrition directly to the stomach) site per the registered nurse (RN) admission note. On 5/7/19 at 9:26 A.M., an interview was conducted with the SLT. The SLT stated when Resident 38 came back from the hospital in August of 2018, she was dependent on tube feeding for nutrition because of her dysphagia. The SLT stated Resident 38 had failed several swallowing evaluation attempts and she had provided treatments to Resident 38 off and on between August of 2018 and March 2019. On 5/7/19, Resident 38's medical record was reviewed. The Speech Therapy notes indicated Resident 38 was treated for dysphagia and food trials by mouth in August and September of 2018 and again in November 2018, December 2018 and February 2019. An SLT note, dated 8/8/19, indicated Resident 38's ability to swallow was absent with little to no attempts to initiate/participate. The SLT long term goal for Resident 38 was to improve swallow abilities .to safely and efficiently swallow least restrictive diet . A review of Resident 38's MDS (a tool to assess functional ability) assessments, Section K Swallowing/Nutritional Status, from August 2018 through March 2019 indicated Resident 38 had no difficulty with swallowing and was dependant more than 51% of overall nutrition from the tube feeding. On 5/8/19 at 9:05 A.M., an interview was conducted with the SLT. The SLT stated she could not understand how MDS assessments were coded as no difficulty with swallowing as Resident 38 definitely had dysphagia. On 5/8/19 at 9:45 A.M., an interview and record review of Resident 38, was conducted with the MDS nurse. The MDS nurse noted Resident 38 had been NPO (nothing by mouth), tube fed, had a diagnosis of dysphagia and had been treated by the SLT for dysphagia. The MDS nurse stated she had coded the assessments incorrectly. The MDS nurse stated proper coding in the MDS was important as it generated the plan of care. The MDS nurse also stated the care plan dictates the care delivered to the patient. Per the facility's policy titled Resident Assessment Instrument, dated September 2010 .3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 9 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure written care plans were developed timely or consistently implemented for two of 18 residents (22 and 47) reviewed for care plans. These failures had the potential to put residents at risk by not providing appropriate, consistent, and individualized care. Findings: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included gastrostomy (opening into the stomach from the abdominal wall, made surgically for the introduction of food), per the facility's Resident Face Sheet. On 5/6/19 at 10:34 A.M., an interview was conducted with Resident 22. Resident 22 stated he self-administered his own g-tube feedings (food formula administered through a tube that goes into the stomach) and medications through his g-tube. Resident 22 stated he has been self-administering for months. A record review was conducted on 5/6/19. Resident 22's physician's orders, dated 2/19/19, indicated, Able to self administer medication through g-tube . On 5/9/19 at 10:19 A.M., an interview was conducted with LN 53. LN 53 stated Resident 22 had been self-administering his own medication for the past couple of months. Resident 22's written care plan titled Self Admin (administration) Med (medications) Care Plan, dated 4/10/19, was reviewed. On 5/9/19 at 1:36 P.M., a joint interview and record review was conducted with LN 51. LN 51 stated she reviewed Resident 22's written care plan for self-administration of medications created on 4/10/19 and the care plan was not developed timely. LN 51 stated Resident 22 had started to self-administer his own medications on or around 2/19/19 when the physician's order was written. LN 51 stated the written care plan should have been created prior to Resident 22 starting to self-administer medications. On 5/9/19 at 2:07 P.M., an interview was conducted with the DON. The DON stated written care plans guided the care given to a resident. The DON stated a written care plan should have been developed back when Resident 22 started to self-administer his own medications. The DON stated Resident 22's written care plan for self-administering medication was not created in a timely manner. The facility's policy titled Goals and Objectives, Care Plans, revised April 2009, did not provide guidance on care plan development. 2. Resident 47 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 5/8/19 at 6:03 A.M., an observation was conducted of the outside patio across from the conference room. Resident 47 was alone outside with no other staff or residents present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 10 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0656 On 5/8/19 at 6:08 A.M., the human resources director (HRD) was observed going outside to the resident. Level of Harm - Minimal harm or potential for actual harm On 5/8/19 at 6:15 A.M., an interview was conducted with the HRD. The HRD stated Resident 47 was on a 1:1 supervision (staff constantly monitored a resident by remaining in close proximity to the resident). Residents Affected - Few A record review was conducted on 5/8/19. Resident 47's written care plan titled Smoking Care Plan, revised 5/8/19, indicated, .Resident continues to be non compliant with non smoking policy at facility and will be monitored one to one due to potential harm to other residents and self . On 5/8/19 at 7:16 A.M., a joint interview and record review was conducted with LN 48. LN 48 stated Resident 47 should not have been alone outside for any length of time. LN 48 stated 1:1 supervision required a constant staff present with the resident at all times. LN 48 reviewed Resident 47's written care plan for smoking and stated the care plan had not been consistently implemented when the resident was left unattended. On 5/8/19 at 11:03 A.M., an interview was conducted with LN 50. LN 50 stated Resident 47's intervention of 1:1 supervision had not been implemented when the resident was observed unattended outside. LN 50 stated Resident 47's smoking care plan should have been consistently implemented. On 5/9/19 at 7:34 A.M., an interview was conducted with the HRD. The HRD stated Resident 47 was left outside unattended on 5/8/19 when he was supposed to be on 1:1 supervision. The HRD stated the attendant left without waiting for their replacement. The HRD stated this should not have happened. The HRD stated Resident 47 should not have been unattended for any length of time while on 1:1 supervision. On 5/9/19 at 8:19 A.M., an interview was conducted with the DON. The DON stated Resident 47 was not consistently on 1:1 supervision when observed unattended on 5/8/19. The DON stated it was her expectation for staff to be in very close proximity to a resident during 1:1 supervision. The DON stated Resident 47 should not have been left alone at any time. The DON stated Resident 47's written care plan for smoking was not consistently implemented when the resident was outside unattended. The DON stated written care plans should be consistently implemented. Per the facility's policy titled Safety and Supervision of Residents, revised December 2007, .5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently; . The facility's policy titled Goals and Objectives, Care Plans, revised April 2009, did not provide guidance on care plan implementation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 11 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 nursing staff completely and thoroughly assessed pressure injuries (localized damage to the skin and/or underlying tissue that occurs over a bony prominence as a result of prolonged pressure) according to professional standards for one of two residents (275) reviewed for pressure injuries. In addition, Resident 275 was not provided a low air loss mattress (LAL, uses alternating pressure to prevent and treat pressure injuries). Residents Affected - Few These failures had the potential for Resident 275's pressure injuries to be misidentified and mistreated, and for wounds to deteriorate. Findings: Resident 275 was admitted to the facility on [DATE] with diagnoses to include displaced fracture of neck of left femur (hip fracture), per the facility's Resident Face Sheet. On 5/6/19 at 11:17 A.M., an interview was conducted with Resident 275 via an interpreter. Resident 275 stated she had wounds on both heels, and her heels felt sore when they touched the mattress. On 5/6/19 at 11:34 A.M., an interview was conducted with LN 47. LN 47 stated he first noticed Resident 275 had SDTI (suspected deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin that looks like a deep bruise) on both heels about a week ago. On 5/7/19 at 10:19 A.M., a wound treatment observation was conducted with LN 47 of Resident 275's bilateral heels. The back of Resident 275's right heel had an intact, dark maroon area the size of a silver quarter. The back of Resident 275's left heel had a dark maroon area the size of two silver quarters, and the wound was beginning to open. Resident 275 was not on a LAL mattress. On 5/7/19 at 12:16 P.M., a joint interview and record review was conducted with LN 47. LN 47 reviewed Resident 275's Resident Progress Note, dated 5/6/19, Resident wound current measurement is 2.5 x (by) 2.7 cm with skin currently intact. No bleeding noted . LN 47 stated he was the author of the note. LN 47 stated the note on 5/6/19 was his weekly wound assessment for Resident 275's pressure injuries. LN 47 stated his assessment did not describe the type or quality of the wound or the location of the wound. LN 47 stated both heels should have been assessed since the resident had two pressure injuries. LN 47 stated the weekly wound assessment indicated one wound was assessed, and he could not say whether it was the right or left heel. LN 47 stated his weekly wound assessment on 5/6/19 was not thorough or complete. LN 47 stated it was very important to thoroughly assess pressure injuries to make sure they were not getting worse. LN 47 further stated weekly wound assessments had to be thoroughly documented on a paper record that was sent to the DON. LN 47 stated he had not thoroughly documented for his weekly wound assessment on 5/6/19. LN 47 further stated Resident 275 should have had a LAL mattress due to the severity of tissue injury on both heels. LN 47 stated Resident 275 was in bed for most of the day and did not comply with frequent turning and repositioning. LN 47 stated a LAL mattress would help heal Resident 275 pressure injuries and prevent new ones from developing. LN 47 stated when she considered Resident 275's wounds, mobility issues, and lack of turning, the resident would have benefited from a LAL mattress. On 5/7/19 at 3:03 P.M., a joint interview and record review was conducted with LN 54. LN 54 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 12 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0686 Level of Harm - Minimal harm or potential for actual harm reviewed Resident 275's weekly wound assessment dated [DATE]. LN 54 stated the weekly wound assessment lacked clear wound identification, if treatment was effective, or if there was pain. LN 54 stated the weekly wound assessment was not descriptive enough and did not indicate a measurement of depth. LN 54 stated the weekly wound assessment dated [DATE] was not a thorough or a complete assessment of a pressure injury. Residents Affected - Few On 5/7/19 at 3:19 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 275's weekly wound assessment dated [DATE] and stated the assessment was not done to her expectation as it was not thorough or complete. The DON further stated Resident 275 should have had a LAL mattress in place. The facility's policy titled, Pressure Ulcer/Injury Risk Assessment, revised July 2017, did not provide guidance on conducting an assessment of a pressure injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 13 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a medical device (hand roll) for one of three residents (Resident 5) reviewed for limited range of motion. This failure had the potential to result in Resident 5 to have further decreased range of motion (ROM) in her left contracted hand. Findings: During a record review for Resident 5, the Resident Face Sheet, indicated Resident 5 was admitted on [DATE] with diagnoses to include hemiplegia (weakness of one entire side of body) following cerebrovascular disease (condition where blood vessels of the brain are damaged affecting the supply of oxygen to the brain). During an observation in Resident 5's room on 5/6/19 at 10:12 A.M., Resident 5 was seen lying in bed. Resident 5's left hand was in a fist, and there was no hand roll. During an observation in Resident 5's room and concurrent interview with Resident 5's family member on 5/6/19 at 2:55 P.M., Resident 5 was observed sitting in a wheelchair, without a hand roll in the left hand. Family member stated she had to buy Resident 5's hand rolls. Family member stated she did not know where staff had placed the hand roll she had purchased. During an observation in Resident 5's room, on 5/7/19 at 9:50 A.M., Resident 5 was observed lying in bed. Resident 5's left hand was seen without a hand roll in place. During an interview with RNA 1 on 5/7/19 at 3:44 P.M., RNA 1 stated Resident 5 had RNA exercises on Mondays, Wednesdays, Fridays, and Saturdays. RNA 1 stated she stretched Resident 5's hands, especially the left side. RNA 1 stated Resident 5 was unable to move the left hand on her own. During an observation in Resident 5's room, on 5/8/19 at 6:18 A.M., Resident 5 was observed lying in bed. Resident 5's left hand was seen without a hand roll in place. During a record review for Resident 5, the care plan dated 5/4/18, indicated Resident 5 was at risk for further decline in ROM. The care plan indicated to place hand-roll in Resident 5's left hand when in bed and in chair every shift. During an interview and concurrent record review with COTA on 5/8/19 at 12:03 P.M., COTA stated the family member was correct and Resident 5 should have had a hand roll placed in left hand. During an interview with LN 42 on 5/8/19 at 3:53 P.M., LN 42 stated she had seen Resident 5 with a hand roll placed in left hand in the past, but did not currently know where the hand roll was. LN 42 stated I don't know if we have it. LN 42 stated the hand roll (medical device) was to help correct or prevent contractures (permanent shortening of muscles) in Resident 5's left hand. During an interview with the DON on 5/9/19 at 3:05 P.M., the DON stated Resident 5 should have had the hand roll in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 14 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0688 Level of Harm - Minimal harm or potential for actual harm Per the facility's policy titled, Quality of Life - Accommodation of Needs, revised August 2009, indicated 1. The resident's individual needs .shall be accommodated to the extent possible .2. including the need for adaptive devices . to assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 15 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not supervise a resident (47) while smoking cigarettes. This failure put all residents at risk for potential fires and burns due to Resident 47's unsupervised smoking. Findings: Resident 47 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 5/6/19 at 4:35 P.M., an observation was conducted. Resident 47 was entered the facility by self-propelled wheelchair from the back patio which was adjacent to the resident's room. Resident 47 smelled strongly of fresh cigarette smoke. On 5/7/19 at 7:45 A.M., an interview was conducted with Resident 47 in the resident's room. Resident 47 stated he did not smoke cigarettes because smoking was not allowed at the facility. Resident 47's room smelled strongly of cigarette smoke. On 5/7/19 at 7:52 A.M., an interview was conducted with CNA 51. CNA 51 stated Resident 47 sneaks smoking, even though he is not allowed. CNA 51 stated Resident 47 kept cigarettes in his room and smoked whenever he wanted to. CNA 51 stated Resident 47 did not comply with the facility's non-smoking policy. On 5/7/19 at 4:20 P.M., an observation was conducted on the back patio by Resident 47's room. Resident 47 was on the back patio, and was observed with smoke exiting his mouth upon exhale. Resident 47 appeared startled and made a flicking motion of the cigarette butt toward the tall, dry grass surrounding the patio. Resident 47 self-propelled his wheelchair back inside the facility. On 5/7/19 at 4:23 P.M., an interview was conducted with Resident 47. Resident 47 stated he was not smoking on the back patio. Resident 47 had a pack of cigarettes hanging out of his right coat pocket and had a cigarette lighter in his left hand. On 5/7/19 at 4:33 P.M., an interview was conducted with CNA 47. CNA 47 stated she occasionally smelled the odor of a freshly lit cigarette around Resident 47, but had not directly observed him smoking while at the facility. CNA 47 stated it was dangerous for any resident to smoke unsupervised as they could get burned or start a fire. On 5/7/19 at 4:41 P.M., the DON and ADM were informed Resident 47 was observed smoking out on the back patio. The DON and ADM both stated the facility was non-smoking. The DON and ADM stated they were not aware Resident 47 smoked cigarettes on the facility's property. A record review was conducted on 5/8/19. Resident 47's progress notes indicated the following: 9/12/15 . found 2 packs of cigarette [sic] in his drawer . made aware this is non smoking facility . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 16 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0689 3/22/16 . entered the facility . smelling like cigarettes . reminded pt (patient) that smoking is not allowed . Level of Harm - Minimal harm or potential for actual harm 10/6/17 . noted strong cigarette [sic] scent coming from resident . noted cigarette [sic] butts outside . Residents Affected - Few 12/5/17 .Resident refused to hand over cigarettes and lighter. No manager attempted to take paraphernalia or tried to stop resident . 2/9/18 saw smoking . resident stated 'Okay that's what you want, report me' raising right hand showing lighted cigarette . 3/13/18 Resident was on back west patio smoking when educated on the policy of no smoking pt. being [sic] to raise his voice and say 'you want to pick a fight and you go tell who you want on me if you like, nothing will happen.' 5/28/18 resident smoked on the west back patio . another resident complained . 6/1/18 .Episodes of smoking to designated west wing patio noted reminded of facility policy . 6/7/18 .strong odor of cigarettes noted, and resident aware of non-smoking policy but non-compliant . 8/3/18 Resident not seen smoking but smelled smoke x2 (twice) this shift . 9/28/18 .smoking lit cig (cigarette) re-educated on no smoking policy . 3/8/19 Resident continues to be non compliant with non smoking policy at facility . On 5/8/19 at 7:16 A.M., an interview was conducted with LN 48. LN 48 stated Resident 47 would often smell strongly of fresh cigarette smoke and she was suspicious of him smoking unsupervised on facility property. LN 48 stated she did not report her suspicions to management because she did not actually observe the resident smoking. LN 48 stated she should have reported her suspicions because unsupervised smoking could have started a fire. On 5/8/19 at 8:42 A.M., an interview was conducted with CNA 50. CNA 50 stated she had observed Resident 47 go outside and smoke a cigarette. CNA 50 stated she reported the incident to LN 49. CNA 50 stated she felt she had to report the smoking incident because she only knew of one resident who had supervised smoking (an electronic cigarette), and that resident was not Resident 47. CNA 50 stated unsupervised smoking was considered a fire safety risk. On 5/8/19 at 10:29 A.M., an interview was conducted with LN 49. LN 49 stated she often smelled fresh cigarette smoke and suspected Resident 47 was smoking unsupervised while on facility property. LN 49 stated CNA 50 did tell her of a witnessed incident which she reported to the charge nurse and SSD. LN 49 stated she would educate Resident 47 on the non-smoking policy and he would tell her he had the right to smoke. LN 49 stated she did not report or document each incident because this was the resident's behavior and he would do it so often. LN 49 stated Resident 47's unsupervised smoking put everyone in the facility at risk for fire, and something should have been done about it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 17 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/8/19 at 11:52 A.M., an interview was conducted with the SSD. The SSD stated she was aware staff suspected Resident 47 smoked cigarettes unsupervised on facility property. The SSD stated she had been informed a staff member observed Resident 47 smoking a cigarette unsupervised. The SSD stated the facility had one IDT meeting about Resident 47's noncompliance with the facility's non-smoking policy. The SSD stated there should have been other IDT meetings for each incident of unsupervised smoking, since that posed safety concerns. The SSD stated the facility was allowing Resident 47's noncompliance with the non-smoking policy by not having a solid action plan to address the resident's unsupervised smoking. On 5/9/19 at 8:19 A.M., a joint interview was conducted with the DON and ADM. The DON and ADM stated Resident 47's unsupervised smoking posed a safety risk to all residents. The DON and ADM stated Resident 47 had not been effectively monitored since he was smoking without staff present. The DON and ADM stated there had been one IDT meeting about Resident 47's unsupervised smoking. The DON and ADM stated there should have been more IDT meetings to address the resident's ongoing violations of the facility's non-smoking policy. The ADM stated there should have been a smoking action plan developed to keep everyone safe. The ADM stated when Resident 47's room was searched on 5/7/19, there were several cigarette butts and a lighter found. The ADM stated Resident 47's unsupervised smoking was not brought to the facility's QAA Committee's attention and it should have been. A review of the facility's policy titled, Facility Smoking Policy/ Smoke Free Facility -Policy & Procedures, effective July 2015, and signed by Resident 47 on 8/30/15 indicated, .It is the policy of the facility that it has been designated a smoke-free facility . 1. Smoking is not permitted anywhere on healthcare center property. This includes all buildings, grounds, and parking areas controlled by the health care center. 2. No lighting materials (matches, lighters), tobacco products, or smoking devices will be allowed to remain in the possession of the residents, either on their person or in the facility . C. If non-compliance persists, the Interdisciplinary Team will determine if further actions are necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 18 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 assess and manage pain for one of three residents reviewed for pain management (Resident 56). Residents Affected - Few This failure resulted in Resident 56 not receiving prescribed medication for pain. Findings: During a record review for Resident 56, the Resident Face Sheet, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses to include muscle weakness. During a record review for Resident 56, the MDS assessment (an assessment tool), Section C, dated 3/29/19, indicated Resident 56's BIMS Summary Score was 13 out of 15 (attention, level of orientation, and ability to recall information was intact). During an observation and concurrent interview with Resident 56 on 5/6/19 at 9:46 A.M., Resident 56 stated he was having pain in his right knee. Resident 56 pointed to his right knee, and stated the pain is right here. During an observation on 5/6/19 at 9:47 A.M., in Resident 56's room, Resident 56 used his call light to request pain medication. CNA 43 came into Resident 56's room and informed Resident 56 she was going to update Resident 56's LN about his pain. CNA 43 immediately returned to Resident 56's room and informed him LN 42 stated he had already received aspirin. During a record review for Resident 56, a physician order dated 11/26/18, indicated aspirin 81 mg was ordered for stroke prophylaxis (prevent the supply of blood to the brain from becoming reduced or blocked) and to be given once a day. A physician order dated 9/23/18, indicated Tylenol 325 mg was ordered for mild pain/Generalized Body, and may be given every four hours as needed. During a record review for Resident 56, the Pain Care Plan dated 9/23/18, indicated, Administer pain medication as ordered & assess the effectiveness of the medication as indicated. Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors. During an interview with CNA 43 on 5/7/19 at 12:18 P.M., CNA 43 stated on 5/6/19, when she asked LN 42 for pain medication for Resident 56, LN 42 stated Resident 56 had been given aspirin in the morning. During a record review for Resident 56, the PRN Medications Administration History dated 5/1/19-5/9/19, indicated aspirin was given by LN 42 on 5/6/19 at 8:22 A.M. During an interview and concurrent record review with LN 42 on 5/8/19 at 3:53 P.M., LN 42 stated she was working 5/6/19. LN 42 stated Resident 56 did have episodes of pain in legs. LN 42 stated when Resident 56 was given Tylenol, it did help Resident 56's pain. LN 42 stated CNA 43 had informed her that Resident 56 was in pain and requested pain medication. LN 42 stated she did tell CNA 43 to tell Resident 56 that aspirin had been given. During review of the clinical record, LN 42 stated aspirin was ordered for stroke prophylaxis. LN 42 stated I should have offered the Tylenol. LN 42 further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 19 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0697 stated she should have assessed Resident 56's pain. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 5/9/19 at 3:20 P.M., the DON stated LN 42 should have gone in to Resident 56's room and assessed his pain. The DON further stated LN 42 should have offered pain medication as ordered for pain. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 20 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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** 2. Per the facility's Resident Face Sheet, Resident 74 was admitted on [DATE] with diagnoses which included, history of falling and cognitive impairment. On 5/6/19 at 10:50 A.M., during an interview with Resident 74, two medications were observed on his bedside table. There was a tube labeled, [Brand name] Maximum Strength pain relieving cream (skin ointment) and a bottle labeled, [Brand name] with 4% Lidocaine (medicated skin ointment) both laying on one end of his bedside table. On 5/6/19 at 10:51 A.M., Resident 74 stated, I have bad knees so my son brought me these pain medications for my knee. I've been putting them on myself whenever I need it. It helps with the pain in my knees. On 5/6/19 a review of Resident 74's medical record was conducted. Resident 74's records indicated there was no careplan for storing medications at the resident's bedside. On 5/8/19 at 7:45 A.M. a concurrent observation, interview and record review was conducted with the nurse in charge, LN 52. LN 52 stated, He has pain meds at his bedside, I'll have to check for an order. Review of Resident 74's physician's orders, indicated there was no order allowing the pain medications to be at the bedside. LN 52 stated, This (pain medication) should not be stored at his bedside without a doctor's order. Per the facility's policy titled Storage of Medications, revised April 2007, .7. Compartments (including but not limited to drawers, cabinets, rooms, .carts) containing drugs and biologicals shall be locked when not in use .shall not be left unattended if open or otherwise potentially available to others. Based on observation and interview the facility failed to ensure one of four carts containing medications was not left unattended or unlocked when reviewed for drug storage. In addition, medications were kept at the bedside for one resident (74). As a result, the medications were not safely stored and were easily accessible to residents, staff, and visitors. Findings: 1. On 5/8/19 at 10:05 A.M., a treatment cart on the west unit, was observed to be unlocked and unattended in the hallway outside the DSD's office. There were several residents in the area at that time. There were multiple medicated creams, powders and sprays, scissors and various treatment supplies in the cart. The cart was unlocked and unattended for seven minutes. On 5/8/19 at 10:12 A.M., an observation and interview was conducted with LN 16. LN 16 observed the unlocked treatment cart. LN 16 stated the treatment cart should have been locked. LN 16 stated there were many residents with dementia that could have gotten into it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 21 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 On 5/8/19 at 10:17 A.M., an interview was conducted with the DSD. The DSD stated a cart containing medications should never be left unlocked and unattended. The DSD stated there were many residents with dementia, who could have gotten into the cart and taken the medications out. The DSD stated an unlocked, unattended cart containing medications was a safety issue. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 22 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and document review, the facility failed to ensure Dietary Services department staff effectively performed kitchen tasks safely, competently, and in a sanitary manner when: Residents Affected - Few 1. A staff member was unable to accurately describe the correct method for thermometer calibration. 2. A staff member incorrectly washed produce in a 3-compartment sink used for washing, rinsing and sanitizing dishware. 3. A staff member was unable to verbalize and demonstrate the correct techniques related to testing sanitizer solution in the red buckets. These practices had the potential for residents to be exposed to food borne illness due to unsanitary practices related to lack of knowledge of kitchen tasks demonstrated by staff. Findings: On 5/6/19 at 9:05 A.M., the initial facility kitchen tour was conducted with the RD/DSS. 1. On 5/6/19 at 9:15 A.M., an interview was conducted with the [NAME] (CK 1) on thermometer calibration. CK 1 was unable to verbalize what the correct reading on the thermometer should be when calibrating or how often the thermometer should be calibrated. A review of the thermometer calibration log indicated the thermometer was not being calibrated weekly, per the policy. Per the calibration log, the last date of calibration prior to 5/6/19 was 4/8/19. The calibration log was signed and dated but no thermometer calibration readings were documented. Per the facility's Food and Nutrition Services policy, titled THERMOMETER USE AND CALIBRATION, dated 2018, .Food thermometers are to be calibrated each week .3. If the thermometer does not read 32 degrees, then the thermometer must be .discarded. 2. On 5/6/19 at P.M. an observation and interview was conducted with DA 1 and the RD/DSS. DA 1 was preparing a green salad. DA 1 was cutting cucumbers and stated she washed the cucumbers and tomatoes by hand in the wash side of the 3-compartment sink. DA 1 continued to prepare salad with green leaf lettuce being rinsed off in the wash side of the 3-compartment sink. The RD/DSS stated the produce should not have been rinsed in the wash section of the 3-compartment sink. According to the 2017 Federal Food Code, the standard of practice for washing fruits and vegetables, in section 3-302.1.5 titled Washing Fruits and Vegetables .Scrubbing with a clean brush .for produce with a tough rind or peel .removes pathogenic organisms, such as salmonella, and chemicals such as pesticides, which may be present on the exterior surfaces of raw fruits and vegetable . 3. On 5/6/19 at 3:20 P.M., an observation and interview was conducted with DA 2. DA 2 was testing the Quaternary Ammonium (disinfecting) solution in the sanitizing bucket and stated, it is changed every 2 hours. DA 2 changed and tested the solution in the sanitizer bucket 3 times without holding the test strip in the sanitizing solution for 10 seconds. On the fourth attempt the test strip reached an appropriate sanitizing level of 200 ppm (parts per million) after being held in the solution for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 23 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10 seconds. DA 2 stated she was not aware the test strip was to remain in the sanitizing solution for 10 seconds each time she tested the sanitizing solution. DA 2 acknowledged test strips submerged for 10 seconds in the sanitizer solution was in accordance with the test strip packaging guidelines, accurate reading. In addition, when rinsing and changing the sanitizing bucket solution, DA 2 used the wash side of the 3-compartment sink which held a colander full of green leaf lettuce. The RD/DSS stated the vegetables should not have been left in the sink. On 5/8/19 at 11:13 A.M., a document review of the kitchen department in-services was conducted with the RD/DSS. There was no evidence an in-service had been conducted with dietary staff regarding calibrating the thermometer, sanitizer strength testing or washing produce in a 3-compartment sink. Per the facility's Food and Nutrition Services policy titled, Sanitation, dated 2018, Section 8 .21. The FNS (Food and Nutritional Services) Director is responsible for instructing .personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 24 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interviews and document review, the facility failed to ensure menus were followed to meet the needs of four of four residents on renal therapeutic diets. Residents Affected - Few This failure negatively affected resident's nutritional needs and had the potential to further compromise their health status. Findings: On 5/6/19, a review of the therapeutic lunch menu spreadsheet for 5/6/19 was conducted. The lunch menu for the renal therapeutic diet indicated chicken with parmesan cheese, brown rice, seasoned broccoli and a wheat roll. On 5/6/19 at 11:30 A.M., a lunch tray line observation and interview with the [NAME] (CK 1) was conducted in the kitchen. On the steamtable, there were pans with: chicken with parmesan cheese, scalloped potatoes, spinach and wheat rolls. On the stovetop there were pots with carrots and brown rice. There were no pans with broccoli on the steam table or being prepared. CK 1 was asked if he had prepared all the food on the menu and he stated yes, he had everything prepared for the lunch menu that day. On 5/6/19 at 11:50 A.M., an observation was conducted in the resident dining room. Residents with renal diet meal trays revealed no broccoli was served on their plates, but rather carrots. On 5/6/19 at 2:35 P.M., an interview was conducted with CK 1 and the RD/DSS. CK 1 stated he did not prepare broccoli because it was not available in the kitchen, even though it was on the menu, so he stated he prepared carrots instead. CK 1 stated he did not get the vegetable substitution to serve carrots approved by the RD/DSS. CK 1 stated the change in vegetables had not been documented on a menu spreadsheet, a log book or the posted menu. The RD/DSS stated she was unaware broccoli had not been available and that CK 1 had made the decision to substitute carrots to replace the broccoli. Per the facility's Food and Nutrition Services policy titled MENU PLANNING, dated 2018, SECTION 3 .3. All Daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet or a log book may be kept. Only the Dietician .can make these changes .Menu changes should also be noted on menus .which may be posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 25 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to ensure an appropriate alternative meal option of similar nutritive value was provided to one resident (17). Residents Affected - Few This failure had the potential to affect this resident's meal intake and ultimately nutritional and health status. Findings: On 5/7/19 at 3:20 P.M., an observation and interview was conducted with Resident 17 regarding food choices and her lunch meal. The lunch meal for 5/7/19 on the menu indicated: zesty lasagna, Italian green beans, garlic bread and a peanut butter cookie. Resident 17 stated she had been served a peanut butter and jelly sandwich for lunch that day because she did not like cheese. Resident 17 stated the food was horrible and mistakes were typically made with her meals. Resident 17 also stated the alternate food choices had been the same for years and were undesirable. A document review of the facility's Alternate Meal Options indicated alternative entrées such as hamburger, tuna or egg salad sandwich, grilled chicken sandwich, ham or turkey sandwich and chef salad. A peanut butter and jelly sandwich was not listed as an alternate meal option. Per the facility's Food and Nutrition Services policy titled FOOD SUBSTITUTIONS DURING TRAYLINE, dated 2018, .The cook will provide a food substitute at each meal for a food item that a resident may dislike . Per the facility's Food and Nutrition Services policy titled FOOD SUBSTITUTIONS for RESIDENTS WHO REFUSE THE MEAL, dated 2018, .Residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 26 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 document review, the facility failed to ensure safe and sanitary conditions were met in the kitchen when: Residents Affected - Few 1. A serving scoop for mashed potato flakes had hard, brown dried crusted substances on it. 2. A microwave, used to reheat resident food, was not maintained in a sanitary manner. 3. An ice machine, providing ice to residents, was not maintained in a sanitary manner. 4. Expired cheese sticks were found in a reach-in refrigerator. 5. Dirty and wet utensils were stored in a drawer, with a broken handle, containing crumbs and black grime. 6. Several utensils with burned and broken handles were used to prepare residents meal trays on the tray line. 7. Dirty light fixtures were above the food production and meal tray line areas. 8. A dirty floor area had trash, black and brown grime, and other particles under the dish sink area. These failures had the potential to cause food-borne illness in 78 of 81 residents who consumed food from the kitchen. Cross Reference Tags 802 and 925 Findings: On 5/6/19 at 9:05 A.M., during the initial facility kitchen tour with the RD/DSS, several observations and interviews were conducted regarding food safety and sanitation. 1. On 5/6/19 at 9:15 A.M., an observation and interview of the dry food storage area was conducted with the RD/DSS. A food scoop, crusted with a hard, brown dried substance, was noted on top of a bin containing mashed potato flakes. The RD/DSS stated the food scoop was dirty and should not have been sitting on top of the bin. 2. On 5/6/19 at 9:25 A.M., an observation of the microwave used to reheat resident's food was conducted. The microwave had dried food on the outside handle and also on the inside. The RD/DSS stated it was used to reheat resident's food and acknowledged it was dirty. 3. On 5/6/19 at 9:40 A.M., an observation and interview of the facility's ice machine was conducted with the RD/DSS and the MS. The ice machine had brown and black grease and grime around the connectors on the bin door. The RD/DSS stated the ice machine cleaning was completed by the MS. The MS stated he deep cleaned the inside of the ice bin every four months. The MS stated he cleaned the outside of the machine and the back coils monthly. The MS and RD/DSS acknowledged the brown and black grime (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 27 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on the connectors of the bin door. The MS stated he had not noticed the grime on the connectors of the machines door, he did not know they needed to be wiped clean. The RD/DSS stated the ice machine was the only one in the facility and was used to obtain ice for the residents. Per the facility's Food and Nutrition Services policy, titled SANITATION, dated 2018, Section 8 .9. All utensils .and equipment shall be kept clean .12. Ice which is used in connection with food or drink shall be from a sanitary source . Per the facility's policy titled Maintenance Service, dated December 2009, .5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. Per the ice machine's manufacturers guide .CLEANING/SANITIZING PROCEDURE: This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled cleaned and sanitized . PREVENTATIVE MAINTENANCE CLEANING PROCEDURE: This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure. 4. On 5/6/19 at 10:15 A.M., an observation and interview was conducted with the RD/DSS. Refrigerator # 4 contained a small bin with four string cheese packages. The use by date on the packages of cheese was 3/25/19. The RD/DSS stated they were expired and should not have been in the refrigerator. 5. On 5/6/19 at 11:15 A.M., the following observations and interviews were conducted with the RD/DSS: A food preparation table was noted to have a drawer underneath a food preparation counter containing kitchen utensils, with broken and melted rubber grip handles. The inside of the drawer had crumbs and black grime. Several scoops in the drawer were still wet and a spatula had dried food particles on it. The RD/DSS stated they should not have been in the drawer. 6. On 5/6/19 at 11:30 A.M.,during an observation of the lunch trayline, CK 1 was noted to be using a scoop with a burned handle to serve the main entrée. There were several scoops with broken handles, used to place food on the resident's plates. The RD/DSS stated she knew they should not be used. 7. On 5/6/19 at 11:40 A.M., also during the lunch trayline observation, light fixtures above the food production and meal tray line areas, were noted to have a dirty, brown film. The RD/DSS stated it was the MS's responsibility to clean them. Per the facility's Food and Nutrition Services policy, titled SANITATION, dated 2018, Section 8: .6. The maintenance department will assist Food & Nutrition Services as necessary in .doing janitorial duties .9. All utensils .and equipment shall be kept clean, maintained in good repair and shall be free from breaks .cracks and chipped areas. Per the facility's Food and Nutrition Services policy titled GENERAL APPEARANCE OF FOOD &NUTRITION DEPARTMENT, dated 2018 .6. Clean all light fixtures. 8. On 5/7/19 at 10:55 A.M., an observation and interview was conducted with the dishwasher (DW) in the dishwashing area of the kitchen. The floor surrounding the dishwasher and under the sink had been littered with pieces of trash, food particles and black and brown grime was noted on the floor. The DW stated he was supposed to clean the floor every day after breakfast. The DW stated he had not cleaned the floor that morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 28 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Per the facility's Food and Nutrition Services policy, titled SANITATION, dated 2018, Section 8 .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over the stove . On 5/8/19 at 11:13 A.M., an interview was conducted with the RD/DSS. The RD/DSS stated with both roles, RD and DSS, she is able to only spend 25% of her time in kitchen/food service which includes weekly kitchen sanitation. The RD/DSS stated a kitchen audit had been conducted by the CDM in the beginning of May, 2019. The auditor noted dust accumulation on light fixtures, fans and a pipe above the clean side of the dishwasher. Per the facility's Food and Nutrition Services policy, titled SANITATION, dated 2018, Section 8 .21. The FNS (Food and Nutritional Services) Director is responsible for instructing employees in the fundamentals of sanitation in food service . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 29 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review, the facility's QAA committee failed to identify, develop, and implement action plans related to Resident 47's unsupervised cigarette smoking and facility's staff awareness of ongoing non-compliance with the facility's non-smoking policy. (see F689) Findings: On 5/9/19 at 3:21 P.M., an interview was conducted with the ADM and DON regarding the facility's QAA committee. The ADM stated Resident 47's unsupervised smoking should have been brought to the QAA committee and addressed because it was an immediate safety concern that affected the entire facility. Per the facility's undated policy titled Quality Assurance and Performance Improvement (QAPI), . Purpose to ensure that a proactive approach is provided in the Quality Plan and Performance Improvement process is applicable to the resident's needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 30 of 31 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 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Mesa Healthcare Center 3780 Massachusetts Avenue LA Mesa, CA 91941 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure pest control recommendations and concerns were addressed. Residents Affected - Few This failure had the potential to contaminate food stored in the kitchen and dining areas which could lead to widespread foodborne illness. The facility census was 81. Findings: On 5/6/19 at 2:35 P.M., an observation and interview was conducted with the RD/DSS of the kitchen. There were two dirty food carts outside the back screen door of the kitchen. Each cart contained 16 dirty food trays. There was also a coffee cart which contained a dirty food tray and six dirty plate lids outside the back screen door of the kitchen. The RD/DSS stated the CNAs left them there but should not have. The RD/DSS acknowledged the flies and stated flies get into the kitchen because the back door was not always closed. On 5/7/19 at 10:32 A.M., a fly was observed flying around the food preparation area where [NAME] 2 prepared pureed food. [NAME] 2 acknowledged the fly flying around the food preperation area. A review of the pest company invoice records from January 2019 through March 2019 was conducted. The March 2019 invoice indicated .Interior ILT some fly activity found .; 6/26/18: subarea access vent needs to be replaced. Rodents can easily enter . The January through March 2019 invoices indicated .Need fly curtain on back door leading into kitchen. Action: Install air curtain and add fly service to current service . On 5/8/19 at 8:15 A.M., an interview was conducted with the MS. The MS stated the pest control company sprayed in the kitchen every month in 2018. The MS stated he did not know of any recommendations, made by the pest company, to prevent rodents. The MS viewed the pest control documents from January 2019 through March 2019. The MS stated none of the recommendations had been followed up on. According to the 2017 Federal Food Code, section 6-501.111, .Controlling Pests .The premises shall be maintained free from insects, rodents and other pests .by .routinely inspecting the premises for evidence of pests . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 31 of 31