Health inspection·October 12, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to participate in ADLs to promote independence. Encourage to use call light for assistance. Notify physician of declines in ADLs as needed. Observe for declines and refer to therapy services as indicated. Occupational therapy referral and treatment as indicated. Physical therapy referral and treatment as indicated. On 10/12/23 at 12:35 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD reviewed Resident 1 ' s MDS assessment dated [DATE] and ADL care plan dated 9/11/23 and stated the ADL care plan should have been updated after the MDS assessment was completed. The DSD stated Resident 1 ' s ADL care plan should have been individualized to indicate how much assistance was needed for each ADL and how many staff were required to provide the ADL care. On 10/12/23 at 1:55 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 1 ' s ADL care plan should have been updated after the completion of the MDS Assessment. The DON stated Resident 1 ' s MDS Assessment should have been reflected in the ADL care plan. The DON stated Resident 1 ' s ADL care plan should have been customized to address all the resident ' s ADL needs. A review of the facility ' s policy titled Care Plans, Comprehensive Person-Centered revised March 2022, indicated, .2. The comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment (admission, annual, or significant change in status), and should be completed within 21 days of admission FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 care was provided in a safe and comfortable manner for one of three residents (Resident 1) when activities of daily living (ADL, self-care activities such as moving in bed) were preformed by one staff instead of two staff as was required on the resident ' s Minimum Data Set Assessment (MDS, a comprehensive assessment). Residents Affected - Few As a result of this deficient practice, Resident 1 experienced discomfort and felt the care provided to her was rough. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiparesis and hemiplegia (weakness and paralysis) affecting the left side of the body following a stroke. A review of Resident 1 ' s MDS assessment dated [DATE], indicated the resident required extensive assistance (resident involved in activity, staff providing weight bearing support) provided by two or more staff for bed mobility (how resident moves from lying position, turns side to side, and positions body while in bed). A review of Resident 1 ' s progress notes dated 10/2/23 indicated, [Resident 1] reported that she was handled roughly by the CNA [certified nursing assistant] On 10/12/23 at 10:25 A.M., an observation and interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 was sitting in bed, her lower extremities supported with a pillow. Resident 1 moved her right arm, while her left arm appeared flaccid. Resident 1 stated she was unhappy with the ADL care she received from CNA 2. Resident 1 stated, [CNA 2] was rough and I had pain in my leg. On 10/12/23 at 11:10 A.M., a telephone interview was conducted with CNA 2. CNA 2 stated she had provided care to Resident 1 on 10/1/23 around 6:45 A.M. CNA 2 stated Resident 1 had a bowel movement that required cleaning the resident and changing the bed linens. CNA 2 stated she performed the ADL care while the resident laid in bed and did not have another staff present to assist. CNA 2 stated after she had provided care to Resident 1, the resident suddenly said, You ' re hurting me. CNA 2 stated, I ' m careful, and had not meant to cause the resident any pain or discomfort. On 10/12/23 at 12:30 P.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 required two staff to assist with big care such as a bed linen change, turning in bed, and when toileting in bed. CNA 3 stated Resident 1 could not fully participate in turning from side to side and that another staff had to hold the resident to maintain a side-lying position, or the resident would roll backward. CNA 3 stated if one staff performed Resident 1 ' s ADL care in bed, the resident may perceive the care as being rough. CNA 3 further stated that may be stressful to the resident. On 10/12/23 at 12:32 P.M., an interview was conducted with licensed nurse (LN) 4. LN 4 stated Resident 1 had left-sided paralysis and required two staff to turn in bed. LN 4 stated a brief change in bed would also require two staff since the resident needed to turn side to side to be changed. LN 4 stated it was safer and more comfortable for two staff to provide care to Resident 1 when in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055488 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/12/23 at 12:35 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated Resident 1 had left-sided weakness and pain and relied on staff for turning in bed. The DSD stated CNA 2 should have asked for another staff to assist when performing bed mobility related tasks with Resident 1. The DSD stated staff would have to apply more pressure when turning a full-sized adult on their own. The DSD stated a resident dependent on staff for bed mobility could perceive that the care delivered by one staff was rough even if that was not the intention of the staff. The DSD reviewed Resident 1 ' s MDS assessment dated [DATE] and stated the assessment should have been followed and bed mobility should have been provided to Resident 1 by two staff. The DSD stated two-person assistance would have been safer and more comfortable for Resident 1. On 10/12/23 at 1:55 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 1 should have been provided bed mobility with two staff. The DON stated it was their expectation for the resident ' s MDS Assessment to be followed when providing ADL care. The DON stated two-person assistance would have been more comfortable and safer. A review of the facility ' s policy titled Activities of Daily Living (ADLs), supporting revised March 2018, indicated, .Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055488 If continuation sheet Page 4 of 4