Health inspection·July 11, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm informed her she did not want CNA 4 to care for her anymore. The ADON stated she did not ask Resident 162 why she did not want to be cared for by CNA 4. The ADON stated she told CNA 4 to ask Resident 162 about the situation. The ADON stated she should not have sent CNA 4 to speak with Resident 162. The ADON further stated the resident could have viewed this as threatening and be made to feel unsafe. The ADON further stated she should have investigated to ensure no abuse had occurred. Residents Affected - Few On 7/11/19 at 2:58 P.M., an interview was conducted with the DON. The DON stated Resident 162 was not treated with dignity when CNA 4 was instructed to go back into her room. Per the facility's undated policy, titled Resident Rights, .The resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 2 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement the facility's procedures for investigating potential abuse for one of one resident (162) reviewed. Residents Affected - Few This failure had the potential for resident abuse to not be reported and investigated. Findings: Resident 162 was admitted to the facility on [DATE], with a diagnoses of cellulitis (bacterial infection of the skin) on her lower legs and difficulty walking per the facility's admission Record. On 7/8/19, a record review was conducted for Resident 162. Resident 162's BIMS (a cognitive assessment) was 15, indicating she was cognitively intact. On 7/8/19 at 9 A.M., an interview with Resident 162 was conducted. Resident 162 stated that she did not want CNA 4 to take care of her. Resident 162 stated CNA 4 did not help her when something was poking her in the back, making her uncomfortable. Resident 162 stated CNA 4 did not move her from the wheelchair to the bed, when she requested it. Resident 162 stated two days later, she informed an unknown staff member that she did not want CNA 4 to care for her anymore. Resident 162 stated the staff member did not inquire why she did not want CNA 4 caring for her anymore. Resident 162 further stated when CNA 4 started her shift that same day, she came to the resident's bedside and glared at her. Resident 162 stated she felt confronted by CNA 4, when CNA 4 stated, I thought we were cool. During the interview, Resident 162 was observed to have tears in her eyes while telling her story. Resident 162 stated she told CNA 4 that she did not want her involved in her care. Resident 162 stated she was unable to sleep that evening until she knew CNA 4's shift was over. Resident 162 further stated she felt worried that reporting this incident would cause her future care to be negatively effected. On 7/8/19 at 3:56 P.M., an interview was conducted with CNA 4. CNA 4 stated at the start of her shift, the ADON told her Resident 162 requested not to have her as a CNA. CNA 4 stated she approached the resident and asked her why she did not want to have her care for her. CNA 4 stated Resident 162 told her she wanted another CNA to care for her. CNA 4 stated she now realized she should not have approached Resident 162. On 7/10/19 at 11:32 A.M., an interview was conducted with the ADON. The ADON identified herself as the unknown staff member that Resident 162 spoke to regarding CNA 4. The ADON stated she did not ask Resident 162 why she did not want to be cared for by CNA 4. The ADON stated she told CNA 4 to ask Resident 162 about the situation. The ADON stated she should not have sent CNA 4 to speak with Resident 162. The ADON stated the resident could potentially view this as threatening and be made to feel unsafe. The ADON stated she should have reported the incident to the ADM. The ADON further stated she should have investigated to ensure no abuse had occurred. The ADON stated CNA 4 should not have been allowed back in Resident 162's room. The ADON further stated, It is important to investigate for the protection of the resident. On 7/11/19 at 2:58 P.M., an interview was conducted with the DON. The DON stated that once Resident 162 requested a change in her CNA assignment, it should have been done. The DON stated CNA 4 should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 3 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not have gone back into Resident 162's room. The DON further stated, Protocol was not followed, an investigation should have happened. Per the facility policy, titled Abuse Prevention, revised February 2008, .Investigation .When an incident or allegation of resident abuse .is reported, the Administrator immediately will appoint a staff member who will investigate the incident . Event ID: Facility ID: 055632 If continuation sheet Page 4 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 care plan interventions were developed and implemented for two of 18 residents (364, 362) reviewed for care plans when: 1. A care plan for hearing aids was not developed for Resident 364. 2. A care plan related to swallow precautions was not implemented for Resident 362. Findings: 1. Resident 364 was admitted to the facility on [DATE] with diagnoses which included unspecified hearing loss, bilateral (reduced hearing in both ears) per the facility's admission Record. An observation was conducted on 7/8/19 at 4:43 P.M. Resident 364 was sitting in a wheelchair outside of her room. Resident 364 was not wearing hearing aids. A concurrent observation and interview was conducted on 7/9/19 at 2:39 P.M. with Resident 364. Resident 364 was sitting in a wheelchair in her room. A visitor was seated on the opposite side of the overbed table in front of Resident 364. Resident 364 stated she could not hear very well. Resident 364 was not wearing a hearing aid. Resident 364 stated she did not know where her hearing aid was. Resident 364's visitor suggested that she thought Resident 364's husband may have taken the hearing aid, or was getting new batteries for the hearing aid. Resident 364 replied to her visitor's statement, saying, No, he isn't. A review of Resident 364's IDT Care Plan Review note, dated 6/24/19, was conducted. This record indicated Resident 364 was .hard of hearing with bilateral hear aids . A review of Resident 364's MDS (an assessment tool), dated 7/2/19, was conducted. MDS Section B0200 Hearing, Ability to hear, a 0 indicating adequate was marked. Under Section B0300 Hearing aid or other hearing appliance used, a 0 indicating No was marked. An observation was conducted on 7/11/19 at 9:21 A.M. Resident 364 was sitting in a wheelchair in her room. Resident 364 wore hearing aids in both ears. A small opened package that contained one battery was on top of the overbed table. Resident 364 stated, .found my hearing aids . wearing them . An interview was conducted on 7/11/19 at 9:30 A.M. with LN 11. LN 11 stated Resident 364 was not hard of hearing and did not wear any hearing aids. A concurrent interview and review of Resident 364's record was conducted on 7/11/19 at 11:48 A.M. with the LNS. The LNS was not sure if Resident 364 wore hearing aids. The LNS stated there was no documentation that staff assisted or ensured that Resident 364 wore hearing aids. A concurrent interview and review of Resident 364's record was conducted on 7/11/19 at 2:31 P.M. with the MDSN. The MDSN stated she completed Resident 364's admission MDS dated [DATE]. The MDSN stated Resident 364 was not wearing hearing aids during the MDS assessment. The MDSN stated staff used an emoji of care in the resident's room. The MDSN referred to a white sign in Resident 364's room that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 5 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 indicated, Staff flip over. On the back side of this sign was a drawing of ears with a hearing aid in each ear. The MDSN stated this emoji was circled to indicate that the resident wore hearing aids. A concurrent interview and review of Resident 364's Inventory of Personal Effects (IPE) form dated 6/22/19, was conducted on 7/11/19 at 11:48 A.M. with the LNS. The LNS stated this form was completed when Resident 364 was admitted to the facility. The LNS stated that according to the IPE form, Resident 364 had hearing aids for both of her ears. The LNS reviewed Resident 364's clinical record and stated she was not sure when Resident 364 wore her hearing aids. The LNS stated she was unsure if staff assisted, offered, or reminded Resident 364 to wear them. The LNS stated a care plan related to the use and care of Resident 364's hearing aids had not been developed. An interview was conducted on 7/11/19 at 3:42 P.M. with the DON. The DON stated that residents with hearing aids should be assisted, offered, or reminded of its use, and acknowledged that a care plan that addressed its use should have been developed for Resident 364. 2. Resident 362 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), per the facility's admission Record. Per Resident 362's physician's order dated 7/1 through 7/31/19, Resident 362 was placed on strict aspiration precautions (practices that help prevent food or fluids from entering an individual's airway). Per the same record, Resident 362 was assisted with RNA dining, three times per day, seven days per week, to cue safe swallowing strategies. A concurrent observation and interview was conducted on 7/8/19 at 4:29 P.M. with Resident 362's daughter. Resident 362's daughter stated she was visiting her mother, and brought juice for her mother to enjoy. Resident 362 was sitting in a wheelchair, holding a cup that contained orange-colored liquid. The cup had a straw. A concurrent observation and interview was conducted on 7/9/19 at 1:28 P.M. with RNA 15. RNA 15 stated Resident 362 was able to feed herself, but ate in the dining room because she needs help when swallowing. Resident 362 was observed sitting in front of a table in the dining room . Her lunch tray was set on the table. There were two drinking cups covered with clear plastic wrap. A straw was poked through the plastic wrap of each cup. An observation was conducted on 7/10/19 at 3:02 P.M. Resident 362 was sitting in a wheelchair in her room. The overbed table was positioned in front of her wheelchair. A plastic drink pitcher and a cup with a straw was on top of the table. A review of Resident 362's care plan titled, Swallowing problem r/t (related to) dysphagia, dated 7/8/19 was conducted. This care plan included an intervention that indicated, .Do not use straws. An interview was conducted on 7/10/19 at 3:13 P.M. with LN 16. LN 16 stated that Resident 362 was on strict aspiration precautions that included the need to .sit up straight, close supervision during all meals with RNA dining, nectar thick liquids with no straw . no straw because she might cough. A concurrent interview and review of Resident 362's care plan titled, Swallowing problem r/t dysphagia, dated 7/8/19 was conducted on 7/10/19 at 3:48 P.M. with LN 16. LN 16 referred to the care plan and stated she was aware Resident 362 should not use straws, but was not sure if other staff knew (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 6 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 this. Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on 7/11/19 at 4:01 P.M., the DON acknowledged that the intervention for Resident 362 to not use straws was not followed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 7 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update a resident's care plan to reflect their current condition for one of three residents (56) reviewed for the Bowel and Bladder Program. This failure had the potential to result in Resident 56 receiving inappropriate care for toileting. Findings: Resident 56 was admitted to the facility on [DATE] with a diagnosis of back pain related to a compression fracture (the collapsing of bone tissue in a back bone) per the facility's admission Record. On 7/8/19 a review of Resident 56's MDS (an assessment tool), dated 6/23/19, was conducted. Her BIMS (a cognitive assessment tool) score was 15, indicating Resident 56 was mentally alert and aware. On 7/8/19 at 3:51 P.M., an interview with Resident 56 was conducted. Resident 56 stated she was always continent (able to control bowel and bladder) and never has an accident. She stated she did require assistance to walk to the restroom. On 7/9/19 at 1:27 P.M., an interview with CNA 1 was conducted. CNA 1 stated Resident 56 used to be incontinent (loss of bowel and/or bladder control), but was not any longer. CNA 1 stated if Resident 56 needed to use the restroom, she would use the call light. CNA 1 stated he did not need to offer to take Resident 56 to the restroom because she would notify them when she needed to use the bathroom. On 7/10/19, a review of Resident 56's Point of Care Response History for Bladder Continence dated 6/28/19 through 7/10/19 was conducted. Per this record, the resident was documented as being continent. Resident 56's Bowel and Bladder care plan, dated 6/15/19, was reviewed. The care plan indicated Resident 56 was incontinent of bowel and bladder. The care plan interventions included, .Offer/Assist to toilet/commode/bedpan Q (every) 2 hours while awake per facility protocol . On 7/11/19 at 10:12 A.M., a joint interview and record review was conducted with LN 1. LN 1 acknowledged Resident 56's Bowel and Bladder care plan did not reflect her current status. LN 1 stated Resident 56's Bowel and Bladder care plan should have been updated when the resident became continent. On 7/11/19 at 1:48 P.M., an interview with the ADON was conducted. The ADON stated the Bowel and Bladder care plan for Resident 56 should have been updated when the resident became continent. On 7/11/19 at 3:03 P.M., an interview was conducted with the DON. The DON stated care plans needed to be updated when a resident's condition changed. Per the facility's policy titled Comprehensive Person-Centered Care Planning, revised August 2017, .6. The resident's comprehensive plan of care will be .revised .as needed and necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 8 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure professional standards of quality were met when neurological examinations (an assessment for level of consciousness, pupil reaction, vital signs, sensory and motor responses for early indication of a head injury) were not conducted for one of five residents (48) reviewed for falls. Residents Affected - Few As a result, there was the potential for Resident 48 to have an undetected, untreated head injury. Findings: Resident 48 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, per the facility's admission Record. On 7/8/19, Resident 48's medical record was reviewed. Per the facility's progress notes, dated 7/3/19 at 3:52 P.M., titled Change of Condition, .Patient was lying in the middle of the room on the floor, in front of his wheelchair.M.D. made aware. Orders received to initiate neurological (neurological) checks x (for) 72 hours and monitor vital signs. The clinical record did not include evidence that a 72-hour neurological flowsheet was initiated or completed for Resident 48. On 7/10/18 at 10:40 A.M., an interview and review of Resident 48's medical record was conducted with the DON. The DON stated she expected LNs to perform 72-hour neurological checks after any unwitnessed fall. The DON stated the purpose of neurological checks was to catch any early signs of a potential head injury. The DON stated neurological assessments included checking the resident's hand grips for equal strength, assessing pupil size, vital signs and the resident's level of consciousness. The DON stated neurological checks should be performed at certain time intervals such as every 15 minutes, every hour, every four hours and then every 8 hours. The DON stated they had a pre-printed neurological assessment flowsheet which included the required time intervals and areas to evaluate. The DON stated Resident 48's progress notes only documented vital signs and level of consciousness. The DON could not locate a neurological flowsheet in Resident 48's chart. The DON requested additional time to locate Resident 48's neurological flowsheet. On 7/11/19 at 10:25 A.M., an interview was conducted with LN 21. LN 21 stated any resident with an unwitnessed fall required neurological checks for three days following the fall. LN 21 stated the neurological assessments were documented at specific time intervals, on a pre-printed neurological form. LN 21 stated the purpose of doing the neurological assessments was to identify any early signs of closed head injuries, which could be fatal to the resident. On 7/11/19 at 2:01 P.M., a subsequent interview was conducted the with DON. The DON stated Resident 48's neurological flowsheet from the unwitnessed fall could not be located. The DON stated if the neurological assessments were not documented, then they were not performed. Per the facility's policy, titled Neurological Evaluation, dated May 2017, . a neurological assessment for any unwitnessed fall .for a minimum of seventy-two (72) hours. A neurological assessment flowsheet will be utilized . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 9 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide scheduled and requested showers for one of one resident (162) reviewed for ADL. Residents Affected - Few This failure had the potential to affect Resident 162's self-image and confidence. Findings: Resident 162 was admitted to the facility on [DATE] with diagnoses of cellulitis (bacterial infection of the skin) on her lower legs and difficulty walking per the facility's admission Record. On 7/8/19 Resident 162's clinical record was reviewed. Resident 162's BIMS (a cognitive assessment), dated 7/5/19, score was 15, indicating Resident 162 was mentally alert and aware. On 7/8/19 at 4:41 P.M., an interview with Resident 162 was conducted. Resident 162 stated she had received only one shower since she was admitted 11 days ago. Resident 162 stated she was told she was only scheduled for showers on Saturdays, and could not have a shower unless she was scheduled. On 7/10/19 at 3:40 P.M., a joint interview and record review was conducted with the DSD. A review of the facility's shower schedule showed Resident 162 was scheduled to receive showers during the evening shift on Tuesdays and Saturdays. On Resident 162's POC Response History under the Bathing task, it was documented that the resident had received two showers in the past 11 days (July 6, 2019 and July 9, 2019). There was no documentation of Resident 162 refusing a shower. During the record review, the DSD compared the CNA assignment sheets with the shower schedule and stated the showers were assigned incorrectly. The DSD stated a mistake had been made, and some residents may have missed their showers. The DSD stated, Showers are important for hygiene, dignity, preventing skin breakdown, and infection control. On 7/11/19 at 10:49 A.M., an interview with LN 1 was conducted. LN 1 stated residents should be showered as scheduled and when they wanted to be. LN 1 stated showers promoted comfort, cleanliness and self-respect. On 7/11/19 at 2:54 P.M., an interview with the DON was conducted. The DON stated Resident 162 should have received a shower when she wanted one, for hygiene and for preference. The DON stated the staff should find a way to fit it into their schedule if the resident requested one. Per the facility policy titled, Activities of Daily Living, Care, and Hygiene revised May 2017, It is the policy of this facility to promote cleanliness, sanitation, hygiene, and assist in necessary Activities of Daily Living .will include, but not limited to: Appropriate Bathing and/or Showers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 10 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 a physician's order related to the use of an arm sling was followed for one of four residents (362) reviewed for rehabilitation. This failure had the potential to affect Resident 362's comfort and physical well-being. Residents Affected - Few Findings: Resident 362 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (slight paralysis or weakness on one side of the body) following cerebral infarction (also known as a stroke - damage to tissues in the brain due to loss of oxygen to the area), per the facility's admission Record. A clinical record review of Resident 362 was conducted. The physician's order dated 7/3/19 indicated, Left arm sling when OOB (out of bed) and not on for rehab (rehabilitation therapy) . An observation was conducted on 7/8/19 at 9:10 A.M. Resident 362 was sitting in a wheelchair outside of her room. Resident 362 was not wearing an arm sling. An observation was conducted on 7/8/19 at 4:35 P.M. Resident 362 was sitting in a wheelchair in the outside patio. Resident 362 was not wearing an arm sling. An observation was conducted on 7/9/19 at 1:22 P.M. Resident 362 was sitting in a wheelchair in the dining room eating lunch. Resident 362 was not wearing an arm sling. An observation was conducted on 7/9/19 at 2 P.M. Resident 362 was sitting in a wheelchair beside her bed. Resident 362 was not wearing an arm sling. An observation was conducted on 7/10/19 at 3:02 P.M. Resident 362 was sitting in a wheelchair in her room. Resident 362 was not wearing an arm sling. An interview was conducted on 7/10/19 at 3:13 P.M. with LN 16. LN 16 stated Resident 362 had left side weakness and should wear an arm sling when she was out of her bed. An interview was conducted on 7/11/19 at 3:53 P.M. with the DON. The DON acknowledged that Resident 362 had left sided weakness with a physician's order to wear the left arm sling for comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 11 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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** 2. Resident 362 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (slight paralysis or weakness on one side of the body) following cerebral infarction (also known as a stroke - damage to tissues in the brain due to loss of oxygen to the area), and osteoporosis (loss of bone density that causes the bones to become weak and brittle), per the facility's admission Record. An observation was conducted on 7/8/19 at 4:29 P.M. Resident 362 was sitting in a wheelchair in the outside patio. A review of Resident 362's record titled Fall Risk Evaluation, dated 6/29/19, was conducted. Under section H. Predisposing Diseases/Condition was instruction for the LN to mark as followed: Respond below based on the following predisposing conditions: Hypotension (low blood pressure), CVA (cerebrovascular accident - stroke), .Osteoporosis . The option 0. None present was marked. A concurrent interview and review of the Fall Risk Evaluation, dated 6/29/19, was conducted on 7/9/19 at 4:17 P.M. with the LNS. The LNS stated that Resident 362 was admitted with diagnoses which included stroke (CVA) and osteoporosis. The LNS acknowledged that the Fall Risk Evaluation was not accurately completed when the option, 0. None present was marked. An interview was conducted on 7/11/19 at 3:56 P.M. with the DON. The DON acknowledged that the fall risk evaluation for Resident 362 was not accurately completed. Per the facility's policy, titled Fall Management System, dated April 2018, .It is the practice of this facility to provide each resident with appropriate evaluation and interventions to prevent falls . Based on observation, interview, and record review, the facility failed to accurately assess two of five residents (7, 362), reviewed for falls. These failures had the potential to place Residents 7 and 362 at a higher risk for falls and/or injuries. Findings: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses of respiratory failure with hypoxia (inability to get enough oxygen) and weakness per the facility's admission Record. A review of Resident 7's MDS (assessment tool) dated 4/10/19 was conducted. Resident 7's BIMS (a cognitive assessment) score was 3, indicating Resident 7 had difficulty being alert and aware. On 7/8/19 at 8:27 A.M., an interview was conducted with Resident 7. Resident 7 stated he could not remember if he had a fall in the facility. On 7/9/19 at 8:40 A.M., a review of Resident 7's medical record was conducted. Resident 7's fall risk evaluation, dated 4/3/19, indicated a score of 13, identifying the resident at a high risk for falls, based on the facility's fall risk evaluation tool. The section of the evaluation which assessed for Predisposing Diseases/Condition included two points for the diagnosis of weakness for a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 12 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 predisposing disease. Level of Harm - Minimal harm or potential for actual harm Resident 7's progress note dated 6/21/19 at 7 P.M., indicated Resident 7 was found on the floor, in his room, next to his bed. Residents Affected - Few Resident 7's updated fall risk evaluation dated 6/21/19 was incomplete; the section which referred to Resident 7's Gait/Balance/Ambulation (walking) was left blank. The section of the evaluation which assessed for Predisposing Diseases/Condition did not consider Resident 7's diagnosis of weakness, resulting in zero points for that section. Resident 7's total evaluation score was seven, which identified the resident at a medium risk for falls. On 7/9/19 at 3:58 P.M., an interview was conducted with CNA 5. CNA 5 stated he was often assigned to care for Resident 7. CNA 5 stated he did not know if Resident 7 had any falls. CNA 5 further stated he did not believe Resident 7 was a fall risk and that the resident was not on fall precautions. On 7/11/19 at 9:41 A.M., a joint interview and record review was conducted with the LNS. In reviewing Resident 7's Fall Risk Evaluation, dated 6/21/19, the LNS stated the evaluation was incomplete. The LNS further stated Resident 7's Fall Risk Evaluation was inaccurate, the nurse who completed the evaluation did not consider Resident 7's diagnosis of weakness. The LNS stated weakness was a condition which predisposed a resident to falls. On 7/11/19 at 2:49 P.M., an interview with the DON was conducted. The DON stated staff not being aware of resident's fall risk status and their interventions, placed residents at risk for further falls. The DON stated Resident 7's Fall Risk Evaluation was not complete and accurate. Per the facility's policy, titled Fall Management System, dated April 2018, .It is the practice of this facility to provide each resident with appropriate evaluation and interventions to prevent falls . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 13 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement incontinence (loss of bowel and/or bladder control) interventions for one of three residents (163) reviewed for the facility's Bowel and Bladder Incontinence Program. This failure had the potential to result in Resident 163 not improving his bowel and bladder continence (control of bowel and/or bladder). Findings: Resident 163 was admitted to the facility on [DATE] with diagnoses of difficulty walking and Type 2 Diabetes (condition which effects the body's ability to control blood sugar) per the facility's admission Record. On 7/8/19 a review of Resident 163's MDS (assessment tool) dated 7/2/19 was conducted. Resident 163's BIMS (a cognitive assessment) score was 10, which indicated he was moderately alert and aware. On 7/8/2019 at 10:30 A.M., an interview was conducted with Resident 163. Resident 163 stated sometimes it took a long time to receive care when he needed toileting or needed a soiled brief changed. He stated that sometimes, I am waiting and waiting and waiting. On 7/9/19 at 4:10 P.M., an interview was conducted with CNA 5. CNA 5 stated he took care of Resident 163 on 7/9/19 during the morning shift (7 A.M.-3 P.M.). CNA 5 stated Resident 163 should be checked and changed every two hours. CNA 5 stated Resident 163 required extensive assistance to the toilet and that he was incontinent. CNA 5 stated he was unsure if Resident 163 was on a bowel and bladder program. On 7/10/19 at 1:43 P.M., a record review of Resident 163's Bowel and Bladder Evaluation was conducted. The Bowel and Bladder Evaluation, dated 6/25/19, indicated the resident was incontinent of bowel and bladder, and identified Resident 163 as a Possible Candidate for the Bowel and Bladder Program. On 7/10/19 at 1:48 P.M., a record review of Resident 163's bowel and bladder care plan, dated 6/24/19, was conducted. The bowel and bladder care plan identified Resident 163 as incontinent. Interventions for Resident 163 included placing him on the Bowel and Bladder Program and, Offer/Assist to toilet/commode/bedpan/urinal Q (every) two hours while awake per facility protocol. On 7/11/19 at 9:22 A.M., a joint interview and record review was conducted with the LNS. The LNS stated that Resident 163 was on the Bowel and Bladder Program. The LNS stated Resident 163 should be encouraged to use the toilet at least every two hours or as needed. The LNS stated Resident 163's Bowel and Bladder Program was not followed. On 7/11/19 at 2:47 P.M., an interview with the DON was conducted. The DON stated the CNAs should have encouraged Resident 163 to use the restroom or urinal, as indicated in the resident's bowel and bladder program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 14 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 0690 Per the facility's undated policy, titled Bowel and Bladder Program, It is the policy of this facility to develop an individualized, goal-oriented approach to elimination, restore and/or maintain continence . 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: 055632 If continuation sheet Page 15 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure O2 was administered per physician's order for one of one residents (52), reviewed for oxygen therapy. This failure had the potential to affect the health and well-being of Resident 52. Residents Affected - Few Findings: Resident 52 was admitted to the facility on [DATE] with diagnoses which included systolic congestive heart failure (weakness of the heart that leads to a buildup of fluid in the lungs) per the facility's admission Record. An observation was conducted on 7/11/19 at 9:12 A.M. Resident 52 was sitting in a wheelchair in his room. Resident 52 wore a nasal cannula (NC; device used to deliver supplemental oxygen or increased air flow to an individual in need of respiratory help). The O2 was set and delivered at four (4) L/min (liter per minute flow rate). A concurrent observation and interview was conducted on 7/11/19 at 10:15 A.M. with LN 11. Resident 52 wore a NC. The O2 was set and delivered at 4 L/min. LN 11 stated Resident 52 was supposed to receive O2 at two (2) L/min. LN 11 stated that sometimes therapy staff (referring to physical and/or occupational therapy staff) titrated (adjusted) the resident's O2, but he would need to check Resident 52's record to verify if there was an order for the O2 flow rate to be titrated to 4 L/min. A joint interview and review of Resident 52's record was conducted with LN 11 and LN 12 on 7/11/19 at 10:34 A.M. Resident 52's physician's order dated 6/6/19 indicated, O2 at 2 L/min per nasal cannula as needed . LN 12 stated it was not typical for therapy staff to titrate O2. LN 12 stated that therapy staff .would usually let the nurse know, and the nurse would get an order to change it (referring to the O2). LN 12 stated that Resident 52 had .pneumonia (inflammation of the lung), which makes him need the oxygen . LN 11 and 12 could not find physician's orders for Resident 52's O2 to be titrated to 4 L/min. A concurrent interview and review of Resident 52's clinical record was conducted on 7/11/19 at 12:13 P.M. with the LNS. The LNS reviewed a therapy note dated 7/10/19. This record indicated that Resident 52's O2 was delivered at 4 L/min. The LNS reviewed Resident 52's Order Summary Report. This record included a physician's order dated 6/6/19, for O2 at 2 L/min per nasal cannula as needed . The LNS stated there was no order to titrate Resident 52's O2 to 4 L/min. The LNS acknowledged Resident 52 should have received O2 at 2 L/min as ordered by the physician, and not 4 L/min. During an interview with the DON on 7/11/19 at 3:55 P.M., the DON acknowledged that Resident 52's O2 should have been administered as ordered by the physician. A review of the facility's undated policy titled, Oxygen, Use of was conducted. This policy indicated, .The following guidelines will be observed in oxygen administration. 1. The O2 should be administered as prescribed Physician Orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 16 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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** 2. Resident 63 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare (care provided for healing and recovery after an injury to the bones or muscles) per the facility's admission Record. Residents Affected - Few A concurrent observation and interview was conducted on 7/8/19 at 9:36 A.M. with Resident 63. Resident 63 was sitting in a wheelchair in her room. Resident 63 wore a splint (device worn to support and protect injured/broken bone) on her right leg. A review of Resident 63's physician's order dated 7/1 through 7/31/19 was conducted. This record included orders for .Norco (medication to treat pain) 5-325 mg .2 tablet .every 6 hours as needed for severe pain . Tylenol (medication to treat pain) Tablet 325 mg .2 tablet .every 4 hours as needed for pain . A review of Resident 63's progress notes, titled eMAR- Medication Administration Note (eMARN) was conducted. The eMARN dated 7/8/19 at 5:44 P.M., indicated that two tablets of Tylenol 325 mg were administered when Resident 63 complained of pain in her right leg. At 11:34 P.M., a follow-up assessment to monitor the effectiveness of the Tylenol was completed. The eMARN dated 7/8/19 at 9:15 P.M., indicated that two tablets of Norco 5-325 mg were administered when Resident 63 complained of severe pain in her right leg. At 11:33 P.M., a follow-up assessment to monitor the effectiveness of the Norco was completed. An interview was conducted on 7/10/19 at 4:07 P.M. with LN 13. LN 13 stated that when a resident was administered a medication to treat pain, the licensed nurse reassessed for effectiveness of the pain medication .20 minutes .or within the hour that the PRN (medication that was administered as needed) was given. An interview was conducted on 7/11/19 at 9:07 A.M. with LN 14. LN 14 stated that licensed nurses checked for pain medication effectiveness between 30 minutes to 1 hour after the pain medication was administered. LN 14 stated residents were reassessed .within the hour to see if it (pain medication) was effective so the resident isn't waiting so long. A concurrent interview and review of Resident 63's eMARN was conducted on 7/11/19 at 11:52 A.M. with the LNS. The LNS stated the Tylenol that was administered on 7/8/19 at 5:44 P.M. was reassessed for effectiveness six hours later, at 11:34 P.M. The LNS stated the Norco that was administered on 7/8/19 at 9:15 P.M. was reassessed for effectiveness two hours later, at 11:33 P.M. The LNS stated that an assessment for the effectiveness of a pain medication should be completed within 30 minutes to one hour. The LNS acknowledged that two to six hours was too long of a time delay to reassess the effectiveness of pain medications. An interview was conducted on 7/11/19 at 3:40 P.M. with the DON. The DON stated it was her expectation that reassessment for the effectiveness of a pain medication was completed, 30 minutes to one hour after a pain medication was administered. Based on observation, interview, and record review, the facility failed to ensure pain was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 17 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appropriately managed and assessed for two of six residents (39) (63), reviewed for pain management. These failures had the potential to affect the physical and psychosocial well-being of Residents 39 and 63. Findings: 1. Resident 39 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke damage to tissues in the brain due to loss of oxygen to the area) per the facility's admission Record. On 7/8/19 a record of MDS (an assessment tool) dated 6/13/19 was conducted. Resident 39's BIMS (a cognitive assessment) score of 13, indicated Resident 39 was mentally alert and aware. On 7/8/19 at 9:40 A.M., an interview was conducted with Resident 39. Resident 39 stated she had pain in her right leg on some nights, caused by muscle spasms. Resident 39 stated, sometimes her pain was 8 out of 10 on the pain scale (0 being no pain, 10 indicated extreme pain). Resident 39 stated she was given Tylenol for the extreme pain in her right leg. The resident stated the Tylenol brought the pain to a more tolerable level of 5 out of 10, but that she preferred to have less pain than that. Resident 39 stated she asked for pain medication before the leg spasms began, but was told she needed to wait until the pain actually occurred. On 7/11/19 at 11:04 A.M., a joint interview and record review was conducted with the LNS. Resident 39's physician orders indicated: Tylenol 325 mg. Give 2 tablets by mouth every 4 hours as needed for Mild Pain (1-3) on pain scale. No other pain medications were ordered for Resident 39. Resident 39's MAR for the month of July 2019 recorded the resident's pain above 3 on five separate occasions, with the pain scale ranging between 4 and 7: July 2, 4:55 A.M., the pain was rated 7. July 5, (no time documented), the pain was rated 4. July 6, 3:41 A.M., the pain was rated 6. July 7, 4:35 A.M., the pain was rated 4. July 7, 8:53 P.M., the pain was rated 6. The LNS acknowledged there were no nurse's progress notes indicating the doctor was called to request stronger pain medication. The LNS stated, Resident 39's pain was not managed effectively. She acknowledged that calling a doctor to receive further pain medication orders was an appropriate intervention for pain higher than the level ordered. The LNS further stated that pre-medicating a resident was an appropriate intervention. The LNS stated, We don't want pain to be strong. On 7/11/19 at 3:10 P.M., and interview was conducted with the DON. The DON stated the doctor should have been called to address Resident 39's pain. The DON stated, We should be an advocate for the resident. If the resident wanted pain medication, she should have gotten it. Per the facility's policy titled Recognition and Management of Pain, dated July 2017, .The facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 18 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 Level of Harm - Minimal harm or potential for actual harm assists each resident with pain management to maintain the highest practicable level of well-being and functioning by .evaluating pain and working with the resident .If the pain management program is not effective, the licensed nurse will contact the resident's physician . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 19 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to remove expired milk that was stored for resident consumption. This failure had the potential to affect the quality of foods containing milk, prepared for residents who consumed food from the kitchen. Findings: A concurrent interview and inspection of the facility's kitchen walk-in refrigerator was conducted on 7/8/19 at 7:58 A.M. with the DSS. Four one-gallon containers of milk were stored on the refrigerator shelf. One container was opened with approximately one quarter of milk remaining in the container. Each gallon container had a best by date of 7/6/19. The DSS stated the facility had just received the milk on 7/8/19, and did not know why the best by dates were 7/6/19. The DSS acknowledged that the milk was outdated and should not have been in the refrigerator. An interview was conducted on 7/11/19 at 3:50 P.M. with the DON. The DON acknowledged that the four one-gallon containers of milk with best by dates of 7/6/19 were expired, and should not have been accepted upon delivery or stored in the refrigerator for resident consumption when they were received on 7/8/19. The facility's undated policy titled, Accepting Food Deliveries indicated . 3.Staff will refuse or remove any foods not safe for consumption . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 20 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: Residents Affected - Few 1. An RNA did not perform hand hygiene before and after resident contact during meal service for four of 11 residents. 2. A CNA did not perform hand hygiene after removing dirty gloves. 3. A CNA served a resident's meal tray in an unsanitary manner. These failures had the potential to spread infection among residents, staff, and visitors. Findings: 1. On 7/8/19 at 12:39 P.M., a meal service observation was conducted in the resident dining room. RNA 23 was observed touching the shoulder and clothing of a female resident, seated at table one while applying a food drape. RNA 23 then went to another female resident at the same table and began unwrapping a straw, placing it in her juice and removing food covers from the second resident's food tray. On 7/8/19 at 12:42 P.M., RNA 23 was observed getting a tray and bringing it to a male resident seated at table two, without washing or disinfecting her hands in between resident contact. RNA 23 was observed cutting the male resident's meat, opening the milk container, opening the butter and buttering the bread roll with bare hands. On 7/8/19 at 12:45 P.M., RNA 23 was observed returning to table one without washing or disinfecting her hands. RNA 23 squatted next to the original female resident and assisted with the meal by holding the resident's fork. On 7/8/19 at 12:47 P.M., RNA 23 stood from a squatting position, patted the female resident's back and clothing and walked to table three. RNA 23 placed a food drape on a male resident seated at table three. On 7/8/19 12:48 P.M., RNA 23 placed disinfectant on her hands and went to the food cart to deliver a food tray to table three. On 7/8/19 at 1:02 P.M., an interview was conducted with RNA 23. RNA 23 stated she should have sanitized her hands after touching the residents and opening their food containers. RNA 23 stated it was important to wash and sanitize hands because bacteria could be passed from resident to resident, which might cause infections. On 7/8/19 at 1:06 P.M., an interview was conducted with the ICN. The ICN stated hand sanitation should always be done between resident contact and especially during meal service. The ICN stated by not performing hand hygiene residents were at risk for cross contamination and infections. On 7/11/19 at 2:05 P.M., an interview was conducted with the DON. The DON stated hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 21 of 22 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 055632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm should always be performed during meal service and resident contact. The DON stated it was an infection control issue and bacteria could spread from one resident to another. Per the facility's policy, titled Infection Control Prevention and Control, revised September 2017, .The hand hygiene procedures will be followed by staff involved in direct resident contact .or their food . Residents Affected - Few Surveyor: Crocker, [NAME] 2. On 7/8/19 at 8:06 A.M., CNA 2 and CNA 3 were observed assisting Resident 164 to the bathroom. CNA 3 removed his gloves and proceeded to the clean linen closet, without performing hand hygiene. CNA 3 reached into the clean linen closet and removed some wash cloths. CNA 3 returned to assist CNA 2 in the bathroom and was observed donning new gloves. Hand hygiene was not observed between glove changes. On 7/8/19 at 11:15 A.M., an interview was conducted with CNA 3. CNA 3 stated he should have performed hand hygiene before and after wearing gloves. Per the facility's policy, titled Infection Control Prevention and Control, dated August 2017, .The hand hygiene procedures will be followed by staff involved in direct resident contact. 3. On 7/8/19 at 8:06 A.M., CNA 2 was observed assisting Resident 164 to the bathroom. After helping the resident in the bathroom, CNA 2 did not remove her gloves. CNA 2 was observed setting-up Resident 164's breakfast tray in her room. CNA 2 touched the resident's food, drinks, and utensils while still wearing the dirty gloves. On 7/8/19 at 11:15 A.M., an interview was conducted with CNA 2. CNA 2 stated she should have taken off her gloves and performed hand hygiene before serving Resident 164's breakfast. CNA 2 stated, It's important to have good hand hygiene for infection control. Per the facility's policy, titled Infection Control Prevention and Control, revised September 2017, .The hand hygiene procedures will be followed by staff involved in direct resident contact .or their food . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 22 of 22