Health inspection·June 20, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm On 6/18/25 at 11:53 A.M., a record review was conducted on Resident 281's Social Assessment Evaluation dated 6/17/25. Resident 281's Social Assessment Evaluation indicated, .She has not yet completed a DPOAHC (durable power of attorney for health care: a document that allows you to appoint someone to make medical decisions) . There was no information that a written form was given to Resident 281's right to formulate an AD and/or no AD in Resident 281's clinical chart was available. Residents Affected - Few On 6/18/25 at 2:39 P.M., an interview was conducted with Resident 281, in Resident 281's room. Resident 281 stated she had previously made an AD prior to coming to the facility and that her husband had her AD at home. Resident 281 stated the AD she completed was for medical decisions she wanted in an event she was unable to make health care decisions. Resident 281 stated she did not remember receiving or given written information regarding an AD since she had one available at home. On 6/19/25 at 8:57 A.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD stated, I write vaguely for all the residents I ask regarding an AD because they either want help, don't want it or refuse but I should make it clear that information had been given. The SSD stated Resident 281's Social Evaluation assessment dated [DATE] was unclear if written information regarding an AD was given. The SSD stated that residents who have an AD should have a copy of their AD in their chart because it was their right to receive care according to their AD. On 6/20/25 at 10:20 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 281's AD evaluation should be clear in documentation if written information was given and should not be worded the same for all residents being evaluated for an AD. The DON stated it was her expectations that residents who have an AD be readily available to provide care according to their preferences and for residents to be given written information on their right to formulate an AD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 2 of 12 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 06/20/2025 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 record review the facility did not develop a care plan for a pacemaker (implanted device that regulates your heartbeat) for one of 18 sampled residents (34). As a result, the facility staff would not know if the pacemaker was malfunctioning. Finding: Resident 34 was admitted to the facility on [DATE], with diagnosis including atrial flutter, (abnormal heart rhythm where the heart's upper chambers (atria) beat too quickly), and a pacemaker. Resident 34's clinical record was reviewed on 6/20/25. There was no care plan or any documentation referring to Resident 34's pacemaker settings. The only information found related to the pacemaker was a History and Physical dated 5/11/25, that included permanent pacer model l310 .implanted 9/11/18. There was no information to indicate when Resident 34 was to have the pacemaker evaluated with an appointment with cardiology and no documentation of the pacemakers settings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 3 of 12 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 06/20/2025 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, interviews, and record reviews, the facility failed to follow physician-ordered oxygen therapy and ensure safe care practices for one of 18 sampled residents (Resident 286). Residents Affected - Few This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care due to staff performing duties they were not trained or authorized to do. Cross-Reference F726 Findings: According to the National Institutes of Health (2018) .Long-term oxygen therapy (LTOT) has beneficial effects on survival in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxemia [low oxygen] at rest . A review of Resident 286's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses which included a history of chronic (6 months or more of an illness) respiratory distress (difficulty breathing or unable to breathe properly) with hypoxia (low oxygen). A record review of Resident 286's minimum data set (MDS- a federally mandated resident assessment tool) dated 6/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 286 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/17/25 at 11:43 A.M., an observation and interview was conducted with Resident 286 and Resident 286's daughter, in Resident 286's room. Resident 286 was in her bed in an upright position on oxygen wearing a nasal cannula (oxygen therapy through the nose) tube. Resident 286's daughter stated that the night before a CAN removed Resident 286's oxygen then walked her to the bathroom and sat her (Resident 286) on the toilet without oxygen. Resident 286's daughter stated she slept overnight when Resident 286 informed her of this incident. Resident 286 (while taking deep breaths in-between words) stated I did not have my oxygen while I was walking to the bathroom. The CAN removed it but I need my oxygen, cause it's hard to breathe. It should have been on. I had to yell out until the med [medication] nurse came. On 6/19/25 at 8:07 A.M., a clinical chart review on Resident 286's Physician's (MD) Orders, progress notes, and care plan was conducted. Resident 286's MD order's indicated: - Orders for Oxygen 5L/min [liters]/ [per] min [minute] NC with Exertion 2L NC at rest. Start date 5/27/25 dc 6/16/25. New orders on 6/16/25 indicated Oxygen 4LPM via NC Continuously, 5L/min NC with exertion [activity] every shift. - Resident 286's progress noted on 6/16/25 indicated, .Pt [patient] was assisted by the CAN using a walker and sat in the restroom without oxygen for approximately 5 mins, while CAN was getting the portable 02 tank with wheels. Patient called writer and was upset that she was transferred to the restroom and left without oxygen . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 4 of 12 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 06/20/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Resident 286's Care Plan initiated 6/5/25 indicated, .risk for altered respiratory status/Difficulty breathing r/t Emphysema [long term condition that causes shortness of breath] .Interventions .Provide oxygen as ordered . On 6/19/25 at 10:40 A.M., an interview was conducted with CAN 1. CAN 1 stated Resident 286 was the only resident that had continuous oxygen assigned in her area. CAN 1 stated to transfer Resident 286 from the bed to the bathroom she would switch over the concentrator [oxygen device that supplies oxygen not connected to the wall] and switch to portable oxygen and then would transfer them that way [remove the end of oxygen tubing that is connected to oxygen concentrator then connect to portable oxygen]. Usually, I would just turn the knob [oxygen level dial] on and set to the level of the setting and would switch it on. CAN 1 stated upon transfer back to bed that she would switch the tubing back on the concentrator and turn the oxygen back up to their (facility residents) settings. On 6/19/25 at 10:52 A.M., an interview and record review was conducted with Licensed Nurse 2. LN 2 stated CNAs should not be adjusting oxygen settings and should notify LNs when oxygen needs to be switched from a concentrator to a portable oxygen tank. LN 2 stated Resident 286 was being transferred by a CAN per the progress noted on 6/16/25 and assisting Resident 286 to ambulate to the bathroom. LN 2 stated ambulating would be considered exertion and should have been on continuous oxygen per MD orders. LN 2 stated she [Resident 286] could have respiratory failure from lack of oxygen. LN 2 further stated Resident 286 had COPD that could lead to exacerbation (worsening) of respiratory distress. On 6/20/25 at 7:59 A.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that CAN's are not to touch the oxygen settings. The DSD stated she held an in-service on oxygen use to CAN's on 6/18/25. The course content indicated: .CNAs are not to use oxygen .It is not in your scope of practice .If asked CNAs can not turn on oxygen . The DSD further stated that she just tells the CNAs not to touch oxygen and gets checked off for their skills checklist. The DSD stated that prior to this lesson plan on 6/18/25 the CNAs just get told not to touch the oxygen with a return demonstration of not touching oxygen. The DSD stated the only rationale with the lesson plan is that it's not in their scope of practice. The DSD stated that the lesson plan does not address the importance of use and why it should be treated as a medication. The DSD stated that it lacked instructions to notify the LN, and the safety risks associated with oxygen use. The DSD stated it was important to explain this further to the CAN's because the facility serves a population of residents with respiratory disorders who need oxygen to provide safe care to prevent respiratory distress. The DSD stated Resident 286 should have had her oxygen on and safely managed appropriately according to MD orders and that this was not practiced according to professional standards of practice to prevent respiratory distress. On 6/20/25 at 9:47 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the CAN should have called the nurse to help transition Resident 286 from an oxygen concentrator to a portable oxygen prior to getting resident up from bed to ambulate (on excretion) to the bathroom because Resident 286 was on continuous oxygen orders. The DON stated this was not practiced according to professional standards of practice of the MD orders and care plan to provide the treatment and care for the safety of oxygen use. The DON stated this could lead to further respiratory distress (hypoxia and SOB) for Resident 286 because she was on continuous oxygen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 5 of 12 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 06/20/2025 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 A review of the facility's policy and procedure titled OXYGEN, USE of undated, did not indicate oxygen use administration safety. 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 6 of 12 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 06/20/2025 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 0694 Provide for the safe, appropriate administration of IV fluids 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 label (name, date, time, and dose) an intravenous fluid (IVF: hydration therapy given through the vein) therapy and discarding the IVF according to their policies and procedures for one of 18 sampled residents (Resident 275). In addition, the IVF bag and tubing was moved in next to a different resident's bedside and was left uncapped (open to infection). Residents Affected - Few This deficient practice placed all residents receiving IVF and/or IV medications at risk for infection, medication errors, and unsafe care due to improper handling and storage of IVF. Findings: On 6/17/25 at 8:26 A.M., an observation and interview was conducted in Resident 275's room. Resident 275's roommate (Resident 285) stated Resident 275 was still in the dining room being assisted for breakfast. An IVF fluid (without remaining fluid) was hanging on an IV pole that was unlabeled with an uncapped IV tubing in Resident 275's room. A review of Resident 275's admission Record indicated Resident 275 was admitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (stroke). A record review of Resident 275's minimum data set (MDS- a federally mandated resident assessment tool) dated 6/5/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 0 points out of 15 possible points which indicated Resident 275 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/19/25 at 10:09 A.M., an observation, interview and record review was conducted with LN 2, in Resident 275's room. LN 2 was shown pictures of the IVF and tubing in Resident 275's room and she confirmed that was Resident 275's room. LN 2 stated she was unable to find IVF physician's orders for Resident 275. On 6/19/25 at 10:35 A.M., an observation, interview and record review was conducted with LN 1, in Resident 275's room. LN 1 was shown pictures of the IVF and tubing in Resident 275's room and observed the same rainbow flag and bedside dresser next to the IVF hanging on the IV pole. LN 1 stated the IVF bag and tubing was unlabeled and uncapped. LN 1 stated that the IVF should be labeled according to the five rights of medications (right resident, right order, right route, right dosage and right time). LN 1 stated the IV tubing should also be labeled to know when it was used and know when to replace the tubing and capped to protect from cross-contamination. LN 1 stated he was unsure who the IVF was really for and stated since the IVF was used (no fluids remaining in bag) it should have been discarded properly. LN 1 stated that the unlabeled IVF and tubing was unsafe due to possible contamination and could lead to accidentally being used. On 6/19/25 at 10:44 A.M., an interview and record review was conducted with LN 2. LN 2 stated that the IVF had belonged to her roommate (Resident 285). LN 2 stated Resident 285's order on 6/11/25, indicated: - .IVF D5W [Dextrose 5% in water used for hydration therapy] x [times] 500 ml [milliliters] . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 7 of 12 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 06/20/2025 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LN 2 further stated the IVF found in Resident 275's room should have been properly discarded immediately after the IVF was administered. LN 2 stated this had the potential for misuse and infection control issues because it was not discarded properly and was uncapped. LN 2 stated this was probably placed there by the housekeeper because it was unlabeled. On 6/20/25 at 10:08 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the IVF bag and tubing should have been discarded after it was administered and IV pole removed from room. The DON stated her expectations was for IVF/IV medications to be labeled properly to prevent medication errors and for staff to discard IV supplies properly. The DON stated this could be unsafe or misused and a possible infection control issue. A review of the facility's policy and procedure ADMINISTRATION of PARENTERAL MEDICATION undated 5/2002, indicated, .Bag must be used or discarded after 24 hours . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 8 of 12 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 06/20/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that certified nursing assistants (CNA) followed safe and appropriate procedures when providing oxygen administration to one of 18 sampled residents (Resident 286). This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care and potential harm due to nursing staff performing tasks they were not trained or allowed to do. Cross-Reference F684 Findings: A review of Resident 286's admission Record indicated Resident 286 was admitted to the facility on [DATE] with diagnoses which included a history of chronic (6 months or more of an illness) respiratory distress (difficulty breathing or unable to breathe properly) with hypoxia (low oxygen). A record review of Resident 286's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/2/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 286 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 6/17/25 at 11:43 A.M., an observation and interview was conducted with Resident 286 and Resident 286's daughter, in Resident 286's room. Resident 286 was in her bed in an upright position on oxygen wearing a nasal cannula (NC- oxygen therapy through the nose) tube. Resident 286's daughter stated that the night before a CNA removed Resident 286's oxygen then walked her to the bathroom and sat her (Resident 286) on the toilet without oxygen. Resident 286's daughter stated she slept overnight when Resident 286 informed her of this incident. Resident 286 (while taking deep breaths in-between words) stated I did not have my oxygen while I was walking to the bathroom. The CNA removed it but I need my oxygen, cause it's hard to breathe. It should have been on. I had to yell out until the med [medication] nurse came. On 6/19/25 at 8:07 A.M., a clinical chart review on Resident 286's Physician's (MD) Orders, progress notes, and care plan was conducted. Resident 286's MD orders indicated: - Orders for Oxygen 5L/min [liters]/ [per] min [minute] NC with Exertion [activity] 2L NC at rest. Start date 5/27/25 dc [discontinued] 6/16/25. A new order for oxygen dated 6/16/25 indicated Orders for Oxygen 4LPM via NC Continuously, 5L/min NC with exertion every shift. - Resident 286's progress noted on 6/16/25 indicated, .Pt [patient] was assisted by the CNA using a walker and sat in the restroom without oxygen for approximately 5 mins, while CNA was getting the portable 02 tank with wheels. Patient called writer and was upset that she was transferred to the restroom and left without oxygen . - Resident 286's Care Plan initiated 6/5/25 indicated, .risk for altered respiratory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 9 of 12 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 06/20/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status/Difficulty breathing r/t [related to] Emphysema [long term condition that causes shortness of breath] .Interventions .Provide oxygen as ordered . On 6/19/25 at 10:40 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 286 was the only resident that had continuous oxygen assigned in her area. CNA 1 stated to transfer Resident 286 from the bed to the bathroom she would switch over the concentrator [oxygen device that supplies oxygen not connected to the wall] and switch to portable oxygen and then would transfer them that way [remove the end of oxygen tubing that is connected to oxygen concentrator then connect to portable oxygen]. Usually, I would just turn the knob [oxygen level dial] on and set to the level of the setting and would switch it on. CNA 1 stated upon transfer back to bed that she would switch the tubing back on the concentrator and turn the oxygen back up to their (facility residents) settings. On 6/20/25 at 7:59 A.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated that CNA's are not to touch the oxygen settings. The DSD stated she held an in-service on oxygen use to CNA's on 6/18/25. The course content indicated: .CNAs are not to use oxygen .It is not in your scope of practice .If asked CNAs can not turn on oxygen . The DSD further stated that she just tells the CNAs not to touch oxygen and gets checked off for their skills checklist. The DSD stated that prior to this lesson plan on 6/18/25 the CNAs just get told not to touch the oxygen with a return demonstration of not touching oxygen. The DSD stated the only rationale with the lesson plan is that it's not in their scope of practice. The DSD stated that the lesson plan does not address the importance of use and why it should be treated as a medication. The DSD stated that it lacked instructions to notify the Licensed Nurse (LN), and the safety risks associated with oxygen use. The DSD stated it was important to explain this further to the CNA's because the facility serves a population of residents with respiratory disorders who need oxygen to provide safe care to prevent respiratory distress. The DSD stated Resident 286 should have had her oxygen on and safely managed appropriately according to MD orders and that this was not practiced according to professional standards of practice to prevent respiratory distress. On 6/20/25 at 9:47 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations for in-service lesson plans with oxygen safety should indicate the importance of oxygen use for safety and explain why CNAs are not allowed to touch settings and administer oxygen. The DON stated CNAs need to understand why they should not be touching oxygen because of the population of the facility serves to provide the necessary care for residents with pulmonary and respiratory disorders. A review of the facility's Job Description titled, CERTIFIED NURSING ASSITANT dated 12/17/21 did not indicate essential functions for safety with oxygen use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 10 of 12 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 06/20/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document: Residents Affected - Few 1. The disposition of a discharged resident from the facility for one of three residents (Resident 73), reviewed for closed records; and 2. Every two hours, the lint removal in the dryer's maintenance log within the facility's laundry room, reviewed for infection control. These failures resulted Resident 73's location not being known to the reader after discharge and laundry staff being unable to verify when the dryer lint was last removed. Findings: Resident 73 was admitted to the facility on [DATE], with diagnoses which included posthemorrhagic anemia, (a sudden blood loss which leads to low red blood cell count), according to the facility's admission Record. According to the physician's order, dated 3/11/25, .Admit to (name of agency) Hospice (end of life care), for end stage cardiac (heart) disease . According to the nursing progress notes, dated 3/22/25 at 8:29 A.M., Licensed Nurse 11 (LN 11) documented Resident 73, passed away at 1:35 A.M. Hospice notified and arrived at facility at 2:28 A.M., called medical doctor, family, and mortuary. There was no documentation of when Resident 73 left the facility or what mortuary he was transported to. There was no documented evidence of a mortuary receipt being prepared by the facility. An interview and record review was conducted with LN 12 on 6/19/25 at 1:32 P.M. LN 12 stated he performed discharges. LN 12 stated when residents were discharged , the nurse was required to document what time the resident left the facility, who with, and how, such as private vehicle, ambulance etc. LN 12 reviewed Resident 73's nursing progress notes dated 3/22/25, and stated there was no disposition of when or where the resident was discharged to. LN 12 stated it was important to document the resident's discharge because it was a nursing requirement and showed a continuum care. A hard copy medical record review was conducted on 6/19/25, in the Medical Records Department. According to the Hospice file, (name of mortuary, located in Westminster, CA.) was notified by the hospice nurse on 3/22/25 at 3:55 A.M. An interview and record review was conducted with the Director of Nursing on 6/19/25 at 1: 38 P.M. The DON stated all LN's needed to document in the nursing progress note of when a resident left the facility and with whom. The DON stated documentation of discharge dispositions was a nursing requirement and showed consistency in care. The DON reviewed Resident 73's electronic record and could find no documentation of where the resident was sent or at what time the resident left. The DON reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 11 of 12 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 06/20/2025 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 0842 the hard copy medical record, and stated she could not locate the facility's receipt for mortuary pick-up. Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, titled Charting and Documentation, undated, The resident's clinical record is a concise account of treatment .8. Continuous nurse's notes are required on all residents . Residents Affected - Few 2. On 6/18/25 at 9:53 P.M., an observation was conducted of the facility's laundry room as part of the Infection Control task. Present were laundry aide 1 (LA 1) and Laundry Supervisor (LS), for assistance with interpretation. An observation and record review was conducted on 6/18/25 at 10 A.M. with LA and LS, in the drying area. The room contained two industrial dryers. The dryer's maintenance binder was reviewed, titled LINT CLEANING LOG. Entries for 6/17/25 and 6/18/25 at 7 A.M., 9 A.M. and 11 A.M., were blank and not initialed as being completed. Listed on the bottom of the lint cleaning log was, Manufacture Requirements: Lint should be removed from the lint screen after every load or after every two hours of operation . Dryer #2 contained dried chuks, (a thick absorbent bed pad) sitting inside the machine. The lint screen on Dryer #2 was removed by LS for inspection. A moderate amount of lint was present on dryer #2's lint screen with a thicker accumulation on the edges of the screen. LS stated it did not look like the screen had been cleaned at 9 A.M. An observation was conducted of dryer #1, which had a thin coat of lint on the screen. An interview with LA with LS interrupting was conducted. LA stated if the dryer screens were not cleaned every two hours, linens would take longer to dry and the dryer unit would not get as hot as possible. LA stated she usually runs the dryers at the same time and cleans the screens. LA stated Dryer #2, needed to dry some more, because the thick chuks were not dry yet, so the lint screen was not cleaned. LA stated the log entries were not completed as they should have been. An interview and record review was conducted with the LS on 6/18/25 at 10:20 A.M. The LS stated if staff removed the dryer lint, he expected them to document it so they could get credit. The LS stated if it was not documented, it was not done. The LS provided a photocopy of an in-service with laundry staff, titled Proper Documentation/Logging Work, dated 5/21/25. LA was listed as attending the in-service. An interview was conducted with the Infection Control Nurse (ICN) on 6/18/25 at 11:35 A.M. The ICN stated if lint screens were not cleaned every two hours, the linens would not get as hot as possible, which helped with destroying bacteria. The ICN stated lint removal needed to be documented in the maintenance book as removed every two hours, in order to meet the standard of practice for infection control. An interview was conducted with the Director of Nursing (DON) on 6/19/25 at 9:55 A.M. The DON stated she expected dryer lint traps to be cleaned every two hours, which was important for fast drying to prevent hazards, such as fires. The DON stated she also expects staff to routinely documents the lint cleaning in the dryers' maintenance log. The facility was unable to locate a policy related to lint trap removal for the dryers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 12 of 12