Health inspection·November 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Oxycodone) for clarification, parameters, and/or monitoring of CNS depression. In addition, there was no interdisciplinary team (IDT) documented to address Resident 1's change of condition. A review of the Medication Administration Record (MAR) dated, 3/17/23 indicated, .ALPRAZolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth as needed for ANXIETY BID [twice daily] . was given to Resident 1 at 2011(8:11 P.M.).oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 2 tablet mouth every 4 hours as needed for SEVERE PAIN. was given to Resident 1 at 2128 (9:28 PM). A review of the COC note dated 3/17/2023 10:30 (P.M.), indicated, .Shortness of breath Other change in condition HYPOXIA/LETHARGY.02 [oxygen] 73 % .Date and time of clinician notification:03/17/2023 10:50 PM.The COC note dated 3/18/2023 00:30 (12:30 A.M.), indicated, .Pt noted to be lethargic and still having increased SOB, O2 sat is 70% on 3L/min via NC, condition rapidly declined, use of accessory muscle with breathing. Pt [patient] repositioned on. High Fowler's (a position in which the individual lies on their back with the head of bed elevated at 30-45 degrees), O2 sat ranging from 96-97% on non-rebreather mask @ 8L/min at around 2330. MD notified, advised to call 911. On 10/25/25, a record review was conducted on Resident 1's clinical chart. Resident 1's post respiratory vital signs (oxygen levels and respirations) after medications (alprazolam, oxycodone and mirtazapine) were administered indicated:- 3/13/23 all three medications given, alprazolam 0.25 milligrams (mg) given at 2300 (11 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2111 (9:11 P.M.) No respirations, or oxygen levels was taken after alprazolam within one hour of administration.3/14/23 all three medications given, alprazolam 0.25 mg given at 2024 (8:24 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2123 (9:23 P.M.). No respirations, or oxygen levels was taken after alprazolam within one hour of administration.- 3/15/23 all three medications given, alprazolam 0.25 mg given at 2055 (8:55 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2239 (10:39 P.M.). No respirations, or oxygen levels were taken after each medication within one hour of administration for two medications (alprazolam and mirtazapine).-3/16/23 all three medications given, alprazolam 0.25 mg given at 2014 (8:14 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg given at 2150 (9:50 P.M.). No respirations, or oxygen levels were taken after each medication (mirtazapine and oxycodone) within one hour of administration for all three medications.- 3/17/23 all three medications given, alprazolam 0.25 mg given at 2011 (8:11 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.), and oxycodone 20 mg given at 2128 (9:28 P.M.). No respirations, or oxygen levels were taken after each medication (alprazolam, mirtazapine, and oxycodone) within one hour of administration. On 10/15/25 at 11:45 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 was not on Hospice. The ADON stated while in the facility Resident 1 continued with rehab services for occupational therapy (OT) and physical therapy (PT). The ADON stated Resident 1 had malignant rectal cancer (harmful tumor of the rectum) and was treated with radiation/chemo and immunotherapy. On 10/16/25 at 11:05 A.M., an interview and record review were conducted with LN 1. LN 1 stated she was a nurse supervisor that reviews the MRR. LN 1 stated Resident 1 had an MRR dated 3/8/23 to monitor CNS depression because Resident 1 was on medications (Alprazolam, Mirtazapine and oxycodone) that can cause CNS depression to include respiratory distress. LN 1 stated CNS depression on the MRR was vague and was not clarified with the Pharmacist nor physician notified of recommendation as to what should be monitored when all three meds were given because taking three medications (Alprazolam, Mirtazapine and oxycodone), knowing Resident 1's history of respiratory disease and COVID would enhance the incidence of Respiratory depression. On 10/16/25 at 12:28 P.M., an interview and record review were conducted with ADON. The ADON stated they did not have a written policy and procedure for monitoring facility residents who was on several sedating medications. ADON agreed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055632 If continuation sheet Page 2 of 3 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 11/18/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete the care plan was not updated to address CNS depression as recommended per the MRR. The ADON stated the MRR recommendation for CNS depression monitoring was vague and should have been clarified with Resident 1's physician because monitoring for Resident 1's respiratory status should have included the respiratory rate, and oxygen saturation levels. On 10/20/25 at 10:15 A.M., an interview and record review were conducted with the Pharmacist (Pharm). The Pharm stated Resident 1 was receiving meds for COPD and given her history, Resident 1 had medications for depression (Mirtazapine) to control her depression. The Pharm stated she would not recommend stopping Mirtazapine for depression management but would have questioned the Alprazolam and the Oxycodone which were two medications that were short-acting medications (fast onset works within 20-30 minutes to work) that could cause a higher risk for CNS depression. The Pharm stated it would be best for a different class of anti-anxiety medication from a different class that did not interact with opiate medication to minimize the CNS depression. The Pharm stated Resident 1's history of COPD and COVID monitoring for respiratory distress would need to be assessed more often before and after administration of combined medications of Oxycodone and Xanax. On 10/20/25 at 2:14 P.M, an interview was conducted with the Medical Director (MD). The MD stated the combination (oxycodone, mirtazapine, and alprazolam) could cause central nervous system (CNS) depression and respiratory distress. The MD stated if there were any signs of CNS depression during a COC while on narcotic (drugs that are controlled because of their potential for abuse) medications (oxycodone and alprazolam) the nursing staff should notify the assigned physician, and if unable to get a hold of the assigned physician, to notify him. The MD stated, in general if there is CNS depression not responding (not talking, not responding to pain) then Narcan would be recommended but if a resident (any residents) was with it (alert and able to respond), then oxygen administration would be recommended. The MD stated it was professional standards of practice to monitor before and after vital signs (blood pressure, heart rate, respiration rate, and oxygen levels) during medication administration. The MD stated vital signs should be monitored after each medication within one hour of administration. On 10/20/25 at 3:06 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MRR recommendations from the Pharm was vague and was not specific to what needed to be monitored for CNS depression when taking the medications (Alprazolam, Mirtazapine, and Oxycodone). The DON stated it was important when giving medications to have clear instructions to follow as part of Resident 1's specific plan of care to monitor for CNS depression to include lethargy, increased sedation and vital signs before and after administration according to professional standards of practice of high-risk (addictive/life-threating) medications such as Oxycodone and Xanax. According to the Centers for Disease Control and Prevention (CDC), 11/28/22 SUDORS Manual Version 6.3 at https://www.cdc.gov/overdose-prevention/media/pdfs/2025/02/SUDORS_Coding_Manual_OD2A_v6.3b_Feb2025.pdf .Since opioids [ a controlled medication class such as Oxycodone] can cause respiratory depression, having a pulmonary (lung) condition such as COPD can put someone at risk for opioid-involved overdose . A review of the facility's policy and procedure titled, Significant Change in Condition, Monitoring for (Undated), indicated .The IDT shall collaborate with the Attending Physician, Resident, and/or Resident Representative to review risk indicators and the plan of care as well as document this collaboration in the EMR [electronic medical record] in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT . Event ID: Facility ID: 055632 If continuation sheet Page 3 of 3