Health inspection·December 26, 2023

F 0550 being exposed during care if it were to have happened to him. Level of Harm - Minimal harm or potential for actual harm On 12/26/23 at 2:28 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated Resident 3 ' s privacy curtains should have been completely closed during treatment. The IPN stated Resident 3 should have been provided privacy, it ' s a matter of dignity. Residents Affected - Few On 12/26/23 at 3:05 P.M., an interview was conducted with director of nursing (DON). The DON stated privacy should have been provided to Resident 3 during care and treatment. A review of the facility ' s policy titled Resident Rights revised 2/2021, indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. A dignified existence .b. Be treated with respect, kindness, and dignity . t. Privacy and confidentiality FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 2 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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 two of three residents ' (Resident 1 and Resident 3) written care plans were developed and implemented, when: 1. Resident 1 did not have an individualized care plan developed to address his multiple wounds. 2. Resident 3 ' s written care plan for activities of daily living (ADL, self-care activities) which required two staff to perform bed mobility (how a resident moves in bed) was not implemented. As a result of these failures, there was a potential for Resident 1 ' s wounds to deteriorate and for Resident 3 to experience discomfort and possible injury during care. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnosis to include encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (beneath the first layer of skin), second degree (extends into subcutaneous tissue) burn of the right thigh and foot, and pressure ulcer stage three (injury from sustained pressure extending into subcutaneous tissue) of the sacrum (area above tailbone). A review of Resident 1 ' s physician ' s orders indicated the following: - Cleanse left bunion (a bony bump on the joint at the base of the big toe) with soap and water, pat dry, apply bacitracin (antibacterial ointment) and cover with dry dressing (order dated 10/20/23). -Empty [brand name] drain (used to remove liquid accumulating in a wound) every shift (order dated 10/20/23). -Cleanse open wound to right dorsum (top of foot) with normal saline, pat dry, apply santyl (ointment that removes dead tissue) and cover with dry dressing (order dated 10/29/23). -Cleanse pressure wound to sacrum with normal saline, pat dry, apply medihoney (ointment to promote wound healing), followed by calcium alginate (medicated pad) and cover with foam dressing (order dated 10/27/23). -Cleanse right groin open area with normal saline, pat dry and leave open to air (order dated 10/20/23). -Cleanse open wound to right medial foot with normal saline, pat dry, apply triad paste (promotes wound healing) and cover with dry dressing (order dated 10/19/23). A review of Resident 1 ' s clinical record indicated there were no written care plans to guide the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 3 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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 nursing care of the resident ' s wounds and nursing interventions to promote healing and prevent wound deterioration. On 12/26/23 at 2:28 P.M., a joint interview and record review was conducted with the infection prevention nurse (IPN). The IPN reviewed Resident 1 ' s clinical record and stated there were no written care plans developed to address the resident ' s multiple wounds. The IPN stated there should have been a care plan to address each wound. The IPN stated written care plans communicated the expectations for care and what to do for the best outcome. On 12/26/23 at 3:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 1 ' s clinical record and stated Resident 1 ' s wounds should have had an individualized written care plan developed to address each one. 2. A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury extends into the muscle and/or bone) of the sacrum. A review of Resident 3 ' s Minimum Data Set assessment (MDS, a comprehensive assessment) dated 9/23/23, indicated the resident required extensive assistance (staff to provide weight bearing support) from two or more staff to perform bed mobility. A review of Resident 3 ' s undated ADL care plan indicated bed mobility was to be provided by two staff. On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositoned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared to have been lost in the bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled backward onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the used pad on the bed, touching the medicated pad with the resident skin and used pads/linens. On 12/26/23 at 1:52 P.M., an interview was conducted with Resident 3 while inside the resident ' s room. Resident 3 stated she was unable help out very much with turning in bed and could not remain laying on her side. Resident 3 stated usually when her wound treatment was performed, it was provided by two staff with one staff holding her. Resident 3 stated the wound care she had been provided today with one staff had been uncomfortable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 4 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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 On 12/26/23 at 2:05 P.M., an interview was conducted with LN 1. LN 1 stated he should have had another staff present to hold the Resident 3 ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound, apply treatment, and ensure the resident ' s comfort. On 12/26/23 at 4:20 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 3 ' s written ADL care plan and stated the resident ' s bed mobility during wound care should have been provided by two staff. The DON stated it was her expectation for care plans to be fully implemented. A review of the facility ' s policy titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated, .1. A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident The policy did not provide guidance related to care plan implementation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 5 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 2 and 3) reviewed for pressure injuries (damage to the skin and underlying tissues as a result of sustained pressure over long periods of time), had: Residents Affected - Few - Physicians ' orders for pressure injury wound treatments that were followed. -Infection control practices that were adhered to during pressure injury treatments. As a result, there was the potential for Resident 2 and Resident 3 ' s pressure injuries to deteriorate and/or become infected. Findings: 1. A review of Resident 2 ' s admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. On 12/26/23 at 11:30 A.M., an observation of Resident 2 ' s left ankle wound treatment was conducted with licensed nurse (LN) 1. A certified nursing assistant (CNA) was also present to help position the resident. The CNA, wearing gloves, proceeded to position Resident 2 and adjust the resident ' s blankets. LN 1 removed Resident 1 ' s dressing from her left ankle and then asked the CNA to give him one of the individually packaged NS wipes set out on the bedside table. The CNA opened one NS wipe and removed it from the package and handed it to LN 1. LN 1 used the NS wipe to soak off a medicated treatment pad that adhered to the resident ' s wound. The CNA held the resident ' s hand. LN 1 performed hand hygiene (washing hands or using an alcohol-based hand rub and putting on clean gloves). Resident 2 ' s ankle wound was open (non-intact skin) and was approximately the size of a pencil eraser with a red-colored wound base resembling granulation tissue (new connective tissue that fills in a wound). LN 1 asked the CNA to provide him with another NS wipe. The CNA let go of the resident ' s hand and opened another individual package of NS wipes and removed the NS wipe. LN 1 ' s N95 (respirator) slid down exposing his nose and nostrils. LN 1 took the NS wipe and wiped the wound bed (open area with non-intact skin) and around the wound edges. LN 1 adjusted his N95 with his gloved hand and then applied a foam dressing to Resident 2 ' s wound. On 12/26/23 at 11:50 A.M., an interview was conducted LN 1. LN 1 stated it was not within the scope of practice for the CNA to know at which step in wound care hand hygiene should be performed. LN 1 stated since the CNA was following his directions, he should have asked the CNA to perform hand hygiene again before providing him with NS wipes, or he should have reached for the NS wipes himself. LN 1 further stated he should not have touched his N95 in the middle of performing Resident 2 ' s treatment. LN 1 stated there was potential cross contamination of Resident 2 ' s wound. On 12/26/23 at 12:40 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated when the CNA touched Resident 2 and the resident ' s environment with her gloved hands and then opened and handed LN 1 the NS wipes, there was cross contamination. The IPN stated when LN 1 pulled up his N95 in the middle of the treatment procedure there was cross contamination. The IPN stated cross contamination could cause Resident 2 ' s wound to develop an infection. A review of Resident 2 ' s treatment orders dated 12/19/23, indicated, Treatment: Left medial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 6 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few malleolus [inner ankle]: Cleanse with NS [normal saline], pat dry, and apply [brand name] skin prep [follow with] silver alginate [medicated pad] then cover with foam dressing . On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 2 ' s left ankle treatment order dated 12/19/23 and stated that the order had not been followed. LN 1 stated he did not pat Resident 2 ' s wound dry, apply skin prep, and apply calcium alginate. On 12/26/23 at 3:05 P.M., an interview was conducted with the director of nursing (DON). The DON stated infection control practices for gloving, hand hygiene, and masking had not been followed during Resident 2 ' s wound treatment. The DON stated it was her expectation for infection control practices to be followed. The DON further stated Resident 2 ' s treatment order should have been followed. 2. A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury extends into the muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. The wound was round and approximately the size of a half dollar coin and about an eighth of an inch deep. The wound bed resembled granulation tissue. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositioned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared lost among the used bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled back onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the used pad on the bed, touching the medicated pad with the resident skin and used pads/linens. LN 1 placed the calcium alginate with silver against Resident 3 ' s wound bed and pressed it into the wound to fill in the wound depth and then covered it with a foam dressing. A review of Resident 3 ' s physician ' s orders dated 10/24/23, indicated, Treatment: Sacrum -Cleanse wound with wound cleanser or normal saline, gently pat dry, apply collagen dressing followed by calcium alginate to wound bed and cover with silicone foam dressing On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated the calcium alginate with silver pad made contact with Resident 3 ' s skin and the used pad on the bed before being placed on the resident ' s wound. LN 1 stated this was an infection control concern. LN 1 stated there was potential contamination of Resident 3 ' s wound. LN 1 reviewed Resident 3 ' s physician ' s orders dated 10/24/23 and stated he had not followed the order. LN 1 stated he did not pat the wound dry and apply collagen dressing followed by calcium alginate to the wound bed. LN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 7 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the treatment order should have been followed. LN 1 further stated he should have had another staff present to hold the resident ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound and apply treatment. On 12/26/23 at 2:28 P.M., an interview was conducted with the IPN. The IPN stated LN 1 should have had another staff present to hold Resident 3 ' s position so the resident ' s wound could be fully cleaned. The IPN stated sliding the medicated treatment pad against the resident ' s skin and bed pads/linens before placing it on the wound had potentially contaminated the wound. The IPN stated Resident 3 ' s treatment orders should have been followed. The IPN further stated calcium alginate should have been cut to fit the wound bed as folding it made it thicker and could place added pressure on the wound. On 12/26/23 at 3:05 P.M., an interview was conducted with the DON. The DON stated it was her expectation for infection control practices to be followed. The DON stated Resident 3 ' s treatment orders should have been followed. A review of the facility ' s policy titled Prevention of Pressure Injuries revised 4/2020, did not provide guidance related to treatment of pressure injuries. A review of the facility ' s policy titled Wound Care revised 10/2010, indicated, . The purpose of this procedure is to provide guidance for the care of wounds to promote healing .Steps in the Procedure 1 . Arrange the supplies so they can be easily reached . 7. Use no-touch technique A review of the facility ' s policy titled Handwashing/Hand Hygiene revised 10/2023, indicated, . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task . d. after touching a resident; e. after touching the resident ' s environment A review of the facility ' s policy titled Personal Protective Equipment- Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak) revised 9/2021, indicated, .a. Front of mask/respirator is contaminated -DO NOT TOUCH. If your hands get contaminated during the mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 8 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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, interview, and record review, the facility failed to ensure licensed nurse (LN) 1 performed wound care/treatment in a competent manner. In addition, the facility did not assess LN 1 ' s competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) prior to LN 1 providing wound treatment to two residents (Resident 2 and Resident 3). This failure had the potential to cause the residents ' wounds to worsen and/or become infected. Findings: A review of Resident 2 ' s admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. A review of Resident 3 ' s admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (pressure injury extending into the muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 11:30 A.M., an observation of Resident 2 ' s left ankle wound treatment was conducted with LN 1. A certified nursing assistant (CNA) was also present to help position the resident. The CNA, wearing gloves, proceeded to position Resident 2 and adjust the resident ' s blankets. LN 1 removed Resident 1 ' s dressing from her left ankle and then asked the CNA to give him one of the individually packaged NS wipes set out on the bedside table. The CNA opened one NS wipe and removed it from the package and handed it to LN 1. LN 1 used the NS wipe to soak off a medicated treatment pad that adhered to the resident ' s wound. The CNA held the resident ' s hand. LN 1 performed hand hygiene (washing hands or using an alcohol-based hand rub and putting on clean gloves). Resident 2 ' s ankle wound was open (non-intact skin) and was approximately the size of a pencil eraser with a red-colored wound base resembling granulation tissue (new connective tissue that fills in a wound). LN 1 asked the CNA to provide him with another NS wipe. The CNA let go of the resident ' s hand and opened another individual package of NS wipes and removed the NS wipe. LN 1 ' s N95 (respirator) slid down exposing his nose and nostrils. LN 1 took the NS wipe from the CNA and wiped the wound bed (open area with non-intact skin) and around the wound edges. LN 1 adjusted his N95 with his gloved hand and then applied a foam dressing to Resident 2 ' s wound. On 12/26/23 at 11:50 A.M., an interview was conducted LN 1. LN 1 stated it was not within the scope of practice for the CNA to know at which step in wound care hand hygiene should be performed. LN 1 stated since the CNA was following his directions, he should have asked the CNA to perform hand hygiene again before providing him with NS wipes, or he should have reached for the NS wipes himself. LN 1 further stated he should not have touched his N95 in the middle of performing Resident 2 ' s treatment. LN 1 stated there was potential cross contamination of Resident 2 ' s wound. On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 9 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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 lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. The wound was round and approximately the size of a half dollar coin and about an eighth of an inch deep. The wound bed resembled granulation tissue. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositioned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared lost among the bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled back onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the soiled pad on the bed, touching the medicated pad with the resident skin and used pads/linens. LN 1 placed the calcium alginate with silver against Resident 3 ' s wound bed and pressed it into the wound to fill in the wound depth and then covered it with a foam dressing. On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 2 and Resident 3 ' s treatment orders. LN 1 reviewed Resident 2's treatment orders dated 12/19/23, Treatment: Left medial malleolus [inner ankle]: Cleanse with NS [normal saline], pat dry, and apply [brand name] skin prep [follow with] silver alginate [medicated pad] then cover with foam dressing . LN 1 stated that the order had not been followed. LN 1 stated he did not pat Resident 2 ' s wound dry, apply skin prep, and apply calcium alginate. LN 1 reviewed Resident 3 ' s treatment order dated 10/24/23, Treatment: Sacrum -Cleanse wound with wound cleanser or normal saline, gently pat dry, apply collagen dressing followed by calcium alginate to wound bed and cover with silicone foam dressing LN 1 stated he had not followed the order. LN 1 stated he did not pat the wound dry and apply collagen dressing followed by calcium alginate to the wound bed. LN 1 stated the treatment order should have been followed. LN 1 stated the calcium alginate with silver pad made contact with Resident 3 ' s skin and the used pad on the bed before being placed on the resident ' s wound. LN 1 stated this was an infection control concern. LN 1 stated there was potential contamination of Resident 3 ' s wound. LN 1 stated he should have had another staff present to hold the resident ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound and apply treatment. LN further stated it had been a long time since he did wound treatments for residents. LN 1 stated the wound treatment nurses were currently absent and he was asked to perform wound treatments. LN 1 stated he did not feel comfortable or competent doing wound care. LN 1 stated the last time he was assessed for competency in wound care/treatment was about four years ago. On 12/26/23 at 2:28 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated nurses should be assessed annually for competency in doing wound care. On 12/26/23 at 3:05 P.M., an interview was conducted with the director of nursing (DON). The DON stated the wound treatments LN 1 provided to Resident 2 and Resident 3 did not meet acceptable standards of nursing practice and was not competent care. The DON stated assessing a nurse ' s competency involved observation and evaluation of the demonstrated skill and the result should be documented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 10 of 11 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 055806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020 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 The DON stated attending an in-service was not the same as assessing competency. The DON stated nursing competency should be determined before the nurse performed wound care on a resident. The DON stated, Care should be competent. The DON stated it was her expectation for nursing competency assessments to be done annually. On 12/26/23 at 4:20 P.M., an interview was conducted with the DON. The DON stated there was no documentation LN 1 had his competency in wound care/treatment assessed. The DON stated LN 1 had attended some in-service trainings on wound care but there were no knowledge checks or competency assessments done. A review of the facility ' s policy titled Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated, .3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: .i. Skin and wound care .l. Infection control FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055806 If continuation sheet Page 11 of 11