Health inspection·September 23, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the care plan titled, Risk for hypoglycemia/hyperglycemia (low and high blood sugar) related to Diabetes Mellitus, dated 4/20/24, interventions listed included blood sugar checks as ordered by the physician, random blood sugar checks via fingerstick before meals. Notify medical doctor if less than 70 or greater than 250. The nurses ' progress notes were reviewed on days the blood sugar was recorded to be over 250 (three times on 6:30 A.M., and three times on 6:30 P.M.), and there was no documented evidence the physician was called. An interview was conducted with LN 5 on 8/6/24 at 1:16 P.M. LN 5 stated it was important to follow the physician ' s order for blood sugar checks, because the physician might want the nurse to administer or hold the insulin. LN 5 stated if blood sugar levels were out of the normal range in which the physician was monitoring, the nurse was expected to document that the physician was notified and document any new orders received by the nurse. An interview and record review was conducted with the Director of Nursing (DON) on 8/5/24 at 1:23 P.M. The DON stated she expected the LNs to notify the physician, if the blood sugars were outside of the parameters (normal range) set by the physician. The DON reviewed Resident 1 ' s MAR and nursing progress notes for April 2024, and stated there were no nurses ' notes on 4/21/24, 4/23/24, 4/24/24, and 4/27/24, indicating the physician was notified by staff when the blood sugar levels were over 250. According to the facility ' s policy, titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, . The provider will order the frequency of glucose monitoring and establish appropriate targets for individual residents .6.Establish provider notifications protocols, for example: a. Call provider immediately if resident is hypoglycemic (<70 mg/dl). b .(2) blood glucose levels are >250 mg/dl . 2. a. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal sugar levels in the blood), per the facility ' s admission Record. On 8/5/24, Resident 1 ' s clinical record was reviewed: According to the physician ' s order, dated 4/20/24, Insulin Glargine Subcutaneous Solution 100 units/milliliters, inject 35 units subcutaneously at bedtime (scheduled for 9 P.M.) According to the care plan, titled Risk Hypoglycemia/Hyperglycemia related to Diabetes Mellitus, dated 4/20/24, listed interventions such as, insulin therapy as ordered. The MAR was reviewed from 4/20/24 through 5/5/24, for Insulin Glargine bedtime injections. Twelve of the 13 nursing entries indicated generalized sites where the injection was given. Only one entry had a medically accepted abbreviation of a specific site RUA indicating the right upper quadrant (right upper abdomen). All other entries were broad with abd (abdomen) del and 35 listed as a site. b. Resident 2 was admitted to the facility on [DATE], with diagnoses which included Type 1 Diabetes Mellitus (insulin dependent), per the facilty ' s admission Record. On 8/5/23, Resident 2 ' s clinical record was reviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few According to the physican ' s order, dated 2/14/24, Insulin Aspart Injection Solution 100 units/millilitre, Inject 5 units subcuetaneously before meals (scheduled 6:30 A.M., 11:30 A.M., 4:30 P.M.) for diabestes mellitus. Resident 2 ' s MAR was reviewed from 8/1/24 through 8/5/24 for Insulin Aspart before meals. Eight of the 14 entries had unaccceptable medical abbreviations, and documentation where the injection was given. Entry examples were al, a, AUR, AUFL, a, RUL. On 8/5/24 at 12:14 P.M. an interview and record review was conducted with Licensed Nurse 3 (LN 3) after her initials were identified as making five of the entries for the 11:30 A.M. shift of insulin admininstration. LN 3 reviewed Resident 2 ' s August 2024 MAR and stated she had admininstered the insulin and documented the sites used for the infection. LN 3 stated she was not using the standarized medical abreviatons for the sites where the insulin was admininstered. LN 3 stated she should have used medcial standadized abreviations to indicate exactly where the insulin injections were administered, so nurses after her would rotate the injections and give at a different site. On 8/6/24 at 1:16 P.M., an interview was condcuted with LN 5. LN 5 stated it was important to identify specific insulin injections sites, so the sites could be rotated. LN 5 stated if nurses were not documenting correct abbreviation sites, staff could be given the injection in the same area repeatedly. LN 5 stated documneting the specific sites in medical abreviations was a nursing standard of practice and should always be done. On 8/6/24 at 1:29 P.M., an interview and record review was condcuted with the DON. The DON stated nurses should always document injection sites, with medically acceptable abbreviatios. The DON stated it was important for nurses to document the specific injection site, so other nurses would given injections in different areas, so the injection sites could be rotated, to prevent bruises and pain. The DON reviewed Resident 2 ' s MAR for the Insulin Aspart injections for August 2024. The DON stated some of the entries were unacceptable and did not list a specific site, which was very important to know. The DON continued, stating the facility ensured all nurses were trained by the consulting pharmacist, upon hire for medication admininstration. The DON provided proof of an insevice she gave to medication nurses, titled Admininstration of Subcuetaneous Injections, dated 7/27/23. LN 3 ' s name was not listed as attending the inservice for Admininstration of Subcuetaneous Injections. The DON stated the facility used MED PASS as their reference for nursing Standards of Practice. The facility ' s policy, titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, did not given direction for medical standards of abbreviations for site injections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 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 interview and record review, the facility failed to prevent a deep tissue injury (DTI-pressure-related injury of intact skin with non-blanchable {discoloration of the skin that does not turn white when pressed}, redness in a localized area, usually over a bony prominence), from developing after admission for one of four residents (Resident 1) reviewed for skin-related injuries. OR Residents Affected - Few As a result, Resident 1 developed a DTI, measuring 15 centimeters (cm) in length by 17 cm in width in size, which resulted in delayed healing and a delayed recovery process. Findings: On 8/5/24, an announced visit was made to the facility. A review of Resident 1 ' s admission Record was conducted. Resident 1reviewed. was admitted to the facility on [DATE], with diagnosis which included multiple falls and chronic kidney disease (when the kidneys do not filter toxins from the blood adequately). On 8/5/24, Resident 1 ' s record was reviewed. According to the facility ' s admission Assessment, dated 4/20/24 at 5:38 P.M., Resident 1 ' s skin was intact, except for some bruising identified on the abdomen (stomach). Resident 1 was continent (able to control urine and bowel movements) of bowel and bladder. On 8/5/24, Resident 1 ' s record was reviewed. According to the facility ' s document, titled Braden Scale for Predicting Pressure Sore Risk (an assessment for determining the risk of developing skin injuries), dated 4/20/24 at 6:01 P.M., Resident 1 ' s assessment risk score for developing pressure ulcer was 20, (score of 20 indicates no risk factors). The documented listed the At Risk for developing a pressure ulcer scores to be: Over 18: No Risk, Low Score: 15-18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 10-12, Very, Very High Risk: 9 or below. Resident 1 ' s record was reviewed on 8/5/24. The physician ' s order, dated 4/20/24, Nitrofurantoin Macrocytal (antibiotic to treat urine infection) Oral Capsule 100 milligrams. Give 1 capsule by mouth every 12 hours for urinary tract infection for 5 days. (medication ended on 4/25/24). Resident 1 ' s record was reviewed on 8/5/24. The Nurse Practitioner (NP) note, dated 4/23/24, indicated Resident 1 was examined by the NP and the skin was described as warm and intact, with no rash or skin breakdown. A review of the facility ' s Resident Shower Sheets were conducted on 8/5/24. Resident 1 ' s was provided showers on 4/22/24 and 4/25/24, with documentation, no skin issues were identified. Certified nursing assistant 2 (CNA 2) provided Resident 1 a shower on 4/29/24, and documented new skin condition in the groin and buttocks area. CNA 2 documented the nurse was notified. A review of Resident 1 ' s Change of Condition Evaluation form was conducted on 8/5/24, which was created by Licensed Nurse 2 (LN 2) on 4/29/24 at 2:25 P.M. LN 2 documented moisture associated skin damage (MASD- prolonged exposure to various sources of moisture, including urine or stool, characterized by inflammation of the skin), to right/left groin and to right/left buttocks. The physician and family were notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 ' s record was reviewed on date 8/5/24. The physician ' s order, dated 4/29/24, listed a skin treatment of Nystatin External Powder 100,000 units/gram (an antibiotic powder used primarily to treat fungus). Apply to left/right groin topically (a medication that goes directly on the skin) every day and evening shift for MASD for 21 days with a discontinue date of 5/8/24. Collagenase Powder (an enzyme that breaks down collagen in damaged tissues and helps healthy tissue grow). Apply to left/right buttocks topically every day shift for MASD for 21 days. Cleanse with normal saline, pat dry, apply collagen powder then cover with foam dressing daily for 21 days with a discontinue date of 5/8/24. There was no documented evidence the physician ordered a low air loss mattress (LAL- a mattress designed to distribute weight over a broad surface to prevent skin breakdown). There was no documented evidence a dermatology (physicians ' who specialize in skin disorders) consult was ordered and recommended. A review of Resident 1 ' s care plans were reviewed on 8/5/24. Resident 1 ' s had independent care plans developed on 4/30/23, for each site of MASD, titled Alteration in skin integrity related to: MASD left groin, MASD right groin, MASD left buttocks, MASD right buttocks, which listed interventions such as; assess progress of skin weekly, change clothes and linens daily and as needed, observe/report any skin irritations, eruptions, rashes, redness, itchiness to medical doctor, treatment as ordered, dermatology consult if indicated, keep skin clean and well lubricated. Resident 1 ' s care plan for skin integrity did not list an intervention related to turning and re-positioning every two hours, or hydration or protein needs. On 8/5/25 the facility ' s Treatment Administration Record (TAR-a record for documenting skin and wound treatments) for Resident 1 was reviewed from 4/29/24 through 5/6/25. The skin treatments remained the same from 4/29/24 through 5/6/24, with no updates or changes in the physician ' s orders. A review of Resident 1 ' s record was conducted on 8/5/24. The facility ' s Certified Nursing Assistant (CNA) Task documentation was reviewed from 4/20/25 through 5/6/24. Resident 1 began having incontinence (inability to control bowel and bladder function) of bowel and bladder on 4/24/24, which continued through 5/6/24. The CNA task did not include an area for documenting the CNAs were turning and repositioning every two hours. A review of Resident 1 ' s Weekly Nursing Progress Note, dated 5/2/24 at 3:28 P.M was conducted on 8/5/24. According to the facility ' s Weekly Nursing Progress Note, Resident 1 was awake, alert, and oriented to person and place. Resident 1 ' s skin condition was documented as, new skin condition noted on 4/29/24 with MASD to right/left groin and right/left buttocks. A review of Resident 1 ' s record was conducted on 8/5/24. LN 4 documented a Change of Condition Evaluation, dated 5/2/24 at 4 P.M., Resident 1, demonstrating a notable generalized weakness/tiredness, and not wanting to get out of bed. Resident 1 ' s physician was notified, and the physician ordered blood tests (a sample of blood used to determine medical problems or illness), urine analysis, (a test to determine disease or infection), and an x-ray (a photograph of an internal body part). A review of Resident 1 ' s record was conducted on 8/5/24. The facility ' s Wound Consult (WC LN) examined Resident 1 on 5/3/24 and documented, redness to groin and bottom without openings. The WC LN made no changes to the skin treatment plan. A review of Resident 1 ' s record was conducted on 8/5/24. The facility ' s treatment nurse (Tx LN), documented on Resident 1 ' s Wound Evaluation, dated 5/3/24, Trauma due to MASD in the sacrum (lower mid-back), measuring 10.2 (length) centimeters (cm) x11 cm (width) x 0.2 cm (depth) with 100% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few granulation (describes the appearance of red, bumpy tissue in the wound bed, as the wound heals), with treatment recommendation of NS (normal saline-clear cleaning solution)/ wound cleanser and apply collagen powder with foam dressing pad. A review of Resident 1 ' s record was conducted on 8/5/24. According to the physician ' s Progress Note, dated 5/3/23, Resident 1 ' s physician (MD 1), documented the resident did not currently have the capacity to understand or make medical decision, with a + decb ulcer (decubitus ulcer, damage to an area of the skin caused by constant pressure). MD 1 wrote an order for Resident 1 to be sent to the emergency room to rule out dehydration (low amount of water in the body), versus urinary tract infection (infection in the urine), versus cerebral vascular accident, (stroke) versus worsening Parkinson ' s disease (progressive disorder that affects the nervous system). A review of Resident 1 ' s emergency room record was reviewed on 8/5/24. According to Resident 1 ' s emergency room records, dated 5/3/24, Resident 1 arrived to the emergency room of the hospital with complaints of generalized weakness. The emergency room physician documented Resident 1 ' s skin was dry with no rashes. Resident 1 was given 500 cc (cubic centimeters) of intravenous (IV-fluid that is administered into a vein) normal saline solution. The emergency room physician ordered and reviewed Resident 1 ' s blood test, urine analysis, and a negative cat scan (a specialized-detailed x-ray). Resident 1 was then sent back to the skilled nursing facility on 5/3/24, with no new orders. Resident 1 ' s skilled nursing facility record was reviewed on 8/5/24. According to the facility ' s nursing Progress Note, dated 5/3/24, Resident 1 returned to the facility at 10 P.M. with no new orders from the emergency room. While in the emergency room Resident 1 received intravenous fluids. The physician and family were notified of the resident ' s return. A Review of Resident 1 ' s nursing facility record was conducted on 8/5/24. The physician (MD 1) added an order on 5/6/24 at 5:43 P.M. for a low air loss (LAL- a mattress designed to distribute weight over a broad surface to prevent skin breakdown) Resident 1. A review of Resident 1 ' s Transfer Form, dated 5/6/34 at 9:30 P.M., was conducted. Resident 1 was sent to the hospital per the physician ' s order for evaluation of being disoriented and not being able to follow simple instructions. The family was notified. A review of Resident 1 ' s medical record for the second hospital examination was conducted on 8/5/24. According to the hospital medical records, Resident 1 arrived in the emergency room on 5/6/24 at 10:10 P.M., for an altered mental status and failure to thrive. Blood test and x-rays were performed. A hospital Wound Assessment was conducted on 5/6/2 a 10:50 P.M., which was documented a moisture related skin breakdown to the sacrum (lower mid back area), defined as an unstageable pressure injury to the sacrococcygeal (pertaining to both the sacrum and coccyx [bottom of spine] to inner buttocks, measuring 15 cm (length) x 17 cm (width) in size. A Braden Skin Assessment Score of 13 was given, indicating Resident 1 was at moderate risk. (At Risk 15-18, Moderate Risk 13-14, High Risk 10-12, Very High Risk 10-12, Very High Risk 9 or below). A continued review of Resident 1 ' s hospital medical records, dated 5/6/24, indicated Resident 1 was admitted to the hospital with diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), secondary to a urinary tract infection (urine culture showed ESBL-extended spectrum beta-lactamase, an enzyme found in bacteria) and dehydration. An interview was conducted with Restorative Nursing Assistant 1 (RNA 1-a CNA specialized in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transferring, ambulating, and range of motion) on 8/5/24 at 10:42 A.M., RNA 1 stated she recalled assisting Resident 1 with transfers and toiletry. RNA 1 stated Resident 1 did well at first, but started to be become more confused each day and no longer wanted to get out of bed, shave, or dress. An interview was conducted with CNA 1 on 8/5/24 at 10:57 A.M. CNA 1 stated Resident 1 preferred to sleep in and eat his breakfast later around 10 A.M. CNA 1 recalled Resident 1 ate good at first, but as time went on, he did not want to eat as much. CNA 1 recalled trying to get Resident 1 to eat a little, even the daughter tried, but he did not seem interested. CNA 1 stated Resident 1 was more dependent after the emergency room visit (5/3/24) then before, and he remained dependent for daily care and hygiene care. An interview and record review was conducted on 8/5/24 at 12:31 P.M., with the Director of Rehabilitation (DOR). The DOR reviewed Resident 1 ' s documentation for physical therapy and occupational therapy. The DOR stated Resident 1 was getting services 5 times a week and started out good. The DOR stated he started walking 75 feet with assistance , but later decreased down to 30 feet, and sometimes refused, saying he was too tired. The DOR stated when the resident was too tired, they worked with him in his room, doing bed mobility and transfers. The last recorded day of service was on 5/2/24 because the resident went out the hospital the next day, and then it was the weekend. On 8/5/24 at 1:32 P.M., an interview and record review was conducted with the Registered Dietician (RD). The RD stated Resident 1 was eating 76-100 % of food the first week he was admitted , with a recorded weight of 202 pounds lbs. The RD noticed the resident ' s food intake had started to decline. The last documented weight was on 5/6/24, at 188 lbs., which triggered her to evaluate him on 5/7/24. The RD stated she planned on re-weighing Resident 1 because the weight documented indicated Resident 1 had lost 14 lbs. in four days (last weight 202 on 5/2/24), which was hard for her to believe. The RD stated when she returned to work on 5/7/24, she learned the resident had been admitted to the hospital the night before. An interview was conducted with LN 4 on 8/5/24 at 2:12 P.M. LN 4 stated Resident 1 was transferring (moving self from bed to chair, to bathroom) and going to the bathroom independently when he first arrived. LN 4 stated as time went on, Resident 1 needed more assistance with using the bathroom and was not eating or drinking as much, as when he first arrived. An interview was conducted with the treatment nurse (Tx LN), on 8/6/24 at 12:30 P.M. The TX LN recalled Resident 1 developed a MASD, which required daily treatments. The TX LN stated she was informed by an unknown Certified Nurse Assistant of Resident 1 developing a reddened area in the buttocks over the weekend on 4/29/24. The Tx LN stated LN 2 informed the physician and LN 2 started the skin treatments on 4/29/24, per the physicians ' order. The TX LN stated the physician ' s order instructed LNs to providing daily and evening care of a cleaning, applying Nystatin powder and collagen powder with a foam dressing. The TX LN stated the MASD was remaining the same, with little improvement, so a Wound Consult was performed 5/3/24, with the same treatment to continue. The Tx LN stated if an DTI occurred after the wound consult, she would consider it as an unavoidable wound, due to the resident ' s declining condition of moving, eating, and drinking. The Tx LN stated the last wound treatment performed on Resident 1 was on 5/6/24 at 3:52 P.M., and the Tx LN, did not identify any changes in wound status, which was still described as MASD. On 8/6/24 at 1P.M. a joint interview and record review of Resident 1 ' s shower sheet dated 4/29/24 was conducted with CNA 2. CNA 2 stated she had assisted Resident 1 with previous showers, but on 4/29/24, she identified a reddened, skin area in the groin and buttocks. CNA 2 stated she informed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few charge nurse, who then went to examine the resident. CNA 2 stated she was involved with Resident 1 ' s care at the beginning of his stay because he wanted to shave and have clean clothes every day. As time went on, CNA 2 stated the resident no longer wanted to get out of bed or dress. CNA 2 stated Resident 1 was no longer continent of bowel and bladder, and it required two staff members to clean and change him. An interview was conducted with the Director of Nurses (DON) on 8/6/24 at 1:29 P.M. The DON stated Resident 1 could have developed the DTI while on the ambulance gurney or during the emergency room visit on 5/3/24. The DON stated Resident 1 ' s MASD skin treatment continued between the first emergency room treatment on 5/3/25 and before the hospital admission on [DATE], and the treatment nurse never saw any signs of a deep tissue injury. The DON stated the facility notified the physician and intervened when changes in status were identified. The DON continued, stating the facility had been working diligently on identifying and treating skin issues all year, which was part of their Quality Assurance Performance Improvement (QAPI) plan. The DON provided me with copies of all skin-related in-services provided to staff prior to 5/6/24. 10/12/23- Providing good peri-care, offering/assisting with toileting/care- Attended: 24 CNAs, and 13 LNs 10/2/23- Prevention of Pressure Ulcers/Skin Management-Attended: 13 CNAs with handouts provided. 2/5/24-Wound Staging, Clean dressing changes-Attended: 17 LNs 4/8/24-Using soap and water to clean patients, informing charge nurse-Attended: 26 CNAs, 2 LNs An interview was conducted on 8/7/24 at 11:24 A.M., with the facility ' s wound consultant nurse (WC LN), who examined Resident 1 on 5/3/24. The WC LN stated on the day of her exam, Resident 1 had a MASD which was a moisture related skin disorder, involving partial skin thickness. The WC LN stated MASD ' s were warm to the touch and blanched when touched. The WC LN stated a DPI can develop from force or prolonged pressure which is resembled by a dark purplish dislocation, that is cool to the touch. The WC LN stated medical issues can contribute to DTI such as diabetes, kidney disease, anticoagulant therapy (medication that thins the blood) and not moving. The WC LN stated MASD and DTI were two separate distinctive issues, and one does not cause the other. The WC LN continued, stating DTI develop from prolonged pressure, such as not moving. The WC LN stated based on Resident 1 ' s hospital DTI description from 5/6/24, (15 cm x 17 cm), it took over 24 hours to develop into that size. The WC LN stated DTI do not show up suddenly, and it takes time to develop. The WC LN stated having a MASD, does not cause a DTI, because they are two separate, individual conditions. On 8/7/24 at 11:39 A.M., an interview was conducted with MD 1. MD 1 stated he examined Resident 1 on 5/3/24, after staff notified the resident ' s declining mental status, MD 1 stated his primary concern was ruling out a stroke, dehydration, or something else going on. MD 1 was asked about his documentation on his Progress Note, dated 5/3/24, for skin indicating + decb ulcer. MD 1 stated he was not a wound specialist, and he referred all wound care to the wound consultants. MD 1 stated he documented decub ulcer because he was referring to the MASD and did not see anything other than a moisture-related skin irritation at the time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0686 Level of Harm - Minimal harm or potential for actual harm A record review of the facility ' s policy was conducted on 8/5/24. The policy, titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated February 2024, Assessment: 1. The nursing staff and practitioner will assess and document an individual ' s significant risk factor .3. The staff and practitioner will examine the skin of a newly admitted residents .Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound-healing . Residents Affected - Few A record review of the facility ' s policy was conducted on 8/5/24. The policy, titled Nutrition (Impaired) unplanned Weight Loss-Clinical Protocols, dated September 2017, Assessment: 1. The nursing staff will monitor and document the weight and dietary intake of resident . Cause: The physician will review for medical causes of .anorexia and weight loss before ordering interventions . A record review of the facility ' s policy was conducted on 8/5/24. The policy, titled Acute Condition Changes-Clinical Protocol, dated March 2018Assessment: .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse.Treatment: The physician will help identify and authorize appropriate treatments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure insulin injection sites were rotated before administration for one of four residents (Resident 1), reviewed for pharmacy services. As a result, there was the potential for Resident 1 to experience increased bruising, pain, and possibly a decreased absorption of medication due to repeatedly used injection sites. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal sugar levels in the blood), per the facility ' s admission Record. On 8/5/24, Resident 1 ' s clinical record was reviewed: According to the physician ' s order, dated 4/29/24, Humalog Kwik Pen (a pre-loaded injectable insulin pen), Subcutaneous Solution Pen-injector 100 units/milliliter (insulin Lispo). Inject as per sliding scale: 70-130 = 0 units; 131-180 = 2 units; 181-240 = 4 units; 241-300 = 6 units; 301-350 = 8 units; 352-400 = 10 units; if over 400 give 12 units and call medical doctor. Give subcutaneous before meals and at bedtime for diabetes mellitus. According to the care plan, titled Risk Hypoglycemia/Hyperglycemia relayed to Diabetes Mellitus, dated 4/20/24, listed interventions such as, insulin therapy as ordered. Resident 1 ' s Medication Administration Record (MAR) was viewed from 4/29/24 through 5/6/24, for injections sites used for the administration of the Humalog Kwik Pen Subcutaneous Solution Pen-Injector. The same injection site was used on 5/1/24 at 4:30 P.M. and 9 P.M. by the Licensed Nurse 4 (LN 4), with the site documented as LUQ (left upper quadrant, in abdominal area). A repeated injection site was used on 5/2/24 at 4:30 P.M., and 9 P.M. by LN 4 and LN 7, with the site documented as LUQ. The same injection site was used on 5/4/24 at 11:30 A.M., and 4:30 P.M. by LN 8, with the site documented as LLQ. (left lower quadrant) An interview as conducted with LN 5 on 8/6/24 at 1:16 P.M. LN 5 stated she was a medication nurse and regularly worked the night shift from 11 P.M. to 7:30 A.M LN 5 stated it was important to rotate injection sites. LN 5 stated rotating injections sites was a standard of practice to prevent bruising, pain and decreased absorption of the medication being administered. LN 5 stated it was the nurse ' s responsibility to document the site of injection, so the next nurse could see the documented site and rotate to a different site. An interview was conducted with LN 2 on 8/6/24 at 12:49 P.M. LN 2 stated if insulin injection sites in the subcutaneous tissue were not rotated, the resident might not get the full effect the medication it was intended for, due to a decreased absorption from repeated injections. An interview and record review was conducted with the Director of Nursing (DON) on 8/6/24 at 1:29 P.M. The DON stated insulin injection sites should be rotated to prevent infection and increased bruising to the area The DON stated it was a nursing standard to rotate sites and all nurses should know that. The DON reviewed Resident 1 ' s MAR from 4/29/24 through 5/6/24 and stated the injection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 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 055910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Manor LA Mesa Healthcare Center 5696 Lake Murray Blvd 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sites were not routinely rotated and some days Resident 1 was given back-to- back injections at the same site. The DON continued, stating the facility ensured all nurses were trained by the consulting pharmacist, upon hire for medication administration. The DON provided proof of an in-service she provided to medication nurses, titled Principles of Medication Administration Management, dated 3/25/24 and 3/ 27/24, which included instructions of insulin injections. The printed handout included appropriate subcutaneous injections sites and rotating injections site to prevent lipodystrophies (disturbances of fat tissue). Rotate to a different area with each injection. This will help decrease difference in insulin absorption from day to day. A total of 18 nurses attended the in-service. LN 4 and LN 7 were not on the attendance list. An interview was conducted with the Pharmacy Consultant (PC) on 8/21/24 at 8:46 A.M. The PC stated she reviewed all the facility ' s residents ' medications monthly and insulin injection sites would be part of her review. The PC stated in April 2024, she conducted a Medication Regime Review (MRR) before Resident 1 ' s admission date on 4/20/24, so the resident ' s medication record was not reviewed by the time she submitted her report on 4/25/24. The PC stated if insulin injections were given back-to-back in the same site, it could cause discomfort to the resident and the injection site might develop a decreased absorption of insulin. The PC stated it is a standard of practice for injection sites to be rotated. The facility ' s policy, titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, did not given direction for rotating insulin injection sites. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055910 If continuation sheet Page 11 of 11