Health inspection·April 3, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand. LN 2 stated a care plan should have been developed so staff could monitor the contracted right hand and skin, and document Resident 1's progress. On 4/3/23 at 1:17 P.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated a care plan should have been developed to address Resident 1's contracted hand and skin impairment because the care plan provided Resident 1's assessments, interventions, and goal of treatment so staff could monitor the contracted hand and to be free from foul smell and possible infection. A review of the facility's policy titled, Baseline Care Plan, revised 5/20/22, indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .1. The baseline care plan will . b. Interventions shall be initiated that address the resident's current needs including: 1. Any health and safety concerns to prevent decline or injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 2 of 4 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 056017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a licensed nurse (LN 3) notified the physician immediately after the resident's family member (FM) reported redness in resident's right stump (the extremity of a limb left after a surgical procedure) for one of three sampled residents (Resident 1) and a gauze left in Resident 1's contracted (stiffening of joints) right hand. Residents Affected - Few This deficient practice resulted in a delay of receiving treatment to prevent the onset of infection and placed Resident 1's health at risk. Findings: On 2/17/23, the Department received a complaint related to a delay of notifying the physician related to a redness in a resident's stump. On 2/23/23, an unannounced visit to the facility was conducted. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included high blood sugar and right above the knee amputation (surgical removal of a limb), per the facility's admission Record. A review of Resident 1's minimum data set (MDS - an assessment tool), dated 12/23/22, indicated Resident 1 had a brief interview for mental status (BIMS - an interview to determine the resident's mental status) score of 3/15 which meant Resident 1 had impaired cognition. a. On 2/23/23 at 3:39 P.M., a joint observation of Resident 1 and an interview of Resident 1's family member (FM) 1 was conducted. Resident 1 was sitting in a wheelchair by the activity area with a blanket on his lap, and a bandage on his right stump. Resident 1 just looked at the writer when asked and did not respond to questions. FM 1 stated on 2/11/23 (Saturday), she came to the facility and visited Resident 1. FM 1 stated she reported the soreness and redness on Resident 1's right stump to LN 3. FM 1 stated on 2/13/23, another FM (FM 2) came to visit the resident. Per FM 1, FM 2 checked the resident's right stump and noted some pus (a whitish-yellow, yellow, or brown- yellow protein-rich fluid that accumulates at the site of an infection) in it and requested to talk to the doctor. Per FM 1, the doctor was not notified about the redness in Resident 1's stump and a blister (an area of skin covered by a raised, fluid-filled bubble). FM 1 stated no one addressed the issue to the doctor. FM 1 stated because of the infection, Resident 1 will have to undergo another surgery of his right stump. FM 1 stated Resident 1 had some discomfort when his stump was touched. On 2/23/23 at 5:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 2. LN 2 stated she worked on 2/13/23 (Monday) and was notified that Resident 1 had some redness and soreness on his right stump. LN 2 stated she noted a pus discharge and redness on the resident's right stump. LN 2 stated it could be an indication of infection. LN 2 stated she informed the attending physician on 2/13/23 and the physician ordered oral antibiotic treatment for Resident 1. LN 2 stated Resident 1's attending physician was surprised because of not being informed about it Resident 1's condition. LN 2 stated there was a delay in Resident 1's treatment due to his allergy to the initial oral antibiotics ordered by the the physician. LN 2 stated the new order was started on 2/20/23. LN 2 stated LN 3 was working on 2/11/23 and should have notified the attending physician right away because a delay of treatment could lead to an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 3 of 4 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 056017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037 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 On 3/13/23 at 2:01 P.M., a telephone interview was conducted with LN 3. LN 3 stated he was the nurse supervisor on 2/11/23 (Saturday). LN 3 stated Resident 1's FM reported that Resident 1 had some redness on his right stump. LN 3 stated an ointment and dressing was applied on Resident 1's right stump but forgot to notify the physician about the redness on Resident 1's right stump. LN 3 stated he should have notified the physician immediately to prevent the delay of treatment. Residents Affected - Few On 4/3/23 at 1:17 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated the LN should have notified Resident 1's physician as soon as it was reported to him so treatment could have been initiated promptly, to prevent possible skin infection on resident's stump. A review of the facility's policy titled Notification of Changes, revised 10/16/22, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority . when there is a change requiring notification .Circumstances requiring notification include . 2. Significant change in the resident's physical .condition such as .Clinical complications. b. On 2/23/23 at 3:39 P.M., a joint observation of Resident 1 and an interview of Resident 1's FM (1) was conducted. Resident 1 was sitting in a wheelchair by the activity area with curled right hand inward. FM 1 stated on 2/13/23, FM 2 came to the facility and visited the resident. LN 2 checked Resident 1's right hand and took a black shaded colored gauze out from Resident 1's contracted hand. FM 1 stated, It was gross. We don't know how long it had been there. FM 1 stated Resident 1 was taken to his to his primary care physician (PCP) and an x-ray and a swab was done on his contracted right hand. On 2/23/23 at 5:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 2. LN 2 stated she worked on 2/13/23 (Monday) and was notified by FM 2 about the black shaded colored gauze taken out from Resident 1's contracted hand. LN 2 stated she did not know how long the gauze was left on Resident 1's contracted hand. LN 2 stated there was a foul smell and discharges coming out of Resident 1's contracted hand. LN 2 stated when staff did exercises to Resident 1, nursing staff should have placed a small towel, not a gauze. LN 2 stated the staff should have checked the right hand and removed the gauze to prevent moisture build up, bacteria growth, and infection. On 4/3/23 at 1:17 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated staff should have inspected Resident 1's contracted hand daily, cleaned it, and ensure there was no gauze to prevent skin breakdown and possible infection. A review of the facility's policy titled, Skin Assessment, revised 2/23/22, indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 4 of 4