Health inspection·January 10, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm abdominal wound dressing changes in Resident 6 ' s room. While preparing the new dressing for the mid-abdominal wound, Tx LN 1 used scissors removed from the treatment cart to cut the Xerofoam (a medicated, non-adhesive dressing) package to obtain a smaller dressing to apply to the wound. Tx LN 1 was not seen disinfecting the scissors before removed from the treatment cart or after use cutting the Xeroform package. Residents Affected - Some On 12/29/23 at 10:45 A.M., Tx LN 1 used the same scissors, previously removed from the treatment cart and used to cut the mid-abdominal wound to cut a second package of Xerofoam dressing. The interior Xeroform dressing was applied the smaller wound in the left groin area. Tx LN 1 was not seen disinfecting the scissors before or after use. On 12/29/23 at 10:50 A.M., Tx LN 1 returned the scissors to a drawer in the treatment cart without disinfecting the scissors. On 12/29/23 at 10:52 A.M., an interview was conducted with Tx LN 1. Tx LN 1 stated he was unaware he was supposed to use ABHR or wash hands between all glove changes, and thought he only needed to disinfect his hands when he touched something dirty. Tx LN 1 stated he never thought about disinfecting the scissors between use, but it made sense, since the scissors were touching the contaminated outside packaging and then touching the sterile dressing inside. Tx LN 1 stated by not using ABHR with all glove changes and not disinfecting the scissors between use, he could have caused cross contamination from one wound to the other. On 12/29/23 at 11:29 A.M., an interview was conducted with Tx LN 2. Tx LN 2 stated ABHR or hand washing needed to be completed each time gloves were removed. Tx LN 2 stated it was important to keep the wounds as clean as possible and by using ABHR, you minimized the risk of cross contamination. Tx LN 2 continued, stating if scissors were used during wound treatments such as customizing the new dressings, the scissors needed to be disinfected before and after each use, to ensure they were clean and to prevent cross contamination. 3. At 12/29/23 at 11:11 A.M., an observation was conducted of a common shower room, located between Station 1 and Station 2. The shower room was unlocked and had a foul smell when entered. The room contained three shower stalls on the right side. The first stall appeared recently used and had water droplets on the floor. The second stall contained a shower chair, with a brown substance on the shower floor. The second shower stall was dry and a used dry towel was hanging from the curtain rod. On 12/29/23 at 11:15 A.M. an observation and interview was conducted with certified nursing assistant (CNA 1), of the shower room located between Station 1 and Station 2. CNA 1 observed shower stall #2 and stated, It looks like poop, and it should have been cleaned up. CNA 1 stated the feces on the floor was an infection control issue and should have been cleaned up with disinfectant wipes, which were kept in the shower room for cleaning purposes. CNA stated it appeared the towel hanging on the curtain rod appeared dirty and it also should have been removed after the shower was used. CNA 1 stated the CAN ' s were responsible for cleaning and disinfecting the shower stalls after each resident. On 12/29/23 at 11:18 A.M., an observation and interview was conducted with licensed nurse (LN 3), of the shower room located between Station 1 and Station 2. LN 3 observed the feces on the floor inside shower stall 2 and the soiled towel hanging on the curtain rod. LN 3 stated the shower stall was dirty and should have been cleaned immediately after use. LN 3 stated the shower stall was an (continued on next page) 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 01/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection control issues and could cause cross contamination to others. LN 3 stated the housekeepers were responsible for checking and cleaning the showers. 4. Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a progressive and irreversible lung disease) with acute exacerbation (sudden worsening), per the facility ' s admission Record. On 12/29/23 at 11:05 A.M., an observation was made of Resident 7, while she sat up in bed. Resident 7 was wearing an oxygen cannula (a two-prong plastic tube, that delivers oxygen to the nose). The oxygen tubing was connected to an oxygen condenser (a machine that delivers oxygen), that was next to the right side of the bed. The oxygen tubing was undated, and it was in contact with the floor between the oxygen condenser and Resident 7. 5. On 12/29/23 at 11:05 A.M., an observation was conducted inside Resident 7 ' s room. On the bedside table to the left was an aerosol machine (a small machine that helps deliver a fine mist of medication to the respiratory system to assist in opening the airways). The undated oxygen tubing was connected to the machine and to a mouthpiece (attached to the mouthpiece was a container where the breathing medication was placed). The mouthpiece was resting on the end of the table, exposed to the environment and was not covered or inside its original package of a clear plastic bag. On 12/29/23 at 11:09 A.M., an interview was conducted with LN 2 in the hallway outside Resident 7 ' s room. LN 2 stated oxygen tubing was changed and dated every 7 days, to ensure condensation and bacteria was not gathering within the tubing. LN 2 stated oxygen tubing should never be in contact with the floor, because bacteria could travel from the floor to the lungs and cause an infection. LN 2 stated mouthpieces for breathing treatments should always be placed back in their plastic bags to protect them from being exposed to contaminates. On 12/29/23 at 11:20 A.M., an observation and interview was conducted with LN 3 inside Resident 7 ' s room. LN 3 observed the oxygen tubing on the floor and stating the tubing should never be in contact with the floor because it could lead to cross contamination. LN 3 stated the oxygen tubing was not dated and since Resident 7 was admitted yesterday, her oxygen tubing should have been changed and dated upon admission, since they had no idea how long the hospital placed tubing had been in used. LN 3 observed the mouthpiece and the resident ' s breathing machine on a table top to the left of the bed. LN 3 stated the mouthpiece was exposed to the environment and was not placed back in the plastic bag, so it should be considered contaminated and should not be used again. LN 3 stated he needed to throw the mouthpiece away and get a new one, so the resident ' s airway was protected against cross contamination. On 12/29/23 The Infection Control Nurse (ICN) and the Director of Staff Development (DSD) were unavailable for interviews. On 12/29/23 at 11:35 A.M., an interview was conducted with the DSD assistant (DSD-A). The DSD-A stated handwashing or hand disinfectant should be performed right after any gloves were removed to prevent cross contamination. The DSD-A stated the CNAs were expected to clean and disinfect the shower room after each use. The DSD-A stated oxygen tubing should never be on the floor and the tubing needed to be changed and dated every seven-days, per the facility ' s policy. The DSD-A stated any breathing device needed to be secured in a container between use, because it could become infected, and the bacteria or infection could travel to the residents ' lungs. (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 01/10/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 12/29/23 at 12:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all staff, especially treatment nurses to disinfect their hands between glove changes. The DON stated all scissors and other equipment repeatedly used needed to be disinfected between use, to prevent germs and cross-contamination. The DON stated CNAs were expected to clean and disinfect showers after each use. The DON stated feces and dirty towels in the shower rooms was an infection control issue and did not present a homelike environment. The DON stated oxygen tubing should never be in contact with the floor and any breathing mouth pieces had the potential to gather bacteria, so they should always be contained and secured for protection. On 1/8/23 at 1:06 P.M., an interview was conducted with the ICN. The ICN stated she expected all staff to use ABHR or perform handwashing anytime gloves were removed or put on. The ICN stated showers should always be clean and ready for use and oxygen tubing should never touch the floor. The ICN stated all the infection control issues identified had the potential for cross-contamination and residents could have been infected, causing harm. According to the facility ' s policy, titled Infection Prevention and Control Program, copyright 2023, .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed in accordance with our facility ' s established hand hygiene procedure. e. Environmental cleaning and disinfection shall be performed according to the facility policy. All staff have the responsibilities related to the cleanliness of the facility .10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedure . According to the facility ' s policy, titled Routine Cleaning and Disinfection, copyright 2023, .Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas . According to the facility ' s policy, titled Oxygen Administration, copyright 2023, .5. Staff shall perform hand hygiene and don (to put on) gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .7. Cleaning and care of equipment shall be in accordance with t facility ' s policies for such equipment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 4 of 4