Health inspection·April 15, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few penis, then she left to get the charge nurse for help. Resident 1 stated the charge nurse decided to send him to the hospital for evaluation. Resident 1 stated the emergency room physician said the catheter most likely had not been placed properly, which caused the bleeding. Resident 1 stated the emergency room staff placed a condom catheter on him and he was sent back to the long-term care facility with extra condom catheters. Resident 1 was told he needed to see a urologist for urethral scoping (allows a physician to see the inside of the urethra and bladder by using a small scope-like camera), in a week to see if there was any long-term damage inside his urethral. Resident 1 stated he was so worried the facility might run out of condom catheters again, and they would try to put another internal urinary catheter in him. Resident 1 stated the internal catheter really, freaked me out, and he never wanted to go through that again. On [DATE], Resident 1 ' s clinical record was reviewed. The admission Minimal Data Set (MDS-a clinical assessment tool), dated [DATE], listed a cognitive score of 12, indicting cognition was intact. The functional abilities indicated Resident 1 was dependent with transferring from bed to chair, showers, toiletry, but he could assist staff with rolling from side to side. The bladder and bowel section indicated Resident 1 was always incontinence of bowel and bladder. According to the facility ' s document, titled Skin & Wound Evaluation, dated [DATE], Moisture Associated Skin Damage (MASD) . right gluteal fold (right buttocks) . edge appears flush with wound bed or a sloping edge . Per the physician ' s order, dated [DATE], Right buttock, MASD: wash with soap and water, apply barrier cream at brief changes every day and evening shift for skin maintenance and, Patient agrees to have foley (brand name) catheter. There was no documented evidence of a physician ' s order for discontinuing the urinary catheter. Per the care plan, undated, titled Resident is incontinent (unable to control bowel and bladder discharge) related to quadriplegia, listed interventions such as: Check and change during personal care, house barrier ointment/cream, clean with each incontinence episode. There was no documented evidence a care plan was developed for indwelling or condom catheter. On [DATE] at 12:05 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she started on [DATE], and could not find any documented evidence urinary catheters care in-services were provided to LNs or certified nursing assistants (CNAs) since she started. LN 1 ' s employee record was reviewed. LN 1 started working at the facility on [DATE]. Included, LN 1 ' s employee file was a 5-page document, titled Job Description/Performance Evaluation, both dated and signed by LN 1 on [DATE]. The first page, titled IV. Key/Essential Duties listed 32 job functions and at the end of each job functions were columns listed as: Great Performance (GP), Good Performance (G), Must Improve (MI). All the columns were blank with no checks or comments from an evaluator or supervisor. There was no documented evidence a supervisor or evaluator observed, documented, or reviewed LN 1 ' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 2 of 7 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 04/15/2024 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 0684 s knowledge or skills, and no other signatures except LN 1 ' s were present on the document. Level of Harm - Minimal harm or potential for actual harm The DSD stated she had not conducted any annual competence skills evaluation with LNs since she took over the position. The DSD stated ideally nurses should have their skills and performances evaluated upon hire and annually to identify each staff members strengths and weakness. Residents Affected - Few On [DATE] at 12:36 P.M., an interview was conducted with LN 1. LN 1 stated she had not performed any skills or performance checks when hired. LN 1 stated she had not received any in-services related to urinary catheter insertion or care while at this facility. LN 1 stated she graduated from nursing school in 2021 and received some urinary catheter training while in school. LN 1 stated she has inserted 6-7 catheters since nursing school and has never had any problems except for this last time, involving Resident 1. LN 1 continued, stating the facility had condom catheters size #25, but they were expired. More condom catheters were ordered, but central supply (Person who orders supplies for the facility) stated it would take about a week to receive more. LN 1 stated Resident 1 was placed in incontinence briefs until the condom catheters arrived. LN 1 stated on [DATE], she noticed moisture skin damage on Resident 1 ' s buttocks and suggested a urinary catheter. LN 1 stated Resident 1 was very resistant, but finally agreed to let her insert one. LN 1 stated while she was inserting the catheter, Resident 1 yelled that it hurt and asked her to stop. LN 1 stated she got a flash of urine in the tube, so she assumed the tip of the catheter was in the bladder. LN 1 stated she started to inflate the 10 cubic centimeter (cc) balloon with saline (a clear sterile solution to inflate the balloon, so it stays in place in the bladder), but she was getting a lot of resistance and was only able to insert 4-5 cc in the balloon. LN 1 stated the balloon usually holds 10 cc of saline, but she was getting lots of resistance at 4-5 cc. LN 1 denied gently pulling or pushing on the catheter after the balloon was inflated. LN 1 stated the resistance was strange, and she never experienced anything like that before and could not figure out what was going on. LN 1 continued, stating the next day Resident 1 told her he wanted the urinary catheter removed, because he felt something was wrong and he was not putting out as much urine as he usually did. Resident 1 stated he wanted to go back to the incontinent briefs until the condom catheters arrived. LN 1 agreed to remove the catheter. LN 1 stated she deflated the balloon and began to pull out the catheter, when she noticed Lots of red blood coming from his penis. LN 1 stated she ran to get some paper towels to apply pressure, but the resident continued bleeding. LN 1 stated she left Residents 1 ' s room to inform her charge nurse and to get an ice pack to apply to Resident 1 ' s groin area. LN 1 stated this had never happened to her before and she was not sure what was going on. LN 1 stated the physician was informed and Resident 1 was sent to the hospital for an evaluation. LN 1 could not estimate the blood amount that was lost. LN 1 continued, stating she returned to work the following day and Resident 1 informed her the physician said the urinary catheter was not placed in the bladder, as it should have been and was inflated in the urethra (a stricture that allows urine to drain from the bladder out the penis). LN 1 stated she was so upset, and she does not want to ever insert a urinary catheter again. On [DATE] at 12:51 P.M., an interview was conducted with the Charge Licensed Nurse (C-LN) on duty [DATE]. C-LN stated LN 1 said she was removing a urinary catheter from Resident 1, when he suddenly started to bleed from the penis. C-LN stated he went into the resident ' s room and noticed bright red blood on several paper towels, covering the residents groin area. C-LN stated he asked LN 1 how long the catheter had been in, and she replied one day. C-LN stated he instructed LN 1 to call the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 3 of 7 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 04/15/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician, while he completed a Change of Condition form. C-LN stated Resident 1 continued to bleed bright red blood slowly from the penis, so he was sent to the hospital for evaluation. C-LN stated he informed the Director of Nursing that Resident 1 was being sent out, but did not know what the cause of the bleeding was from. On [DATE] at 1:06 P.M., an interview was conducted with LN 2. LN 2 stated when inserting a urinary catheter, you will see a flash of urine in the clear flexible tubing. LN 2 stated before inflating the balloon, the LN should insert the tubing 1-2 inches more, to ensure the catheter was in the bladder. LN 2 stated if you got resistance with the balloon inflation, you probably were still in the urethra and should delated the balloon immediately, and insert the tubing further in. LN 2 stated if a nurse inflates the balloon in the urethra and not the bladder, you could cause damage to the urethral tissue and pain to the patient. On [DATE], the Director of Nursing (DON) was unavailable. On [DATE] at 1:20 P.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she expected all LNs to have competency reviews upon hire and annual, to ensure they had the skills required to perform each nursing task. On [DATE], the hospital medical record were reviewed. According to the emergency room record, Resident 1 arrived in the emergency room on [DATE] at 3:58 P.M., with bleeding controlled. Resident 1 was seen by a urologist (a doctor who specializes in the urinary tract system) and cleared to return to the facility on [DATE], with condom catheters supplied. Resident 1 was to follow up the urologist in one week. On [DATE] at 3:16 p.m., an interview was conducted with the Urologist Nurse Practitioner (U-NP). The U-NP stated Resident 1 was seen on [DATE] for a follow-up of hematuria (blood in the urine). The U-NP stated Resident 1 had on a condom catheter, was urinating clear urine and had no pain, so a ureteroscopy (looking in the urethra via a scope) was not required or performed. The C-NP stated Resident 1 was told to return if there were any problems or concerns in the future. The U-NP stated she could not say what the bleeding was caused from, because she was not there when the urinary catheter was inserted or removed. On [DATE] at 1:41 P.M., an interview was conducted with the facility ' s central supply staff (CS 1). The CS 1 stated when Resident 1 was admitted ([DATE]) they had condom catheters, but not his size, which was #25. The CS 1 stated they had sizes that were larger and smaller, but not the #25 size. The CS 1 stated if you put on a larger size, it would just fall off, and a smaller size would not be comfortable. The CS 1 stated she ordered more and expected them to be delivered the following Monday ([DATE]). The CS 1 stated she informed staff and they said Resident 1 would be alright and could wait until they arrived. The CS 1 stated if something was urgent, she could have gotten additional condom catheters from one of their two sister facilities. The CS 1 also stated if they needed them stat (urgently) she could have ordered them over night on Amazon (an on-line delivery service), after getting the Administrator ' s permission, but the staff told her it was okay to wait and have them delivered. On [DATE] at 2:16 P.M., a follow-up interview was conducted with Resident 1. Resident 1 stated he has had a total of four urinary catheters placed since his 2007 accident. The first was immediately after the accident and he was in a coma. The second was a straight in and out catheter. The third was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 4 of 7 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 04/15/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm while he was recovering in a skilled nursing facility, and he was later told the catheter caused scar tissue damage to his urethra. Since the 3rd catheterization, he had a tissue prolapse (tissue coming out of the penis) which doctors refer to now as a skin tag. Resident 1 stated this last catheterization with the blood, freaked him out. He said he is better now and will never consent to a urinary catheter again, if he is given the choice. Residents Affected - Few According to the facility ' s policy, titled Catheter (Indwelling) Insertion and Removal (Female and Male), undated, .11. DO NOT FORCE WATER INTO THE BALLOON. IF RESISTANCE IS ENCOUNTERED OR THE RESIDENT COMPLAINS OF PAIN, DEFLATE BALLOON, ADVANCE FARTHER INTO THE BLADDER AND INFLATE. 12. Tug gently on catheter until you feel resistance . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 5 of 7 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 04/15/2024 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 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. Based on interview and record review, the facility failed to ensure staff were competent upon hire for Licensed Nursing (LN) skills, such as the insertion of a urinary catheter for one of one staff reviewed (LN 1) for nursing competency. As a result, an indwelling urinary catheter (a sterile flexible tube placed inside the penis, to drain urine from the bladder into an external bag), was improperly inserted into Resident 1, resulting in bleeding when the catheter was removed the following day. (Cross reference F-684 Findings: An unannounced visit was made to the facility on 3/14/24, in response to a complaint received by California Department of Public Health involving the insertion of an indwelling urinary catheter. On 3/14/24 at 12:05 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she started working at the facility on 3/31/22. The DSD reviewed all the past in-services and stated she could not find any documented evidence urinary catheters care training was provided to LNs, reviewing in-service documents back to 2021. On 3/14/24, LN 1 ' s employee record was reviewed. LN 1 started working at the facility on 8/15/22. Inside LN 1 ' s employee file was a 5-page document, titled Job Description/Performance Evaluation, both dated and signed by LN 1 on 8/15/22. The first page, titled IV. Key/Essential Duties listed 32 job functions and at the end of each job functions were column boxes listed as: Great Performance (GP), Good Performance (G), Must Improve (MI). All the columns were blank with no checks or comments from an evaluator or supervisor. The remaining pages had sections uncompleted with titles such as Performance Accountabilities, Annual Review of Key Leadership Actions, Professional Growth, Documentation for Areas of Must Approve, and Performance Evaluation Acknowledgement. There was no documented evidence a supervisor or evaluator observed, documented, or reviewed LN 1 ' s knowledge or skills and no other signatures or dates were written on the document. The DSD stated she had not conducted any annual competence skills evaluation with LNs since she took over the position and believed the document titled, Job Description/Performance Evaluation was providing the LNs with their job description. The DSD stated ideally nurses should have their skills and performances evaluated upon hire and annually to identify each staff members strengths and weakness. The DSD stated LN 1 did not have any skill evaluations performed by an evaluator, so the facility was unaware of any additional training that should have been provided to improve her skills. On 3/14/24 at 12:36 P.M., an interview was conducted with LN 1. LN 1 stated she had not performed any skills or performance checks when hired. LN 1 stated she had not received any in-services related to urinary catheter insertion or care while at this facility. LN 1 stated she graduated from nursing school in 2021 and received some urinary catheter training while in school. LN 1 stated she had inserted 6-7 catheters since nursing school and has never had any problems before, except for this last time involving Resident 1. On 3/14/24, the Director of Nurses (DON) was unavailable for an interview. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 6 of 7 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 04/15/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/14/24 at 1:20 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated competency assessments should be perform on all staff upon hire. The ADON stated competency assessments were important to know the employees ' strengths and weaknesses, and to identify areas where additional training was required. The ADON stated without competency assessments, there would be no baseline to know how the employees grow and enrich their skills. The ADON stated annually competencies were also expected to be evaluated in order to refresh staff with the current standards of nursing practices. According to the facility ' s policy, titled Competency Evaluations, dated October 2022, .3. Initial competency is evaluated during the orientation process. An employee remains on orientation until all the competencies are verified. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations .6. Checklist are used to document training and competency evaluations. 7. Only designated individuals may verify competency: a. Staff Development Coordinator, b. Orientation preceptor, c. Department head/Administrator, d. Higher level employee/professional who has demonstrated competency, e. Consultant expert, f. Physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056017 If continuation sheet Page 7 of 7