Health inspection·April 24, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on interview, record review, document review, and facility policy review, the facility failed to complete an annual Minimum Data Set (MDS) for 1 (Resident #33) of 11 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, [Resident Assessment Instrument] MDS 3.0 Manual. 3.0 User's Manual, dated 10/2024, revealed The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA [Significant Change in Status Assessment] or an SCPA [Significant Correction to Prior Comprehensive Assessment] has been completed since the most recent comprehensive assessment was completed. Its completion dates depend on the most recent comprehensive and past assessments' ARDs [Assessment Reference later than 14 days after the ARD. An admission Record revealed the facility admitted Resident #33 on 03/09/2022. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes and chronic kidney disease. An annual MDS, with an ARD of 03/05/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. During an interview with MDS Coordinator #1 and MDS Coordinator #2 o on 04/24/2025 at 8:59 AM, it was reported there were some MDSs that had not been submitted. They both reported the MDS should be signed as being completed 14 days after the ARD and from day 15 forward the MDS was considered late. It was reported the expectation was that all assessments are submitted on time. MDS Coordinator #1 stated Resident #33's annual MDS with an ARD of 03/05/2025 had not been submitted and was late. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated it was her expectation that MDS assessments were completed and submitted within the required timeframe. Page 1 of 13 056017 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0636 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/24/2025 at 10:58 AM, the Executive Director (ED) stated the facility had deadlines to complete, submit, and transmit MDS assessments. The ED stated it was his expectation that all MDS assessments were completed and submitted within the required timeframe. Residents Affected - Few 056017 Page 2 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm 6. An admission Record indicated the facility admitted Resident #24 on 11/25/2020. According to the admission Record, the resident had a medical history that included diagnoses of age-related osteoporosis and atherosclerotic heart disease. Residents Affected - Some Resident #24's quarterly MDS, with an ARD of 03/04/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 7. An admission Record indicated the facility admitted Resident #27 on 12/06/2022. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and type 2 diabetes mellitus. Resident #27's quarterly MDS, with an ARD of 03/03/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 8. An admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure and chronic kidney disease. Resident #55's quarterly MDS, with an ARD of 03/09/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 9. An admission Record indicated the facility admitted Resident #83 on 04/19/2022. According to the admission Record, the resident had a medical history that included diagnoses of hypertensive chronic kidney disease and anemia. Resident #83's quarterly MDS, with an ARD of 03/09/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 10. An admission Record indicated the facility admitted Resident #94 on 09/01/2022. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and hypothyroidism. Resident #94'sA quarterly MDS, with an ARD of 03/04/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. During an interview with MDS Coordinator #1 and MDS Coordinator #2 o on 04/24/2025 at 8:59 AM, it was reported there were some MDSs that had not been submitted. They both reported the MDS should be signed as being completed 14 days after the ARD and from day 15 forward the MDS was considered late. It was reported the expectation was that all assessments are submitted on time. MDS Coordinator #1 stated the quarterly MDS for Residents #7, #21, #24, #27, #44, #55, #83, #94, #102, and #130 had not been submitted and was late. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated it was her expectation that MDS assessments were completed and submitted within the required timeframe. During an interview on 04/24/2025 at 10:58 AM, the Executive Director (ED) stated the facility had deadlines to complete, submit, and transmit MDS assessments. The ED stated it was his expectation 056017 Page 3 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0638 that all MDS assessments were completed and submitted within the required timeframe. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, document review, and facility policy review, the facility failed to complete a quarterly Minimum Data Set (MDS) for 10 (Residents #7, #21, #24, #27, #44, #55, #83, #94, #102, and #130) of 11 sampled residents reviewed for resident assessment. Residents Affected - Some Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, [Resident Assessment Instrument] MDS 3.0 Manual. 3.0 User's Manual, dated 10/2024, revealed The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are [Assessment Reference Date]. 1. An admission Record revealed the facility admitted Resident #21 on 12/09/2018. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and atherosclerotic heart disease. Resident #21's quarterly MDS, with an ARD of 03/15/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 2. An admission Record revealed the facility admitted Resident #44 on 06/08/2024. According to the admission Record, the resident had a medical history that included diagnoses of heart failure and acute respiratory failure. Resident #44's quarterly MDS, with an ARD of 03/08/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 3. An admission Record revealed the facility admitted Resident #102 on 03/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and emphysema. Resident #102's quarterly MDS, with an ARD of 03/08/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 4. An admission Record revealed the facility admitted Resident #7 on 11/07/2024. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Resident #7's quarterly MDS, with an ARD of 02/28/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 056017 Page 4 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. An admission Record revealed the facility admitted Resident #130 on 08/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with foot ulcer and essential hypertension. Resident #130's quarterly MDS, with an ARD of 02/25/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 056017 Page 5 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 residents (Resident #55 and Resident #71) of 27 sampled residents. Residents Affected - Few Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, It is the practice of this facility to conduct accurate coding and delivery of services provided to capture accurate assessment of each [Resident Assessment Instrument] MDS 3.0 Manual guidelines. 1. An admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder and anxiety disorder. An annual MDS, with an Assessment Reference Date (ARD) of 12/07/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #55 was not currently considered by the state level II preadmission screening and resident review (PASARR) process to have a serious mental illness or related condition. The MDS indicated Resident #55 had active diagnoses that included anxiety disorder and schizophrenia. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/24/2025 at 8:59 AM, it was reported that Resident #55 had a positive level II PASARR and it should have reflected on their annual MDS with an ARD of 12/07/2024. 2. An admission Record indicated the facility admitted Resident #107 on 02/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of end stage renal disease, dependence on renal dialysis, dysphagia, and attention to gastrostomy. and. A quarterly MDS, with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #107 did not have a feeding tube or receive dialysis while they were a resident of the facility. Resident #107's Care Plan Report included a focus area initiated 05/09/2024, that indicated the resident required hemodialysis related to a diagnosis of end stage renal failure. The Care Plan Report included a focus area initiated 02/19/2024, that indicated the resident required tube feeing related to a diagnosis of dysphagia. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/24/2025 at 8:59 AM, it was reported that Resident #107 was a dialysis and it should have been reflected on the resident's quarterly MDS with an ARD of 01/12/2025. They also stated the resident's MDS should have indicated the resident received a tube feeding. Resident #107's Order Summary Report, with active orders as of 01/12/2025, revealed an order dated 12/31/2024, for enteral feeding every eight hours and an order dated 01/02/2025, for dialysis 056017 Page 6 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0641 treatment every Tuesday, Thursday, and Saturday. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated she expected a resident's MDS to be accurate and confirmed tube feeding and dialysis should have been coded on Resident #107's quarterly MDS. Residents Affected - Few In an interview on 04/24/2025 at 10:59 AM, the Executive Director stated he expected a resident's MDS to be accurate. 056017 Page 7 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure a Level I preadmission screening and resident review (PASRR) was timely resubmitted after a resident remained in the facility longer than 30 days for 2 (Resident #120) of 6 sampled residents reviewed for PASRR. The facility further failed to ensure the accuracy of the Level I PASRR for 1 (Resident #108) of 6 sampled residents reviewed for PASRR. Residents Affected - Few Findings included: A facility policy titled, Admission, Transfer, Discharge and Bed-Holds dated 12/2016, revealed, The facility, in compliance with the Omnibus Budget Reconciliation Act of 1987, requires individuals diagnosed with major mental illness, mental retardation, or developmental disabilities to be screened prior to admission and throughout stay in accordance with PASRR requirements. 1. An admission Record revealed the facility admitted Resident #120 on 02/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, schizoaffective disorder, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. A letter from the California Department of Health Care Services dated 01/30/2025, revealed If the individual [Resident #120] remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. Resident #120's Care Plan Report included a focus area initiated 02/10/2025, that indicated the resident was a long-term stay in the facility for rehabilitation. Resident #120's medical record revealed no evidence to indicate a new Level I Screening was submitted when the resident remained in the facility after 30 days. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/23/2025 at 10:49 AM, both stated they were unable to articulate the process for residents admitted to the facility under a hospital discharge exemption for a PASRR. MDS Coordinator #2 stated he would investigate to see if another Level I was resubmitted. During an interview on 04/23/2025 at 12:01 PM, MDS Coordinator #2 stated the facility overlooked the resubmission of Resident #120's Level I when the resident remained in the facility. MDS Coordinator #2 confirmed the new Level I was not completed or submitted within the specified timeframe. During an interview on 04/24/2025 at 10:36 AM, the Director of Nursing stated it was her expectation that the Level 1 be submitted within the required timeframe. During an interview on 04/24/2025 at 10:58 AM, the Executive Director stated he expected a resident's Level I should be resubmitted within 30 days for any resident who remained in the facility longer than the anticipated 30 days. 2. An admission Record revealed the facility admitted Resident #108 on 09/26/2023. According to the admission Record, Resident #108 had a medical history that included diagnosis of depression and schizophrenia. 056017 Page 8 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2025, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had active diagnoses to include depression and schizophrenia. Resident #108's Care Plan Report included a focus area initiated 02/10/2025, that indicated the resident had depression. The Care Plan Report included a focus area initiated 02/10/2025 and revised 04/24/2025, that indicated the resident had a psychosocial wellbeing problem related to a diagnosis of schizophrenia. Resident #108's Preadmission Screening and Resident Review Level 1 Screening dated 09/26/2023, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disorder. During an interview on 04/23/2025 at 2:29 PM, MDS Coordinator #2 stated Resident #108's Level I Screening was inaccurate and he should have reviewed it for accuracy. During an interview on 04/24/2025 at 10:52 AM, the Director of Nursing stated it was her expectation that a Level I Screening be resubmitted if it was not correct. During an interview on 04/24/2025 at 11:00 AM, the Executive Director stated his expectation was for the Level I Screening be accurate. 056017 Page 9 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, record review, and facility policy review, the facility failed to properly dispose of medication for 1 (Resident #71) of 27 sampled residents. Residents Affected - Few Findings included: A facility policy titled, Disposal of Medications and Medication-Related Supplies, updated 08/2019, indicated, Discontinued medications and medications left in the facility after a resident's discharge are destroyed. Destruction methods comply with federal and state laws and regulations, including the Office of National Drug Control Policy (ONDCP) guidelines for medication destruction. An admission Record indicated the facility admitted Resident #71 on 04/07/2021. According to the admission Record, the resident had a medical history that included a diagnosis of overactive bladder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #71's Order Summary Report that contained active orders as of 04/22/2025, revealed an order dated 04/07/2021, for desmopressin acetate tablet 0.1 milligram, give one table by mouth two times a day for overactive bladder. During an observation of the dumpster on 04/21/2025 at 8:51 AM, the surveyor noted a bubble pack card of desmopressin tablets on the ground with Resident #71's name on it that contained four tablets. During a concurrent interview and observation of the dumpster on 04/22/2025 at 9:00 AM, the surveyor noted a bubble pack card of desmopressin tablets on the ground with Resident #71's name on it that contained four tablets. The Dietary Manager (DM) stated she would have to ask nursing about the medication on the ground, as it was not her department. During an interview on 04/22/2025 at 9:10 AM, Registered Nurse (RN) #3 stated the facility disposed on medications in a bucket in the medication room. RN #3 stated the facility did not throw medication outside by the dumpster because it could be a danger to anyone as they could access the medication. According to RN #3, when medications are disposed of, the resident's name was removed and shredded and any remaining pills/tablets were popped out and placed in the destruction bucket for destruction/disposal. During an interview on 04/22/2025 at 9:30 AM, the Director of Nursing stated medications should be disposed of by placing the medication in the destruction receptable. During an interview on 04/23/2025 at 11:31 AM, RN #4 stated medications are placed in a discard bin for destruction/disposal. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated staff should follow the facility protocol for medication destruction and not place medications in the dumpster. 056017 Page 10 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside of 2 (Resident #55 and Resident #71) of 27 sampled residents Findings included: A facility policy titled, Medication Storage in the Facility, updated 08/2019, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 1. An admission Record indicated the facility admitted Resident #71 on 04/07/2021. According to the admission Record, the resident had a medical history that included diagnoses protein-calorie malnutrition and disorders of bone density and structure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #71's Care Plan Report with an admission date of 04/07/2021, revealed no care plan to indicate the resident could self-administer their medications. Resident #71's Order Summary Report that contained active orders as of 04/22/2025, revealed an order dated 04/07/2021, for albuterol sulfate hydrofluoroalkane (HFA) aerosol solution, inhale two puffs orally every four hours as needed for wheezing and shortness of breath and calcium carbonate tablet chewable, give two tablets by mouth one time a day for supplement. There was also an order dated 08/23/2024, for calcium citrate-vitamin D oral tablet, give two tablets by mouth one time a day for supplement. There was no order to indicate the resident could self-administer their medications. During an observation on 04/21/2025 at 10:14 AM, the surveyor noted an albuterol inhaler, Coricidin D (an over-the-counter oral cough suppressant medication), and calcium supplement at the bedside of Resident #71. In an interview on 04/22/2025 at 9:10 AM, Registered Nurse (RN) #3 stated Resident #71 did not self-administer their medications and the resident's albuterol inhaler should be stored in the medication cart. In an interview on 04/23/2025 at 11:31 AM, RN #4 stated staff should not leave medications at a resident's bedside. 2. An admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the admission Record, the resident had a medical history that included a diagnosis of congestive heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident 056017 Page 11 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0761 had moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Resident #55's Care Plan Report with an admission date of 12/14/2023, revealed no care plan to indicate the resident could self-administer their medications. Residents Affected - Few Resident #55's Order Summary Report that contained active orders as of 04/22/2025, revealed no physician's order for Coricidin high blood pressure (HBP), an over-the-counter oral cough suppressant medication. During a concurrent interview and observation on 04/21/2025 at 2:24 PM, the surveyor noted Coricidin HBP on Resident #55's overbed table. Resident #55 stated they was waiting to get the physician's approval for the Coricidin HBP. During an interview on 04/23/2025 at 11:31 AM, Registered Nurse #4 stated staff should not leave medications at a resident's bedside. In an interview on 04/23/2025 at 2:06 PM, the Director of Staff Development stated medications should not be left at the resident's bedside unless it was care planned and in a locked container. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated medications were only allowed to be stored at a resident's bedside when there was a physician's order to do so. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated medications could only be left at a resident's bedside when a resident had been assessed to self-administer their medications and there was a physician's order to do so. 056017 Page 12 of 13 056017 04/24/2025 LA Jolla Post-Acute 2552 Torrey Pines Rd LA Jolla, CA 92037

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility policy review, the facility failed to ensure the dumpster area was clean and the dumpster lid was closed. This had the potential to affect all 140 residents who resided in the facility. Residents Affected - Many Findings included: A facility policy titled, Environmental Maintenance - Grounds Maintenance effective 08/2014, indicated Purpose To define the procedure for inspecting the grounds and performing corrective maintenance as needed. The policy specified, 5. Visually inspect dumpster areas for any unsafe or unsanitary conditions. 6. Visually inspect for trash, debris, pests or rodents. During an observation of the dumpster on 04/21/2025 at 8:51 AM, the surveyor noted the dumpster was opened and there were disposable gloves, aluminum foil, and food packaging on the ground. During an observation of the dumpster on 04/22/2025 at 8:52 AM, the surveyor noted the dumpster was full, the dumpster lid was opened and could not close due to overflowing bags, and empty boxes were on the ground around the dumpster. During a concurrent interview and observation of the dumpster on 04/22/2025 at 9:00 AM, the surveyor noted the dumpster was full, the lid was opened and could not close due to overflowing bags, and empty boxes were on the ground around the dumpster. The Dietary Manager (DM) stated the dumpsters were full. During an interview on 04/23/2025 at 10:47 AM, the Director of Environmental Services (DES) stated he and the janitors were responsible for keeping the dumpster area clean. The DES stated there should be no papers or trash on the ground around the dumpsters and the dumpster lid should be closed. During a follow-up interview on 04/23/2025 at 1:01 PM, the DM stated maintenance made sure that everything was cleaned around the dumpster and the lids were closed. During an interview on 04/23/2025 at 1:05 PM, the Registered Dietician stated the dumpster area should be clean and the lids should be closed. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated he expected the dumpster area to be clean and there should be nothing on the ground around the dumpster. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated the expectation was that the dumpster lid should be closed and all debris should be picked up around the dumpster. 056017 Page 13 of 13