Inspection·May 14, 2021

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) matched the electronic medical record (EMR) in one of 24 sampled residents (Resident 16), This facility failure had the potential to cause a delay in receiving or incorrectly administering life-sustaining treatments. Findings: During a concurrent interview and record review on 5/12/21, at 12:11 p.m., with the director of nursing (DON), Resident 16's POLST was reviewed. The POLST indicated do not attempt resuscitation (DNR), selective treatment IV (in the vein) fluids, IV antibiotics, do not intubate and a trial period of artificial nutrition including feeding tubes. Resident 16's Physician Orders in the EMR were reviewed. The physician orders indicated DNR and comfort measures only. The physician orders did not indicate a trial period of artificial nutrition. The DON agreed the records did not match. The DON indicated the physician order in the EMR was changed on 11/11/19 discontinuing the trial period of artificial nutrition and was changed to no artificial means of nutrition. The DON further indicated the POLST needed to be updated to reflect the current orders in the EMR. During a review of the facility's policy and procedure titled, Request/Refuse/Discontinue Treatment; Formulate Advanced Directive dated 3/2018, indicated in part . Compass Health Inc. facilities maintain guidelines regarding advanced directives .residents or resident's representatives are given written information on their right to accept or refuse medical treatment and formulate an advanced directive if the resident so wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care) was accurate for two of 24 sampled residents (Resident 14 and Resident 17) when: Residents Affected - Few 1. The dental assessment of Resident 14's broken and missing teeth was not reflected on the MDS. 2. Resident 17's neurological status of Traumatic Brain Injury (TBI) was left blank. These failures had the potential to result in Resident 14's and 17's identified care needs to go unmet. Findings: 1. During a concurrent observation and interview on 5/11/21, at 11:55 a.m., with Resident 14, Resident 14 indicated having right upper tooth pain. The tooth was observed to be yellow/brown in color and also noted were several missing teeth. Resident 14 further indicated x-rays of teeth was performed ,the tooth needed to be extracted and causes pain when eating. During a review of Resident 14's Dental Care evaluation form dated 3/2/20, the evaluation indicated, Resident 14 had multiple missing teeth and many cavities that are not restorable. During a review of Resident 14's Dental Care evaluation form dated 5/3/21, the evaluation indicated, Resident 14 had poor teeth condition and does not want full mouth extractions or dentures. During a review of Resident 14's MDS Assessment Section L dated 9/1/20, 11/24/20, and 2/16/21, was blank, indicating Resident 14 did not have any dental concerns. During concurrent interview and record review on 5/14/21, at 11:00 a.m., with the MDS nurse (MDS 1), Resident 14's Dental Care evaluations and MDS Assessments for Section L were reviewed. MDS 1 agreed Resident 14 had dental concerns and section D (obvious or likely cavity or broken natural teeth) should have been checked. MDS 1 further agreed assessments should be accurate. 2. During concurrent interview and record review on 5/14/21, at 8:43 a.m., with the director of nursing (DON), Resident 17's Physician Progress Notes, dated 7/3/20 were reviewed. The notes indicated Resident 17 had dementia with cognitive impairment, history of traumatic brain injury (TBI) and history of subarachnoid hemorrhage (brain bleed). Resident 17's Physician Progress Notes, dated 3/21/21 were reviewed. The notes indicated Resident 17 had a subarachnoid hemorrhage, traumatic brain injury secondary to an aneurysm (a ballooning and weakened area of an artery that can rupture and cause internal bleeding) in 2001, and memory impairment. During a review of Resident 17's MDS Assessment Section I dated 9/1/20, 12/1/20, and 2/24/21, the box under neurological diagnoses for TBI was blank, indicating Resident 17 did not have a traumatic brain injury. During a concurrent interview and record review on 5/14/21, at 10:45 a.m., with the MDS 1, Resident 17's Physician Progress Notes and MDS Assessments for Section I were reviewed. MDS 1 agreed Resident 17 had a TBI and and this should have been checked off under neurological diagnoses. MDS 1 stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete I missed it and indicated MDS assessments was filled out according to the physician diagnoses , progress notes, and should be accurate. During a review of the facility's policy and procedure titled, Accuracy of Assessments dated 3/18, indicated in part . Compass Health facilities will ensure that each resident receives an accurate assessment by qualified staff that is reflective of resident's status at the time of the assessment. Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, and interview, the facility failed to develop and implement a comprehensive care plan for one of 24 sampled residents (Resident 32). Residents Affected - Few This facility failure had the potential for Resident 32's dental care needs to not be met. Findings: During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 3/2/20, indicated Pt (Resident 32) refuses Tx (treatment) .multiple missing teeth. The document further indicated Resident 32's cooperation and motivation for dental services was Poor/Negative. During a review of Resident 32's Onsite Dental Visit Summary dated 4/8/21, indicated that Resident 32 Refused X-Ray. During a review of Resident 32's Dietary Progress Notes dated 4/21/21, indicated the registered dietician (RD 1) spoke with Resident 32. The progress notes indicated RD 1 Spoke with resident (Resident 32) regarding request to change diet due to oral pain. During a review of Resident 32's dental consult titled Onsite Skilled Dental Care dated 5/3/21, indicated Resident 32's cooperation and motivation for dental services was Poor/Negative. The document further indicated Pt (Resident 32) refuses dental tx. During an interview on 5/14/21, at 8:42 a.m., with the director of social services (DSS 1), DSS 1 was asked if the facility had developed a care plan pertaining to Resident 32's missing and painful teeth and if the facility had developed care planned interventions in response to Resident 32's repeated refusals for dental care services. DSS 1 stated I don't see it and further stated Right now its generic pertaining to care, nothing in the care plan specific to oral care. During a review of the facility's policy and procedure titled Develop/Implement Comprehensive Care Plan dated 3/1/18, indicated in part The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being. Residents' right to refuse care and treatment shall also be included in the comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 Ensure services provided by the nursing facility meet professional standards of quality. 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 obtain an order prior to the administration of oxygen for one of 24 sampled residents (Resident 31). Residents Affected - Few This failure had the potential for Resident 31 to suffer complications from incorrect dosage of oxygen administration. Findings: According to [NAME] and Perry's Fundamentals of Nursing, Eighth Edition, page 336, Nurses follow physicians orders unless they believe the orders are in error or harm clients. During an initial tour on 5/11/2021 at 2:43 p.m., Resident 31 was observed lying in bed with a nasal cannula (a device placed in the nose to deliver oxygen), connected to an oxygen concentrator administering 2 liters per minute of oxygen. During a review of Resident 31's clinical record on 5/13/2021 at 2:20 p.m., no physician order for oxygen administration was located. During an interview on 5/13/2021 at 2:25 p.m. with a licensed nurse (LN2), LN2 indicated Resident 31 is on 2 liters of oxygen via nasal cannula. LN2 agreed there was no physician order for oxygen and there should be prior to administration. The facility policy and procedure titled Oxygen Procedure undated, indicates Patients that require oxygen as ordered by the physician will be placed on an oxygen concentrator or oxygen tank. The oxygen therapy will be administered as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Residents Affected - Few a nasal cannula and tubing (a device used to deliver supplemental oxygen or increased airflow to a patient) was secured in the designated storage bag for one sampled resident, (Resident 25). This failure had the potential for increased risk of infection due to improper storage of the nasal canula and tubing. Findings: During a concurrent observation and interview on 5/11/21, at 3:03 P.M with a Certified Nursing Assistant (CNA 1), in Resident 25's room, the nasal cannula tubing was hanging over the side rail of the bed. CNA 1 stated, This (pointing to the nasal cannula and tubing) should be in this bag (pointing to the storage bag hanging on the oxygen concentrator). During a concurrent observation and interview on 5/14/21, at 9:06 A.M., with a Student Nursing Assistant (SNA 1), in Resident 25's room, observed nasal cannula and tubing wrapped over the side rail of the bed. SNA 1 confirmed this stating, Yes, it is. Would you like me to put it in the bag? During a review of the facility's policy and procedure titled. F 695- Oxygen Procedure, (undated), indicated, The equipment will be maintained in a manner to ensure the best possible outcome for the patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0761 Level of Harm - Minimal harm or potential for actual harm 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, and record review, the facility failed to ensure : Residents Affected - Few 1. A medication cart and medication storage closet were free from expired medications. This failure had the potential to result in residents receiving expired medications (drugs which are past their shelf life can decompose and either be ineffective or even harmful). 2. Tube feeding formula and tubing were labeled when open for use on resident .This failure had the potential for formulas and tubings to be used over shell life . Findings: 1. During a concurrent observation and interview on 5/12/2021, at 12:07 P.M., with the Assistant Director of Nursing (ADON), observed in Station 2 medication storage closet, one bottle of Senna Syrup, natural vegetable laxative had expired 02/2021. ADON confirmed this and stated, Yes, it's expired. During a concurrent observation and interview on 5/13/2021, at 9:59 A.M., with licensed nurse (LN 1), the following expired medications were found inside Station 1 medication cart: -Fexofenadine Hydrochloride expired 11/2020. -Cetirizine HCL 10 milligram (mg) tablets expired 04/2021. -ASA (aspirin) 325 mg tablets expired 11/2020. -Multi Vitamin expired 12/2020. -Mucus Relief expectorant expired 02/2021. -Levsin 0.125 mg expired 3/05/2020. LN 1 confirmed these medications were expired and stated, They are expired. I went through these last week. Where did they come from? 2. During initial tour at 5/11/2021 at 10:36 a.m., Resident 22 was in bed with an ongoing feeding formula via gastronomy (GT- opening in the stomach ).The GT tubing and formula were noted to be unlabelled . During an interview at 5/11/2021 at 10:52 a.m., LN 3 indicated tube feedings are labeled with the time and date when hanged for use . LN3 agreed there were no label on the tubing and the formula bottle. During an interview on 5/12/2021 at 10:58 a.m., the registered dietician (RD1) indicated tube feedings are considered as medication when it is administered to a resident and should be labeled accordingly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 5/13/2021 at 10 a.m., the director of nursing (DON) indicated tube feedings are considered as medication and should be labeled. The facility policy and procedure titled Label/Store Drugs & Biological dated 3/1/2018 indicated in part . drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principles as well as the expiration date when applicable .in part Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the necessary adaptive equipment was provided for one of 24 sampled residents (Resident 17), when spouted cups with handles were not provided on the lunch tray. Residents Affected - Few This failure resulted in Resident 17 not having the appropriate assistive devices to consume drinks with increased risk for aspiration of liquids. Findings: During an observation on 5/11/21, at 12:55 p.m., in the dining room, Resident 17 was eating lunch. The lunch tray had a plate of meat, noodles, vegetables, and a fruit cup. The tray had a glass of tomato juice, two glasses of water, a glass of milk, and a glass of apple juice with a straw. During a concurrent interview and record review of Resident 17's meal tray ticket, on 5/11/21, at 1:05 p.m., with the nursing assistant (CNA 2), the meal tray ticket indicated Resident 17 was to have a two-handled spouted cup for each drink. There were no two handled spouted cups observed on Resident 17's tray. CNA 2 acknowledged Resident 17's lunch tray should have a two-handled spouted cup for each drink. During an interview with the registered dietician (RD 1), and dietary manager (DM 1), on 5/12/21, at 10:50 a.m., RD 1 indicated orders for assistive devices for eating and drinking come from occupational, physical, and speech therapy. RD 1 further indicated the order is put into the computer system. DM 1 indicated once the order is in the system, kitchen staff print out the meal tray ticket and if a resident is on a therapeutic diet, and/or requires adaptive equipment, it will show up on the meal tray ticket. DM 1 further indicated all the meal trays get checked before they leave the kitchen and get checked a second time, by the CNA's, before the resident starts eating. When informed Resident 17's lunch tray was missing the two-handled spouted cups, RD 1 and DM 1 agreed Resident 17 should have the proper equipment on the tray. During a review Resident 17's Physician Order Sheet dated 5/21, the orders indicated to use a spouted cup during all meals to increase safety during oral intake and decrease risk for aspiration of liquids. During a review of the facility's policy and procedure titled, Assistive Devices-Eating Equipment/Utensils dated 3/18, indicated in part . Compass Health Facilities will provide special eating equipment and utensils for residents who need them .the food and nutrition services department will provide residents with assistive eating devices to maintain or improve their ability to eat independently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 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 056189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/14/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Post Acute Center 3033 Augusta Street San Luis Obispo, CA 93401 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, and interview, the facility failed to maintain a sanitary environment in the kitchen. Residents Affected - Few This facility failure had the potential for residents meals to be contaminated with dust and debris. Findings: During an observation on 5/12/21, at 12:23 p.m., in the facility kitchen, three fans were observed covered in dust and debris. One fan was in operation and angled toward kitchen staff plating food for residents. During an interview, on 5/12/21, at 12:45 p.m., with dietary manager (DM 1), DM 1 agreed the three kitchen fans needed cleaning and indicated he would inform the maintenance supervisor to clean the kitchen fans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056189 If continuation sheet Page 11 of 11