Health inspection·April 7, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/7/23 at 9:24 A.M., a joint interview and record review was conducted with the DON. The DON was reviewing Resident 1's electronic medical record (EMR) when Resident 25's psychiatry follow up note dated 1/26/23 was found to be inside of Resident 1's medical record. The DON stated Resident 25's clinical documentation should not have been electronically filed within Resident 1's EMR. The DON further stated this was a confidentiality concern as individuals who were not authorized to view Resident 25's clinical documentation would have had access to it when reviewing Resident 1's EMR. The DON reviewed Resident 2's EMR when Resident 14's provider assessment and note, dated 3/16/23, was found inside of Resident 2 medical record. The DON stated Resident 14's clinical documentation should not have been electronically filed within Resident 2's EMR. The DON further stated this was a confidentiality concern as individuals who were not authorized to view Resident 14's clinical documentation would have had access to it when reviewing Resident 2's EMR. On 4/7/23 at 9:30 A.M., the medical records director (MRD) joined the interview and record review being conducted with the DON. The MRD reviewed Resident 1's EMR containing Resident 25's clinical documentation and Resident 2's EMR containing Resident 14's clinical documentation. The MRD stated it was important to maintain medical records so that resident documentation was not being misfiled. The MRD stated being able to view another resident's clinical documentation because it was in the wrong EMR was a violation of the resident's confidentiality and privacy. A review of the facility's undated policy titled Resident Rights, indicated, .These rights include the resident's right to: .privacy and confidentiality .3. the unauthorized . access . of resident information is prohibited. A review of the facility's undated policy titled Release of Information, indicated, .Our facility maintains the confidentiality of each resident's personal and protected health information . 5. Access to the resident's medical records will be limited to the staff and consultants providing services to the resident Based on observation, interview, and record review, the facility failed to ensure four of 15 residents' (Resident 20, 40, 25, and 14) privacy and confidentiality was respected and maintained when: 1. Staff entered Resident 20 and Resident 40's private space without knocking or announcing themselves. 2. Resident 25 and Resident 14's clinical documentation was found within other residents' medical records. As a result of this deficient practice, the residents had the potential to feel disrespected. In addition, there was a potential for residents' private medical information to be accessed by unauthorized individuals. Findings: 1a. During an observation on 4/5/23, at 8:44 A.M., Staff 1 went into room A without knocking, walked out of room, then went into room B without knocking or announcing himself. An interview was conducted on 4/5/23, at 8:45 A.M., with Resident 20 who was in room A. Resident 20 stated she saw the man who walked in her room and did not know who he was. Resident 20 stated, That (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 2 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0583 was bothersome. He should have said hello or something. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/06/23, at 8:02 A.M., with Staff 1, Staff 1 stated, he did not knock on the residents' doors prior to entering because the doors were open, and the residents were aware of what was going on. Staff 1 stated he was not aware of the facility policy regarding knocking before entering. Staff 1 stated he did not receive training regarding knocking, and it was common sense when to knock. Staff 1 stated he would knock before entering if the room door was closed and if a resident was confused. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 3 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 15 residents (Resident 22), reviewed for homelike environment, had a landing mat (a cushioned device similar in shape and size to a mattress that was used to prevent injury if the resident were to fall out of bed) that was maintained in an acceptable condition. As a result, there was the potential for Resident 22's comfort and safety to become compromised. Findings: A review of Resident 22's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 4/4/23 at 4:24 P.M., a joint observation and interview was conducted with certified nursing assistant (CNA) 33 while inside of Resident 22's room. Resident 22 was observed in bed, and on the floor next to the resident's bed, was a landing mat. The landing mat was in two separate sections and appeared to have fallen apart. Each section was ripped and torn with frayed edges and the foam insert was hanging out of each section. There were also stains on the fabric on both sections of the landing mat. CNA 33 stated Resident 22's landing mat should have been in one piece and not in two sections. CNA 33 stated the foam insert should not be visible and hanging out. CNA 33 stated Resident 22's landing mat needed to be replaced. CNA 33 further stated in the landing mat's current state of disrepair, it could not be sufficiently cleaned. On 4/4/23 at 4:30 P.M., a joint observation and interview was conducted with licensed nurse (LN) 34 while inside of Resident 22's room. Resident 22 was observed in bed with a landing mat in disrepair next to his bed. LN 34 stated the landing mat was used to prevent injury if Resident 22 fell from bed and should have been in one piece. LN 34 stated if the resident fell out of bed and onto the mat, there was a possibility the two separated sections of the mat would push further apart and the resident would hit the hard floor. LN 34 stated, It shouldn't be in this condition with the foam hanging out. LN 34 stated it should have been replaced with a landing mat that was in an acceptable and working condition. On 4/6/23 at 2:15 P.M., an interview was conducted with LN 11. LN 11 stated it was everyone's responsibility when rounding to have noticed the condition of Resident 22's landing mat. LN 11 stated Resident 22 should have had a landing mat that was in good condition. On 4/7/23 at 9:24 A.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 22 should not have had a landing mat that was not in one piece, torn, and had foam coming out. The DON stated the resident's landing mat should have been in good working order. A review of the facility's undated policy titled Quality of Life- Homelike Environment, indicated, .2. the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: 1. Clean, sanitary, and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 4 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 21's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Wegener's Granulomatosis with renal involvement (a rare blood vessel disease that can cause symptoms in the kidneys) and long term current use of anticoagulants (a blood thinning medication). On 4/4/23 at 3:15 P.M., an observation and interview were conducted with Resident 21. Resident 21 was in bed, on a low air loss mattress (a mattress designed to prevent and treat pressure wounds). Resident 21 was noted to have dark purple bruising from her elbow to her hand on her right side. Resident 21 had areas of redness on her mid forearm and two locations with steri-strips on her right side. Resident 21 was noted to have dark purple bruising from her wrist to her knuckles on her left side. Resident 21 stated that her skin was delicate and that staff needed to be extra careful and gentle when caring for her. On 4/7/23 at 8:29 A.M., an interview and concurrent record review was conducted with Licensed Nurse (LN) 1 regarding Resident 21. A review of the document titled Mental Health Diagnostic Assessment, dated 3/12/23, indicated, Staff recommendations include: care preferences expressed by patient are encouraged and accommodated when possible. According to the same document, Staff recommendations include: model patience and empathy to patient. LN 1 acknowleged that Resident 21's skin was delicate and that the resident had verbally informed staff of her preference regarding how staff should care for her, especially during cleaning. LN 1 stated, There's no care plan or interventions that are specific to the care preferences expressed by patient related to peri-care (cleaning of private areas of a patient) or repositioning. We need to add her preferences related to peri-care and repositioning and follow the recommendation of the psychologist. LN 1 stated, There are no care plans or interventions that are specific to the recommendations regarding modeling patience and empathy. During a review of the facility's undated Policies and Procedures (P&P), titled Care Plans, Comprehensive, Patient Centered, the P&P indicated, 1. The Interdisciplinary Team (IDT- team members from different disciplines working together toward the goals of their residents), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 11. Care plan interventions are chosen only after careful data gathering .when possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. Based on observation, interview, and record review, the facility failed to accurately develop and/or implement patient centered care plan for two of 18 residents (Resident 1 and Resident 21) reviewed for care plans. This failure had the potential risk of not providing appropriate, consistent, and individualized care to the resident. Findings: 1. Resident 1 was admitted to the facility on [DATE] with the diagnosis of Senile Degeneration of the Brain (A decrease in cognitive abilities or mental decline) according to Resident 1's Face Sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 5 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 During observation and interview on 4/04/23, at 8:24 A.M., with Certified Nurse Assistant 1 (CNA), CNA 1 stated Resident 1 only spoke Spanish. CNA 1 translated in Spanish to Resident 1. Resident 1 stated she was doing well. Resident 1 stated she was happy because she knew she was not alone as she raised both hands and looked up at the ceiling. Resident 1 then reached for the bible from the bedside and stated she loved everyone. CNA 1 re-directed Resident 1 to the breakfast tray. Residents Affected - Some During an interview on 4/6/23, at 8:58 A.M., with CNA 11, CNA 11 stated Resident 1 was confused and had an episode of accusing others of taking her belongings but only required re-direction and explanation. CNA 11 stated Resident 1 was not combative. An interview and concurrent record review was conducted on 4/6/23, at 10:23 A.M., with Licensed Nurse 1 (LN). LN 1 stated Resident 1 had a physician's order on11/23/22 for Seroquel (a medication that changes the actions of chemicals in the brain) 100 mg (milligram) to be administered in the morning and 75 mg at bedtime for Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with episode of agitation. LN 1 stated Resident 1 occasionally refused care, brief change and laundry staff hanging clothes in the closet. LN 1 stated Resident 1 was forgetful but only needed reminders and redirection. During an interview and concurrent record review on 4/6/23, at 3:21 P.M. with LN 11, LN 11 stated Resident 1's care plan indicated the use of Seroquel due to fighting with staff. LN 2 stated there was no documentation regarding Resident 1 fighting with staff and the care plan did not have the correct interventions of explaining procedures and redirecting Resident 1 as needed. A review of the psychiatrist's progress notes dated 11/30/22 indicated, Staff endorses that she has demonstrated no problematic behaviors, ambulates appropriately and never has attempted to strike out at staff or become verbally or physically aggressive. During a review of another psychiatrist's progress notes dated 1/26/23 indicated, Per staff no problematic behaviors, denies verbally and physically aggressive nature. The Director of Nursing (DON) was interviewed on 4/7/23, at 2:30 P.M. The DON stated Resident 1's care plan should have indicated that resident can be redirected after explanation. The DON stated resident care plans should be person-centered for their well-being. During a review of the facility's undated Policies and Procedures (P&P), titled Care Plans, Comprehensive, Patient Centered, the P&P indicated, 1. The Interdisciplinary Team (IDT- team members from different disciplines working together toward the goals of their residents), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 11. Care plan interventions are chosen only after careful data gathering .when possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 6 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide communication devices for two of four residents (Resident 24 and Resident 1) reviewed for communication. Residents Affected - Few This failure had the potential for a lack of communication and residents' inability to have their needs met. Findings: 1. Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. During an observation on 4/4/23, at 8:20 A.M., Resident 24 was in bed speaking Spanish with staff. Certified Nurse Assistant (CNA) 12 translated in Spanish during an interview with Resident 24 on 4/4/23 at 9:38 A.M. Resident 24 was observed with a blanket over her head. Resident 24 stated some staff were good, and some were not so good. Resident 24 stated some staff pulled her up too much or too quickly. Resident 24 stated, Maybe they didn't like me. During an observation on 4/5/23, at 8:18 A.M., Resident 24 was in bed with Licensed Nurse (LN) 12 attempting to speak Spanish while administering oral medications to Resident 24. Resident 24 stated in Spanish, Dolor (pain) pointing in groin area. LN 12 asked Resident 24 in some Spanish words to rate pain but was not able to completely explain her question in Spanish. LN 12 stated Resident 24 had an infection in the groin and completed antibiotics yesterday (4/4/23). LN 12 pulled back Resident 24's blanket and exposed Resident 24's legs and incontinent brief. LN 12 was not able to explain what she was doing in Spanish. During an interview on 4/6/23, at 8:31 A.M., with CNA 13, CNA 13 stated Resident 24 was forgetful and did not like to be touched. CNA 13 stated he spoke Spanish to resident and Resident 24 did not refuse care, yell out or strike out at staff. CNA 13 stated he was unsure how staff could communicate with Resident 24 if staff did not speak Spanish. An observation and interview were conducted on 4/6/23, at 2:21 P.M., with LN 1. LN 1 stated Resident 24 had a communication board in the room. LN 1 went into Resident 24's room, opened the bedside drawer and Resident 24's closet but did not find a communication board. LN 1 stated Resident 24 needed a communication board to communicate her needs if staff did not speak Spanish. During a record review of Social Services progress note titled, Clinical Notes Report, dated 12/7/22, the progress note indicated, She is Spanish speaking only and there is a communication board available if needed. During a review of the facility's undated Policy and Procedure (P&P), titled Communication, the P&P indicated, It is the policy of this facility to provide methods of communication to assure adequate communication between the resident and staff. 2. Resident 1 was admitted to the facility on [DATE] with the diagnosis of Senile Degeneration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 7 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0676 the Brain (A decrease in cognitive abilities or mental decline) according to Resident 1's Face Sheet. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 4/4/23, at 8:24 A.M., with Certified Nurse Assistant 1 (CNA), CNA 1 stated Resident 1 only spoke Spanish. CNA 1 translated in Spanish to Resident 1. Resident 1 was observed ambulating from the bathroom without any assistive device to her bed for breakfast. Resident 1 stated she was doing well. Residents Affected - Few During an interview on 4/6/23, at 9:23 P.M., with CNA 13, CNA 13 stated he was unsure how staff would communicate with Resident 1 if staff did not speak Spanish. An observation and interview were conducted on 4/6/23, at 2:21 P.M., with LN 1. LN 1 stated Resident 1 had a communication board in the room. LN 1 went into Resident 1's room, opened Resident 1's bedside drawer and did not find a communication board. Resident 1 spoke to LN 1 in Spanish and LN 1 was not able to respond back in Spanish. LN 1 stated Resident 1 needed a communication board to communicate her needs if staff did not speak Spanish. The Director of Nursing (DON) was interviewed on 4/7/23, at 2:30 p.m. The DON stated residents who did not speak English should have a communication board for staff to understand resident needs. During a review of Resident 1's care plan, effective 11/18/22, the care plan indicated, At risk for communication deficit. Interventions, communication board/pictures as needed. During a review of the facility's undated Policy and Procedure (P&P), titled Communication, the P&P indicated, It is the policy of this facility to provide methods of communication to assure adequate communication between the resident and staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 8 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 coordinate care for one of three residents (Resident 14) reviewed for hospice services. Residents Affected - Few This failure had the potential for Resident 14 to suffer harm. Findings: A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (the most common cause of memory loss and other cognitive abilities serious enough to interfere with daily life), other abnormalities of gait (a person's manner of walking) and mobility, generalized muscle weakness, difficulty in walking, repeated falls. On 4/6/23 at 2:35 P.M., an interview was conducted with licensed nurse (LN) 41, who stated, Weeks ago, she (Res 14) verbalized Please God, take me now. LN 41 stated when Res 14 said, 'Please God take me now' I gave her a rosary. I didn't tell anyone because it was at night. I told the incoming LN/ RN. Ln 41 stated, I didn't tell the shift supervisors or the hospice. I could have made a note for the shift supervisor. The hospice has a 24-hour phone line, and they will answer at night, I could have called even at night. On 4/7/23 at 11:16 A.M., an interview was conducted with LN 1 who stated, The resident is on hospice. She had an episode of verbalized sadness. She had some crying episodes. Hospice is available by phone 24 hours per day and we can contact them for anything, they can write orders. The nurse should have contacted hospice during her shift, and the LN should not have waited until morning to notify, it's not ok to just report to the incoming LN, the charge nurse should have been made aware. LN 1 continued to state, If she's praying and in distress it needs to be addressed as soon as possible because that's emotional distress, it's harmful for the patient to feel like that and not receive help. On 4/7/23 at 2:40 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated, The resident is on hospice. When the resident was asking for God to take her during the night shift a call should have been placed to hospice to make sure her needs were met and for continuity of care. A record review was conducted of the facility policy entitled Hospice Program. The policy stated, .It is the responsibility of the facility to meet the resident's personal care needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: 3. Notifying the hospice about the following: a) A significant change in the resident's physical, mental, social, or emotional status. 4. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 9 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one of three residents (Resident 14) reviewed for accidents. This failure had the potential for Resident 14's to suffer harm from a fall. Findings: A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease (the most common cause of memory loss and other cognitive abilities serious enough to interfere with daily life), other abnormalities of gait (a person's manner of walking) and mobility, generalized muscle weakness, difficulty in walking, repeated falls. A record review was conducted of Resident 14's fall care plan, with a goal of 4/19/23, indicated, At risk for falls related to Alzheimer dementia, new oxygen use, diuretic and hypertension medication use. Status: active (current). Interventions: sensor alarm to the bed. Status: Active (current). Place call bell/ light within easy reach. Status: Active (current). Respond promptly to calls for assist to the toilet. Status: Active (current). A record review was conducted of Resident 14's Fall Risk Assessment, dated 1/19/23, indicated, High risk if score of 10 or above. Total fall risk assessment score 11. On 4/4/23 at 9:10 A.M., an observation and interview was conducted with Resident 14. There was a fall mat (a device to protect from injury during a fall) at Resident 14's right side of bed. Resident 14's bed had an alarm on it. There was a walker folded and placed out of Resident 14's reach against the wall on her left side. There was a wheelchair out of reach placed by the doorway. Resident 14 stated she did not know where her call bell was to ask for staff assistance. On 4/5/23 at 9:41 A.M., an observation was conducted during which the bed alarm sounded for Resident 14, who was sitting at the side of her bed. LN 41 responded to resident and asked what she needed. Resident 14 requested to get up in a wheelchair. LN 41 left Resident 14 alone and alerted a certified nursing assistant (CNA). The CNA responded to assist resident to wheelchair. The CNA response time to Resident 14 was greater than five minutes while she sat unattended by staff at the edge of her bed trying to get up. On 4/6/23 at 1:46 P.M., an interview was conducted with CNA 32, who stated Resident 14 uses a walker and gets into a wheelchair independently and has no known falls. On 4/6/23 at 2:35 P.M., an interview was conducted with licensed nurse (LN) 41 who stated, She's (Resident 14) a fall risk and requires supervision when she gets up, she's on fall precautions which is why she has a bed alarm and a fall mat. No matter how many times she's reminded by staff to press the button she tends to forget. The bed alarm is loud but it's confusing because there are other alarms but you don't know where it's coming from. Sometimes it rings in the dirty linen and we're looking for where it's coming from, we get confused. We could be a little late because of that. There could be an increased risk of fall because of the time to get to them. The best place for a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 10 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who is a fall risk is by the nurse's station; she's currently almost as far as you can get from the nurse's station which could increase the fall risk. On 4/7/23 at 11:16 A.M., an interview was conducted with LN 1 who stated, If the bed alarm goes off, the expectation is, the nurse should go check to see if the patient has a need for help. They should respond immediately. The linen closet alarm sounds different, you can't hear it in the hallway or the nurse's station. You can't hear it, it's not loud. (name of Resident 14) has had multiple falls and one time she hit her head. If staff doesn't know a patient's history she might fall, they might think she's independent. The room should be the closest to the nurses station, her (Resident 14) room is all the way at the end of the hall. On 4/7/23 at 2:40 P.M., a concurrent interview and record review was conducted with the director of nursing (DON) regarding Resident 14. The DON stated, Resident 14 is a fall risk. The fall assessment done on 1/19/23 is the most recent. The score was 11 which is high risk. The care plan for falls includes a bed sensor. Staff should respond right away to the alarm, anyone can respond. Delayed response to alarms can result in falls. Depending on risk level the residents should be located as close to the nurse's station as possible. A review of the facility's undated policy and procedure titled Falls, indicated, . Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 11 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 16), had her suction equipment (system that removes/sucks up secretions) adequately maintained. Residents Affected - Few This failure had the potential to result in inadequate clearance of Resident 16's oral secretions causing respiratory distress (trouble breathing). Findings: A review of Resident 16's admission Record indicated the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included esophageal obstruction (blockage in tube that connects the throat to the stomach), dysphagia (difficulty swallowing), disturbances of salivary secretion (abnormal mouth saliva) and gastroesophageal reflux (stomach contents go up into the esophagus). Physician order dated 5/27/2018 indicated oral suction to be done three times a day as needed. Physician order dated 6/6/2018 indicated continuous aspiration (choking) precautions. On review of Clinical Notes dated 12/14/22 at 2:48 A.M., LN 2 recorded Resident 16 had excessive secretions .patient is spitting up slimy mucous-like sputum (spit) .administered 2 doses of Glycopyrrolate (medicine that helps dry up secretions) .heaving exacerbated by presence of secretions .patient remains in state of distress .requiring frequent suctioning of upper airway (nose or mouth areas) . On review of the undated Care Plan titled with, Excessive Salivary Secretions (saliva/spit), oral suction as needed is indicated. On observation on 4/4/23 at 10:35 A.M., Resident 16 was awake, and sitting up in a wheelchair. A suction machine was observed by the bed with attached tubing, Yankauer (an oral suctioning tool) and canister (container for suctioned fluids) that were unlabeled. The Yankauer tip was observed lying on the ground. The canister was observed to be half filled with yellow-clear thick fluid. On observation on 4/4/23 at 11:03 A.M., Resident 16 was sitting in a wheelchair with a family member at her side. Resident 16 was observed coughing and spitting oral secretions into tissue. On observation on 4/5/23 at 9:30 A.M., Resident 16 was observed resting in bed with her eyes closed. The sealed suction tubing and clean Yankauer suction tip were laid on bedside table in front of suction machine. There was no date noted on the suction tubing or suction tip. There was no suction canister observed on the overbed table. On concurrent interview and observation on 4/6/23, at 8:51 A.M., Certified Nursing Assistant (CNA) 1 stated Resident 16 coughed up her oral secretions. CNA 1 further stated the Licensed Nurse (LN) was responsible for the monitoring of suction equipment and if any suction equipment was on the floor it would be discarded. On concurrent interview and record review on 4/6/23, at 11:30 A.M., LN 1 reported Resident 16 had increased secretions in the evenings and when she became anxious. LN 1 stated suction equipment should be maintained, and ready to use. LN 1 further stated if suction equipment fell on the ground, it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 12 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 should be immediately replaced due to concern for risk of infection and choking. Level of Harm - Minimal harm or potential for actual harm On concurrent observation and interview on 4/7/23, at 9:57 A.M., Resident 16 was alert and lying in bed. Resident 16 indicated the suction device was used when she was unable to cough up her secretions. A suction equipment was observed on overbed table, with tubing and suction tip attached to suction canister. No date noted on the suction equipment. Residents Affected - Few On interview on 4/7/23 at 1:30 P.M., the Director of Nursing (DON) stated facility policy was for suction equipment to be changed weekly, as needed and labeled with the date per policy. The DON stated risk of infection increased if suction policy was not followed. On review of Clinical Notes dated 12/14/22 at 2:48 A.M., LN 2 recorded Resident 16 had excessive secretions .patient is spitting up slimy mucous-like sputum (spit) .administered 2 doses of Glycopyrrolate (medicine that helps dry up secretions) .heaving exacerbated by presence of secretions .patient remains in state of distress .requiring frequent suctioning of upper airway (nose or mouth areas) . On review of the undated Care Plan titled with, Excessive Salivary Secretions (saliva/spit), oral suction as needed is indicated. On review of the undated Policy and Procedure titled, Suctioning the Upper Airway (Oropharyngeal Suctioning), older clients are more susceptible to aspiration of secretions [choking] . with instructions of verify that suction tubing is attached to wall or portable unit .empty and rinse collection container if necessary .place catheter in clean, dry area. On review of the undated Policy and Procedure titled, Suction Equipment, suction bottles (canisters) are to be discarded to trash when it is ¾ full or every shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 13 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure one of two residents (Resident 24) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health). Residents Affected - Few This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience). Findings: Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. Certified Nurse Assistant (CNA) 12 translated in Spanish during an interview with Resident 24 on 4/4/23 at 9:38 A.M. Resident 24 was observed with a blanket over her head. Resident 24 stated some staff were good, and some were not so good. Resident 24 stated some staff pulled her up too much or too quickly. Resident 24 stated, Maybe they didn't like me. During an interview on 4/6/23, at 8:31 A.M., with CNA 13, CNA 13 stated most of his training was from the registry. CNA 13 stated he did not receive trauma training at the facility. CNA 13 stated he did not know if Resident 24 or any of his assigned residents have had a traumatic incident. An interview was conducted on 4/6/23, at 8:58 A.M., with CNA 11. CNA 11 stated he also did not know if any of his residents experienced trauma. A Spanish speaking surveyor translated to Resident 24 during an interview on 4/6/23 at 1:49 P.M. Resident 24 stated she was not aware she had a male caregiver today (4/6/23). Resident 24 then stated she remembered there was a male caregiver who changed her sheets. Resident 24 stated she preferred a female caregiver during showers, going to the bathroom and changing clothes. An interview and concurrent record review was conducted on 4/6/23, at 9:56 A.M., with Licensed Nurse (LN) 1. LN 1 stated Resident 24 received Lorazepam (an antianxiety medication) on 3/31/23, 4/1/23, 4/3/23 and 4/5/23 due to anxiety and agitation. LN 1 stated Resident 1 requested for the medication for feeling anxious. LN 1 stated she did not know why Resident 1 was anxious. During an interview and record review on 4/6/23 at 10:43 A.M., with LN 1, LN 1 stated the document titled, Trauma Screening, dated 12/7/22 indicated Resident 24 was physically & sexually abused by her husband. LN 1 stated if she knew of Resident 24's trauma she would allow Resident 24 to verbalize feelings and provide emotional support. LN 1 stated Resident 24's traumatic event would be triggered if staff provided care without explanation. LN 1 stated Resident 24's care plan did not indicate Resident 24's preference to have female CNAs only. During an interview with CNA 14 on 4/6/23 at 3:24 P.M., CNA 14 stated she worked for the registry. CNA 14 stated Resident 24 was forgetful and communicated in Spanish. CNA 14 stated she was not informed of any resident who had trauma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 14 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An interview was conducted on 4/7/23 at 10:05 A.M., with the Director of Nursing (DON). The DON stated there has been no staff training regarding trauma informed care. DON stated it was important for staff to be aware of any residents who experienced trauma to prevent triggering the traumatic incident. A review of the facility's undated Policy and Procedure (P&P) titled, Trauma Informed Care, the P&P indicated, . Preparation 1. All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. 2. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization.General Guidelines . 2. Trauma-informed care is culturally sensitive and person-centered. Event ID: Facility ID: 555144 If continuation sheet Page 15 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all nursing staff including registry staff (nursing staff provided by a staffing agency) had the necessary training and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics to perform occupational functions successfully) to care for residents with a history of trauma and/or post-traumatic stress disorder (PTSD). In addition, staff providing care to Resident 2 and Resident 24 were unaware of the resident's PTSD diagnosis and history of trauma. This failure had the potential for residents with a history of trauma and/or PTSD to experience triggers and retraumatization that would compromise the residents' safety and their ability to achieve their highest practicable physical, mental, and psychosocial well-being. (Cross reference F699 and F838) Findings: 1. A review of Resident 2's Face Sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses to include PTSD. On 4/5/23 at 8:04 A.M., an interview was conducted with Resident 2 while inside the resident's room. Resident 2 stated he had PTSD related to a childhood incident. Resident 2 stated he wanted the staff providing care to him to be aware that he had a PTSD diagnosis. On 4/6/23 at 9:01 A.M., an interview was conducted with certified nursing assistant (CNA) 35. CNA 35 stated he was a registry staff and that he had not received any training, either from the facility or the registry company, related to providing care to residents with a history of trauma and/or PTSD. On 4/6/23 at 9:17 A.M., an interview was conducted with CNA 1. CNA 1 stated she was a registry staff and had worked in the facility providing care to residents about four to five times a week. CNA 1 stated it felt like she worked at the facility full time but was just paid through the registry company. CNA 1 stated she had not received any training, either from the facility or the registry company, related to providing care to residents with a history of trauma and/or PTSD. On 4/6/23 at 9:25 A.M., an interview was conducted with CNA 32. CNA 32 stated she was a registry staff and worked in the facility providing care to residents on average three to four times a week and that it feels like full time. CNA 32 stated she had not received any training, either from the facility or the registry company, related to providing care to residents with a history of trauma and/or PTSD. On 4/7/23 at 8:07 A.M., an interview was conducted with CNA 36. CNA 36 stated she was a registry staff and worked in the facility providing care to residents on average one to two times a week. CNA 36 stated she had not received any training, either from the facility or the registry company, related to providing care to residents with a history of trauma and/or PTSD. CNA 36 stated she thought that training would be helpful in order to better understand the residents, be more empathetic, and to avoid trauma triggers. CNA 36 stated she did not have any residents under her care with a history of trauma or PTSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 16 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0741 Level of Harm - Minimal harm or potential for actual harm On 4/7/23 at 8:30 A.M., an interview was conducted with licensed nurse (LN) 41. LN 41 stated she had received training upon hire related to providing care to residents with a history of trauma and/or PTSD. LN 41 was asked if she was providing care to any residents with a history of trauma or a diagnosis of PTSD. LN 41 stated, We don't have any residents like that here. LN 41 stated she was providing care to Resident 2. Residents Affected - Some A review of the daily assignment for LNs and CNAs dated 4/6/23 and 4/7/23, indicated CNA 35 provided care to Resident 2 on 4/6/23 and CNA 36 provided care to Resident 2 on 4/7/23. On 4/7/23 at 10:44 A.M., an interview was conducted with the director of nursing (DON). The human resources director was also present. The DON stated it was her responsibility to review the employee files of registry staff and that she verified if they were provided abuse training. The DON stated she had not checked or verified if they had received training related to providing care to residents with a history of trauma and/or PTSD. The DON stated the verification that this training was done and that all staff were competent to provide trauma informed care to residents was important in order to prevent retaumatization of residents. The DON stated it was her expectation that staff providing care to Resident 2 were aware of his PTSD and familiar with his plan of care to avoid his PTSD triggers. The DON stated part of ensuring that care provided to residents was appropriate involved verifying that all staff received training related to trauma informed care. A review of the facility's untitled and undated document listing registry staff, indicated the facility used 21 registry nursing staff from five staffing agencies. A review of the facility provided staffing agency contracts indicated trauma informed care was not listed as a subject the staffing agencies were training their registry staff for. A review of the facility's undated policy titled Trauma Informed Care indicated, .All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting . Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers 2. Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. Certified Nurse Assistant (CNA) 12 translated in Spanish during an interview with Resident 24 on 4/4/23 at 9:38 A.M. Resident 24 was observed with a blanket over her head. CNA 12 explained to Resident 24 the purpose of surveyor's interview and was agreeable. Resident 24 stated some staff were good, and some were not so good. Resident 24 stated some staff pulled her up too much or too quickly. Resident 24 stated, Maybe they didn't like me. During an interview on 4/6/23, at 8:31 A.M., with CNA 13, CNA 13 stated most of his training was from the registry. CNA 13 stated he did not receive trauma training at the facility. CNA 13 stated he did not know if Resident 24 or any of his assigned residents had a traumatic incident. An interview was conducted on 4/6/23, at 8:58 A.M., with CNA 11. CNA 11 stated he also did not receive trauma informed care training at the facility. During an interview with CNA 14 on 4/6/23 at 3:24 P.M., CNA 14 stated she worked for the registry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 17 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA 14 stated Resident 24 was forgetful and communicated in Spanish. CNA 14 stated she was not informed of any resident who has had trauma. An interview was conducted on 4/7/23 at 10:05 A.M., with the director of nursing (DON). The DON stated there has been no staff training regarding trauma informed care. DON stated it was important for staff to be aware of any residents who experienced trauma to prevent triggering the traumatic incident. A review of the facility's undated Policy and Procedure (P&P) titled, Trauma Informed Care, the P&P indicated, . 1. All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. 2. Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 18 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 3 of 5 residents (Resident 1, 42 and 9) were free from unnecessary use of psychotropic medications (any drug affecting behavior, mood, thoughts, or perception) when: 1. A Gradual Dose Reduction (GDR) was not completed for Resident 42. 2. Resident 1 and Resident 42 did not have an approved indications for the use of an antipsychotic medication. 3. Resident 9's sleepiness was not identified as a possible side effect of the resident's psychotropic medications. This failure had the potential for Residents to experience unnecessary side effects from the psychotropic medication. Findings: 1. Resident 42 was admitted to the facility on [DATE] with the diagnosis of Alzheirmer's Dementia (A progressive disease that destroys memory and other important mental functions) according to Resident 42's face sheet. During an observation on 4/4/23 9:29 A.M., Resident 42 came out of the restroom in his wheelchair. Resident 42 stated he was admitted yesterday 4/3/23. Resident 42 was not able to recall current month and year but knew the location of the dining room. Resident 42 proceeded to self-propel the wheelchair to go to the dining room for breakfast. An interview was conducted on 4/5/23, 9:14 A.M., with Certified Nurse Assistant (CNA) 11. CNA 11 stated Resident 42 required extensive assist with Activities of Daily Living (ADL) but was able to help a little. CNA 11 stated some days Resident 42 can understand directions, and other days Resident 42 could not remember things. CNA 11 stated Resident 42 had episodes of refusing to be changed or showered. CNA 11 stated he allowed Resident 42 time to cool off, then return at another time. CNA 11 stated Resident 42 became agreeable when he gave a snack or coffee. CNA 11 stated Resident 42 did not yell or hit staff. An interview was conducted on 4/6/23 at 4:09 P.M., with CNA 15. CNA 15 stated Resident 42 was independent with wheelchair locomotion but required supervision when more confused. CNA 15 stated Resident 42 had attempted to stand up unassisted and was persistent about wanting to go home. CNA 15 stated when Resident 42 had an outburst of sun downing (episode of restlessness, agitation, irritability or confusion in the late afternoon and early evening), listening, redirection and talking with Resident 42's daughter helped Resident 42 to calm down. CNA 15 stated Resident 42 had no physical aggression towards staff. CNA 15 stated Resident 42 had calmed down a lot. CNA 15 stated Resident 42 understood better if redirection and repetitive instructions were provided. During an interview and concurrent record review on 4/6/23 9:56 A.M., with Licensed Nurse (LN 1), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 19 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LN 1 stated Resident 42's physician's order indicated Seroquel (medication that works by changing the actions of chemicals in the brain) for the diagnosis of Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with Behavioral Issues. LN 1 stated the target behavior was combativeness and uncontrollable getting out of bed. LN 1 stated there has been no gradual dose reduction for the Seroquel since Resident 42 was admitted . LN 1 stated Resident 42's care plan indicated to monitor combativeness and getting out of bed. LN 1 stated getting out of bed was not a good indication for giving Seroquel. A review of the pharmacist's Medication Regimen Review (MRR) titled, Note to Attending Physician Prescriber, dated 3/7/23 was conducted. The MRR indicated, Three years after the Food and Drug Administration (FDA) instituted a black- box warning for all second-generation antipsychotic (SGA) medications about increased risk of death in the elderly dementia patients .Would you agree to dc (discontinue) Seroquel or change to other non-antipsychotic medications? Please advise. The MRR indicated the Disagree box was selected under Physician/Prescriber Response. In addition, the MRR indicated a note by the prescriber which read, increased combative behaviors at nighttime. During a review of Resident 42's treatment record titled, 3/1/2021-3/31/2023 Treatments, the treatment record indicated, Target behavior: Easily get Angry without apparent reason, Combative and getting up to bed uncontrollable. The treatment record indicated, 1 episode on 3/16/23 NOC (night shift). The treatment record titled, 4/1/2023-4/7/2023 Treatments, was reviewed. The treatment record indicated, 1 episode PM (afternoon shift), zero episodes NOC. During a review of nurse's notes titled, Clinical Notes Report, dated 3/6/23, the nurse's note indicated, Patient confused and aggressive. Able to be redirected after speaking with daughter. Another nurse's note titled, Clinical Notes Report, dated 3/18/23, the nurse's note indicated, LE (late entry) 03/17/23: .Resident was cursing and yelling bad words .Resident calmed down after talking to his daughter . An interview was conducted on 4/7/23, at 10:05 A.M., with the DON. The DON stated the use of an antipsychotic medication should have an appropriate diagnosis and conduct a GDR as needed. A review of the facility's undated Policies and Procedures (P&P) titled, Psychotropic Medication, the P&P indicated, . Policy Statement . 2. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Policy Interpretation and Implementation . 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions .can be utilized to meet the needs of the individual resident. 2. Resident 1 was admitted to the facility on [DATE] with the diagnosis of Senile Degeneration of the Brain (A decrease in cognitive abilities or mental decline) and Dementia (loss of memory, language, problem solving and other thinking abilities severe enough to interfere with daily life) according to Resident 1's Face Sheet. During observation and interview on 4/04/23, at 8:24 A.M., with Certified Nurse Assistant 1 (CNA), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 20 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA 1 stated Resident 1 only spoke Spanish. CNA 1 translated in Spanish to Resident 1. Resident 1 was observed ambulating from the bathroom without any assistive device to her bed for breakfast. Resident 1 stated she was doing well. Resident 1 stated she was happy because she knew she was not alone as she raised both hands and looked up at the ceiling. An interview on 4/6/23 at 8:58 A.M., with CNA 11 was conducted. CNA 11 stated Resident 1 was continent and only required supervision with her Activities of Daily Living (ADL). CNA 11 stated Resident 1 was confused and had accused laundry staff taking her clothes from the closet. CNA 11 stated he provided redirection and explanation to Resident 1 as needed. CNA 11 stated Resident 1 was never combative. An interview and concurrent review of Resident 1's physician's orders were conducted on 4/6/23 at 10:23 A.M., with LN 1. LN 1 stated Resident 1 had an order on 11/23/22 for Seroquel 100 mg (milligrams) in the morning and 75 mg at 8:00 P.M. or 9:00 P.M. LN 1 stated the Seroquel was for Dementia with episode of agitation. LN 1 stated at times Resident 1 refused care such as changing of Resident 1's brief. LN 1 stated the psychiatrist will determine if the medication was still needed. LN 1 stated she did not find documentation of non-drug interventions prior to start of Seroquel. LN 1 further stated antipsychotics (medication for mental illness) such as Seroquel was not appropriate for the elderly due to potential side effects. During an interview and concurrent record review on 4/6/23, at 3:32 P.M., with LN 11, LN 11 stated Resident 1's medication administration record indicated Seroquel was for Dementia with behavior, fighting staff without apparent reason. LN 1 stated Resident 1 did not hit and did not have aggressiveness. LN 11 stated Resident 1's care plan indicated, Monitor for fighting with staff without any apparent reason. LN 11 stated there was no documentation regarding an incident of fighting with staff, and the care plan did not have the correct interventions of explaining procedures and redirecting Resident 1 as needed. A review of the psychiatrist's progress notes dated 11/30/22 indicated, Staff endorses that she has demonstrated no problematic behaviors, ambulates appropriately and never has attempted to strike out at staff or become verbally or physically aggressive. During a review of another psychiatrist's progress notes dated 1/26/23 indicated, Per staff no problematic behaviors, denies verbally and physically aggressive nature. An interview was conducted on 4/7/23, at 10:05 A.M., with the DON. The DON stated the use of an antipsychotic medication should have an appropriate diagnosis and conduct a GDR as needed. A review of the facility's undated Policies and Procedures (P&P) titled, Psychotropic Medication, the P&P indicated, . Policy Statement . 2. Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Policy Interpretation and Implementation . 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions .can be utilized to meet the needs of the individual resident. 2. A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (the most common cause of memory loss and other cognitive abilities serious enough to interfere with daily life), major depressive disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 21 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some single episode unspecified (a mood disorder that causes a persistent feeling of sadness), anxiety disorder unspecified (persistent and excessive worry that interferes with daily activities), bipolar disorder current episode depressed severe with psychotic features (a mental health condition that causes extreme mood swings), and drug induced subacute dyskinesia (abnormality or impairment of normal movement). On 4/4/23 at 9:30 A.M., an observation was made of Resident 9 in bed on her back with her eyes closed. Resident 9 did not rouse to speech. Resident 9's lower jaw was noted to have continual movements opening and closing. On 4/4/23 at 12:30 P.M., an observation was made of Resident 9 in her bed with her eyes closed. Resident 9 did not respond to verbal cueing and didn't rouse for her lunch tray. On 4/4/23 at 12:30 P.M., an interview was conducted with certified nursing assistant (CNA) 1 who stated, This is a frequent problem, we just try again later. On 4/5/23 at 8:20 A.M., an observation was conducted of Resident 9, who didn't respond to verbal cues from Licensed Nurse (LN) 41 . Resident 9's breakfast tray was set up. Resident 9 did not eat independently and was not assisted. Resident 9 was noted to have continual movement of lower jaw. On 4/05/23 at 9:19 A.M., an observation was made that LN 11 entered the room of Resident 9 and attempted to wake her. Two CNAs at the bedside of Resident 9 attempted to wake her and encourage her to eat breakfast. Resident 9 did not open her eyes in response. On 4/5/23 at 4:08 P.M., an observation was made of Resident 9 in bed with eyes closed. A review of Resident 9's electronic Treatment Administration Record (TAR) for the month on April 2023 was conducted. The TAR indicated to monitor Resident 9 for side effects related to the use of psychotropic medications (medication use to treat mental illness). Two of the side effects indicated in the TAR were drowsiness and sedation (both meant sleepiness). The TAR documentation indicated no side effects of sedation and drowsiness were identified from 4/1/23 through 4/7/23. On 4/07/23 at 2:40 P.M., an interview and concurrent record review was conducted with the director of nursing (DON). The DON stated, The sedation scale is documented as zero for all of April. Zero means the resident is alert and awake. We should be monitoring the side effects of psychotropic medications to assess whether medication should be decreased. The acknowledged that Resident 9's sleepiness should have been identified and addressed. A review of the facility's undated Policy and Procedure titled Psychotropic Medication was conducted. The policy indicated, . primary care physician, PA (physician assistant), or APN (Advance Practice Nurse) . 4. Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications . Nursing 1. Monitors psychotropic drug use at every shift noting any adverse effects such as increase somnolence (sleepiness) and functional decline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 22 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure three of 30 administered medications were given in accordance with the physician orders. Residents Affected - Few This failure resulted in 10% medication error rate. In addition, failure to administer medications in accordance with the physician order had the potential to affect resident safety. Findings: A medication administration observation was conducted on 4/6/23 at 8:07 A.M Licensed Nurse (LN) 41 prepared Resident 16's medication. LN 41 prepared the following medications: 1. Amlodipine (blood pressure medication) 5 milligrams (mg) 1 tab (tablet) 2. Benazepril (blood pressure medication) 10 mg 1 tab 3. Buspirone (anti-anxiety medication) 5 mg 1 tab 4. Cranberry (supplement) 450 mg 1 tab 5. Docusate Sodium (stool softener) 100 mg 2 tabs 6. Glycopyrrolate (medication for excessive saliva production) 1 mg (Crush and dissolve in hot water) 7. Multivitamin with minerals (supplement) 30 milliliters (ml) 8. Omeprazole (medication for acid reflux - acidic stomach fluid flows back up) 20 mg/10 ml gave 10 ml 9. Miralax (laxative) 17 grams 10. Scopolamine (medication for nausea and vomiting) patch 1 mg/3 days 11. Vancomycin (antibiotic) 25 mg/ml one drop in the left eye 12. Clonidine (blood pressure medication) 0.1 mg as needed every 8 hrs A review of Resident 16's physician orders, dated April 2023, was conducted. The record indicated the following active orders that LN 41 did not administer timely or did not administer the correct dose during Resident 16's medication administration observation: - Omeprazole 20 mg/ml give 20 ml (10 ml was prepared and given to Resident 16) every 12 hours - Refresh Tears (for dry eyes) 0.2% eye drops 1 drop both eyes twice daily (not prepared; not given) - Brimonidine (use to lower pressure in the eyes) 0.2% eye drops 1 drop to both eyes twice daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 23 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0759 (not prepared; not given) Level of Harm - Minimal harm or potential for actual harm An interview and joint record review was conducted with LN 41 on 4/6/23 at 1:53 P.M. LN 41 confirmed the orders for Omeprazole, Refresh Tears, and brimonidine. LN 41 acknowledged that the Omeprazole dose given to Resident 16 was incorrect. LN 41 acknowledged that 20 ml should have been given and not 10 ml. LN 41 also stated the ordered Refresh Tears and brimonidine was given to Resident 16 at around 1 P.M. LN 41 stated the order was twice daily and both medications should have been given to Resident 16 at 9 A.M. LN 41 stated both medications were given to the resident late. LN 41 stated it was important for the correct dose of a medication to be given, and administered to the resident at the correct time to ensure the resident's needs were addressed, and to ensure that medications did not overlapped, which may cause medication interaction. Residents Affected - Few An interview with the Director of Nursing (DON) was conducted on 4/7/23 at 2:40 P.M. The DON stated Resident 16's medications should have been administered as ordered by the physician to ensure resident safety. A review of the facility's policy and procedure titled General Medication Guidelines, dated 12/13/2019, was conducted. The policy indicated, Medications are administered as prescribed in accordance with manufacturers' specifications, standard nursing principles and only by persons legally authorized to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 24 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that food items in the kitchen and in a resident's room (Resident 3) were stored according to professional standards for food safety. As a result, there was the potential for residents to be exposed to contaminated food and/or experience foodborne illness. Findings: 1. On 4/4/23 at 8 A.M., an initial kitchen tour was conducted with the head chef (HC). Observed in the walk-in refrigerator, was a large box with approximately 24 green bell peppers in it. There were approximately seven green bell peppers that were covered with gray, fuzzy areas. The HC stated the green bell peppers had mold on them and should not have been stored among non-spoiled produce. The general manager joined the observation in the walk-in refrigerator. A large box of bagged shredded lettuce was observed. Two of the three bags of shredded lettuce had lettuce that appeared discolored and slimy. The HC stated the shredded lettuce should have been thrown out. The boxes of green bell peppers and shredded lettuce had handwritten dates of 3/23/23 on the boxes. The HC stated 3/23/23 was the received date and all produce items had to be removed from circulation and disposed of within five days of the received date. The HC stated all the cooks were responsible for checking the food quality in the refrigerated storage each shift. On 4/7/23 at 9:03 A.M., an interview was conducted with the facility's registered dietitian (RD). The RD stated spoiled produce should not have been stored among non-spoiled produce. The RD stated produce was good for five days after the date of receipt and then it had to be removed from storage and disposed of. The RD stated the lettuce and bell peppers should have been removed from the walk-in refrigerator five days after the received date of 3/23/23. The RD stated it was the responsibility of all kitchen staff to check the dates and food quality in the food storage areas. The RD stated logs were not kept related to checking food storage areas. On 4/7/23 at 9:24 A.M., an interview was conducted with the director of nursing (DON). The DON stated spoiled produce should not have been stored among non-spoiled produce as this was a food safety concern. A review of the facility's policy titled Section 11: Sanitation & Infection Control Receiving & Storage dated 1/2016, did not provide clear guidance related to when to check and remove stored food from circulation. 2. A review of Resident 3's Face Sheet indicated the resident was admitted on [DATE]. On 4/4/23 at 4:37 P.M., an observation was conducted in Resident 3's room. There was a plastic bin on top of Resident 3's dresser with three bottled health shakes in it. One of the health shakes was opened and half full. The manufacturer's guidance for the health shake on the label indicated to refrigerate if opened. On 4/4/23 at 4:46 P.M., an joint observation and interview was conducted with certified nursing assistant (CNA) 31 while inside Resident 3's room. Resident 3 was laying in bed. Resident 3 stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 25 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not know when the health shake had been opened, nor did he know when he last had a health shake. CNA 31 observed the plastic bin and opened health shake that was half full. CNA 31 stated Resident 3's health shake should have been put in the refrigerator once it was opened so the resident did not get food poisoning. On 4/7/23 at 9:03 A.M., an interview was conducted with the facility's RD. The RD stated it was his expectation for residents' health shakes to be thrown away if not finished in one sitting. The RD stated health shakes should not be stored at room temperature after being opened. On 4/7/23 at 9:24 A.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 3 should not have had an opened half consumed health shake stored in his room. The DON stated the resident's health shake should have been immediately disposed of when it was not fully consumed. A review of the facility's policy titled Section 11: Sanitation & Infection Control Receiving & Storage dated 1/2016, did not provide clear guidance related to when to check and remove stored food from circulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 26 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and document review, the facility failed to update the facility assessment to reflect the facilities staffing challenges, the usage of staffing agencies, and address the required training and competencies for agency staff, who cared for the facility residents. This failure had the potential to affect the residents' care due to agency staff's lack of training and knowledge. (Cross reference F-tag 699 and F-tag 741) Finding: An interview and joint document review of the facility's facility assessment, dated 8/18/17, was conducted. The Administrator (ADM) reviewed the signature page of the facility assessment, and confirmed that he and the director of nursing (DON) signed the document on 3/28/23. The ADM stated he reviewed the facility assessment on 3/28/23, but did not dissect the document. Both the ADM and the DON confirmed that the facility currently have residents who had been diagnosed with Post-Traumatic Stress Disorder (PTSD occurs in some individuals who have encountered a shocking, scary, or dangerous situation), and/or residents with history of trauma. The ADM and the DON both confirmed that the facility had been using staffing agencies to meet the staffing needs of the facility. The ADM and the DON acknowledged that the facility assessment did not address the facility's usage of staffing agencies, as well the training and competencies needed to ensure that staff provided by the outside agencies were trained and competent to care for residents with PTSD and/or history of trauma. A review of the facility's undated policy and procedure titled Facility Assessment was conducted. The policy indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 27 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's staff education with regard to Trauma Informed Care. (Cross reference F-tag 699 and F-tag 741) This failure placed any residents admitted to the facility with diagnosis of Post Traumatic Stress Disorder (PTSD - occurs in some individuals who have encountered a shocking, scary, or dangerous situation) and history of trauma at increased risk for emotional distress. Findings: A concurrent interview and record review was completed on 4/7/23 at 3:50 P.M., with the Director of Nursing (DON) and Administrator (ADM). The DON stated the facility was working on the facility's identified issues with quality improvement plan. The DON reported these issues to be resident wounds and falls. On 4/7/23 at 3:57 P.M., the DON confirmed there were no improvement projects for Post Traumatic Stress Disorder The DON denied knowledge of staff not being trained for residents with PTSD. The DON and ADM did not identify a method for collection of data and monitoring adverse events regarding PTSD. The DON stated staff were to have regular PTSD training, as the facility accepted residents with this condition. The DON was unable to confirm PTSD training had been completed for the registry (temporary) staff. The DON and ADM acknowledged that PTSD and resident with history of trauma had not been identified as a concern and area that needed improvement. The DON stated it was important to deliver proper and informed care for post trauma patients, and to have care plan meetings with the IDT (interdisciplinary team - team of people from the different departments). On record review of 2023 QAPI Program, dated 10/2017, the governing body is responsible for identifying and prioritizing problems based on performance indicator data. The QAPI committee is responsible for .developing and implementing appropriate plans of action to correct identified quality deficiencies On record review of an undated Policy and Procedure titled, Trauma Informed Care, the facility staff are to utilize trained and qualified staff members and .All staff are provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting . Under the organization strategies of the Trauma Informed Care policy, trauma informed care is to be part of the QAPI plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 28 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 Provide and implement an infection prevention and control program. 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 fully implement infection control standards of practice when hand hygiene (using alcohol-based hand gel or performing hand washing with soap and water) was not performed before and after direct contact with residents, before and after glove use, and before and after providing feeding assistance to a resident (Resident 29). In addition, a resident's oxygen tubing was not stored properly and did not have a date of when it was first used or changed. Residents Affected - Some These failures had the potential to spread infection and disease among residents and staff. Findings: 1. On 4/6/23 at 8:10 A.M., an observation was conducted. Certified nursing assistant (CNA) 35 was observed going into Resident 3's room. CNA 35 put on gloves, assisted Resident 3 by positioning the resident and opening food items for the resident. CNA 35 removed his gloves, left Resident 3's room, and went to room C. CNA 35 did not perform hand hygiene. CNA 35 was observed leaving room C and going to the coffee cart in the hallway. CNA 35 prepared a cup of coffee for the resident in room C. CNA 35 adjusted the front of the surgical mask he wore, and brought the cup of coffee into room C. CNA 35 did not perform hand hygiene. CNA 35 left room C and went into room D. CNA 35 left room D and went into room E. CNA 35 left room E and went into room F. While inside room F, CNA 35 put on gloves and assisted another CNA by helping to pull up a resident in bed. CNA 35 removed his gloves and left room F. CNA 35 did not perform hand hygiene. At 8:17 A.M., CNA 35 was opening and closing food trays that were in the meal cart. CNA 35 brought a tray to Resident 29 in room D. CNA 35 put on gloves and assisted with pulling up and positioning Resident 29 with the help of another CNA. CNA 35 adjusted Resident 29's hand cones (medical device) that were in each of the resident's hands. At 8:20 A.M., CNA 35 brought a chair over to Resident 29's bedside and sat down. CNA 35 adjusted the front of his surgical mask and opened Resident 29's food items. CNA 35 did not change gloves or perform hand hygiene. CNA 35 began to provide feeding assistance to Resident 29. CNA 35 wiped Resident 29's mouth with a napkin. CNA 35 removed his gloves and went out into the hall and then came back into room D. CNA 35 did not perform hand hygiene. CNA 35 returned to room D and put on a new pair of gloves. CNA 35 resumed providing feeding assistance to Resident 29. CNA 35 adjusted the front of his surgical mask. Resident 29 spit out her mouthful of food. CNA then wiped Resident 29's mouth with a napkin using the same gloved hand he adjusted his surgical mask with. At 8:45 A.M., CNA 35 adjusted Resident 29's pillows and continued providing feeding assistance. At 8:48 A.M., CNA 35 removed his gloves and went into the hallway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 29 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 CNA 35 did not perform hand hygiene. Level of Harm - Minimal harm or potential for actual harm CNA 35 went back into room D and put on a new pair of gloves. CNA 35 continued to provide feeding assistance to Resident 29. CNA 35 adjusted the front of his surgical mask and then cleaned up the resident's food tray. At 9 A.M., CNA 35 removed his gloves, left room D, and placed the resident's food tray in the meal cart. Residents Affected - Some During the continuous 40 minute observation, CNA 35 was not observed to have performed hand hygiene. On 4/6/23 at 9:01 A.M., an interview was conducted with CNA 35. CNA 35 stated he worked for the registry (a company that provided nursing staff). CNA 35 stated he should have performed hand hygiene before going into and before leaving a resident's room, before and after glove use, and before and after feeding a resident. On 4/6/23 at 9:17 A.M., an interview was conducted with CNA 1. CNA 1 stated staff had to perform hand hygiene before and after going into a resident's room, before and after changing or putting on gloves, and before and after feeding a resident. On 4/6/23 at 2:15 P.M., an interview was conducted with licensed nurse (LN) 11. LN 11 stated staff were expected to perform hand hygiene before going into a resident's room, after leaving the room, before and after glove use, and before and after feeding a resident. On 4/7/23 at 8:15 A.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated it was her expectation that all staff performed hand hygiene in between resident care and in between tasks, before and after gloving, and before and after feeding a resident. The IPN stated this was done to prevent cross contamination and spread of infections. The IPN stated she would need to monitor the registry staff to ensure that their infection control practices aligned with the facility's expectations. On 4/7/23 at 9:24 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that all staff were performing hand hygiene before going into residents' rooms, upon leaving residents' rooms, before and after gloving, and before and after providing feeding assistance to residents. A review of the facility's policy titled Handwashing/Hand Hygiene revised 3/10/20, indicated, .The facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . p. Before and after assisting a resident with meals . 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections 2. Resident 24 was admitted to the facility on [DATE] with the diagnosis of End Stage Heart Failure (The body can no longer compensate for the lack of blood the heart pumps, and the heart has limited functional recovery) according to Resident 24's face sheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 30 of 31 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 555144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Pauls Health Care Center 235 Nutmeg Street San Diego, CA 92103 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 During observation on 4/4/23 at 9:38 A.M., Resident 24 was in bed with a blanket over her head. An oxygen concentrator (type of medical device used for delivering oxygen) was at the bedside with a humidifier (device which release water vapor or steam to increase moisture levels in the air) and oxygen tubing connected. The oxygen tubing was hanging inside Resident 24's bedside drawer and did not have a date. During an observation on 4/5/23 at 8:18 A.M., Resident 24's oxygen concentrator was at bedside with oxygen tubing attached to a humidifier without a date. The oxygen tubing was still hanging inside Resident 24's bedside drawer. On 4/6/23 at 7:55 A.M., an observation was conducted. Resident 24 was in bed and the oxygen concentrator with humidifier and oxygen tubing was at the bedside. The oxygen tubing was on the floor. An interview and concurrent observation on 4/6/23 at 8:03 A.M., was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 24 was admitted due to a non-healing wound in the left groin, and Resident 24 was on hospice (comfort care without curative treatment). LN 11 stated Resident 24's oxygen was ordered as needed. LN 11 stated the oxygen tubing should have been in a plastic bag and dated when last changed. LN 11 stated it was important to store in a plastic bag to maintain cleanliness. LN 11 stated since the oxygen tubing was on the floor, it could have been contaminated. During an interview on 4/7/23 at 10:05 A.M., with the director of nursing (DON), the DON stated oxygen equipment should be stored properly and dated when changed as an infection control measure. A review of the facility's undated Policies and Procedures (P&P) titled, Respiratory (Prevention of Infection) was conducted. The P&P indicated, Change the oxygen cannulae (a medical device to provide supplemental oxygen through the nose) and tubing every seven (7) days, or as needed. Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 31 of 31