Health inspection·June 26, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the process was for two licensed nurses to obtain informed consent from the resident or responsible party (RP) and sign the informed consent form. Resident 17's mirtazapine Informed Consent Form, dated 4/6/25 was reviewed. LN 1 stated she remembered LN 15 obtained informed consent and LN 1 was the second nurse to sign off the consent. Resident 17's venlafaxine Informed Consent Form, dated 10/30/24, was also reviewed. LN 1 stated the form indicated two registered nurses obtained informed consent for venlafaxine. A review of Resident 17's Seroquel Informed Consent Form, dated 2/1/25 at 8:32 P.M., indicated two signatures on the line Signature of Person Obtaining Consent. Signature one indicated a registered nurse (RN) and signature two indicated a licensed vocational nurse (LVN). Resident 17's lorazepam Informed Consent Form, dated 2/1/25, indicated two signatures on the line Signature of Person Obtaining Consent. Signature one indicated an LVN and signature two indicated an RN. During a phone interview on 6/26/25 at 10:16 A.M., Resident 17's RP stated someone from the facility called to get permission to give psychotropic medications to Resident 17. When asked who spoke to him, RP stated he was certain a facility nurse spoke to him to get permission. RP further stated the only time he spoke with a physician was during an unrelated infectious disease outbreak. 2. A review of Resident 28's admission record indicated the resident was admitted on [DATE] with diagnoses including vascular dementia (a type of dementia) with psychotic disturbances. Resident 28 had a physician's order, dated 3/28/25, for Risperdal (brand name for risperidone, an antipsychotic medication to treat mental illness) 0.5 mg by mouth two times daily for Vascular dementia with psychotics [sic] features. Resident 28 had multiple previous physician's orders for Risperdal, including: - Risperdal 0.25mg by mouth once daily, dated 9/9/24 and discontinue date not provided; - Risperdal 0.25mg by mouth once daily, dated 10/31/24 and discontinue date not provided; - Risperdal 0.25mg by mouth two times daily, dated 10/31/24 and discontinue date not provided; and - Risperdal 0.25mg by mouth two times daily, dated 10/31/24 and discontinued on 3/27/25. During an interview on 6/26/25 at 8:44 A.M., LN 15 stated a licensed nurse, either a licensed vocational nurse (LVN) or registered nurse (RN), could obtain informed consent from the resident or RP. LN 15 stated if the resident refused the psychotropic medication, the nurse would tell the physician. LN 15 further stated she would get a nurse to act as a witness to the phone call when calling the RP to obtain informed consent. LN 15 stated both nurses would then sign the Informed Consent Form. During an interview on 6/26/25 at 9:41 A.M., the Director of Nursing (DON) stated licensed nurses were allowed to obtain informed consent. When asked if a certified nursing assistant (CNA) could obtain informed consent, the DON stated only an LVN or RN could do it. During an interview on 6/26/25 at 10:30 A.M., the DON stated the physician should call the resident's RP for informed consent when new psychotropic medications were started. The DON stated the physician should review the risks and benefits of the medication when obtaining consent. The DON stated she could not verify this practice was followed in the facility. The DON further stated this practice should be followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 2 of 46 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 06/26/2025 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 6/26/25 at 10:38 A.M. with Psychiatrist Physician's Assistant 1 (PSYC PA), Resident 17's psychotropic Informed Consent Forms, dates ranging from 10/30/24 to 4/6/25, were reviewed. PSYC PA stated he did not obtain any informed consents for Resident 17 and did not recognize any of the signatures on the Informed Consent Forms. PSYC PA stated when he obtained informed consent, he would review the benefits and significant risks of the psychotropic medication with the RP. A review of Resident 28's risperidone Informed Consent Form, dated 8/27/24, indicated two signatures on the line Signature of Person Obtaining Consent. Signature one indicated a licensed practical nurse (LPN) and signature two indicated an RN. The checkbox next to the statement, I HAVE received education regarding this medication, including side effects and Black Box Warnings [required drug labeling indicating the medication has a significant risk of serious or life-threatening adverse events], was not filled out. Resident 28's risperidone Informed Consent Form, dated 9/9/24, also indicated no mark in the checkbox next to the statement, I HAVE received education regarding this medication, including side effects and Black Box Warnings. During a concurrent interview and record review on 6/26/25 at 4:07 P.M. with the DON, Resident 28's risperidone Informed Consent Form, dated 9/9/24, was reviewed. When asked if there was evidence Resident 28 had been informed of significant risks, such as Black Box Warnings, for risperidone, the DON stated no because there was no checkmark. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for risperidone tablets, dated 5/11/12, retrieved from DailyMed, indicated the following Black Box Warning: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. A review of the facility's policies and procedures (P&P) titled, Informed Consent, undated, indicated, The right to receive all information in advance that is material to a decision to accept or refuse treatment .The disclosure of the material information and obtaining informed consent shall be the responsibility of the physician . and The information material .shall include at least the following .The nature, degree, duration and probability of the side effects and significant risks . and Licensed Nurse Shall: When the resident's condition reported to the physician results in the use of a psychotherapeutic drug .Request the physician to obtain informed consent . Document the following in the Licensed Nurse's Notes: Date, time, name of physician called, name of person spoken to (if other than the physician, i.e. Physiician's [sic] Assistant, Nurse Practitioner) .[and] Statement: 'Awaiting physician to obtain informed consent .' Enter in the Licensed Nurse's Notes: Date, time, name of physician, person spoken to, statement that informed consent was obtained and from whom . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 3 of 46 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 06/26/2025 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 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's (Resident 13) personal property (a jar of grape jelly) was treated with dignity and respect when the facility did not communicate the food storage policy to the resident prior to disposal of their property. This deficiency violated Resident 13's rights for dignity and respect. Findings: A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 6/23/25 at 11:30 A.M., an interview was conducted with Resident 13. Resident 13 stated she was informed earlier this morning by the nurse that her personal food item (jar of jelly) had been thrown away. Resident 13 stated it was a gift from her friend and she was very upset and angry that it had been thrown away. Resident 13 stated she had not been informed of a policy for how long a food item could be kept in the facility's resident refrigerator or when it would be thrown out. On 6/24/25 at 10 A.M., an interview was conducted with the Resident Council. Three confidential residents (CR) A, B, and C stated they were unaware of the outside food policy. CR A and C stated they did not know they could bring in food from outside. CR B stated she had a pudding pie thrown out without prior notification and it made her feel mad. On 6/25/25 at 8 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that food brought in from family or friends would be put into a container, labeled with the resident's name and date and put into the facility's resident refrigerator. CNA 1 stated food could only be kept in the resident refrigerator for three days. On 6/25/25 at 8:23 A.M., an interview was conducted with CNA 2. CNA 2 stated when food was brought in by family or friends, any leftovers or extra food was bagged up, labeled with resident's name and date and stored in the facility's resident refrigerator for a period of two days. On 6/25/25 at 8:40 A.M., an interview was conducted with Licensed Nurse (LN) 1 stated food brought in for residents was stored in the facility's resident refrigerator and was good for 72 hrs. LN 1 stated there was no documentation that Resident 13 was informed of the food storage policy or when her food would be thrown away. On 6/25/25 at 10:06 A.M., a concurrent interview and record review was conducted with the Medical Record Director (MRD). The MRD stated there was no documentation in the clinical record of notification to Resident 13 of the food storage policy or that her food would be thrown away. On 6/26/25 at 3:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated outside food that was brought in for a resident would have been put in the facility's resident refrigerator for 72 hours. The DON stated she did not document notifying Resident 13 of the food storage policy or that her food would be thrown away in 72 hrs. The DON stated she should have documented that Resident 13 was informed of the food storage policy and when the jar of jelly would have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 4 of 46 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 06/26/2025 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 0557 thrown out. The DON stated she should have provided Resident 13 with the food storage policy. Level of Harm - Minimal harm or potential for actual harm A review of the facility's food policy titled Meal Service, revision dated 10/2024 does not address resident notification of time frame for food storage and disposal. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 5 of 46 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 06/26/2025 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a response and rationale for the Resident Council grievances and suggestions. Residents Affected - Some This failure resulted in the members of the Resident Council voicing that their complaints were unheard, and they were afraid of retaliation from the facility if they filed a grievance. Findings: On 6/23/25 at 2:44 P.M., an interview was conducted with the Resident Council President (RCP). The RCP stated call lights issues have been frequently discussed in Resident Council and the facility is aware and don't do anything about it. The RCP stated that the Resident Council has not received any written or verbal response from the facility regarding resolution of their complaints. A review of the Resident Council minutes, dated March 27, 2025, indicated Nursing Comments: Residents voiced their concerns about the call lights not being answered in a proper time frame, called in DON [Director of Nursing] to address their concerns. No rationale or facility response was found in the document. A review of the Resident Council minutes, dated April 29, 2025, indicated Nursing Comments: Residents voiced their concerns about the call lights not being answered in a proper time frame [three residents] mentioned this, residents were asked if they would like to file a grievance and all three declined. [Two residents] voiced concerns about sharing their grievance on paper, as they feared retaliation No rationale or facility response was found in the document. A review of the Resident Council minutes, dated May 29, 2025, indicated Nursing Comments: [one resident] .call light takes too long to be answered [one resident] call lights take too long to be answered .[one resident] call lights response time needs to improve .[one resident] mentioned that call light take too long to be answered .On all these concerns I [ AC, Activities Coordinator] asked the residents if they wanted to file a grievance report, they declined. No rationale or facility response was found in the document. On 6/24/25 at 10 A.M., a Resident Council meeting was conducted with the survey team. The Resident Council members stated that the call light complaint applied to all the attendees and after months of complaining, no response or improvement had been made by the facility. The Resident Council members stated that they have not filed a grievance because they were afraid of retaliation. The Resident Council members further stated they feared the retaliation would be staff ignoring the care needs of the residents or intentionally prolonging response time. The Resident Council members stated that the facility should have provided a response to their complaints and should have ensured that the council members felt safe to express their concerns. On 6/26/25 at 11:29 A.M., an interview was conducted with the AC. The AC stated that Resident Council meetings occurred monthly, and she recorded the minutes. The AC stated that when members of Resident Council discussed issues, she would ask them if they would like to file a grievance but the members would decline due to fear of retaliation. The AC stated that in Resident Council call lights are a common issue but the facility does not give support when she discussed call light complaints in QAPI. The AC stated that the facility should have given a written or verbal response to members of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 6 of 46 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 06/26/2025 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 0565 the Resident Council regarding their complaints. Level of Harm - Minimal harm or potential for actual harm On 6/26/25 at 3:13 P.M., an interview was conducted with the DON. The DON stated that there should have been a facility response to the Resident Council complaints, and they should feel safe to share their concerns. Residents Affected - Some A review of the facility's policy titled Resident Council, last reviewed [DATE], indicated Procedure 1. is to provide a forum for: .b. discussion of concerns and suggestions for improvement .6. A Resident Council Response Form will be utilized to track issues and their resolution FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 7 of 46 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 06/26/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement gradual dose reductions (GDR, stepwise tapering of a medication to determine if symptoms can be managed at a lower dose) for two of five sampled residents (Residents 17 and 28) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls. Findings: 1. A review of Resident 17's admission record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression), dementia (memory loss that gets worse over time) with behavioral disturbances, and anxiety disorder. Resident 17 had a physician's order, dated 2/1/25, for Seroquel (brand name for quetiapine, an antipsychotic medication to treat mental illness) 25 milligrams (mg) by mouth daily at bedtime for agitation, anxiety, dementia, and behavioral disturbance. Resident 17 had a prior physician's order, dated 1/27/25, for lorazepam (generic for Ativan, a medication to treat anxiety) 1 mg by mouth every two hours as needed for anxiety, restlessness, difficulty to redirect, discontinued on 6/18/25. During a review of Resident 17's IDT [interdisciplinary team] Psychotropic Medication Review, dated 3/27/25, the record indicated Resident 28 was receiving Seroquel 25 mg daily at bedtime. The record further indicated the IDT recommendation to decrease the Seroquel dose to 12.5 mg and monitor behavior. Further notes from the GDR Meeting, dated 3/27/25, indicated Decrease to 12.5mg QHS [at bedtime] Seroquel. During a concurrent interview and record review on 6/26/25 at 3:36 P.M. with the Minimum Data Set Coordinator (MDSC), Resident 17's Clinical Notes Report, dated 3/27/25, was reviewed. The clinical notes indicated the prescriber agreed with the pharmacy recommendation to trial a GDR for Seroquel to 12.5 mg PO [by mouth] QHS & Lorazepam 0.5 mg PO Q4H [every four hours] PRN [as needed] .agreed with the GDR recommendations .awaiting formal orders . MDSC stated the note indicated the facility requested updated orders for Seroquel and lorazepam on 3/27/25 and never received a response. See F756 for additional information regarding Resident 17's Seroquel and lorazepam. 2. A review of Resident 28's admission record indicated the resident was admitted on [DATE] with diagnoses including vascular dementia (a type of dementia) with psychotic disturbances. Resident 28 had a physician's order, dated 3/28/25, for Risperdal (brand name for risperidone, an antipsychotic medication to treat mental illness) 0.5 mg by mouth two times daily for Vascular dementia with psychotics [sic] features. Resident 28 had a prior physician's order, dated 10/31/24, for Risperdal 0.25mg by mouth two times daily, discontinued on 3/27/25. During a review of Resident 28's IDT Psychotropic Medication Review, dated 3/27/25, the record indicated Resident 28 was receiving Risperdal 0.25 mg twice a day. The record further indicated the IDT recommendation to switch to 0.5 mg q5pm [every day at 5 P.M.] due to behavior. Further notes from the GDR Meeting, dated 3/27/25, indicated to change Risperidone to 0.5mg q5pm [every day at 5 P.M.]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 8 of 46 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 06/26/2025 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 0605 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 28's Clinical Notes Report, dated 3/27/25, the notes indicated GDR meeting recommendation is for Risperidone 0.25mg PO [by mouth] BID [twice a day] to be changed to 0.5mg PO QHS [at bedtime] due to more behaviors during the evening time .Awaiting formal orders . A review of the Clinical Notes Report, dated 3/28/25, indicated Recommendation is to change Risperidone to 0.5mg q5pm due to behavior. See F756 for additional information regarding Resident 28's risperidone. Residents Affected - Some During a review of Resident 28's September 2024 Physician Order Sheet, printed 6/26/25, the record indicated Anti-Psychotic Adverse Reaction Monitors including Sedation, drowsiness, constipation, blurred vision .dizzy or light-headed when standing up . During a concurrent interview and record review on 6/26/25 at 3:57 P.M. with the Director of Nursing (DON), Resident 28's Psychotropic Medication Review, GDR Meeting Notes, and Clinical Notes Report, dated 3/27/25 and 3/28/25 were reviewed. The DON stated if the GDR team approved the GDR for a psychotropic medication, the expectation was that the orders are carried out. The DON stated the best practice was to implement the GDR within 24 hours. The DON stated she did not know why the GDR recommendation[s] from March 2025 were not implemented for Residents 17 and 28. A review of the facility's policies and procedures (P&P) titled, Psychotropic Medication Use, revised October 2018, indicated, If psychotherapeutic medication is ordered .The lowest effective dose shall be used and The interdisciplinary team .will review the resident's status and symptoms for dose reductions or discontinuance of the medication . A review of the facility's P&P titled, Psychotropic Medication Use in Residents with Dementia, revised October 2018, indicated, Appropriate usage will be monitored .To include .Gradual Dose Reduction(s) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 9 of 46 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 06/26/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary for one of three residents (Resident 5) during a closed record review. This failure had the potential for the receiving facility to not receive accurate and timely medical information regarding Resident 5's health status and needs. Findings: A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE] and was discharged from the facility on 6/11/25 with diagnoses to include acquired absence of the left leg below the knee, acquired absence of the right toes, bipolar disorder (characterized by episodes of mood swings), dementia (group of conditions characterized by cognitive impairment and memory loss), dysphagia (difficulty swallowing) and difficulty walking. A review of Resident 5's Wound assessment dated [DATE], indicated the resident had a facility acquired wound to the lateral side of his right foot that measured three by two centimeters and was 100 % covered by necrotic tissue. A review of Resident 5's undated discharge summary document titled Discharge Plan of Care to Home, indicated the resident was discharging to an assisted living facility. The same document had blank sections related to: Activities of daily living needs (ADL, the level of assistance needed to complete self-care tasks), skin conditions (wounds and treatment instructions), medical equipment, dietary/nutritional needs, and discharge teaching. The signature section of the discharge summary, I understand the above instructions which have been explained to me, for any questions I am to call the Resident Service Coordinator listed above was blank. The same document also did not indicated the resident's diagnoses or contain a recapitulation of the resident's stay. On 6/26/25 at 8:17 A.M., a joint interview and record review was conducted with licensed nurse (LN) 2. LN 2 reviewed Resident 5's undated discharge summary document titled Discharge Plan of Care to Home. LN 2 stated a registry nurse (temporary nurse from a staffing agency) had discharged the resident and that there should not have been any blank sections on the discharge summary. LN 2 stated Resident 5's discharge summary should have included information related to the wound on the resident's foot, dietary needs, allergies, ADL needs, and any medical equipment the resident needed. LN 2 stated the receiving facility needed to know this information to provide appropriate care and treatment to the resident. LN 2 stated Resident 5's discharge summary should have been completed and a copy should have been provided to the resident and receiving facility. On 6/26/25 at 3:15 P.M., an interview was conducted with the director of nursing (DON). The DON stated she expected discharge summaries to be completed with enough information for the receiving facility to be able to continue to provide the needed care and treatment to the residents. The DON stated Resident 5's discharge summary should have been completed, documented, and a copy provided to the resident's family member and the receiving facility. A review of the facility's policy titled Discharge Summary Plan, approved March 2025, indicated, .1. The discharge summary includes a recapitulation of the resident's stay at the facility and a final (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 10 of 46 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 06/26/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete summary of the resident's status at the time of discharge . The discharge summary shall include a description of the resident's: a. current diagnosis; b. medical history (including any history of mental disorders .); c. course of illness, treatment and/or therapy since entering the facility .e. physical and mental functional status; f. ability to perform activities of daily living including: (1) bathing, dressing and grooming, transferring and ambulating, toilet use .(2) the need for staff assistance and assistive devices . h. nutritional status and requirements . g. special treatments or procedures . o. cognitive status .12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records .m. the discharge summary. Event ID: Facility ID: 555144 If continuation sheet Page 11 of 46 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 06/26/2025 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** 2c. A review of Resident 50's admission record indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infarction (a type of stroke). Resident 50 had a physician's order, dated 6/12/25, for enoxaparin (generic for Lovenox, an anticoagulant) 40 milligrams (mg) injected under the skin every morning for deep vein thrombosis (DVT, life-threatening blood clots in the legs) prevention. During a concurrent interview and record review on 6/25/25 at 11:03 A.M. with Licensed Nurse 1 (LN 1), Resident 50's anticoagulant care plan, dated 5/6/25, was reviewed. The care plan indicated Resident is at risk for active bleeding [due to] use of anticoagulant meds. The care plan further indicated Observe for S/S [signs and symptoms] of bleeding (bleeding gums, epistaxis [nosebleed], hematemesis [vomiting blood] and report. LVN 1 stated she did not see any documentation in Resident 50's medical record that Resident 50 was monitored for signs of bleeding. See F757 for additional information regarding Resident 50's anticoagulant. 3. Resident 50 had a physician's order, dated 6/21/25, for levetiracetam (generic for Keppra, seizure medication) 500 mg through gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) two times daily for epilepsy (seizure disorder). During a concurrent interview and record review on 6/25/25 at 11:03 A.M. with LN 1, Resident 50's care plans were reviewed. LN 1 stated there was no care plan in Resident 50's medical record for seizures or levetiracetam. LN 1 further stated Resident 50's medical history of stroke and craniotomy (surgery to remove a part of the skull) increased the risk of seizures. LN 1 stated there should be a care plan for seizures because Resident 50's case was complex and it was difficult to know what to do for care. A review of the facility's policy titled Care Plans, Comrehensive Person-Centered, dated 3/2025, indicated A comprehensive, person-centered care plan that includes measueable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Based on interview and record review, the facility failed to ensure person-centered care plans were developed and interventions were implemented for four of 13 sampled residents when: 1. Monitoring for glycemia reactions for Resident 32 was not done. 2. Monitoring for risk of active bleeding for Residents 50, 13, and 3 was not done. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 12 of 46 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 06/26/2025 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 A care plan for seizure disorder was not developed for Resident 50. Level of Harm - Minimal harm or potential for actual harm These failures had the potential for the residents to not receive care and services specific to the residents' needs. Residents Affected - Some Findings: 1. A review of Resident 32's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control). On 6/26/25 at 10:20 A.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed Resident 32's care plan for glycemia (the presence of glucose in the blood). Interventions were to observe for signs and symptoms of hypoglycemic (low blood sugar) reactions listed as: hunger, profuse sweating, and tremor. LN 2 stated there was no documentation Resident 32 was assessed for hypoglycemia in the clinical record. 2a. A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE] following surgery on the digestive system. A review of Resident 13's physician's order dated 9/13/24 indicated Eliquis (a medication used to thin the blood) 5 mg (milligrams) one tablet daily. On 6/25/25 at 10:55 A.M., a record review was conducted on Resident 13's care plan. The care plan of risk for active bleeding listed an intervention to .observe for S/S [signs and symptoms] of bleeding (bleeding gums, epistaxis [nose bleeds], hematemesis [vomiting blood]) On 6/25/25 at 11:11 A.M., a concurrent interview and record review was conducted with LN 1. LN 1 reviewed Resident 13's care plans. LN 1 stated Resident 13 needed to be assessed for bruising and active bleeding due to blood thinner use. LN 1 reviewed Resident 13's clinical record and stated there was no documentation Resident 13 was monitored for bleeding. On 6/26/25 at 12:55 P.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed the care plan for risk of active bleeding for Resident 13 and stated nursing would monitor bleeding, nose bleeds and bruising for a resident on an Eliquis. LN 2 reviewed Resident 13's clinical record and stated there was no documentation Resident 13 was monitored for bleeding. 2b. A review of Resident 3's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of pulmonary embolism (a blood clot travels from another part of the body to the lungs and blocks one or more pulmonary arteries). A review of Resident 3's physician's order dated 5/30/25 indicated Eliquis 5 mg one tablet daily. On 6/25/25 at 10:55 A.M., a record review was conducted on Resident 3's care plan. The care plan indicated Resident 3 was at risk for active bleeding. Interventions included: observe the resident for bleeding, nose bleeds, bruising, epistaxis and hematemesis. On 6/26/25 at 12:55 P.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed Resident 3's clinical record and stated there was no documentation Resident 3 was monitored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 13 of 46 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 06/26/2025 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 for bleeding. Level of Harm - Minimal harm or potential for actual harm On 6/26/25 at 3:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON reviewed Resident 32's care plan for hypoglycemia and stated nursing should have observed for signs and symptoms of hypoglycemia. The DON stated there was no documentation of the nursing assessment for hypoglycemia. The DON stated her expectation was that there would be documentation of assessments for hypoglycemia. The DON then reviewed Resident 3 and 13's care plans for risk of active bleeding and stated nursing should have followed the care plans and should have observed for adverse effects of anticoagulant use, such as bleeding and bruising. The DON stated there was no documentation of monitoring or assessments for adverse effects. The DON stated her expectation was that there would be documentation of the LN assessments of adverse effects for anticoagulants. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 14 of 46 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 06/26/2025 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 0659 Provide care by qualified persons according to each resident's written plan of care. 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 nursing staff fed one of 12 residents (Resident 29) who required feeding assistance. Residents Affected - Few As a result of this deficient practice, Resident 29 received feeding assistance from the Activity Coordinator (AC) who was not qualified. The resident could have experienced choking and was at risk for aspiration. (cross reference F689) Findings: Per facility's Face Sheet Resident 29 was admitted to the facility on [DATE], with a diagnosis of Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Dysphagia (difficulty swallowing). On 6/23/25 at 11:45 A.M, an observation was conducted in the dining room. Resident 29 was observed receiving feeding assistance from the Activities Coordinator (AC). Resident 29's meal consisted of pureed (blended) food. On 6/24/25 at 2:27 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 15. LN 15 reviewed Resident 29's speech note dated 5/14/25 which indicated, .1:1[one staff to one resident] CNA [Certified Nursing Assistant] to provide cues for slow pace, small bites/sips, and for upright positioning LN 15 reviewed Resident 29's Physician Order Sheet dated 3/14/25, which indicated, Assistance with all meals, Diet order fortified large portions, pureed, nectar thick fluids. LN 15 reviewed Resident 29's care plan dated 7/3/24, SNF [skilled nursing facility]-Assistance with all meals, All Staff-Nursing Observe for s/s [signs and symptoms] of aspiration, All Staff-Nursing. LN 15 stated a CNA or a licensed nurse should assist with feeding Resident 29 who was at risk for choking or aspiration. LN 15 stated the AC should not have fed Resident 29. On 6/25/25 at 8 A.M., an interview was conducted with the Restorative Nursing Assistant (RNA). The RNA stated Resident 29 needed assistance with all meals because the resident was at risk for choking and aspiration. The RNA stated Resident 29 had problems swallowing and needed to be monitored for all meals. The RNA stated she received training from the Speech Therapist to give Resident 29 small bites, cue to swallow and small sips to prevent choking. The RNA stated a CNA, RNA or Licensed Nurse were the only ones that could feed Resident 29 in case something happened, or resident started choking. On 6/25/25 at 8:20 A.M., an interview was conducted with Director of Rehabilitation (DR). The DR stated rehabilitation services would not train non-nursing staff to ambulate, transfer or to provide feeding assistance. On 6/25/25 at 8:40 A.M., an interview was conducted with the AC. The AC stated she was familiar with Resident 29 and that he needed feeding assistance during meals. The AC stated a couple of weeks ago during a Covid outbreak, the Administrator told her all hands-on deck and to help feed residents. The AC stated she had been trained in CPR/fist aid. The AC stated if Resident 29 choked, she would panic and call for the nurse as she did not feel comfortable rendering first aid. The AC stated she was not qualified to provide feeding assitance to Resident 29. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 15 of 46 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 06/26/2025 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 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/25/25 at 8:54 A.M., an interview was conducted with LN1. LN 1 stated Resident 29 was at risk of choking. LN 1 stated only a CNA, RNA or Licensed Nurse should assist feeding Resident 29 due to his risk of choking. LN 1 stated the AC should not have been feeding Resident 29. On 6/25/25 at 2:28 P.M., an interview was conducted with the Speech Language Pathologist (SLP). The SLP stated a resident who was on a pureed diet, at risk for aspiration or choking, and needs assistance in feeding should not have been assisted by the AC. On 6/26/25 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the AC had no business feeding Resident 29. The DON stated the AC was not qualified to assist feeding Resident 29. A review of Activities Coordinator job description revised date 10/2010 indicated Basic Function: The Activities Coordinator is responsible for the planning, coordination, and implementation of the Health Center's activity programs Job description did not include feeding residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 16 of 46 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 06/26/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 that one (Resident 28) of two sampled resident's Low Air Loss (LAL) mattress was functioning properly. Residents Affected - Few This failure had the potential for Resident 28 to experience skin breakdown and develop pressure ulcers. Findings: A review of Resident 28's Face Sheet, dated [DATE], indicated the resident was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease (PVD, a condition where blood flow can be limited to the lower part of the body). A review of Resident 28's care plan, dated [DATE], indicated At risk for skin breakdown .LAL mattress in place . A review of Resident 28's physician orders, dated [DATE], indicated Low air loss mattress .Frequency (Scheduled): Three times Daily .monitor placement & that mattress is functioning properly A review of Resident 28's Braden scale for predicting pressure sore risk, dated [DATE], indicated the resident was a moderate risk for developing pressure sores. On [DATE] at 8:12 A.M., 8:42 A.M., 9:40 A.M., 11:04 A.M., 3:07 P.M., and 4:09 P.M., observations were conducted of Resident 28 in his room. Resident 28 was lying on the LAL mattress, and it was not inflated. On [DATE] at 5:10 P.M., an interview was conducted with Licensed Nurse (LN) 18. LN 18 stated the LNs are responsible for checking the LAL mattresses routinely to ensure they are functioning. On [DATE] at 7:46 A.M., an interview was conducted with LN 13. LN 13 stated he was the nurse for Resident 28 yesterday during the day shift. LN 13 stated he did not notice the LAL mattress was deflated yesterday and should have checked it routinely. LN 13 stated if the LAL mattress was not functioning this could cause Resident 28 to experience skin breakdown and or a development of a pressure ulcer. On [DATE] at 7:58 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated she was off on [DATE] but was familiar with Resident 28 and his usage of the LAL mattress. CNA 11 stated she would check the LAL mattress every time she assisted Resident 28 and would report to the Licensed Nurse if it was not functioning. On [DATE] at 3:13 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated rounding on Residents should have been completed every two hours by the CNAs or LNs and the LAL mattresses should have been monitored for proper functioning during those times. The DON stated improper functionality of the LAL mattress could have negatively impacted Resident 28's skin integrity and could have led to the development of pressure ulcers. A review of the facility's policy titled Routine Resident Checks, last reviewed February 2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 17 of 46 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 06/26/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, .Routine resident checks involve entering the residents room .to determine if the residents needs are being met, identify any change in the resident's condition . A review of the Operating, Maintenance, and Trouble Shooting Guide for Adapt Pro Elite LAL mattress indicated, Mattress Not Inflating .Possible Causes: 1. No Power 2. CPR Valve Opened 3. Air Rail or Hoses Kinked 4. Hose not connected to pump .Action: 1. Check plug in outlet, check fuse 2. Twist to close position 3. Check that hoses are not impeded by bed rail or other obstruction . Event ID: Facility ID: 555144 If continuation sheet Page 18 of 46 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 06/26/2025 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure two of four Residents (3, 17) that were reviewed received Restorative Nursing Assistant (RNA) services as ordered by the physician. As a result, Resident 3 and Resident 17 had the potential to experience a further decline in range of motion (ROM). Findings: A review of Resident 3's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of muscle weakness and dementia (a condition that affects memory). A review of Resident 17's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of fracture to the lower end of right femur and fracture of right pubis and dementia. A review of Resident 3's physician orders, dated 5/24/25, indicated .RNA for BLE [Bilateral lower extremity] ROM 3x/week to improve ROM and muscle tissue extensibility A review of Resident 17's physician orders, dated 4/29/25, indicated .RNA for UB [upper body] ROM 5 x week A review of the Residents (3 and 17) RNA Range of Motion logs for the month of June indicated both residents only received RNA services on 6/6/25, 6/11/25, 6/18/25, and 6/25/25. On 6/26/25 at 12:08 P.M., a concurrent interview and record review was conducted with the RNA. The RNA stated she performed RNA services for both Residents (3 and 17) regularly. The RNA reviewed the ROM logs for the Residents (3 and 17) and acknowledged that the RNA services had only been documented once a week. Resident 3 and Resident 17 were not interviewable due to cognitive impairment. On 6/26/25 at 12:35 P.M., a concurrent interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated she oversaw the RNA program. The MDSC reviewed the Residents' (3 and 17) physician orders and Range of Motion logs for the month of June and stated the physician orders were not being followed and could have caused a decline in movement for the Residents (3 and 17). The MDSC stated that her expectation was for the RNAs to perform the RNA services per the physician orders and document after completion. The MDSC further stated the facility did not have a policy related to range of motion and RNA services. On 6/26/25 at 3:13 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON reviewed Residents' (3 and 17) physician orders and Range of Motion logs for the month of June and stated the physician orders for RNA services were not followed. The DON further stated as a result, this could have contributed to further decline in the Residents' (3 and 17) ROM abilities. The DON stated it was her expectation that the RNA services be provided according to the physician orders and the RNA documentation to be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 19 of 46 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 06/26/2025 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 interview and record review, the facility failed to ensure one sampled resident (Resident 29) was provided a safe and physician ordered snack when the Activity Coordinator (AC) gave the resident baby teething crackers. As a result of this deficient practice, Resident 29 could have experienced choking and was at risk for aspiration. (cross reference F659) Findings: Per facility's Face Sheet Resident 29 was admitted to the facility on [DATE], with a diagnosis of Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and Dysphagia (difficulty swallowing). On 6/25/25, a record review was conducted. A review of Resident 29's Speech Note dated 5/14/25 indicated, .1:1[one staff to one resident] CNA [certified nursing assistant] to provide cues for slow pace, small bites/sips, and for upright positioning . A review of Resident 29's Physician Order Sheet dated 3/14/25 indicated, Diet order fortified large portions, pureed, nectar thick fluids. On 6/25/25 at 8:40 A.M., an observation and interview was conducted with the AC. The AC stated she was familiar with Resident 29 and that he needed feeding assistance during meals and he was on a pureed diet. The AC stated she had given him Gerber teethers teething wafers as a snack. A box of baby teething crackers was observed in the AC's office. The crackers were hard and approximately three inches long and two inches wide. The AC stated she had not cleared the snack with any medical staff. The AC stated she thought the teething crackers were a good idea to give to Resident 29. On 6/25/25 at 2:28 P.M., an interview was conducted with the Speech Language Pathologist (SLP). The SLP stated snacks for Resident 29 would consist of pudding, yogurt or a pureed type of snack, and any other snacks would need approval by SLP and a physician order. The SLP stated any food, or snack should be supervised by a CNA or RNA. The SLP stated AC should not have given Resident 29 baby teething crackers. On 6/25/25 at 3:10 P.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 29 was at risk for choking and aspiration. LN 2 stated snacks for Resident 29 would consist of pudding, thicken shake, or a yogurt. LN 2 stated it was not appropriate to give Resident 29 a snack that differed from the resident's diet order. LN 2 stated only CNA, RNA, LN or Speech Therapist could assist with feeding or giving Resident 29 a snack. LN 2 stated the AC should not have given Resident 29 a snack of any kind. On 6/26/25 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the AC should not have given Resident 29 a snack. The DON stated baby teething crackers were unsafe to give to Resident 29. A review of Activities Coordinator job description revised date 10/2010 indicated Basic Function: The Activities Coordinator is responsible for the planning, coordination, and implementation of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 20 of 46 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 06/26/2025 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 Health Center's activity programs Job description did not include feeding residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 21 of 46 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 06/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper pharmaceutical services when: Residents Affected - Some 1. The documentation on Controlled Drug Record (CDR) and Medication Administration Record (MAR) did not reconcile for two of three randomly selected residents (Resident 23 and 45). This failure had the potential for diversion and/or inadequate pain management. 2. The facility did not verify the accuracy of outside medications for three residents (Resident 9, 25, and 306). This failure had the potential for inaccurate medications to be administered to the residents. 3. The medication storage room and its refrigerator temperature logs were missing entries. This failure had the potential for undetected inappropriate temperature storage which could alter the efficacy of medications. Findings: 1a. A review of Resident 23's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including polyneuropathy (damage or disease affecting peripheral nerves) and pain in the left knee. A review of Resident 23's physician's orders dated 1/15/25, indicated: - Oxycodone 20 mg (milligrams)/mL (milliliter) oral (by mouth) solution, take 0.25 mL by mouth every 2 hours as needed for mild pain or shortness of breath. - Oxycodone 20 mg /mL oral solution, take 0.5 mL by mouth every 2 hours as needed for moderate pain or shortness of breath. - Oxycodone 20mg /mL oral solution, take 1 mL by mouth every 2 hours as needed for severe pain or shortness of breath. On 6/24/25 10:24 A.M., an interview and record review of Resident 23's CDR and MAR for oxycodone oral solution was conducted with Licensed Nurse (LN) 15 at Medication Cart South. LN 15 verified that Resident 23's MAR was missing entries on: 1/24/25 at 7:00 P.M. 6/14/25 at 6:08 P.M. 6/22/25 at 12:43 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 22 of 46 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 06/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm LN 15 also verified that there was a dose discrepancy when Resident 23's MAR indicated administration of oxycodone 0.25 ml at 9:30 P.M. while the CDR indicated administration of 0.5 ml on 2/16/25 at 10:00 P.M. 1b. A review of Resident 45's admission record indicated the resident was admitted to the facility on [DATE] with diagnosis including bone cancer and multiple fractures in various parts of the body. Residents Affected - Some A review of Resident 45's physician's orders dated 5/16/25, indicated: - Oxycodone 5 mg tablet, take one tablet by mouth as needed every four hours for severe pain (7-10) On 6/23/25 at 11:52 A.M., an interview and record review of Resident 45's CDR and MAR for oxycodone tablets was conducted with LN 13. LN 13 verified that Resident 45's MAR records were missing on: 6/16/25 at 10:00 A.M. 6/16/25 at 21:00 P.M. 6/18/25 at 6:00 P.M. On 6/25/25 at 12:38 P.M., an interview with the Consultant Pharmacist (CP) from Ron's Pharmacy Service (RPS) was conducted. When asked about narcotic accountability, the CP stated nurses document on the CDR and the MAR for narcotics to prevent diversion. The CP stated her job included educating the nurses if missing documentation on the MAR was found. On 6/26/25 at 3:58 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was very important to maintain corresponding documentation between CDR and MAR especially for diversion. The DON also stated what was given to a resident should be documented under the correct medication order. A review of the facility's policy titled Administering Medications approved March 2025, indicated, .4. Medications are administered in accordance with prescriber orders A review of the facility's policy titled Controlled Substances approved March 2025, indicated, .Dispensing and Reconciling Controlled Substances .2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: .a. Records of personnel access and usage .b. Medication administration records 2. On 6/23/25 at 11:04 A.M., a concurrent review of the medication cart South and interview with LN 13 was conducted with LN 13. In the top right drawer of the cart, three amber vials from outside pharmacies (the facility is contracted with Ron's Pharmacy Services) with medications and resident names were found: - One vial of Senna (a medication for constipation) 8.6 mg tablet labeled for Resident 255 - One vial of bisacodyl (a medication for constipation) 10 mg suppository labeled for Resident 255 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 23 of 46 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 06/26/2025 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 0755 - One vial of melatonin (a supplement) 5 mg tablets labeled for Resident 306 Level of Harm - Minimal harm or potential for actual harm When LN 13 was asked about the three amber medication vials found in the medication cart drawer, LN 13 stated he did not recognize where the vials came from or why the vials were in the cart, therefore he would not administer them. LN 13 stated he would not accept any outside medications because he would not know what they might be. LN 13 stated that outside medications would have to be sealed if they were to be administered to the residents. Residents Affected - Some On 6/24/25 at 11:26 A.M., an interview with LN 15 was conducted. LN 15 stated that medications brought from outside of the facility were not allowed to be administered unless they came directly from a hospice pharmacy. LN 15 stated outside medications were returned to the resident or to their responsible party at the time of discharge from the facility. When LN 15 was asked about the medications in the amber vials found in the medication cart South, LN 15 stated they should have been taken out of the cart and kept in the medication storage room. On 6/24/25 at 4:11 P.M., a concurrent review of the medication cart North and interview with LN 16 was conducted. In the top right drawer of the cart, three amber vials from outside pharmacies with medications and resident names were found: - One vial of Senna 8.6mg tablet labeled for Resident 255 - One vial of bisacodyl 10 mg suppository labeled for Resident 255 - One vial of Nitroglycerin (generic for Nitrostat, a medication for chest pain) 0.4 mg SL (sublingual, under the tongue) labeled for Resident 9 LN 16 stated he did not know anything about the vials or where they came from. On 6/25/25 at 9:50 A.M., an interview with the DON was conducted. The DON stated outside medications were supposed to be given back to patient's family, but it was acceptable to store them in the medication cart with the facility's medications stating, where am I supposed to store them? On 6/25/25 at 12:23 P.M., an interview with CP was conducted. The CP stated if a non-controlled medication was brought from outside and the medication was necessary for the resident's medical treatment, the facility was allowed to administer the medication. The CP stated the procedure was for the nurse to verify the medication and confirm physician order. The CP stated she did not verify the contents of outside medications. A review of physician orders confirmed all medications in the amber vials found in the medication cart South and North had active orders: - senna 8.6 mg tablet, take one tablet by mouth as needed every 12 hours - labeled for Resident 255 (ordered 6/17/25) - bisacodyl 10 mg suppository, 1 rectal - labeled for Resident 255 (ordered 6/16/25) - melatonin 5 mg tablet, 1 tab Oral - labeled for Resident 306 (ordered 5/29/25) - Nitrostat 0.4 mg sublingual tablet, 1 tab Sublingual - labeled for Resident 9 (ordered 12/5/24) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 24 of 46 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 06/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/26/25 at 9:24 A.M., an interview with the DON was conducted. When the DON was asked about the facility's outside medication verification protocol, the DON stated outside medications in sealed bottles were acceptable to administer. When presented with the photos of the outside medications found in the medication cart South and North, the DON stated the outside medications should not be in the carts. When the DON was asked how to find the proof of verification if an outside medication was verified by a licensed pharmacist, the DON stated the MAR contained the information. The DON stated that nurses could verify medications with their phones, but the contents of the outside/home med containers should be verified by the pharmacist. On 6/26/25 at 3:00 P.M., a concurrent interview and record review with Medical Records Director (MRD), Minimum Data Set Coordinator (MDSC), and EMR (Electtronic Medical Record) 1 was conducted. MRD, MDSC, and EMR 1 confirmed there were no records that a licensed pharmacist verified the contents of outside medications found in the medication carts South and North for Resident 9, Resident 255, and Resident 306. On 6/26/25 at 4:31 P.M., an interview with the DON was conducted. The DON acknowledged the outside medications should not have been stored in the medication carts. The DON acknowledged if outside medications were to be administered at the facility, they must go through pharmacy verification. The DON stated that she did not have proof of pharmacy verifications for the outside medications found in the medication cart South and North. A review of the facility's policy titled Medications Brought to the Facility by the Resident/Family approved March 2025, indicated, .3 the director of nursing services and nursing staff .shall check to ensure that .c. the contents of each container are labeled in accordance with established policies .d. the contents of each container have been verified by a licensed pharmacist .4. Non-prescription medications in sealed containers and/or medications received directly from a transferring facility may be administered without further verification, if approved for uses as stated above A review of the facility's policy titled V. HANDLING MEDS admitted WITH RESIDENTS revised 10/2018, indicated, A. MEDS TO BE VERIFIED .However, all meds admitted with resident's where medication(s) were brought in directly from HOME or RESIDENTIAL/ASSISTED LIVING CARE FACILITIES (unless in an original pharmacy/manufacturer sealed container) must be sent to RPS for verification or be verified by the attending physician prior to using .3. Medication sent for verification will be returned with a sticker showing that the med has or has not been verified 3. On 6/23/25 at 8:40 A.M., an observation of the facility's medication storage room with LN 12 was conducted. A medication storage temperature log titled MED ROOM TEMPERATURE LOG dated June 2025 was located on the wall. A medication refrigerator temperature log titled MED FRIDGE TEMPERATURE LOG dated June 2025 was located on the door of the refrigerator. The June 2025 temperature logs were missing entries for the following dates and shifts: AM shift on 6/16/25 (refrigerator log) PM shift 6/15/24 (both logs) PM shift 6/17/25 (both logs) On 6/24/25 at 11:26 A.M., an observation and interview with LN15 was conducted in the medication storage room. The missing entries in the June 2025 temperature logs were noted to be filled in. LN 15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 25 of 46 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 06/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete stated the temperatures in the medication storage and its refrigerator were entered by charge nurse or medication nurse once each shift, twice a day. When informed that the blanks of both June 2025 room temperature log and refrigerator logs were found to be backfilled, LN 15 stated they were not supposed to. On 6/26/25 at 4:22 P.M., an interview with the DON was conducted. The DON stated the expectation was for the temperature logs of both the medication storage room and the medication refrigerator to be complete, to keep the consistency of the medications. The DON was informed that June 2025 medication room and medication fridge temperature logs were missing entries on 6/23/25 but were found filled in on 6/24/25. The DON stated backfilling the temperature logs were not acceptable. Event ID: Facility ID: 555144 If continuation sheet Page 26 of 46 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 06/26/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond to the consultant pharmacist's monthly medication regimen review (MRR) recommendations for two of five sampled residents (Residents 17 and 28). This failure had the potential for unaddressed medication irregularities and inadequately monitored medications. Findings: 1. A review of Resident 17's admission record indicated the resident was admitted on [DATE] with diagnoses including major depressive disorder (also known as depression), dementia (memory loss that gets worse over time) with behavioral disturbances, and anxiety disorder. Resident 17 had physician's orders for the following medications: - Mirtazapine (generic for Remeron, a medication to treat depression) 15 milligrams (mg) by mouth daily at bedtime for major depressive disorder, dated 10/30/24; - Effexor XR (brand name for venlafaxine, a medication to treat depression) 75 mg by mouth every morning for major depressive disorder, dated 10/30/24; - Lorazepam (generic for Ativan, a medication to treat anxiety) 1 mg by mouth every two hours as needed for anxiety, restlessness, difficulty to redirect, dated 1/27/25 and discontinued on 6/18/25; and - Seroquel (brand name for quetiapine, an antipsychotic medication to treat mental illness) 25 mg by mouth daily at bedtime for agitation, anxiety, dementia, and behavioral disturbance, dated 2/1/25. A review of the February 2025 MRR, dated 2/17/25, indicated Resident 17's medication regimen was reviewed by the consultant pharmacist (CP). Resident 17's name was not indicated on the form Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendation. There was no documentation provided for Resident 17's recommendations from the CP in February 2025. During a concurrent interview and record review on 6/26/25 at 3:36 P.M. with the Minimum Data Set Coordinator (MDSC), the March 2025 MRR, dated 3/11/25, was reviewed. The MRR included one recommendation for Resident 17's Seroquel and a separate recommendation for Resident 17's lorazepam. The response portion of both forms was blank. Resident 17's Clinical Notes Report, dated 3/27/25, was also reviewed. The note indicated .agreed with the pharmacy recommendation .for Seroquel .& Lorazepam .Requested for orders to be sent. MDSC stated the records indicated the prescriber agreed with the MRR recommendations for updated orders. MDSC further stated the note indicated the facility requested updated orders on 3/27/25 and never received a response. See F605 for additional information regarding Resident 17's Seroquel and lorazepam. A review of the April 2025 MRR, dated 4/20/25, indicated Resident 17's medication regimen was reviewed by the CP. The MRR included one recommendation for Resident 17's mirtazapine and venlafaxine, which indicated, The resident is currently receiving the following psychotropic medication [drug that affects brain activities associated with mental processes and behavior]. Please assess orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 27 of 46 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 06/26/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm semi-annual assessment .If appropriate, please consider a GDR [gradual dose reduction, stepwise tapering of a medication to determine if symptoms can be managed at a lower dose] at this time. If not appropriate, please document rationale for contraindication. The response portion of the form was blank. Resident 17's Clinical Notes Report, dated 4/21/25, was also reviewed. The note indicated, Pharmacy recommendation sent via fax .Awaiting on a response. Residents Affected - Some A review of the May 2025 MRR, dated 5/14/25, indicated Resident 17's medication regimen was reviewed by the CP. The MRR included one recommendation for Resident 17's medications, which indicated, The coadministration [of the medications] may cause dizziness and drowsiness and may increase the fall risk .if the current orders are required to maintain this resident's clinical status, please document the risks v. [versus] benefits below and/or in a progress note. The prescriber response portion of the form was blank. Resident 17's Clinical Notes Report, dated 5/19/25, was also reviewed. The note indicated, Sent pharmacy recommendation via fax .Awaiting on a response. 2. A review of Resident 28's admission record indicated the resident was admitted on [DATE] with diagnoses including vascular dementia (a type of dementia) with psychotic disturbances. Resident 28 had a physician's order, dated 3/28/25, for Risperdal (brand name for risperidone, an antipsychotic medication to treat mental illness) 0.5 mg by mouth two times daily for Vascular dementia with psychotics [sic] features. A review of the April 2025 MRR, dated 4/20/25, indicated Resident 28's medication regimen was reviewed by the CP. The MRR included one recommendation for Resident 28's risperidone, which indicated, Resident has an order for Risperidone .Have good documentation as to why the resident requires an antipsychotic. Is the medication helping? Is the resident tolerating the medication OK without side effects? The prescriber response portion of the form was blank. The MRR included a second recommendation for Resident 28's medications, which indicated Resident 28 was taking multiple medications linked with increased falls and Please monitor resident closely and discuss with the doctor if any adjustments to the medication are necessary. The Follow-Through portion of the form was blank. Resident 28's Clinical Notes Report, dated 4/21/25, was also reviewed. The note indicated, Pharmacy recommendation sent via fax .Awaiting on a response. See F756 for additional information regarding Resident 28's risperidone. A review of the May 2025 MRR, dated 5/14/25, indicated Resident 28's medication regimen was reviewed by the CP. The MRR included one recommendation for Resident 28, which indicated If clinically appropriate, please consider the following lab work . The prescriber response portion of the form was blank. Resident 28's Clinical Notes Report, dated 5/19/25, was also reviewed. The note indicated, Sent pharmacy recommendation via fax .Awaiting on a response. During an interview on 6/26/25 at 3:00 P.M., MDSC stated the facility provided copies of all available MRR and related documents, including CP recommendations. MDSC further stated no documented response indicated the facility never received a response from a provider to the CP recommendations. During an interview on 6/26/25 at 3:00 P.M., the Director of Nursing (DON) stated the MRR process was for CP to complete a monthly MRR and send recommendations to the facility. The DON stated the facility followed up and implemented CP recommendations when approved by the physician. The DON stated the expectation was that the physician responded to the non-urgent recommendations within 30 days per policy. The DON further stated she expected the pharmacy to follow up if no response was received. The DON stated the facility needed to follow their policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 28 of 46 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 06/26/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policies and procedures (P&P) titled, Pharmacy Medication Regimen Review, revised October 2018, indicated, The consultant pharmacist documents in a separate written report any found irregularities. Reports must be sent to the attending physician, medical director, and director of nursing . and Residents Affected - Some .if an irregularity does not require urgent action, attending physician is to be contacted by nursing using the provided recommendation forms. Nursing will undertake the appropriate follow-up, then date, initial, and indicate action taken . and .a response must be noted within 30 days with rationale documented in the resident's medical record .For those recommendations with no response within 30 days of when the recommendation was printed, facility should notify the medical director for appropriate action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 29 of 46 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 06/26/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four sampled residents (Residents 50, 32, 13, and 3) were free of unnecessary medications when: Residents Affected - Some 1. Residents 50, 13, and 3 received anticoagulant (blood thinner) medications without staff monitoring for signs and symptoms of side effects; and 2. Resident 32 received an inappropriate dose of insulin and was not monitored for hypoglycemic (low blood sugar) side effects. These deficiencies had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising, and hypoglycemic side effects, including hunger, profuse sweating and tremors. Findings: 1a. A review of Resident 50's admission record indicated the resident was admitted on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infarction (a type of stroke). Resident 50 had a physician's order, dated 6/12/25, for enoxaparin (generic for Lovenox, an anticoagulant) 40 milligrams (mg) injected under the skin every morning for deep vein thrombosis (DVT, life-threatening blood clots in the legs) prevention. During a concurrent interview and record review on 6/25/25 at 11:03 A.M. with Licensed Nurse 1 (LN 1), Resident 50's electronic medical record was reviewed. LN 1 stated the anticoagulant medication orders usually included side effect precautions and stated this was not included in Resident 50's orders. LN 1 stated she did not see any documentation of routine monitoring for bleeding or enoxaparin side effects in Resident 50's record. LN 1 further stated bleeding and bruising were common side effects of blood thinners. See F656 for additional information regarding Resident 50's anticoagulant. During a concurrent interview and record review on 6/26/25 at 11:28 A.M. with Electronic Medical Record Trainer 1 (EMR 1), Resident 50's electronic medical record was reviewed. EMR 1 stated Resident 50's medical record did not have monitoring for bleeding or anticoagulant adverse effects. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for enoxaparin injection, dated 5/26/25, retrieved from DailyMed, indicated, .Increased Risk of Hemorrhage [bleeding] . Major hemorrhages .have been reported. Some of these cases have been fatal .Bleeding can occur at any site during therapy with enoxaparin . A review of the facility's policies and procedures (P&P) titled, Adverse Consequences and Medication Errors, reviewed February 2025, indicated, Residents receiving medication are monitored for adverse consequences. 1b. A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE] following surgery on the digestive system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 30 of 46 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 06/26/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm A review of Resident 13's physician's order dated 9/13/24, indicated Eliquis (a medication used to thin the blood) 5 mg (milligrams) one tablet daily. A review of Resident 13's care plan indicated at risk for active bleeding and had interventions to observe for signs and symptoms of bleeding. Residents Affected - Some On 6/25/25 at 11:11 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 13's care plans. LN 1 stated Resident 13 needed to be assessed for bruising and active bleeding due to blood thinner use. LN 1 reviewed Resident 13's clinical record and stated there was no documentation Resident 13 was monitored for bleeding. On 6/26/25 at 12:55 P.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed the care plan for risk of active bleeding for Resident 13 and stated nursing would monitor bleeding, nose bleeds and bruising for a resident on an Eliquis. LN 2 reviewed Resident 13's clinical record and stated there was no documentation Resident 13 was monitored for bleeding. 1c. A review of Resident 3's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of pulmonary embolism (a blood clot travels from another part of the body to the lungs and blocks one or more pulmonary arteries). A review of Resident 3's physician's order dated 5/30/25 indicated Eliquis 5 mg one tablet daily. A review of Resident 3's care plan indicated Resident 3 was at risk for active bleeding. Interventions included: observe the resident for bleeding. On 6/26/25 at 12:55 P.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed Resident 3's clinical record and stated there was no documentation Resident 3 was monitored for bleeding. On 6/26/25 at 3:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON reviewed Resident 3 and 13's care plans for risk of active bleeding and stated nursing should have followed the care plans and should have observed for adverse effects of anticoagulant use, such as bleeding and bruising. The DON stated there was no documentation of monitoring or assessments for adverse effects. The DON stated her expectation was that there would be documentation of the LN assessments of adverse effects for anticoagulants. A review of the facility policy titled, Anticoagulation-Clinical Protocol, revised 11/2018, indicated, .a. Assess for any signs and symptoms related to adverse drug reactions 2. A review of Resident 32's Face Sheet indicated the resident was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). On 6/26/25 at 10:20 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 2. LN 2 reviewed Resident 32's physician's order dated 4/7/25 for Glargine 100 unit/ml 6 U (units) to be given SQ (the layer of fat and connective tissue located just beneath the skin). The order indicated to check BS (blood sugar) before administering insulin and if BS = < (equal to or less than) 120 hold insulin Glargine for that day. A review of the Medication Administration Record (MAR) dated 6/1/25 had a BS documented of 118 and 6 units of Glargine insulin was administered to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 31 of 46 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 06/26/2025 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 0757 Level of Harm - Minimal harm or potential for actual harm Resident 32. LN 2 stated this is incorrect and Resident 32 should not have received insulin. LN 2 reviewed Resident 32's care plan for glycemia (the presence of glucose in the blood). Interventions were to observe for signs and symptoms of hypoglycemic (low blood sugar) reactions listed as: hunger, profuse sweating, tremor. LN 2 stated there was no documentation Resident 32 was assessed for hypoglycemia in the clinical record. Residents Affected - Some On 6/26/24 at 3:50 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 32's MAR. The DON stated the physician's order to hold Glargine insulin if the BS = < 120 should have been followed. The DON stated Resident 32 should not have received 6 U of Glargine insulin because his BS was documented as 118. The DON reviewed Resident 32's care plan and stated nursing should have observed for signs and symptoms of hypoglycemia. The DON stated there was no documentation of nursing assessments for hypoglycemia. The DON stated her expectation was that there would be documentation of assessments for hypoglycemia. A review of facility's provided document titled, Older adults: Standards of Medical Care in Diabetes-2020, indicated, .To achieve between glycemic control and risk for hypogylcemia, it is important to carefully assess and reassess patients' risk for worsening of glycemic control and functional decline A review of the facility's policies and procedures (P&P) titled, Adverse Consequences and Medication Errors, reviewed February 2025, indicated, Residents receiving medication are monitored for adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 32 of 46 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 06/26/2025 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 4 of 37 administered medications were given in accordance with the physician orders and manufacturer's instructions for two of six residents (Resident 33 and 50). Residents Affected - Few This failure resulted in a 10.81% medication error rate and the potential to affect resident safety and medication effectiveness. Findings: 1. On 6/23/25 at 10:37 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 13. LN 13 prepared, dispensed, and administered 10 medications for Resident 33, including one tablet of cranberry (a supplement) 450 milligrams (mg), one capsule of potassium chloride (a medication to treat low potassium levels) 10 milliequivalents (mEq, a unit of measurement), and one drop of Refresh Classic (to treat dry eyes)1.4 - 0.6 % into each eye. A review of Resident 33's physician order was conducted. The record indicated LN 13 did not follow physician's orders during Resident 33's medication administration observation for the listed medications: - Cranberry 450mg tablet, take two tablets by mouth every morning, dated 11/15/24 (one tablet was given) - Potassium chloride ER (extended release) 10 mEq one tablet every morning, dated 12/3/24 (a capsule was given instead of a tablet) - Refresh Tears (to treat dry eyes) 0.5% eye drops, 1 drop into Both Eyes two times daily, dated 2/10/25 (different product and strength was given) On 6/23/25 at 3:13 P.M., a joint interview and record review was conducted with LN 13. LN 13 confirmed physician orders for cranberry, potassium, and Refresh Tears were not followed. LN 13 acknowledged that only one tablet of cranberry was given. LN 13 acknowledged that the potassium bubble packs contained capsules, not tablets as ordered. LN 13 acknowledged that the strength of Refresh Tears was not 0.5% as ordered. On 6/25/25 at 2:24 P.M., an interview with the Consultant Pharmacist (CP) was conducted. Regarding the potassium capsules, CP stated if the order was for tablet and pharmacy could only dispense capsules, the facility needed to update the order from tablets to capsules before administering the medication. Regarding the Refresh Tears, CP stated the ordered product and the strength needed to match what was given to Resident 33. A review of the facility's policy titled XI. MEDICATION LABELING & PROPER STORAGE revised 10/2018, indicated, .D. HANDLING LABEL CHANGES .It is essential that medication labels agree with current orders A review of the facility's policy titled Administering Medications approved March 2025, indicated, .4. Medications are administered in accordance with prescriber (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 33 of 46 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 06/26/2025 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 orders Level of Harm - Minimal harm or potential for actual harm 2. On 6/25/25 at 9:05 A.M., a medication administration observation was conducted with LN18. LN 1 prepared, dispensed, and administered 8 medications with water for Resident 50, including a packet of pantoprazole (a medication used to reduce the amount of acid produced in the stomach) granules (small particles). LN 1 dissolved the pantoprazole granules with small amount of water and administered the medication to Resident 50 through the G-tube (a feeding tube inserted through the abdominal wall directly into the stomach). Residents Affected - Few The record indicated Resident 50 had physician's orders, dated 6/21/25, for the following medication: - Pantoprazole DR (delayed release) 40mg granules for suspension in packet, G-tube two times daily, dated 6/21/25 A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Pantoprazole delayed release oral suspension (granules), dated 4/1/25, retrieved from DailyMed, indicated.suspension in apple juice or applesauce only . on 6/25/25 at 02:24 P.M., an interview with CP was conducted. CP stated Protonix granules are supposed to be given with apple sauce or apple juice, it cannot be given with water for G tube or oral administration. On 6/26/25 at 4:22 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated following physician's orders and manufacturer's instructions were important and expected. The DON acknowledged the medication errors. A review of the facility's policy titled Adverse Consequences and Medication Errors approved March 2025, indicated, .2. Examples of medications errors include .c. Wrong dose .e. Wrong dosage form (e.g., liquid ordered, capsule given) .h. Failure to follow manufacturer's instructions FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 34 of 46 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 06/26/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications/biologicals were labeled and stored according to acceptable standards of practice when: 1. Medication and medication Vials were stored opened and undated. 2. There were expired vials and medications stored in medication carts and the medication storage room. 3. Medications in the medication room and medication refrigerator were not stored in the acceptable range of temperatures. 4. An unauthorized facility staff had access to the medications in the medication room. These failures had the potential for medications to be ineffective and potentially harmful to residents. In addition, the medications were not stored securely from unauthorized access. Findings: 1. On 6/23/25 at 8:41 A.M., a concurrent observation of the medication storage room and interview with Licensed Nurse (LN) 12 was conducted. The refrigerator in the room was observed. The refrigerator contained one open vial of tuberculin, purified protein derivative (TB PPD, a substance used in a skin test to help diagnose tuberculosis infection), 5 units per 0.1 mL (milliliters) without opened date written. In the overhead cabinet of the medication room, one undated, open Polyethylene Glycol 3350 bottle was observed. LN 12 verified that the opened medications should have been dated. On 6/23/25 at 10:37 A.M., a concurrent observation of the medication cart South and interview with LN 13 was conducted. A heparin sodium injection (a blood thinner), 50,000 units per 10mL vial without opened date was found in the top right drawer of the cart. When LN 13 observed the undated vial of heparin, he stated the vial should have been labeled with their opened date. A review of the facility's policy titled XI. MEDICATION LABELING & PROPER STORAGE revised 10/2018, indicated, .A. All injectable medications must be dated when first opened/punctured A review of the facility's policy titled Medication Labeling and Storage approved March 2025, indicated, .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial A review of the facility's policy titled Administering Medications approved March 2025, indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container 2a. On 6/23/25 at 8:41 A.M., a concurrent observation of the medication storage room and interview with Licensed Nurse (LN) 12 was conducted. The medication room had one refrigerator. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 35 of 46 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 06/26/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refrigerator contained one expired open vial of TB PPD, 5 units/0.1 mL with opened date written as 5/22. After reading the manufacturer's instruction on the package, LN 12 acknowledged the TB PPD vial should not be used. A record review of the instructions on the TB PPD 5 units/0.1 mL package undated, indicated, Once entered, vial should be discarded after 30 days. A review of the facility's policy titled I. INJECTABLE MEDICATIONS revised 10/2018, indicated, .B.2) Tuburculin PPD .opened and in use for 1 month should be discarded because oxidation and degradation may have reduced the potency A review of the facility's policy titled Medication Labeling and Storage approved March 2025, indicated, .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacture specifies a shorter or longer date for the open vial 2b. On 6/23/25 at 09:56 A.M., a concurrent observation of the medication storage room and interview with LN 12 was conducted. When presented with an expired Fleet Saline enema (a type of enema used to relieve occasional constipation) (expired 11/2022), LN 12 verified it was expired. 2c. On 6/24/25 at 4:29 P.M., a concurrent observation of the treatment cart North and interview with LN 15 was conducted. In the treatment cart, expired skin treatment medications were found: - One opened and without cap Medihoney Skintegrity Hydrogel (a sterile, water-based gel dressing, promote healing in wounds) black bottle (expired July 2021) - One opened and without cap Terbinafine (treats various fungal infections of the skin) 1% cream (expired [DATE]) When LN 15 was presented with the expired medications, LN 15 stated they should not be reused. On 6/25/25 at 10:06 A.M., an interview with Medical Record Director (MRD) was conducted. The MRD stated she could not find a policy regarding expired treatment supplies. A review of the facility's policy titled Medication Labelling and Storage approved March 2025, indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items 3a. On 6/24/25 at 11:26 A.M., a joint observation, interview, and record review with LN15 was conducted in the medication storage room. LN 15 stated the charge nurse or medication nurse entered the medication storage room and its refrigerator temperatures once each shift, twice a day. LN 15 stated the medication refrigerator temperature should be between 36 &deg;and 46 &deg;F and the numbers were written on the temperature log. When LN 15 was presented with the following logged temperatures that were below 36 &deg;, LN 15 stated the low temperatures could have affected the medications. 6/7/25 at 7:30 P.M. 31 &deg;F 6/9/25 at 9:06 A.M. 34 &deg;F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 36 of 46 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 06/26/2025 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 0761 6/1/25 at 7:30 P.M. 31 &deg;F Level of Harm - Minimal harm or potential for actual harm 6/18/25 at 8:00 A.M. 32 &deg;F 6/19/25 at 8:00 A.M. 32 &deg;F Residents Affected - Some Reviewing the contents of the refrigerator, LN 15 verified that the medications listed below should have not been kept below 36 &deg; F. - Five vials of TB PPD, 5 units/0.1 mL - Two Mounjaro pens (brand name for tirzepatide, a prefilled injection pen to improve blood sugar control) - Six Lantus Solostar pens (a brand name for insulin glargine, a prefilled insulin injection pen to manage high blood sugar) - One insulin degludec flex (a prefilled insulin injection pen to manage high blood sugar) - One box of Trulicity (a medication that helps regulate blood sugar)1.5mg/0.5ml A review of the manufacturer instructions on the package of TB PPD, 5 units/0.1 mL undated, indicated, Store between 2 &deg;and 8 ? (36 &deg; and 46 &deg;F). DO NOT FREEZE A review of the facility's policy titled I. INJECTABLE MEDICATIONS revised 10/2018, indicated, .B 2) Tuburculin PPD .should be stored between 2 &deg;and 8 ? (36 &deg; and 46 &deg;F). Do not freeze. Discard product if exposed to freezing A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Mounjaro pen dated 6/19/25, retrieved from DailyMed, indicated: .Store MOUNJARO in a refrigerator at 2&deg; to 8&deg; Celsius (C) (36&deg;F to 46&deg;F) . Do not freeze MOUNJARO. Do not use MOUNJARO if frozen A review of the PI for Lantus Solostar pen, dated 11/27/23, retrieved from DailyMed, indicated: .Store unused LANTUS in a refrigerator between 36&deg;F and 46&deg;F (2&deg;C and 8&deg;C). Do not freeze. Discard LANTUS if it has been frozen A review of the PI for insulin degludec flex, dated 7/1/22, retrieved from DailyMed, indicated: .Store unused Insulin Degludec in a refrigerator (36&ordm;F to 46&ordm;F [2&ordm;C to 8&ordm;C]). Do not store in the freezer or directly adjacent to the refrigerator cooling element. Do not freeze. Do not use Insulin Degludec if it has been frozen A review of the PI for Trulicity 1.5mg/0.5ml pen (a prefilled injection pen to improve blood sugar control), dated 6/13/25, retrieved from DailyMed, indicated: .Store your Pen in the refrigerator between 36&deg;F to 46&deg;F (2&deg;C to 8&deg;C) .Do not freeze your Pen. If the Pen has been frozen, throw the Pen away and use a new Pen 3b.1. On 6/24/25 at 11:26 A.M., a joint observation, interview, and record review with LN15 was conducted in the medication storage room. In the overhead cabinet, medications that require to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 37 of 46 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 06/26/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stored between the temperatures of 68 &deg; to 77 &deg; F were found. When reviewing the June 2025 medication room temperature log, LN 15 verified that most of the entries were above 77 &deg; F, which was out of acceptable storage temperature range for the medications below: - one box Prilosec (brand name for omeprazole, treats excessive stomach acid) OTC (over the counter) 20 mg tablets - two bottles of omeprazole 20mg capsules - four boxes of omeprazole 20mg capsules - one opened box loperamide (relieves the symptoms of diarrhea) 2mg tablets define - one box of fexofenadine (treats allergy symptoms) 180mg tablets define A review of the June 2025 medication room temperature log indicated 32 out of 46 entries were greater than 77 &deg;F. A review of the PI for Prilosec OTC and omeprazole, dated 10/10/24, retrieved from DailyMed, indicated: .store at 20-25&deg;C (68-77&deg;F) A review of the PI for loperamide tablets, dated 1/22/25, retrieved from DailyMed, indicated: .store at 20-25&deg;C (68-77&deg;F) A review of the PI for fexofenadine tablets, dated 4/30/19, retrieved from DailyMed, indicated: .store between 20&deg; and 25&deg;C (68&deg; and 77&deg;F) On 6/25/25 at 9:36 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that if the refrigerator temperature was out of acceptable range the nurses were supposed to adjust the temperature. On 6/25/25 at 12:24 P.M., an interview was conducted with the Consultant Pharmacist (CP). Regarding the medication storage temperature, CP stated the facility should follow manufacturer instructions. 3b.2. On 6/23/25 at 8:41 A.M., a joint observation, interview, and record review was conducted with LN 12 in the medication storage room. Six vitamin B12 (a medication to treat vitamin B12 deficiency) vials were found in the refrigerator. A review of the PI for vitamin B12, dated 11/2/22, retrieved from DailyMed, indicated: .Store at 20-25&deg;C (68-77&deg;F) LN 12 stated the medications should not be used because they should not have been refrigerated. A review of the facility's policy titled K. TEMPERATURE OF MEDICATIONS revised 10/2018, indicated, .Drugs shall be stored in appropriate temperatures .B. 1) Drugs requiring refrigeration shall be stored in a refrigerator between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) 4. On 6/23/25 at 8:35 A.M., 6/23/25 at 8:40 A.M., and on 6/26/35 at 8:41 A.M., a Certified Nursing Assistant (CNA) 11 was observed to unlock the door to the facility's mediation storage room using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 38 of 46 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 06/26/2025 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 0761 the passcode. Level of Harm - Minimal harm or potential for actual harm On 6/24/25 at 11:26 A.M., an interview was conducted with LN15. When LN 15 was asked if a CNA should have access to the medication storage, LN 15 stated CNA should not, and verified that CNA 11 was not a LN. LN 15 stated only LNs have access to the room. Residents Affected - Some On 6/26/25 at 9:14 A.M., an interview was conducted with LN 15. LN 15 acknowledged that CNA 11 unlocked the medication storage room door. LN 15 stated only LN should have access to the medication room and CNA 11 was not a LN. On 6/26/25 at 9:16 A.M., an interview was conducted with the DON. The DON stated CNA 11 was allowed access to the room to help stock OTCs with a charge nurse. When the DON was informed that CNA 11 used the pass code to open the medication storage room, the DON stated CNA 11 was not an LN and should not have had the code to the medication room because only licensed nurses, meaning RN and LVN, have access to med room and med cart. A review of the facility's policy titled F. ACCESS TO MEDICATIONS revised 10/2018, indicated, .Only authorized staff at a facility may have access to any medication storage areas. Authorized staff shall keep keys (or not to share access code) A review of the facility's policy titled Medication Labeling and Storage approved March 2025, indicated, The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 39 of 46 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 06/26/2025 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. Based on observation, interview, and record review, the facility failed to ensure food safety in dietary services were maintained for food storage according to standards of practice when the facility did not ensure the dry food storage room and two of three refrigerator (Unit 2 and Unit 6)temperatures were monitored consistently. These failures had the potential to cause food borne illness among the residents who received food from the kitchen. Findings: During the initial kitchen tour on 6/23/25 at 7:43 A.M., an interview and observation was conducted with the Kitchen Manager (KM) and Registered Dietician (RD). The dry food storage room did not have a thermometer to measure temperature. The KM stated the dry food storage room temperature should have had a thermometer to measure the room temperature. The KM retrieved a thermometer and placed it in the dry food storage room. The KM stated temperatures in the dry food storage room should have been monitored and documented daily to ensure the quality and safety of the food. Two refrigerators (Unit 2 and Unit 6) had written temperature logs attached to each unit. Both logs were reviewed and had missing temperature entries. Refrigerator Unit 2 had missing temperature entries on 6/16,6/19,6/20,6/21,6/22/25. Refrigerator Unit 6 had missing temperature entries on 6/19/25 through 6/22/25. The RD stated the temperature of the facility's refrigerators should have been monitored daily and documented for food quality and safety. On 6/26/25 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for all foods temperatures to be monitored for the safety of the residents. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section, 4-204.112, titled Temperature Measuring Devices, .A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms A review of facility's policy titled Food Safety, revised 5/2023, indicated, .6. Accurate food thermometers are available and used by all food employees during storage, preparation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 40 of 46 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 06/26/2025 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to identify and develop an ongoing QAPI (Quality Assurance and Performance Improvement) plan related to medication storage. (Cross reference F761) Residents Affected - Few This failure had the potential for residents to receive expired medications and supplies. Findings: On 6/26/25 at 4:53 P.M., an interview was conducted with the Director of Nursing (DON), Chief Operating Officer (COO) and Minimum Data Set (MDS) Coordinator. The DON and COO stated that the QAPI committee should have identified medication storage as an ongoing project. A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, review dated 2/2025, .to provide a means to measure current and potential indicators for outcomes of care and quality of life .to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 41 of 46 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 06/26/2025 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 follow appropriate infection prevention and control practices when: Residents Affected - Some 1. A nurse did not disinfect the rubber seal (the point of connection between the needle and the body of the pen) of a multi-dose insulin pen while preparing the medication for one resident. 2. A nurse did not clean the blood pressure machine after it was used for one resident. 3. Expired and opened intravenous (IV, into the vein) access supplies and wound treatment supplies were not removed from the carts. 4a. Staff did not provide an opportunity for hand hygiene for 12 residents (Resident 44, 6, 10, 309, 7, 24, 29, 23, 16, 47, 12, 255) before eating lunch. 4b. Two staff did not wash their hands after leaving an isolation room where a Resident (308) was positive for Clostridium difficile (C-diff, a bacteria that causes infectious diarrhea). 5. Urinary catheter bags for two Residents (28 and 51) were laying on the floor. 6. Both shower rooms (north and south) and a shower chair seat cushion were unsanitary. As a result of this deficient practice, residents, staff, and visitors were placed at risk for contracting infections. Findings: 1. A review of Resident 13's admission record indicated the resident was admitted on [DATE] with diagnosis including Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control). On 6/24/25 at 12:15 P.M., an observation and interview for Licensed Nurse (LN) 14 was conducted. While preparing insulin for Resident 13, LN 14 removed the insulin pen's cover and attached a needle without disinfecting the Rubber Seal. LN 14 finished preparing the insulin dose for the resident, entered the resident room and injected the insulin into the resident's left upper arm. After returning to the medication cart, LN 14 was asked if the rubber real should have been disinfected before attaching the needle, LN 14 stated should have done that. On 6/25/25 at 8:44 A.M., an interview with Infection Preventionist (IP) was conducted. The IP agreed that the rubber seal of insulin pens needed to be disinfected before needle attachment, and stated there was a risk of infection if this process was not followed. A review of Resident 13's physician's order dated 2/3/25, indicated: Insulin lispro 100 unit/ml (units per milliliter) subcutaneous (under the skin) pen, sliding scale (adjusted based on a person's current blood sugar level) Before Meals A review of the facility's policy titled Administering Medications approved March 2025, indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 42 of 46 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 06/26/2025 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 .25. Staff follows established facility infection control procedures .for the administration of medications Level of Harm - Minimal harm or potential for actual harm A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Humalog Kwikpen, revised July 2023, indicated, Residents Affected - Some .Step 1: Pull the Pen Cap straight off. Do not remove the Pen Label. Wipe the rubber seal with an alcohol swab 2. On 6/24/25 at 8:32 A.M., observation and interview were conducted with LN 14. LN 14 was observed using a portable blood pressure machine to check blood pressure on a resident's right wrist in the dining room. LN 14 then returned to her medication cart in the hallway and placed the blood pressure machine on the cart. LN 14 continued with medication preparation without disinfecting the machine. LN 14 was observed touching the uncleaned blood pressure machine while preparing medications. On 6/24/25 at 9:10 A.M., a follow up interview with LN 14 was conducted regarding the blood pressure machine. When LN 14 was asked about leaving the blood pressure machine uncleaned for more than 30 minutes, LN 14 stated she forgot to follow the protocol after using the machine on the resident in the dining room. LN 14 stated the machine should be disinfected at the start of shift and immediately after each resident use per protocol. A record review of the facility's policy titled Cleaning and Disinfection of Resident - Care Items and Equipment approved March 2025, indicated, .5. Reusable items are cleaned and disinfected or sterilized between residents 3. On 6/23/25 at 9:58 A.M., a concurrent observation of the IV Cart in the South hallway and interview with the IP was conducted. Over 70 expired and/or opened items were found, including items such as opened sterile IV access needles and sterile central line (a tube inserted into a large vein, usually near the heart) dressing change kits. When the IP was presented with the expired supplies, she stated supposed to be discarded. On 6/23/25 at 10:26 A.M., the Director of Nursing (DON) joined the IV cart review. The DON stated the supplies in the IV cart were considered ready for use. The DON verified the observation of expired and opened items and stated the IV cart should not have opened or expired supplies. On 6/24/25 at 4:29 P.M., a concurrent observation of the treatment cart in North Unit and interview with LN 15 was conducted. The observation found 19 items including expired, opened and marked one-time use or sterile wound dressings and they were presented to LN 15. LN 15 agreed that opened dressings that were marked for single use and/or sterile should have been discarded immediately after use and should not have been kept in the treatment cart. LN 15 stated once a sterile medication seal was broken, the medication should not be used because it was not sterile anymore. On 6/25/25 at 9:36 A.M., an interview with the DON was conducted. The DON stated there should not have been expired supplies or medications in the treatment carts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 43 of 46 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 06/26/2025 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 On 6/25/25 at 10:06 A.M., an interview with Medical Record Director (MRD) was conducted. The MRD stated the facility did not have a policy regarding expired treatment supplies. 4a. On 6/23/25 at 11:45 A.M., a dining observation was conducted of 12 residents (Resident 44, 6, 10, 309, 7, 24, 29, 23, 16, 47, 12, 255) waiting for lunch. Two staff were present and did not offer the residents an opportunity to perform hand hygiene. Meal trays were observed being passed out to the residents. Resident 6 was observed eating finger foods and inserted his fingers into his mouth. Resident 24 stated no hand hygiene was offered to her prior to receiving her meal tray and then she looked at her hands and stated they look clean. Resident 309 stated she was not offered hand hygiene. On 6/25/25 at 8 A.M., an interview was conducted with Restorative Nurse Assistant (RNA). RNA stated residents should have been offered hand hygiene before meals to the prevent spread of infections. 4b. A record review of Resident 308's Face Sheet indicated admission date of 6/20/25 with a diagnosis of C-diff . A review of Resident 308's Physician Order Sheet dated 6/20/25, indicated, Contact Isolation Precaution, notes C-diff. On 6/23/25 at 3:22 P.M., an observation was conducted outside of Resident 308's room. Licensed Nurse (LN) 12 exited Resident 308's room and used hand sanitizer that had a sign posted on the hand sanitizer Do Not Use This Sanitizer. LN 12 then walked to nurses' station and started using the computer. On 6/23/25 at 3:44 P.M., an interview was conducted with LN12 who stated she was from a registry (temporary nursing staff). LN 12 stated Resident 308 was on contact isolation for positive C-diff. LN 12 stated the sign on the hand sanitizer was so staff were aware to wash their hands with soap and water to get rid of the C-diff. LN 12 stated she should have washed her hands with soap and water after exiting the room. On 6/23/25 at 3:52 P.M., an observation was conducted outside Resident 308's room. A therapy staff (TS) exited Resident 308's room and used the hand sanitizer with sign do not use this sanitizer and then walked down hall and embraced another staff member with a hug. On 6/23/25 at 3:58 P.M., an interview was conducted with the TS. The TS stated Resident 308 was on contact isolation for C-diff. The TS stated technically, I should have washed my hands with soap and water. The TS did not know why washing her hand after C-diff contact was important. On 6/26/25 at 7:45 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated it was her expectation for residents to be offered hand hygiene before meals to prevent spread of infections. The IP stated all staff should have washed their hands with soap and water when leaving Resident 308's contact isolation room because hand sanitizer does not kill C-diff spores. On 6/26/25 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was for residents to be offered hand hygiene before meals. The DON stated staff should always wash their hands with soap and water after caring for a resident with C-diff. A review of facility's policy titled Handwashing/Hand Hygiene dated 3/2025, indicated, 7. Use an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 44 of 46 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 06/26/2025 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 alcohol-based hand rub . or alternatively, soap and water for the following situations . o. before or after eating or handling food A review of facility's policy titled Clostridium Difficile dated 3/2025, indicated .14. When caring for residents with CDI [Clostridium Difficile Infection], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR [alcohol-based hand rub] for the mechanical removal of C. difficile spores from hands 5. A review of Resident 28's Face Sheet, indicated the resident was admitted to the facility on [DATE] with obstructive and reflux uropathy (abnormality of urinary tract), and benign prostatic hyperplasia (enlargement of prostate). A review of Resident 28's physician orders, dated 8/26/24, indicated an order for a urinary catheter. On 6/23/25 at 9:37 A.M., and 10:12 A.M., observations were made of Resident 28 in his room. Resident 28 was lying in bed, and his urinary catheter bag was on the floor. Resident 28's urinary catheter bag was filled with 600 milliliters (ml) of amber colored urine and urine was backing up into the tubing. A review of Resident 40's Face Sheet, indicated the resident was admitted to the facility on [DATE] with a diagnosis of benign prostatic hyperplasia. A review of Resident 40's physician orders, dated 5/26/25, indicated an order for a urinary catheter. On 6/23/25 at 9:50 A.M., and 10:23 A.M., observations were made of Resident 40 in his room. Resident 40's urinary catheter bag was observed on the floor while the resident was sitting up in bed. On 6/26/25 at 8:41 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 28's and Resident 40's urinary catheter bags should not have been on the floor because the urine could back up into the tubing and contribute to infection. On 6/26/25 at 3:13 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 28's and Resident 40's urinary catheter bags should not have been on the floor and could have caused the residents to develop an infection. 6. On 6/23/25 at 10:35 A.M., A resident was observed exiting the north shower room, having just received a shower. An observation was made of the inside of the north shower room. There was a black spotted substance on the caulking on the floor, on the grout in between tiles, and on the leg of the shower chair. A brown substance was smeared on a white shower curtain. An observation was made of the south shower room. There was a black substance on the caulking on the floor. There was a black substance underneath an orange-colored shower chair cushion. There was worn tape with a black substance on the seat of the shower chair. Photographs were taken of these observations. On 6/23/25 at 10:58 A.M., a joint observation, interview, and photograph review was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 observed the south shower room and stated the shower chairs are disinfected and ready for resident use. CNA 3 observed the orange-colored shower chair seat cushion and stated it was ripped open underneath. CNA 3 stated that the seat cushion was not clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 45 of 46 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 06/26/2025 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 and there appears to be mold growing underneath. CNA 3 stated that if she was a resident she would not want to use it. CNA 3 stated the CNAs and LNs are responsible for cleaning and inspecting the shower chairs. CNA stated a resident was showering in the north shower room. CNA 3 reviewed photographs of the north shower room and stated ewww and that it looked like mold in the caulking of the shower. CNA 3 stated that housekeeping was responsible for deep cleaning the showers. Residents Affected - Some On 6/24/25 at 10 A.M., a meeting with Resident Council members was conducted. Another confidential resident stated there was mold in the shower and it was wrong because it could make people sick and needs to be cleaned. A confidential resident stated he did not wear his glasses in the shower, and was unaware of the condition of the shower rooms. Another confidential resident stated she would like the shower to be clean. On 6/25/25 at 9:07 A.M., an interview was conducted with the Housekeeping Supervisor (HS). The HS reviewed the photographs of the north shower room and stated that it looked like mold on the caulking at the bottom of the shower and had probably been there for a while. The HS observed the south shower room and stated that it looked like mold had developed in the caulking on the floor. The HS stated it was his expectation for the housekeeping staff to deep clean the showers every day and to ensure mold did not develop. The HS stated maintenance should have been called if the caulking needed to be replaced and could not be properly cleaned. A review of the EVS Care Route Duty List for North and South Wings, revised 4/26/23, indicated .Monday to Sunday .Areas Of Responsibility .16. 2nd floor South Shower room (1 X day) . 2:00-2:45pm Clean .Shower .18. 2nd floor North Shower room (1 X day) .2:45-3:15pm Clean .Shower . On 6/26/25 at 8:41 A.M., an interview was conducted with the Infection Preventionist (IP). The IP reviewed photographs of the facilities north and south shower rooms and stated she was concerned about mold development and that residents could have been breathing in spores while showering. The IP reviewed photographs of the orange-colored shower chair seat cushion and stated it should have been replaced because it was an infection control issue that could have negatively affected the residents. On 6/26/25 at 3:13 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the shower rooms should have been sanitary for resident use and the shower chair seat cushion should have been thrown away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555144 If continuation sheet Page 46 of 46