Health inspection·May 18, 2023

F 0695 Policy: 1. The Oxygen Protocol will be initiated on patients by a written order from the physician . 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: 555572 If continuation sheet Page 2 of 6 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 555572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to consistently monitor specific target behaviors and adverse side effects for the use psychotropic medications for two of three residents (3, 8) selected for unnecessary medication review. As a result, the residents were at increased risk for receiving unnecessary medication. 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included left humerus (arm) fracture, per the resident's demographic sheet. On 5/17/23, Resident 3's clinical record reviewed. A physician's progress note, dated 4/28/23, indicated Resident 3 also had diagnoses that included bipolar disorder and adjustment disorder. According to the physician's orders, on 2/1/23 Resident 3 was prescribed quetiapine (antipsychotic) 150 mg at bedtime for bipolar disorder. The order directed staff to monitor the resident for episodes of agitation every shift, and to monitor side effects of quetiapine every shift. Resident 3 was also prescribed sertraline (antidepressant) 200 mg daily for depression on 2/2/23. The physician's order directed staff to monitor the resident for episodes of depression every shift, and to monitor for side effects of sertraline every shift. A concurrent interview and record review was conducted with Licensed Nurse (LN) 2 on 5/18/23 at 11:01 A.M. The monitoring for Resident 3's quetiapine and sertraline were reviewed. There was no documentation of behavior or side effect monitoring for both quetiapine and sertraline on the following shifts: 5/1 day, 5/3 night, 5/6 day, 5/10 day, 5/10 night, 5/11 night, 5/14 night, and 5/16 night. LN 2 acknowledged the monitoring for behavior and side effects was missed. LN 2 stated, They [nursing] should be documenting every shift. According to the facility's policy, Monitoring of Antipsychotic Medications, dated 5/11/22, When antipsychotic therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . 2. Resident 8 was admitted to the facility on [DATE] with a diagnosis of osteomyelitis (infection) of right hip, per the resident's demographic sheet. On 5/17/23, Resident 8's clinical record was reviewed. According to the physician's orders, on 3/8/23 Resident 8 was prescribed diazepam 5 mg three times a day for anxiety. The order directed staff to monitor the resident for episodes of anxiety every shift, and to monitor for side effects of diazepam every shift. A concurrent interview and record review was conducted with LN 2 on 5/18/23 at 10:36 A.M. The monitoring for Resident 8's diazepam was reviewed. There was no documentation of behavior or side effect monitoring for diazepam on the following shifts: 5/2 day, 5/9 day, 5/10 day, 5/10 night, 5/11 night, 5/14 day, and 5/15 day. LN 2 acknowledged the monitoring for behavior and side effects was missed. LN 2 stated, They [nursing] should be documenting once a shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555572 If continuation sheet Page 3 of 6 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 555572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, Monitoring of Anxiolytic Medications, dated 5/11/22, When anxiolytic therapy is initiated or the dosage changed, the resident is monitored to determine the effectiveness of the medication . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555572 If continuation sheet Page 4 of 6 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 555572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen staff were knowledgeable of the proper chemical sanitation range values. As a result, there was a potential for spread of food-borne illness. Findings: On 5/17/23 at 10:50 A.M., a review of the 3 Compartment Sink and Sanitizer Log was conducted. The required sanitizer range value was indicated to be 272-700 parts per million (PPM). On 5/17/23 at 10:56 A.M., a joint observation and interview of Food and Nutrition Services Staff (FAN) 1 was conducted with the Executive, Nutrition and Services ([NAME]). FAN 1 was unable to state the required chemical sanitation values for the three-compartment sink. On 5/17/23 at 11:11 A.M., a joint observation and interview of Kitchen Supervisor (KS) 1 was conducted with the [NAME]. KS 1 was unable to state the required sanitation values for the three-compartment sink. On 5/17/23 an interview with the Manager of Nutrition Services (MNS) was conducted. The MNS stated the kitchen staff did not understand the meaning of the required chemical sanitation values for the three-compartment sink. The MNS stated it was important for the staff to know these to keep the patients safe. Per the facility's policy and procedure titled Infection Prevention for Food & Nutrition Services, revised 8/31/21, .III .B. EDUCATION AND TRAINING .2. Effectiveness of education is monitored . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555572 If continuation sheet Page 5 of 6 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 555572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grossmont Hospital D/P Snf 5555 Grossmont Center Drive LA Mesa, CA 91941 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen staff consistently documented accurate final rinse temperature of the dishwashing machine. As a result, there was a potential the final rinse temperatures were not in the required range. Findings: On 5/16/23 at 8:32 A.M., a concurrent interview and record review of the document titled, Dishwashing/Warewashing Machine Temperature Log was conducted with the Manager of Nutrition Services (MNS) and Kitchen Supervisor (KS) 1. The log indicated the following temperature requirements: Wash 150F, Rinse 160F and Final Rinse 180F. The final rinse temperatures were not consistently documented accurately from 5/1/23. The MNS stated the kitchen staff were not looking at the correct gauge, which was the blue gauge for the final rinse temperature. The MNS stated the staff were instructed by the Executive, Nutrition Services ([NAME]) to check the green gauge for the final rinse temperature. KS 1 stated the staff was instructed by the [NAME] to check the green gauge and record the readings for the final rinse temperatures. On 5/16/23 at 8:34 A.M., an interview with the [NAME] was conducted. The [NAME] stated the green gauge was not the final rinse temperature gauge but the PSI [Pounds Per Square Inch], which was part of the final rinse validation. The [NAME] stated the staff should have recorded the final rinse temperature and the PSI. On 5/17/23 at 10:42 A.M., an interview with the [NAME] was conducted. The [NAME] stated the kitchen staff did not use the new and correct temperature log form which was implemented in August 2022. The [NAME] stated the staff needed retraining. The [NAME] stated if the staff recorded the wrong temperatures, the kitchen would have switched to disposables as part of infection control. Per the facility's policy and procedure titled Infection Prevention for Food & Nutrition Services, revised 8/31/21, .TEXT: E. EQUIPMENT/SANITATION 1. Proper temperature of dishwashers is maintained and recorded daily: The facility's document titled Food Safety Management System, revised 4/1/22, .D-8 Cleaning and Sanitizing Food Contact Surfaces .A high temperature dish machine must have a minimum final rinse temperature of 180 F .must be verified .Dish machine temperatures must be checked and recorded . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555572 If continuation sheet Page 6 of 6