Health inspection·June 20, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy on specimen collection for one of two sampled residents (Resident 69) when Resident 69 was instructed to provide a sputum specimen. As a result, staff did not follow-up on what to do with the specimen. Residents Affected - Few This failure resulted in the resident feeling bothered and not cared for when the sputum specimen was left at his bedside and not picked up by staff who instructed him to provide the sputum specimen. Findings: Resident 69 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (condition where lungs cannot provide adequate oxygen), pneumonia (lung infection) and hemoptysis (coughing out blood), per the clinical record. Resident 69's minimum data assessment (MDS - nursing assessment tool) dated, 6/18/25 indicated that Resident 69 was cognitively intact. During a concurrent observation and interview with Resident 69 on 6/18/25 at 8:40 A.M., a specimen cup with reddish liquid inside was observed on Resident 69's bedside table. Resident 69 stated that on 6/17/25 around noon, a facility staff gave him the specimen cup and instructed him to cough out his sputum into the cup. Resident 69 stated that the sputum specimen had been on the table for 16 hours. Resident 69 further stated he was mentally bothered by the facility's lack of communication and was not aware of the purpose (for providing a sputum specimen). An interview was conducted with certified nursing assistant (CNA) 1 on 6/18/25. CNA 1 acknowledged the specimen cup containing reddish-colored liquid was on Resident 69's table. CNA 1 stated she was not made aware by the licensed nurse, that Resident 69's sputum needed to be collected. CNA 1 further stated that she would have followed up with Resident 69 if had she been made aware by the licensed nurse. During a concurrent interview and record review with licensed nurse (LN) 2 on 6/19/25 at 2:03 P.M., LN 2 stated that Resident 69 did not have a physician's order to collect sputum. LN 2 further stated that a physician order would indicate the purpose of the specimen collection and would have been communicated to Resident 69. During an interview with the Director of Nursing (DON) on 6/20/25 at 8:30 A.M., the DON stated that per her follow up on this incident, a respiratory therapist (RT) gave a specimen cup to Resident 69 on the morning of 6/17/25 and instructed him to provide the sputum. The DON stated that there were no physician orders to collect a sputum specimen from Resident 69. The DON further acknowledged that there should have been a physician's order to collect Resident 69's sputum prior to instructing Resident 69 to provide the specimen. In addition, the physicians order would have alerted nursing staff to collect Resident 69's sputum. The facility's policy Sputum Induction Protocol dated 9/21/23 indicated. PROCEDURE: A. A written order from the physician order to induce sputum 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 06/20/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate care and services for one of two sampled residents (Resident 72) when Resident 72 had a delay in straight urinary catheterization (SUC -tube to drain the bladder). This failure had the potential to result in discomfort and/or health complications for Resident 72. Findings: Resident 72 was admitted to the facility on [DATE] with diagnoses including cystitis (inflammation of the bladder) and generalized weakness, per the clinical record. During an interview with Resident 72 on 6/17/25 at 8:45 AM, Resident 72 stated that she was retaining urine in her bladder and the staff sometimes delayed providing SUC. Resident 72's physician order dated 6/13/25, indicated .bladder scan of intermittent catheter . [Resident 72] .if unable to void (empty; the act of urinating) in 6 hours for post void residual (PVR - urine retained in the bladder after urinating) . During a concurrent interview and record review with licensed nurse (LN) 2 on 6/19/25 at 2:40 PM, LN 2 stated that Resident 72 was unable to void, and that per Resident 72's urine flow sheet dated: 6/15/25 at 4:20 PM, Resident 72 had a PVR of 389 milliliters (ml- unit of measurement) and SUC was not done/provided in a timely manner. 6/16/25 at 11 AM, Resident 72 had a PVR of 481 ml and SUC was not done/ provided in a timely manner. 6/17/25 12:40 PM, Resident 72 had a PVR of 424 ml and SUC was not done/provided in a timely manner. LN 2 stated that the LNs should have performed SUC for Resident 72 as ordered by the physician to relieve Resident 72's bladder from urine retention and prevent infection. During an interview with the director of nursing (DON) on 6/20/25 at 9:40 AM, the DON stated that all LNs should follow physician orders. The DON acknowledged that the SUC should have been implemented by LNs as ordered for Resident 72, to prevent discomfort and urine retention. The facility's policy titled Standardized Procedure - Nurse -Directed indwelling Catheter Removal and Bladder Management dated 7/30/24 indicated, .PROCEDURE .c. if 300 ml, perform intermittent catheterization . 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 06/20/2025 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. Based on observation, interview and record review, the facility failed to ensure food safety and practices were maintained in the kitchen according to standards of practice and policy when food items were not labeled and dated. These failures had the potential to expose the residents to contaminated food and unsanitary practices and place them at risk of developing foodborne illness. Findings: During a kitchen observation conducted on 6/17/25, with the certified dietary manager (CDM), the following items were observed. 1. In the fresh produce walk-in refrigerator at 8:40 A.M., a box of strawberries and a box of potatoes were observed without a label of date received. The CDM stated that the box of strawberries and box of potatoes should have been labeled but were not. The CDM stated it was important to ensure stored items had labels, date and time for the safety of residents from food borne illness. 2. In the dairy walk-in refrigerator at 8:46 A.M., a container of margarine was observed unlabeled and was stored together with the string cheese. The CDM stated the margarine should be labeled with an open date (food item originally opened) and use by date (last day a product is safe to consume) and should not have been stored with the string cheese to prevent cross - contamination (bacteria transferred from one substance to another). 3. In the dry storage room at 8:54 A.M. a bag of tortillas was observed without an open date and no use by date. The CDM stated that the bag of tortillas should have been labeled with an open and use by date, to track how long the food had been exposed under storage. According to the 2022 US FDA Food Code, Section 3-602.11 titled Food Labels, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . A review of facility's policy and procedure titled Infection Prevention for Food and Nutrition Services last revised 8/31/21 indicated, III. Text .G. Food Storage/Disposal . 1. All foods are labeled, covered and dated when stored .Outdated foods are discarded 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 06/20/2025 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 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 implement infection control procedures when visitors were not educated regarding the need to wear Personal Protective Equipment (PPE-gown, gloves, masks) or hand hygiene. Residents Affected - Few This failure had the potential for the spread of infection to other residents in the facility. Findings: According to the Face Sheet, Resident 73 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection and microcytic anemia (a condition where red blood cells are smaller than normal). On 6/18/25 at 9:09 A.M., an observation of Resident 73's room was conducted. A green sign was posted outside the room, which indicated Resident 73 was on Contact Precautions, and All visitors please report to the nursing station .To Enter Clean Hands .Put on and tie gown .Cover cuffs with gloves .To Exit, Remove Gloves, Remove gown in room, Clean Hands . On 6/18/25 at 9:18 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated Contact Precautions meant anybody who entered Resident 73's room was required to do hand hygiene and to wear PPE before entering the room, and to remove the PPE and do hand hygiene before leaving the room. CNA 6 stated, .it doesn't matter if you're just talking to [Resident 73] .you still have to wear PPE. On 6/18/25 at 10:48 A.M., a visitor was observed inside Resident 73's room. Resident 73 was observed laying in bed. The visitor was sitting on a sofa inside Resident 73's room. The visitor was not wearing PPE. On 6/18/25 at 11:21 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated if a resident is on Contact Precautions, all visitors and staff were required to do hand hygiene and to immediately gown up and wear PPE prior to entering the room. The IP stated it was important to do hand hygiene and wear PPE, .to prevent transmission of bacteria . On 6/20/25 at 7:46 A.M., Dietary Hostess (DH) 1 was observed inside Resident 73's room. DH 1 was sitting on the sofa inside Resident 73's room, and was not wearing PPE. On 6/20/25 at 7:48 A.M., a joint observation and interview was conducted with DH 1. DH 1 walked out of Resident 73's room, and did not perform hand hygiene. DH 1 stated she was going into each resident's room to take their lunch orders. DH 1 stated she did not know she was required to perform hand hygiene, or wear PPE in a Contact Precaution room. DH 1 stated, I thought we only had to wear the gown and gloves if we are touching them . DH 1 further stated, If we deliver meal trays, we will use the hand gel. Otherwise, if we go inside [a Contact Precaution Room] we don't have to do hand hygiene .I'm gonna [sic.] ask my supervisor downstairs because I don't want to get sick .I also don't want to get other patients sick since I'm going room to room . On 6/20/25 at 12:12 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation for visitors and staff to perform hand hygiene and wear PPE prior to (continued on next page) 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 06/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete entering a Contact Precaution room. The DON stated, They should be doing hand hygiene .all visitors should wear PPE when going into a Contact room .for the safety of the patient. You don't know if your hands are clean or dirty . The DON further stated it was her expectation for staff to provide education to visitors prior to entering a room on Contact Precautions. A review of the facility's policy titled Standard Precautions and Transmission-Based Precautions for hospitalized Patients revised 5/31/24 indicated, Patient/Visitor Transmission-Based Precautions Education: a. Educate patients and their families/visitors who are infected or colonized with an MDRO or communicable disease about infection prevention strategies including isolation precautions as needed .All visitors should be instructed to perform hand hygiene before and after patient contact .Visitors in rooms of patients with CDI should be instructed to wash their hands with soap and water upon exit of patient room .Visitors are encouraged to wear isolations gowns and gloves . Event ID: Facility ID: 555572 If continuation sheet Page 6 of 6