Inspection·July 31, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a tool used to assess all residents in Medicare or Medicaid certified nursing homes) assessment accurately reflected the assessment for 2 of 8 sampled residents (Resident 11 and Resident 24) when:1. Resident 11's functional limitations in range of motion indicated the resident had no impairment for upper extremity (shoulder, elbow, wrist, hand) or lower extremity (hip, knee, ankle, foot).2. Resident 24's functional limitations in range of motion indicated the resident had upper extremity limitations but no impairment in the lower extremities. These failures had the potential to result in inaccurate care plans, inappropriate interventions, and unmet needs. 1. During a review of Resident #11's admission Record (AR), dated 7/30/25, the AR indicated the diagnoses included a fracture (a break in a bone) of left pubis (pubic bone on the pelvis area), acute pain due to trauma, history of falling and difficulty walking. During a review of Resident 11's Physical Therapy (PT) notes, dated 7/9/25 - 8/07/25, indicated the resident functional mobility assessment as follows:Bed mobility (roll left to right, sit to lying, lying to sitting on side of bed): substantial/maximal assistanceTransfers (sit to stand, chair/bed to chair transfer): Partial/moderate assistanceAmbulation (walk): Dependent During a review of Resident 11's MDS section GG for Functional Abilities, dated 7/11/25, section GG0110 indicated there was no range of motion limitations for upper (arms, hands, and shoulders) and lower (legs, feet, and hips) extremities which were contrary to the PT notes. 7/30/25 10:03 AM During a concurrent interview and review on 7/30/25 at 10:03 a.m. with Director of Nursing (DON), Resident 11's MDS section GG0110 was reviewed. The DON stated MDS section GG0110 was coded incorrectly and confirmed Resident 11 had lower extremity range of motion limitations from the pubic bone fracture and GG0110 should have been coded as a one for lower extremity impairment on one side. 2. During a review of Resident #24's admission Record (AR), dated 7/30/25, the AR indicated the diagnoses included encounter for surgical after care following surgery of the circulatory system (heart, blood vessels, blood, lymph, and lymphatic vessels and glands), embolism (obstruction by a clot of blood or air bubble) and thrombosis (a clot obstructing blood flow) of lower extremity arteries, and unspecified atherosclerosis of right leg arteries. In further review of Resident 24's History and Physical (H&P), dated 7/19/25, the H&P indicated the resident was discharged from the hospital post thromboembolectomy (surgical removal of a blood clot) with staples intact in the right groin/thigh area. During a review of Resident 24's MDS section GG for Functional Abilities, dated 7/20/25, section GG0110 was coded as 1 meaning impairment on one side of upper extremity and the lower extremity was coded as 0 meaning no impairment on either side. During a concurrent interview and record review on 7/30/25 at 3:56 p.m. with DON and Assistant Administrator (AA), Resident #24's MDS section GG0110 dated 7/30/25 was reviewed. The DON stated that Resident 24 does not have upper extremity ROM limitations but does have lower extremity range of motion limitations on one side due to post femoral (relating to femur or thigh) surgery. AA stated the MDS was not coded appropriately - upper extremity should have been coded as zero for no impairment and lower extremity should be coded as one for one side impairment. During a review of the facility's policy and procedure (P&P) titled, MDS Policy, dated October 2024, the P&P indicated Staff assigned to complete designated sections of the MDS assessments and tracking forms will do so following the coding guidance and instructions of the MDS 3.0 RAI User's Manual to insure OBRA and PDPM compliance for timeliness and accuracy of assessments.MDS nurses and coordinators will.communicate this to designated facility staff in a timely manner following established procedures. MDS Sections are assigned as follows.GG Qualified clinicians including MDS nurse, Rehab lead or designee, DON or DON designee. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555592 If continuation sheet Page 2 of 5 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 555592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Transitional Care 1575 Bishop Street San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 one expired package of Maxorb II alginate wound dressing (material applied directly onto an open wound to keep the wound clean and promote healing) was discarded and not readily available for staff use. This failure had the potential for residents to receive expired and ineffective wound dressings. During a concurrent observation and interview on [DATE] at 11:20 a.m., with the Director of Nursing (DON), one open package of Maxorb II Alginate wound dressing with an expiration date of [DATE] was observed stored in the treatment cart. DON acknowledged the Maxorb II Alginate wound dressing is expired and should have been discarded. DON stated, it was missed. During a review of the facility's policy and procedure (P&P) titled, Medication Storage: ID1: Storage of Medications, dated [DATE], the P&P indicated, Outdated, contaminated, or deteriorated medications and those in containers .are immediately removed from stock, disposed of according to procedures for medication disposal . Event ID: Facility ID: 555592 If continuation sheet Page 3 of 5 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 555592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Transitional Care 1575 Bishop Street San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interview, the facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections when staff did not follow handwashing protocol per infection control standards to provide hand hygiene to five of eight sampled residents (Residents 25, 24, 2, 9 and 7) before residents began eating their lunch.These facility failures had the potential to transmit and spread infection to residents, visitors, and staff.During an observation on 7/28/25 at 12:11 p.m., Certified Nursing Assistant (CNA 1) placed a lunch tray on Resident #25's bedside table and did not offer hand sanitizer or hand washing before the resident started eating. Subsequently, observed Registered Dietitian (RD) distribute Resident 7's meal tray and did not offer hand sanitizer or hand washing. During an interview on 7/28/25 at 12:30 p.m. with Resident #24, the resident stated staff normally do not offer handwashing before or after meals. During an observation on 7/30/2025 at 12:05 p.m. during meal tray distribution, RD distributed meal trays to Residents #2 and #9. The residents began eating their meals and RD walked out of the rooms without offering hand hygiene. During an interview on 7/30/2025 at 12:15 p.m. with RD, the RD acknowledged hand sanitizer and hand washing was not offered to Residents #2 and #9 when meal tray was distributed. During a concurrent observation and interview on 7/30/2025 at 12:33 p.m. with Certified Nursing Assistant (CNA 2), CNA 2 wheeled Resident #24 to room upon arrival to the facility from a doctor's appointment. CNA 2 positioned the resident to eat lunch, removed the meal tray lid, and offered to heat the food as the meal tray had been sitting on the bedside table for approximately 20-30 minutes. Resident 24 lifted the hamburger bun with uncleaned right hand and with the other hand touched the meat patty and said, You don't need to warm it up, it still feels warm. CNA 2 acknowledged hand washing or hand sanitizer was not offered before Resident 24 touched the food. During a review of the facility's policy and procedure (P&P) titled Standard Precautions, dated 2001, the P&P indicated in part, a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water.b. Hand hygiene is performed with ABHR or soap and water.g. Personnel assist the residents with hand hygiene before meals, after toileting and when indicated. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555592 If continuation sheet Page 4 of 5 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 555592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Luis Transitional Care 1575 Bishop Street San Luis Obispo, CA 93401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. 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 maintain one of one evaporative cooler (a device for cooling air) located in the kitchen, in safe operating condition when the manufacturer's recommended preventive maintenance was not performed. This failure had the potential for the unit to transmit mold, mildew, bacteria, and other allergens on resident's food and affect the facility's indoor air quality resulting in respiratory issues or exacerbating existing health conditions for residents and staff.During a concurrent observation and interview on 7/30/25 at 4:48 p.m. with Maintenance Director (MD), an evaporative cooler was observed to be located on a kitchen window that was blowing air directly on clean dishes and towards the stove cooking area. MD stated the filters are changed every six months but could not provide maintenance records for the evaporative unit. MD stated the filter cleaning/replacement is not documented. During a concurrent interview and record review on 7/31/25 at 09:15 a.m., with MD, the facility's policy and procedure (P&P) titled Heating, Ventilation and Air Conditioning Systems, undated, and the manufacturer maintenance instructions (MMI) titled Bonaire [NAME] 4500E Owner's Manual, undated, were reviewed. The P&P indicated in part, Policy: It is the policy of this facility to properly maintain and service the heating, cooling, and ventilation system(s) as to ensure a comfortable environment for our patients as free as possible of air pollutants and odors .Procedure: Air filters and Air Record - check all air filters monthly .Record inspection, cleaning, and/or replacement, and the date in the Maintenance Log and Air Filter Log. The MMI indicated in part, Gently hose down pads from both sides to remove any buildup of salts, dust and pollen.Check the water distributor, making sure it is clear and free from blockage.Keep the water tank clean and free from sediment and algae growth.Check that the fan spins freely and that there is no build up on the blades. Check the motor for corrosion and spray with an anti-corrosive agent if necessary . MD acknowledged and confirmed the facility is not performing the preventive maintenance that is listed on the Bonaire [NAME] MMI. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555592 If continuation sheet Page 5 of 5