Health inspection·March 21, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/20/24 at 7:59 A.M., an interview was conducted with Resident 20, in Resident 20's room. Resident 20 stated that he had gone to an appointment on Monday (3/18/23) to see his MD. Resident 20 stated he was not asked what he wanted to wear prior to his MD appointment and would have wanted to be asked. On 3/20/24 at 8:06 A.M., an interview was conducted with CNA 1. CNA 1 stated that prior to going out for appointments, Resident 20 should had been groomed and dressed appropriately to include dignity bags to cover urinary catheter bags. CNA 1 stated it was a shared responsibility to check and make sure a dignity bag was available for his urinary catheter to prevent embarrassment for Resident 20. CNA 1 stated that the Resident 20 had his own clothing and should have been asked to pick out his own clothing prior to the appointment versus using the hospital gown to prevent feeling embarrassed. CNA 1 stated that Resident 20 should have been dressed in his room to provide privacy instead of the hallway while he was on a stretcher to avoid feeling embarrassed and uncomfortable when he was pulling down on his gown for comfort. On 3/20/24 at 8:25 A.M., an interview was conducted with the DOR. The DOR stated that she was helping Resident 20 get ready for a MD appointment the morning of 3/18/23 and helped resident get ready on the stretcher outside the hallway. The DOR stated she helps the nursing staff for transfers and an extra hand for the nursing staff. The DOR stated being aware Resident 20 had a gown on prior to his appointment. The DOR stated she was aware Resident 20 had his own clothing but stated I did not feel he [Resident 20] would feel embarrassed wearing the hospital gown because he had a urinary catheter, and it was Resident 20's preference. The DOR stated that she usually offered facility residents their preference of clothing but had not offered Resident 20 that choice. The DOR stated, It should have been offered and would have made any residents to [sic] feel better. The DOR stated that the transportation service was rushing as to why she covered Resident 20 in the hallway with a shower blanket. The DOR stated that Resident 20's urinary catheter without a dignity bag is a dignity issue to promote privacy and self-esteem. A record review of Resident 20's clinical record did not indicate hospital gown as a personal preference. On 3/20/24 at 9:42 A.M., an interview was conducted with LN 1. LN 1 stated that Resident 20 is alert and oriented and able to make needs known. LN 1 stated that Resident 20 has personal items such clothing and it was important that Resident 20 look presentable with own clothes during appointments. LN 1 stated Resident 20 should have been able to make his own choices because if not his needs were not being met. LN 1 stated this can make someone feel that their needs are not taking inconsideration and emotionally you'll feel down and potentially embarrassed. LN 1 stated Resident 20's catheter bag should had been covered to prevent Resident 20 from feeling self-conscious about people looking at his urinary catheter and feeling uncomfortable during his appointment. On 03/20/24 10:51 A.M., an interview was conducted with the DON. The DON confirmed that Resident 20 had a cardiology appointment on 3/18/24. The DON stated that Resident 20 should had been appropriately dressed and stated especially if they have a catheter bag it should be stealthily (done without attracting attention or hidden) hidden. The DON stated his expectations are for any residents with outside appointments to be properly dressed in their own clothing before they leave the room and not outside of public spaces to prevent Resident 20 from feeling embarrassed and not cared for. According to the facility's undated policy and procedures titled Dignity and Privacy, indicated .2. Residents will be appropriately dressed in clean clothes arranged comfortably . 3. Residents shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 2 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 be examined and treated in a manner that maintains the privacy Privacy [sic] of a Resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene . 2. A review of Resident 17's admission Record indicated Resident 17 was re-admitted to the facility on [DATE] with diagnoses which included a history of chronic respiratory failure (a lung disorder that prevents the right amount of oxygen needed for the body to breathe normally). A record review of Resident 17's MDS (Minimum data set: nursing facility assessment tool) dated 1/20/24 indicated Resident 17 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) deficits to understand and make decisions. On 3/21/24 at 8:08 A.M., an observation was conducted outside the conference room hallway in front of the shower room. The shower door was wide open with Resident 17 being showered that exposed Resident 17's feet. CNA 2 was seen behind the shower curtains showering Resident 17 on a shower bed and RT 1 sitting by the doorway with the computer. On 3/21/24 at 8:18 A.M., an observation of RT 1 and CNA 2 was seen exiting the shower room with Resident 17 who was covered with a shower blanket on the shower bed to wheel Resident 17 back into his room. On 3/21/24 at 8:29 A.M., an interview was conducted with RT 1, while CNA 2 provided daily care for Resident 17. RT 1 stated that her role was to be on the side to help CNA 2 with Resident 17 due to tracheotomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe through the neck) care. RT 1 stated that the shower door should have been closed during Resident 17's shower to prevent his feet from being exposed and to provide privacy. RT 1 stated not closing the door during a shower could have caused Resident 17 to feel uncomfortable and embarrassed. On 3/21/24 at 8:48 A.M., an interview was conducted with CNA 2. CNA 2 stated when giving showers to any residents it's important to close curtains and doors for privacy. CNA 2 stated that the door was not closed timely when Resident 17 was on the shower bed, and this could have caused Resident 17 to feel embarrassed or disrespected. CNA 2 stated Resident 17 has the right to feel comfortable and his privacy respected to promote dignity. On 3/21/24 at 10:54 A.M., and interview was conducted with the DON. The DON stated that his expectations were that the staff who showered Resident 17 should have closed the door immediately to provide privacy and respect for Resident 17's dignity. According to the facility's undated policy and procedures titled Dignity and Privacy, indicated .2. Residents will be appropriately dressed in clean clothes arranged comfortably . 3. Residents shall be examined and treated in a manner that maintains the privacy Privacy [sic] of a Resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 3 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 12) was assessed and provided with the appropriate call light type to call staff when needed. Residents Affected - Few This failure increased the risk for Resident 12 to experience psychological and physical harm (banging on bed rails)with needs not addressed appropriately. Findings: A review of Resident 12's admission Record indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses which included a history of traumatic brain injury (happens when a sudden, external, physical assault damages the brain). A record review of Resident 12's MDS (Minimum data set: nursing facility assessment tool) dated 3/5/24 indicated that Resident 12 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. On 3/18/24 at 10:46 A.M., an observation and interview was conducted with CNA 3 and the DOR, in Resident 12's room. Resident 12 was heard banging on his bed rails with his mitted right hand throughout the hallways and nursing station. CNA 3 stated Resident 12 banged his right hand on the right bed rail to get the staffs attention. The DOR walked in during the interview with CNA 3 and stated Resident 12 has a push button call light but is unable to use the call light because he does not know how to use it. The DOR stated that the resident would pull on the call light to make the call light turn on in the hallway to communicate his needs. The DOR stated Resident 12 did not need a modified call light because he was being checked every 15 minutes for safety. CNA 3 stated that Resident 12 had punched her just now and attempted to bite her (CNA 3) hand while trying to re-position resident with the DOR. On 3/18/24 at 11:53 A.M., a record review of Resident 12's care plan for falls dated 10/3/21 indicated .Interventions Be sure the call light is within reach and encourage to use it to call for assistance as needed . Resident 12's care plan dated 7/28/2023 indicated Xanax, (medication used for mood to relieve anxiety) AEB (as evidenced by) nervousness, repeated banging of side rails or sides of gerichair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) when out of bed . Resident 12's care plan dated 3/9/22 indicated Resident noted with episodes of hitting his leg, grabbing staff, pulling on tubes . There was no documented evidence recorded related to safety checks every 15 minutes in Resident 12's clinical record. On 3/18/24 at 3:38 P.M., a phone interview was conducted with Resident 12's RP. The RP stated that Resident 12 would get frustrated and will bang his right hand on the bed rail for the staff to go in his room to check on him. RP stated that the facility has never tried to use a modified call light in the past and has relied on staff to check on him (Resident 12) when he bangs his hands on the bed rail. On 3/19/24 at 12:09 P.M., an interview with CNA 1 was conducted. CNA 1 stated that even though Resident 12 is non-verbal that there were other ways Resident 12 would communicate, such as using his body language and vital signs if he was in pain or uncomfortable. CNA 1 stated Resident 12 would get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 4 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physically aggressive when he needed staff attention and nodded his head or made facial expressions to communicate. CNA 1 stated Resident 12 had a call light next to him but it would not be beneficial for Resident 12 because of his padded right hand mitten that kept him from clicking the call light. On 3/20/24 at 9:51 A.M., an observation and interview was conducted with LN 1, in Resident 12's room. LN 1 stated Resident 12 would bang on the bed rail when in bed or when he was out of bed would bang on the walls to communicate that he needed something. LN 1 stated that when staff addressed his banging that Resident 12 demonstrated signs of frustration and would physically grab you and pull you toward him. LN 1 confirmed Resident 12 required the use of his right hand to click the call light with his finger but would not be able to do it because Resident 12 had a padded right-hand mitten. LN 1 stated she did not think Resident 12's call light was appropriate due to Resident 12's inability to grip and click the call light with his right padded hand mitten. LN 1 stated that using an appropriate call light to accommodate Resident 12's physical limitations would be beneficial and a safer option to prevent the use of Resident 12's right hand from banging against his bed rail. On 3/20/24 at 11:01 A.M., an interview was conducted with the DON. The DON stated that Resident 12 had gross (using large muscles such as your arm for movement) motor movement to grab a Styrofoam (a cup made from foam) cup but has not demonstrated fine motor skills such as clicking. The DON stated that using a pressure sensor call light for Resident 12 may be beneficial. The DON stated that his expectations were for all the staff to have some interaction with Resident 12 and check on him more often to prevent Resident 12's frustration and promote safety. According to the facility's undated Resident's Rights policy and procedures titled Accommodation of Needs, indicated It is the policy of this facility to provide accommodation of reasonable needs to the resident's while in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 5 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document reviews, the facility failed to ensure a low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for one of six residents (Resident 30) reviewed for pressure ulcer. Residents Affected - Few These failures increased the risk for skin breakdown for all residents. Findings: 1. A review of Resident 30's admission Record indicated the resident was re-admitted to the facility on [DATE] with diagnoses that included non-traumatic acute subdural hemorrhage (develops when tiny veins that are located between the membranes covering the brain (the meninges) leak blood after an injury to the head). A record review of the Resident 30's Minimum Data Set (MDS, nursing assessment tool), dated 3/6/24, indicated Resident 30 was at risk for developing pressure ulcers and had severe impairment (diminishment or loss of function) in cognition (the understanding of thought processing with language, learning, attention, and memory). A review of Resident 30's physician's order, dated 3/15/24 indicated an order for a pressure relieving device, .LAL (Low air loss Mattress: a specialty mattress used to relieve pressure to boney areas while in bed that to off-load pressure and help with healing and prevention of pressure ulcers) for skin maintenance. A review of Resident 30's Braden scale (pressure ulcer risk assessment) dated 3/14/24 indicated Resident 30 at high risk for developing pressure ulcers. A review of Resident 30's care plans indicated Resident 30 had a Stage 4 pressure ulcer injury to the left hip bone initiated 3/15/24, a left stage 4 (the worst pressure injury that is a deep wound that extends to muscle, tendon and bone) foot pressure injury initiated 3/15/24, right posterior chest stage 4 pressure injury, and a left ankle stage 4 pressure ulcer initiated 3/15/24. On 3/20/24 at 2:00 PM an observation and interview was conducted with CNA 5, in Resident 30's room. CNA 5 stated that Resident 30 needed to be repositioned every two hours and/or as tolerated. CNA 5 also checked LAL mattress setting and was set on 150 lbs (pounds). On 3/20/24 at 2:03 P.M., an observation, interview and record review was conducted with LN 2, in Resident 30's room. LN 2 stated that the purpose of the LAL mattress was to help with wound healing and to offset pressure on boney prominences (areas where bones are close to the surface without fatty cushion). LN 2 stated that it was important to follow manufacture directions regarding LAL mattress. LN 2 stated that Resident 30's clinical record confirmed Resident 30's was weighed on 3/15/24 at 95.5 lbs. LN 2 checked Resident 30's LAL mattress and stated that it was set on 150 lbs. LN 2 stated that the LAL mattress settings were not set properly and could compromise the prevention or healing of pressure ulcers and should be set according to Resident 30's weight for the right amount of air and firmness to off load Resident 30's weight and pressure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 6 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0658 Level of Harm - Minimal harm or potential for actual harm On 3/21/24 at 2:01 P.M., an interview was conducted with the DON. The DON stated that Resident 30's LAL mattress should be set based on the Resident 30's weight according to the manufacturer's recommendations. The DON further stated the correct setting would help with the prevention and healing of Resident 30's pressure ulcers. The DON expected that the nursing staff including the wound nurse to responsible and check the correct settings when doing wound rounds. Residents Affected - Few The undated facility policy and procedure titled, Pressure Injury Prevention and Management, indicated .Evaluation of treatment effectiveness . A review of the manufacturer guidelines for Low Air Loss, provided by the facility: [Brand Name] Alternating Pressure Mattress Mattress [sic] Low Air Loss Mattress manual undated Adjust the dial to correspond to the patients' appropriate weight setting or comfort level . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 7 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) for two of six residents reviewed for pressure injuries (Resident 17, Resident 26.) Residents Affected - Few As a result, Resident 17 developed a new pressure injury on the right trochanter (hip) and Resident 26 developed a new pressure injury on the right trochanter area. Findings: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure; subdural hemorrhage (bleeding in the brain); anoxic brain damage (lack of oxygen to the brain); tracheostomy (a surgical opening in the neck to help air and oxygen reach the lungs, and sepsis (a serious infection that leads to organ failure) per the facility's admission Record. A record review of Resident 17's document titled, Braden Scale for Predicting Pressure Sore Risk, dated 3/6/24 indicated Resident 17 was at high risk for developing pressure injuries due to very limited mobility . cannot always communicate discomfort ., and chairfast .cannot bear own weight . A review of Resident 17's care plan dated 1/2022 related to potential for pressure ulcer development due to weakness indicated, .skin checks as needed, use lift sheet to reduce friction, requires LAL (pressure relieving) bed mattress . A review of Resident 17's undated care plan related to pressure injury indicated, .Resident 17 has actual skin impairment r/t (right) trochanter Stage 4 pressure injury identified 11/24/23, follow facility protocols for treatment of injury . and turn and reposition every shift . The turning and repositioning began in January 2024. Observations of Resident 17 were conducted on the following dates and times: 3/18/24 8:20 A.M., Resident was turned on his left side and a soft pillow was placed under his back. A large sign was posted on the wall behind the bed labeled, Turning Schedule, indicating every 2-hour schedule of turning from back-door-window. On 3/18/24 at 10:20 A.M., Resident was turned on his left side and a soft pillow was placed under his back. On 3/18/24 at 12 P.M., Resident was turned on his left side and a soft pillow was placed under his back. On 3/20/24 at 8:41 A.M. a concurrent observation and interview was conducted with the Wound Care Nurse (WCN) 31 during a dressing change. Resident 17 was positioned on his back. The right trochanter pressure injury measured approximately 1.6 centimeters (cm) and had a hole in the center. WCN 31 stated the depth of the wound was not known. There was approximately 4 cm of scar tissue around the wound. WCN 31 stated, It is a facility acquired (developed while the resident was in the facility) pressure injury. We just implemented the turning and repositioning protocol 2 months ago. It was not consistently done prior to that and that contributed to the pressure injury development. He also has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 8 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 multiple co-morbidities. Level of Harm - Actual harm An interview was conducted on 3/20/24 at 10:42 A.M. with WCN 31.WCN 31 stated, The resident developed the right trochanter pressure ulcer on 11/19/23 and was seen by the nurse practitioner one week later and the wound was now a stage 4 pressure ulcer. Residents Affected - Few A review of the Interdisciplinary Team (IDT) Skin Review-Weekly Update dated 11/29/23 was conducted on 3/20/24 at 8:45 A.M. Section II: Wound Management/Pressure Ulcer Review indicated: .Wound location/etiology: right trochanteric/Stage 4 pressure injury Tissue Bed 5x5x0 cm (centimeters), slough 30% with biofilm (70%) Inflammation/Infection: without periwound cellulitis, purulent or pain out of proportion. Moisture: mild serous exudate Edge of Wound normal defined edge Preoperative Indications: Slough, biofilm poor healing. Procedure: debridement (muscle) Operative Note: pain control was achieved by topical 20% benzocaine spray. A curettage debridement technique was employed using a 3mm (millimeter) surgical steel curette. Devitalized muscle tissue was identified and excised until healthy, bleeding tissue was encountered. Hemostasis was achieved with direct pressure. Estimated blood loss was less than 5cc (cubic centimeters) Wound was dressed as described below. Post-op dimension 5x5x1. Dressing used Dakin's solution, gauze apply island dressing . A review of the Turning and Positioning documentation for March 2024 for Resident 17 was reviewed. March turning schedule (1st through 21st, 2024): AM (day) shift - positioned x1 PM (evening) shift - positioned x 1 NOC (night) shift - positioned x 1 From March 1 through March 21, Resident 17 was only turned once per shift. A concurrent interview and record review of the above turning and positioning documentation was conducted on 3/20/24 at 10:20 A.M. with the Director of Nursing (DON). The DON stated, Documentation was not done for night shift. If it is not documented, it is not done. Four things we need for pressure injury prevention are nutrition, treatment, equipment (LAL-low air loss mattress) and doing turning and repositioning. Not turning residents according to the protocol can contribute to the slowing/decline in healing of the pressure injury. An interview was conducted with certified nursing assistant (CNA) 32 on 3/20/24 8:59 A.M. CNA 32 stated he had worked for the facility for 2 months and, Our protocol is to turn residents every 2 hours. An interview was conducted on 3/20/24 at 2:07 P.M. with CNA 33. CNA 33 stated she worked for the facility for two months and We have a turn protocol, it is posted near the bed, and we stick to it. An interview was conducted on 3/20/24 at 2:54 P.M. with CNA 34. CNA 34 stated, Turn protocol only started two months ago. I have been here three months; before that, there was no schedule, it was if we noticed the resident was in the same (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 9 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 position, we would turn them. Level of Harm - Actual harm An interview was conducted on 3/20/24 at 3:32 P.M. with CNA 35. CNA 35 had worked for the facility for six months. CNA 35 stated, We have a turning protocol posted above the patient's bed that tells us what to do and when. It has been in place about one month. Prior to that, it was based on the CNA's knowledge to just do it. Residents (including Resident 17) did not get turned and repositioned every two hours regularly before and that can lead to bed sores. Residents Affected - Few An interview was conducted on 3/21/24 at 1:33 P.M. with the DON. The DON stated, The turning protocol should have always been in place, it is taught in school, but it was started probably around November 2023. January 2024 was when I started pushing it because wounds (facility residents with doucumented pressure injuries including Resident 17 ) were not improving. Staff said they were turning residents, but based on my observations, it wasn't happening, and wounds were not improving. I couldn't tell if they were really turning. As DON, I expected residents to be turned every two hours at least; especially for non-verbal residents. The progression of this ulcer (Resident 17) should have been identified and reported. It is documented that the pressure ulcer was avoidable; if a resident is high risk and not turned, a pressure ulcer would erupt. The turning change implemented two months ago did not help prevent this resident's (Resident 17) injury in November. Also, care plans (all) that say q (every) shift are wrong! That is 8 hours in the same position. 2. Resident 26 was admitted to the facility on [DATE] with diagnoses which included moderate protein calorie malnutrition (a nutritional deficiency that can impact healing), and quadriplegia (inability to move arms and legs independently), and cognitive communication deficit (impairment in the ability to communicate). An observation of the turning schedule posted on the wall at the head of Resident 26's bed indicated 12 AM back. 2 AM door. 4 AM window. 6 AM back. 8 AM door. 10 AM window. noon back. 2 PM door. 4 PM window. 6 PM back. 8 PM door. 10 PM window. Observations of Resident 26 were conducted on the following dates and times: 3/18/24 at 4:35 P.M., Resident 26 was observed in bed on her back with the head of the bed raised to fifteen degrees (a slight incline). According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/19/24 at 11:37 A.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/20/24 at 5:15 P.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her left side facing the window. 3/21/24 at 8:10 A.M., Resident 26 was observed in bed on her back. According to the turning schedule, Resident 26 should have been positioned on her right side. An observation and interview were conducted on 3/20/24 at 11:08 A.M., with the wound care nurse (WCN) during wound care for Resident 26. The WCN stated Resident 26 had a facility acquired pressure injury on her right hip that started as a skin tear from a brief. An interview was conducted on 3/21/24 at 8:13 A.M., with CNA 22. CNA 22 stated all residents should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 10 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 be repositioned every two hours at a minimum. CNA 22 stated, The importance of turning is for the comfort of the residents and to prevent bed sores. Level of Harm - Actual harm Residents Affected - Few An interview was conducted on 3/21/24 at 8:37 A.M., with CNA 23 who stated, In the past couple of months the turning became strict. The importance of the resident of being turned regularly is for good circulation and to make them comfortable and out of pain. If a resident is left in one position too long, they might have skin breakdown and get open wounds. An interview was conducted on 3/21/24 at 10:34 A.M., with the WCN who stated, The sign on the headboard was implemented two months ago. Prior to 2 months ago the turning was hit or miss. (Resident 26's) right hip wound developed in the facility because the brief was too tight and caused a scratch. It happens like this every time because the urine is acidic. Her skin was macerated (a breakdown of skin resulting from prolonged exposure to moisture). Lack of turning was part of the cause. In addition, the WCN stated, Intervention of turn and reposition as tolerated is vague. An interview with the Director of Nursing was conducted on 3/21/24 at 1:36 P.M. regarding Resident 26's position during the above observation times. The DON stated, They always seem to be on their back. A review of the risk for skin breakdown care plan initiated on 10/17/23 for Resident 26 indicated, Turn and reposition as tolerated. Encourage to turn and reposition, provide assistance as necessary. Follow facility policies/ protocols for the prevention/ treatment of skin breakdown. Educate resident, family/ caregivers as to causes of skin breakdown; including: .frequent repositioning. Needs monitoring/ reminding/ assistance to turn/ reposition. Resident 26 could not reposition herself due to her diagnosis of quadriplegia. A review of physician orders dated 2/18/24 for Resident 26 indicated Santyl external ointment 250 unit/ gram (Collagenase) apply to right trochanter topically each day shift for stage 4 pressure injury for 21 days. This was the first physician order related to treatment of the pressure injury. An interview was conducted with the WCN on 3/21/24 at 10:24 A.M. The WCN stated, The right trochanter wound developed in the facility. A review of the facility Interdisciplinary Team (IDT) Care Plan Review dated 3/11/24 was conducted. Resident 26's right hip wound was not mentioned in the IDT document although the existence of the wound was known to the facility and physician who wrote an order for wound care on 2/18/24. A review of the Physician Progress Note dated 3/14/24 indicated Resident 26 had decreased movement of both right and left upper and lower extremities. A review of the Change of Condition (COC) note dated 3/17/24 indicated wound on left groin area. This wound was not present on admission to the facility. A review of the Wound Physician Note dated 3/13/24 indicated Change in Health: Noted sacral wound increased in size.Wound 7: right trochanter stage 3 (a wound in which fatty tissue may be visible) pressure injury. Tissue bed: 11.5 x 10.5 x 0.4 cm (centimeters, a metric unit of measurement). A review of an undated facility policy titled, System: Skin/ Wound Prevention Management Best Practice indicated, frequent turning and repositioning as tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 11 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Actual harm Residents Affected - Few A review of a staff training titled Proper Positioning dated 1/26/24 indicated, Importance of turning every 2 hours and as tolerated. 26 staff members signatures were on the Attendance Record, seven of which were CNAs and one of which was a Restorative Nursing Aid (RNA). An interview was conducted on 3/21/24 at 1:36 P.M., with the Director of Nursing (DON), who stated Turning patients is a typical nursing responsibility, we are taught that in school. My expectation is the staff should turn the residents every 2 hours at least. They always seemed to be on their back. Turning should be automatic. There was no turning protocol prior to January 2024. I said to myself, they say that they're turning their patients so why does it look like they're still in the same positions? If a resident who is high risk for pressure ulcer development is not turned their skin would erupt, it would not stay intact. A review of the facility's undated policy titled Pressure Ulcer Management indicated, .Procedures: 6. Turn and Reposition as tolerated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 12 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Some 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 failed to provide RNA services for six of six residents reviewed (Residents 2, 3,12, 26, 27, 28). This failure had the potential to cause: 1. A reduction in range of motion (ability to move and use joints) for six residents. 2. An increase in contractures due to splints not being used for three residents. Findings: a. Resident 2 was re-admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness and abnormalities of gait and mobility according to the facility's admission Record. A review of Resident 2's Preadmission Screening and Resident Review (PASRR) Level II, dated 12/21/22 indicated Recommended Specialized Services: Physical Therapy Consultation: Services to enhance and restore functional ability and quality of life to those with physical impairments. A review of Resident 2's medical record was conducted on 3/19/24 at 11:10 A.M. Resident 2's undated care plan, titled, has limited mobility r/t weakness indicated : Interventions: Nursing Rehab: RNA to provide AAROM on BUE/BLE QD 4x (times)/week A concurrent interview and record review with RNA 1 was conducted on 3/19/24 at 11:44 A.M. RNA 1 stated, The Resident was resistant to RNA at first but now participates. She has an order for 4x per week. A record review of RNA documentation for March 2024 indicated that the week of 3/4/24, the Resident received only two days of RNA, and the week of 3/11/24, also only two times per week. RNA 1 stated, I didn't do it those weeks, because I got pulled to do another things. It is ordered for 4x per week and it is important because the resident could decline in range of motion (ROM). A concurrent interview and record review with the DOR was conducted on 3/19/24 at 11:57 A.M. The DOR reviewed the RNA documentation for Resident 2 for March 2024. The DOR stated, She only had two times per week because we are having a problem with finding RNA's and sometimes they get pulled to do four hours of CNA work and then four hours of RNA work. An interview was conducted with the DON on 3/21/24 at 3:30 P.M. The DON stated, The RNA's were covering for the CNA's; Residents could lose progress if the RNA is not done; RNA is very important. A review of the facility's undated policy, titled, Restorative Care, indicated, Policy: It is the policy of this facility that: 1. Restorative care will be provided to each resident according to his/her individual needs . 2. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care . 3. Residents restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 13 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Some b. Resident 3 was admitted to the facility on [DATE] with diagnoses that included abnormalities of gait and mobility per the facility's admission Record. A review of Resident 3's medical record was conducted on 3/19/24 at 11:10 A.M. Resident 3's care plan, titled, has limited physical mobility r/t weakness indicated : Interventions: RNA AMB (ambulate) inside parallel bars distance as tolerated with w/c (wheelchair) in tow 4X/week. A concurrent interview and record review with RNA 1 was conducted on 3/19/24 at 11:44 A.M. RNA 1 stated, He has an order for 4x per week. A record review of RNA documentation for March 2024 indicated that the week of 3/4/24, the Resident received only two days of RNA, and the week of 3/11/24, also only two times per week. RNA 1 stated, I didn't do it those weeks, because I got pulled to do another things. It is ordered for 4x per week and it is important because the resident could decline in range of motion (ROM). A concurrent interview and record review with the DOR was conducted on 3/19/24 at 11:57 A.M. The DOR reviewed the RNA documentation for Resident 3 for March 2024. The DOR stated, He only had two times per week because we are having a problem with finding RNA's and sometimes they get pulled to do four hours of CNA work and then four hours of RNA work. An interview was conducted with the DON on 3/21/24 at 3:30 P.M. The DON stated, The RNA's were covering for the CNA's; Residents could lose progress if the RNA is not done; RNA is very important. A review of the facility's policy, undated, titled, Restorative Care, indicated, Policy: It is the policy of this facility that: 1. Restorative care will be provided to each resident according to his/her individual needs . 2. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care . 3. Residents restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department . c. From 3/18/24 through 3/21/24 range of motion exercises and splint applications for Resident 26 was not observed as provided by staff. A review of physician orders for Resident 26 indicated RNA to apply PROME on BUE/BLE in all planes of motion then apply soft hand splints on both hands x4 hrs (four hours) and remove [sic] skin checks and skin breakdown QD 4x/wk. A review of Resident 26's physical mobility care plan indicated Nursing rehab: RNA to apply PROME on BUE/BLE in all planes of motion then apply soft hand splints on both hands x4 [sic] (four days per week) and remove [sic] skin checks. Initiated 3/1/23. There were no other interventions in this care plan. On 3/21/24 at 4:58 P.M., an interview was conducted with the DOR who stated Resident 26 had physician orders to receive RNA services four times per week. The DOR stated, The residents didn't get RNA four times per week because of staffing. A review of the facility records of RNA services provided for Resident 26 indicated six encounters were documented between March 1, 2024 and March 21, 2024. Resident 26 should have had 12 encounters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 14 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 in that time period. Level of Harm - Minimal harm or potential for actual harm A review of the undated facility policy titled Restorative Care indicated, Restorative care will be provided to each resident according to his/ her individual needs and desires as determined by assessment and interdisciplinary care planning. The resident will receive services to attain and maintain the highest possible mental/ physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care. Resident's restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department. Residents Affected - Some d. From 3/18/24 through 3/21/24 range of motion exercises and splint applications for Resident 27 was not observed as provided by staff. A review of Resident 27's physical mobility care plan indicated Nursing rehab: RNA PROME on BUE/ BLE in all planes of motion and apply bilateral soft splints x4 hours on both hands and skin checks before and after application QD x4/wk (week). On 3/21/24 at 4:58 P.M., an interview was conducted with the DOR who stated Resident 27 had physician orders to receive RNA services four times per week. The DOR stated, (Resident 27) didn't get RNA four times per week because of staffing. A review of the facility records of RNA services provided for Resident 27 indicated seven encounters were documented between March 1, 2024 and March 21, 2024. Resident 27 should have had 12 encounters in that time period. A review of the undated facility policy titled Restorative Care indicated, Restorative care will be provided to each resident according to his/ her individual needs and desires as determined by assessment and interdisciplinary care planning. The resident will receive services to attain and maintain the highest possible mental/ physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care. Resident's restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department. e. From 3/18/24 through 3/21/24 range of motion exercises and splint applications for Resident 28 was not observed as provided by staff. A review of Resident 28's physical mobility care plan indicated Nursing rehab: RNA PROME on BLE in all planes of motion, no PROM on both shoulders except elbows, wrist and hands and apply soft splints on bilateral hand x 4 hrs (hours) and remove for skin checks and hygiene before and after application QD 4x/wk. Date initiated 3/8/24. There were no other interventions in this care plan. On 3/21/24 at 4:58 P.M., an interview was conducted with the DOR who stated Resident 28 had physician orders to receive RNA services four times per week. The DOR stated, The resident didn't get RNA four times per week because of staffing. The DOR stated RNA records for Resident 28 could not be located. The DOR stated, If I had the record I would have expected that Resident 28 would have had the same number of services as the other two residents. A review of the undated facility policy titled Restorative Care indicated, Restorative care will be provided to each resident according to his/ her individual needs and desires as determined by assessment and interdisciplinary care planning. The resident will receive services to attain and maintain the highest possible mental/ physical functional status and psychosocial well-being defined by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 15 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Some comprehensive assessment and plan of care. Resident's restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department. f. A review of Resident 12's admission Record indicated Resident 12 was re-admitted to the facility on [DATE] with diagnoses to include a history of traumatic brain injury (happens when a sudden, external, physical assault damages the brain). A record review of Resident 12's MDS (Minimum data set: nursing facility assessment tool) dated 3/5/24 indicated that Resident 12 was rarely or never understood with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. A review of Resident 12's physician's order, dated 6/3/22 indicated, .RNA GENTLE PROME [sic] in all planes of notion on LUE/BLE and apply LUE splint for 4-6 hrs (hours) . On 3/18/24 at 11:28 A.M., an interview was conducted with LN 2. LN 2 stated that Resident 12 used a splint on his left hand due to contractures and had minimal usage of his left lower extremities. LN 2 stated that Resident 12 communicated by nodding head yes or no and could be un-cooperative. On 3/20/24 at 8:13 A.M., an interview was conducted with CNA 1, in Resident 12's room. CNA 1 stated that Resident 12 had contractures on both hands and had limited movement on his legs. CNA 1 stated that he (Resident 12) was on an RNA program to assist with ROM exercises. CNA 1 further stated it was important for residents on the RNA program to prevent the worsening of contractures and maintain their mobility. On 3/20/24 at 8:20 A.M., an interview was conducted with RNA 1. RNA 1 stated that Resident 12 required the use of splints for his left hand for contracture (the shortening of muscles due to lack of movement) management and was on RNA program to get ROM exercises to his LUE and BLE. RNA 1 stated that the Resident 12 did not receive services for his ordered RNA program on 3/6/24, 3/7/24 and 3/13/24 because the facility was short on CNA staff to provide resident care. RNA 1 stated that it was important to provide Resident 12 with his ordered RNA program because Resident 12 has contractures and to prevent the worsening of contractures and to increase his (Resident 12) mobility and overall well-being versus staying in bed all day and not being moved. RNA 1 stated that there was two RNA's for the facility and both get called on the floor when there was a staffing shortage of CNAs. On 3/20/24 at 8:20 A.M., an interview and record review was conducted with the DOR. The DOR reviewed the RNA program list and confirmed that Resident 12 was on a RNA program as ordered by the MD. The DOR stated that it was important to have a RNA program because the program helped the maintenance of mobility with ROM exercises, to prevent the limitation and decline in mobility for all residents on the RNA program. The DOR stated that the RNA's provide gentle LUE, BLE and L hand splints for Resident 12. The DOR also confirmed that Resident 12 did not receive RNA services on 3/6/24, 3/7/24 and 3/13/24 due to CNA shortage. On 3/20/24 at 9:51 A.M., an interview was conducted with LN 1. LN 1 stated RNAs were an important part of the nursing team to provide all residents on RNA with 1:1 exercise and to also motivate residents on the program to not loose their mobility and for some residents to improve mobility as well. LN 1 stated complications for Resident 12 could include the worsening of contractures due to lack of movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 16 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 - Some On 3/20/24 at 11:01 A.M., an interview and a record review was conducted with the DON. The DON stated that his expectations was for any residents with RNA program orders to be followed as ordered by the MD. The DON confirmed that Resident 12 was not provided RNA services on 3/6/24, 3/7/24 and 3/13/24. The DON stated that complications could include the back track [sic] from improvement on mobility and expected that if Resident 12 had orders as stated to be done 4-5 times per week that we [nursing staff] should adhere to those orders. A review of the facility's undated policy and procedure titled Restorative Care, indicated It is the policy of this facility that: 1. Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. 2. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 17 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review, the facility failed to provide enough staff to meet the needs of three of six residents (Resident 26, 27, 28) reviewed for basic nursing care and RNA services. Residents Affected - Few As a result, three residents did not receive RNA services as prescribed by a physician and were not positioned according to the posted facility turning schedule. Cross-Reference F688 Findings: On 3/18/24 through 3/21/24 the position of residents 26, 27 and 28 in their beds was observed as mostly on their backs without position changes every two hours. On 3/21/24 at 10:34 A.M., an interview was conducted with the WCN who stated, The acuity is too high for the number of staff. We try our best to turn and reposition the residents but due to low census the staff get [sic] cut. Full timers have been asked to work double shifts. Being a CNA here is a lot of work, they're running like headless chickens. On 3/21/24 at 1:36 P.M., an interview was conducted with the DON who stated, They (facility staff) say that they're turning their patients so why does it look like they're still in the same positions? They always seemed to be on their backs. On 3/21/24 at 4:58 P.M., an interview was conducted with the DOR who stated Residents 26, 27 and 28 had physician orders to receive RNA services four times per week. The DOR stated, The residents didn't get RNA four times per week because of staffing. The DOR stated RNA records for Resident 28 could not be located. The DOR stated, If I had the record I would have expected that Resident 28 would have had the same number of services as the other two residents. A review of the facility records of RNA services provided for Resident 26 indicated six encounters were documented between March 1, 2024 and March 21, 2024. Resident 26 should have had 12 encounters in that time period. A review of the facility records of RNA services provided for Resident 27 indicated seven encounters were documented between March 1, 2024 and March 21, 2024. Resident 27 should have had 12 encounters in that time period. A review of the facility's staffing waiver dated 7/17/23 indicated .When the facility cannot provide 2.4 certified nurse assistant direct care service hours per day, the facility shall use licensed vocational nurses and/or registered nurses. The facility shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all applicable state and federal staffing requirements . A facility policy regarding staffing based on Resident needs was requested. The facility stated they did not have a written policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 18 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post actual staffing hours for four of four days. Residents Affected - Some This failure resulted in the total number of staff and actual hours worked by staff not accessible to residents and visitors. Findings: An observation of posted projected staffing of RNAs, CNAs, Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs) was conducted on 3/18/24 at 9:20 A.M. No actual staffing hours were posted. An observation of posted projected staffing of RNAs, CNAs, LVNs and RNs was conducted on 3/19/24 at 9:02 A.M. No actual staffing hours were posted. An observation of posted projected staffing of RNAs, CNAs, LVNs and RNs was conducted on 3/20/24 at 7:45 A.M. No actual staffing hours were posted. An observation of posted projected staffing of RNAs, CNAs, LVNs and RNs was conducted on 3/21/24 at 7:55 A.M. No actual staffing hours were posted. An interview was conducted on 3/20/24 at 3:00 P.M., LN 24 who stated, I was not aware that we have to post our actual staffing hours. I did not receive any specific training. An interview was conducted on 3/20/24 at 3:15 P.M., with the Human Resources Specialist (HRS) who stated, Normally I post the actual staffing but the last few days I didn't get it done. A review of the staffing waiver dated 7/17/23 indicated .The facility shall post in a prominent place readily accessible to residents and visitors information about staffing levels that includes the current number of licensed and unlicensed staff directly responsible for resident care . A facility policy regarding posting of actual staffing was requested. The facility stated they did not have a written policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 19 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to document administration of a controlled medication (a medication with a high potential for abuse) on the Controlled Drug Record for three of unsampled residents (12, 20, 37). As a result, there was a potential risk for diversion (theft) of controlled medications. Findings: A random record review was conducted on 3/19/24 of a controlled medication for Residents 12, 20 and 37. On 3/20/24 at 3:25 P.M., an interview and record review were conducted with the DON, Nurse resource and LN 15: a. Resident 37 had a physician order of Tramadol 50 mg give 0.5 tablet via G- tube (gastrostomy/surgical insertion of device to the abdomen for feeding, hydration and medicine) every 6 hours as needed for moderate pain 4-6 and give one tablet via G -tube every 6 hours as needed for severe pain 7-10. Resident 37's Tramadol 50 mg was delivered by facility pharmacy in a bubble pack and dispensed as ½ tablet (25 mg) in each bubble. Resident 37's Tramadol 50 mg: On 3/2/24 at 10 A.M., Tramadol 50 mg, ½ tablet was pulled from the Controlled Drug Record. There was no documentation on 3/2/24 on the MAR. LN 15 stated LNs should have documented in the MAR to indicate Resident 37 really got it (administered to Resident 37). On 3/7/24 at 11:26 A.M., Tramadol 50 mg, ½ tablet mg was pulled from the Controlled Drug Record. The MAR indicated there was documentation of pain level of 7 on 3/7/24 and given ½ (25 mg) tablet. On 3/11/24 at 11:39 A.M., Tramadol 50 mg, ½ tablet was pulled from the Controlled Drug Record. The MAR indicated there was documentation of pain level of 7 on 3/11/24 and given ½ (25 mg) tablet. On 3/12/24 at 9:56 A.M., Tramadol 50 mg, ½ tablet was pulled from the Controlled Drug Record. The MAR indicated there was documentation of pain level of 7 on 3/12/24 and given ½ (25 mg) tablet. b. On 9/28/23, Resident 12 had a physician order of Oxycodone 5 mg, give 5 mg enterally every 4 hours as needed for moderate body pain (4-6) and another physician order of Oxycodone 5 mg, give 10 mg enterally every 6 hours for severe body pain (7-10). Resident 12's Oxycodone 5 mg tablet was delivered by facility pharmacy and with label give one tablet via G tube every 4 hours as needed for moderate pain or two tablets every 6 hours as needed for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 20 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 severe pain. Level of Harm - Minimal harm or potential for actual harm Resident 12's Oxycodone 5 mg: Residents Affected - Some On 8/19/23 at 12 P.M., Oxycodone 5 mg was pulled from Controlled Drug Record. There was no documentation on the MAR on 8/19/23. On 8/24/23 at 6 A.M., Oxycodone 5 mg was pulled from the Controlled Drug Record. There was no documentation on the MAR on 8/24/23. c. On 3/14/24, Resident 20 had a physician order of Lorazepam 2 mg give one tablet by mouth every 4 hours as needed for anxiety for 14 days. Resident 20's Lorazepam was delivered by the facility pharmacy as Lorazepam 0.5 mg, take one tablet by mouth every 6 hours as needed for anxiety. The MAR indicated Resident 20 received Lorazepam 2 mg by mouth every 6 hours as needed for anxiety on 11/15/23, 11/17/23, 11/23/23 and 12/1/23. There was no documentation on Resident 20's Controlled Drug Record to indicate Lorazepam 2 mg was pulled out on 11/15/23 (11/15/23 was struck out), 11/17/23 and 11/23/23. During this interview and record review with the DON, Resource nurse and LN 15. The DON stated for Resident 37 and Resident 12, LNs should document on both the Controlled Drug Record and MAR. The DON stated Resident 37's and Resident 12's Controlled Drug Record should match Resident 37's and 12's MAR respectively.The DON stated documentation on Resident 37's and Resident 12's Controlled Drug Record indicated the medication was pulled out and documentation in Resident 37's and 12's MAR indicated Resident 37 and Resident 12 actually received the medication. The DON stated for Resident 37 and Resident 20, LNs did not follow the physician's order and given the wrong dose. The Controlled Drug Record did not match the Resident 20's MAR. Resource nurse stated would ask facility pharmacy to separate the medications for moderate and severe pain. Per the undated facility policy entitled Section: Nursing Services Subject: Physician Orders indicated .7. Administer all medications as ordered. Per the undated facility policy entitled Section: Medication Administration Subject: Medication Administration and Storage indicated .2. Review and verify MD orders and follow 6 Rights of Medication Administration . Per the undated facility policy entitled 'Section: Medication Administration Subject: Controlled MedicationsStorage and Reconciliation indicated .6. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: Date and time of administration .Amount of administered .Signature of the nurse administering the dose, completed after the medication is actually administered . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 21 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 6.45%. Two medication errors were observed out of 31 opportunities, during the medication administration process for two of three randomly observed residents (Resident 3, 17, 39). Residents Affected - Few As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 03/19/2024 at 10:18 A.M., an observation of medications administration was conducted with LN 11. LN 11 prepared and administered medications to Resident 39, which included Ivermectin (drug to prevent scabies caused by mites) by mouth. LN 11 administered three (3) tablets of Ivermectin 3 mg per tablet. On 03/21/2024 a medication reconciliation for Resident 39 was conducted. Per the physician order, dated 3/5/24 listed Ivermectin oral tablet, give 15 mg by mouth in the morning starting on the 6th and ending on the 20th for prophylactically [sic] until 3/20/24. Give on March 6, 7, 10, 14 and 20, 2024. The facility had Ivermectin oral tablet available in 3 mg tablet form. On 3/19/24 at 10:40 A.M., an observation and interview was conducted with LN 11. LN 11 administered medications to Resident 39, including three tablets of Ivermectin 3 mg per tablet. On 3/21/24 at 10:55 A.M., a concurrent observation, interview and record review was conducted with LN 12. LN 12 stated the Ivermectin delivered by the pharmacy had one remaining 3 mg tablet. The Ivermectin pharmacy package label indicated Resident 39's name, Ivermectin 3 mg tablet, give 5 tablets by mouth in the morning on 14th and 20th. LN 12 stated the pharmacy package label indicated 10 each which meant ten tablets was delivered. LN 12 stated five tablets should have been given to follow physician's order of 15 milligrams. On 3/21/24 at 3: 45 P.M., an interview and record review was conducted with the DON and Nurse resource. The DON stated LN 11 was not working today. The DON stated he called LN 11 and confirmed LN 11 gave only three tablets of Ivermectin 3 mg per tablet. The DON stated LN 11 should have given five tablets to make the correct dose of 15 milligrams of Ivermectin per the physician order. 2. On 3/20/24 at 9:40 A.M., an observation of medications administration was conducted with LN 13. LN 13 prepared and administered medications to Resident 17 which included Vitamin C. LN 13 administered a half tablet of Vitamin C. Vitamin C was a house supply available in 500 milligram tablet. On 3/21/24, a medication reconciliation was conducted. Resident 17 had a physician order of, ascorbic acid (Vitamin C) give two tablets of 250 mg enterally every 12 hours for iron absorption and wound management. On 3/21/24 a review of Resident 17's admission Record indicated Resident 17's diagnoses to include anemia (a decrease in red cells carrying oxygen to a person's body) On 3/21/24 at 10:45 A.M., an interview and record review was conducted with LN 13. LN 13 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 22 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 Resident 17's physician order was 500 mg of Vitamin C. LN 13 she should have given 500 mg Vitamin C. Level of Harm - Minimal harm or potential for actual harm On 3/21/24 at 3:57 P.M., an interview and record review was conducted with the DON. The DON stated LNs should follow the physician order and administer the correct dose. Residents Affected - Few Per the undated facility policy titled Section: Nursing Services Subject: Physician Orders indicated .7. Administer all medications as ordered . Per the undated facility policy titled Section: Medication Administration Subject: Medication Administration and Storage indicated .2. Review and verify MD orders and follow 6 Rights of Medication Administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 23 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 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. Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Some 1. Medications were stored and labeled according to the manufacturer's specifications and policy. 2. Medications were disposed appropriately. As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: 1. The respiratory cart (RT cart/medication cart for inhalers) was inspected with RT 11 on 3/20/24 at 1:48 P.M. Resident 2's Levalbuterol 0.63 mg/3 ml solution (medication to help breathing) had a date written 2/28/24. RT 11 stated date written 2/28/24 was the date medication was opened. RT 11 stated Levalbuterol inhalation should be thrown away and order a new one. According to the manufacturer's specifications written on foil pouch, .Once the foil pouch is opened, the vials should be used within two weeks . 2. On 3/20/24 at 3:02 P.M., an inspection of medication room (med room) was conducted with LN 15 and LN 16. There were objects that look like pills, loosed particles and unidentified debris on the floor in the medication room. LN 15 picked up about 6 1/2 medications on the floor. LN 16 verified the 6 ½ pills on the floor. LN 16 stated LNs should dispose the medications properly on the medication disposal bin to prevent someone diverting the medications. LN 16 stated the medication room should be cleaned more often. On 3/21/24 at 4:17 P.M., an interview was conducted with the DON. The DON stated the LNs should be careful, to check their surroundings and check the floor for any medications to prevent other persons getting the medications on the floor. The DON stated we do not know what medications were on the med room floor. The DON stated the med room should contain only stock medications. Per the undated facility policy entitled Section: Medication Administration Subject: Medication, Destruction of -CA indicated .It is the policy of this facility to establish uniform guidelines concerning the destruction of medications safely and effectively . 3. Pharmaceutical waste shall be placed in a sturdy container . Per the undated facility policy entitled Section: Medication Administration Subject: Medication Administration and Storage indicated .It is the policy of this facility to .ensure the proper and safe storage of drugs and biologicals . 4. Drugs and/or biologicals should not be left unsecured/unattended . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 24 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and document review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) when: Residents Affected - Some - The facility's pressure injury (a localized damage to the skin and underlying soft tissue usually over a bony area) data was not analyzed to identify trends. - A root cause analysis (a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems) was not attempted to identify cause of acquired pressure injuries in the facility. (Refer to F 686, F 725) Findings: An interview with the Administrator (ADM), Director of Nursing (DON), and facility consultant (FC) 1 and FC 2 was conducted on 3/21/24 at 6:01 P.M. to discuss the facility QAPI projects. The DON, the ADM, and FC 1 stated that pressure injury was one of the items being reviewed in the facility QAPI. The DON stated that he met with the wound physician and nurse practitioner around November or December of last year to discuss the increase of pressure injury in the facility. The facility was asked to verbally provide the survey team their pressure injury data that were discussed during their QAPI meetings to determine the facility trends and action plan taken by the facility. The facility was not able to provide the survey team with data that were discussed during QAPI meetings and action plans taken to address identified concerns. The DON stated that sufficient staffing was not looked at or discussed as a probable cause of the increased in facility acquired pressure injury. The DON stated complete analysis of the pressure injury concerns was not conducted. The DON stated that root cause analysis should have been completed to identify the possible causes of the increased incidents of facility acquired pressure injury. A review of the facility's undated 2024-2025 Quality Assurance and Performance Improvement (QAPI) Plan indicated, . A. Our facility uses systemic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. B. Our facility applies a thorough and highly organized/structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. C. Our facility's approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. D. Our facility also has developed policies and procedures regarding expectations for the use of root cause analysis when problems are identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 25 of 26 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 555871 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to designate one or more individuals with specialized training (prior to assuming the role of the Infection Preventionist) in Infection Prevention and Control who are responsible for the facility Infection Control Program. This failure had the potential to cause a decline in Infection Control practices in the facility. Findings: An interview was conducted on 3/20/24 at 7:50 A.M. with the IP. The IP stated he was also the DSD. The IP further stated, I have taken the Center for Disease Control (CDC) on-line course but I have not taken the test and so, I don't have a credential. I was also scheduled to take the San Diego County Infection Control (IC) training this week, but had to cancel. In addition, the facility was not able to provide any proof of specialized IC training for the IP. An interview was conducted on 3/21/24 at 3:42 P.M. with the DON. The DON stated, We need a full time IP because there is a lot to do and coordinate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555871 If continuation sheet Page 26 of 26