San Diego Post-acute Center

F-F804

A joint interview on 2/27/25 at 2:27 P.M., with the Administrator (ADM) and the Acting Director of Nursing (aDON) was conducted .The ADM stated they were not aware of the call light issues and food concerns. The ADM stated the expectation was the QAA committee should have identified the trends in the facility prior to being identified by the surveyors.

A joint interview on 2/27/2025 at 2:27 P.M., with the ADM and the DON was conducted. The DON stated it was important to identify the residents food concerns to provide the highest quality of life for all residents in

the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 555659 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555659 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Diego Post-Acute Center 1201 South Orange 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40610 potential for actual harm Based on observation, interview, and record review the facility failed to ensure infection control procedures Residents Affected - Few were followed when a Licensed Nurse (LN) 12 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves while passing medications (meds) during medication pass observation for 2 residents (Residents 141, 22).

This failure had the potential for cross contamination and spread of infection between the residents.

Findings:

1. A review of Resident 141's Admission Record indicated Resident 141 was readmitted to the facility on [DATE REDACTED], with diagnoses which included functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord) and she had a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings/ meds to be administered directly to the stomach common for people with swallowing problems).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 555659 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555659 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Diego Post-Acute Center 1201 South Orange 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 0880 On 2/26/25 at 7:46 A.M., an observation and an interview were conducted of Licensed Nurse (LN) 12 prepared medications for Resident 141. LN 12 stated she had been observed before. LN 12 put gloves on, Level of Harm - Minimal harm or crushed Resident 141's medications and placed each med in a med cup. LN 12 removed gloves and did not potential for actual harm perform hand hygiene. Upon entering Resident 141's room, LN 12 picked up an alcohol swab from the floor, put on a gown and put gloves on without performing hand hygiene. With gloved hands, LN 12 went to Residents Affected - Few Resident 141's bathroom and filled the empty cups with water from the bathroom sink. After coming out from

the bathroom, LN 12 pulled the privacy curtain with gloved hands, retrieved two small boxes of facial tissue from another staff member, proceeded with the task, disconnected the tube feeding from Resident 141's g-tube, checked Resident 141's g-tube placement, placed the 60 ml syringe to Resident 141's g-tube. LN 12 then flushed the g-tube with water, administered the orange liquid meds, flushed with water. While the orange liquid meds and the water were being administered through gravity, LN 12 put some water to the crushed med from another med cup, administered the crushed med in Resident 141's g-tube, and flushed with water. This time, the meds and the water did not go through the g-tube through gravity, LN 12 then pushed the med with the plunger, the meds and the water still did not go through. LN 12 aspirated the water from the syringe, placed the water from the syringe back to the plastic cup. LN 12 stated Resident 141's g-tube was clogged. LN 12 removed gown and gloves asked another staff member to get some ointment for Resident 141. LN 12 then put on a new pair of gloves and gown without performing hand hygiene. LN 12 then milked (compressing the tube with the fingers and moving them along the course of the tube) the tube towards the resident with an ointment. LN 12 removed her gloves, then put on a new pair without performing hand hygiene, put the syringe back to the g-tube. LN 12 removed a small amount of administered crushed meds from the small tube of the gtube. LN 12 removed her gloves, put a new pair of gloves without performing hand hygiene. LN 12 then received a declogger (a safe, flexible threaded device that bores through occlusions to quickly restore nutrition and medication to patients with obstructed enteral tube) from another staff member, placed the declogger into Resident 141's g-tube and LN 12 maneuvered back and forth to the g-tube, then flushed the g-tube with water, until the water went through with gravity. LN 12 was not consistent in performing hand hygiene during the med pass observation.

On 2/26/25 at 10:56 A.M., an interview was conducted with LN 12. LN 12 stated she was not consistent in performing hand hygiene during the med pass. LN 12 stated it was important to perform hand hygiene during med pass for infection control.

On 2/27/25 at 9:22 A.M., a joint interview with the acting Director of Nursing (aDON) and the Assistant DON (ADON) was conducted. The ADON stated the expectation was for LN 12 to perform hand hygiene in between tasks to prevent infection to the resident.

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2. Per the facility's admission record, Resident 22 was admitted on [DATE REDACTED] with diagnoses that included epilepsy (brain disorder characterized by recurrent, unprovoked seizures) and encephalopathy (general dysfunction of the brain).

On 2/26/25 at 8:24 A.M., an observation and an interview were conducted of Licensed Nurse (LN) 21's preparation and administration of medications for Resident 22. LN 21 prepared Resident 22's into a medication cup. LN 21 then knocked on Resident 22's door, identified the resident, explained the procedure to the resident and administered the mediations. LN 21 then came out of the room and performed hand hygiene. LN 21 stated she was finished administering medication to Resident 22. LN 21 was observed not performing hand hygiene prior to administering medications to Resident 22.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 555659 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555659 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Diego Post-Acute Center 1201 South Orange 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 0880 On 2/26/25 at 8:44 A.M., an interview was conducted with LN 21. LN 21 stated she did not perform hand hygiene prior to administering medications to Resident 22. LN 21 stated it was important to perform hand Level of Harm - Minimal harm or hygiene to prevent the spread of infection. potential for actual harm

On 2/27/25 at 9:22 A.M., a joint interview with the acting Director of Nursing (aDON) and the Assistant DON Residents Affected - Few (ADON) was conducted. The ADON stated it is their expectation that all nurses perform hand hygiene prior to administering medications.

A review of the facility's policy titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe .manner .25. Staff follows established facility infection control procedures (e.g. handwashing .gloves .) for the administration of medications .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 555659 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555659 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Diego Post-Acute Center 1201 South Orange 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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 43518 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure water from the dishwashing Residents Affected - Few sink drained appropriately onto the drain hole.

This failure had the potential for accidents in the dishwashing area and a preventable flooding of the kitchen.

Findings:

On 2/25/25 at 8:45 A.M. a concurrent observation of dishwashing area and interview with Dietary Aide (DA) was conducted. While DA described the process for washing dishware, water was observed to be draining directly onto the floor beneath the dishwasher sink from the sink pipe and not directly into the drain hole. DA stated that he was not sure how long the water had been draining onto the floor. DA stated that the expectation was the drain water should empty directly into the drain hole and not onto the kitchen floor. DA stated the importance of functioning equipment was for safety of staff washing dishes, as they could slip on

the water.

On 2/25/25 at 8:50 A.M., a concurrent observation of dishwashing drainpipe and interview with the Dietary Manager (DM) was conducted. The DM stated he was not sure how long the pipe had been draining on the floor, and manually adjusted the pipe so it was emptying into the drain hole.

On 2/26/25 at 9:20 A.M., an interview with the DM was conducted. The DM stated that the expectation was that the dishwashing sink should drain directly into the drain hole and not onto the kitchen floor. The DM stated that importance of a working drainpipe, was to prevent staff from slipping on the floor.

Review of facility dietary policy titled ACCIDENT PREVENTION-SAFETY PRECAUTIONS, dated 2023, indicated .FALL PREVENTION PRACTICES .Keep floors clean, dry, and free of obstructions .BACKFLOW PREVENTION/AIR GAPS .equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 555659