Health inspection·December 16, 2022

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based in interview and record review, the facility failed to obtain an informed consent from the resident's representative prior to the use of an antipsychotic medication (a class of drug that helps decrease symptoms like hallucinations, delusions and disordered thinking associated with psychiatric illness) for one of 5 residents (Resident 324) reviewed for consents. Residents Affected - Few This failure resulted in the resident (Resident 324) receiving an antipsychotic medication without the resident or resident representative being informed of the risks and benefits of the medication and prescribed treatment. Findings: A review of Resident 324's Record of admission on [DATE] indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a disease that affects the brain's ability to think, remember and reason) with behavioral features, and weakness following an acute care hospital admission for a recent mechanical fall and fracture of the right ankle. A review of Resident 324's physician order titled, Antipsychotic Medication Order, dated 12/5/22, indicated an order of, Seroquel (antipsychotic medication) 25 mg (milligrams) po (oral) QHS (every night at bedtime) prn (as needed) x 14 days then reassess. The order indicated that the placement of the order was due to episodes of agitation, related to behavioral manifestation secondary to encephalopathy, as evidenced by angry outbursts and getting out of bed unassisted. A review of Resident 324's history and physical, dated 12/9/22, indicated a diagnosis of dementia with behavioral features with a plan cont. Seroquel 25 mg po qhs prn agitation. A review of Resident 324's Medication Administration Record (MAR) indicated the resident was administered Seroquel during the evening shift (3pm-11pm) on 12/7/22, 12/8/22, 12/12/9/22, 12/10/22, 12/11/22, 12/13/22, 12/14/22. The MAR indicated the Seroquel was discontinued on 12/16/22. During a telephone interview with Resident 324's representative (RR), on 12/15/22, at 10:04 A.M., the RR stated that a nurse from the facility called her around 11:00 P.M., on the day after of Resident 324's admission [DATE]), stating that Resident 324's behavior was erratic. During the interview, the RR explained that the nurse asked the RR for consent to give Resident 324 a medication (Seroquel) to treat the erratic behavior. The RR stated she did not know the name of the medication Resident 324 was given. LN 34 stated she was not informed about the risks and benefits of the medication or the length of time Resident 324 would be on the medication. Page 1 of 38 555216 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with Licensed Nurse (LN 43) on 12/15/22, at 3:08 P.M., LN 43 stated she took a telephone order from the medical doctor (MD1) for Seroquel 25 mg po QHS prn x 14 days. LN 43 stated she called Resident 324's RR and explained to the RR that Resident 324 was agitated and getting out of bed. LN 43 stated she explained to the RR that the facility would like the RR's consent to give a medication to Resident 324 that would help decrease the resident's agitation and anxiety. LN 43 stated she filled out the consent form titled, Informed Consent to Receive Psychotropic Medication for the Seroquel 25 mg po QHS prn. LN 43 stated she did not confirm that MD1 obtained informed consent from the from the RR prior to completing the form. During an interview with MD1 on 12/16/22, at 10:43A.M., MD1 stated he spoke with LN 43 about Resident 324's agitation and behavior the evening the Seroquel was ordered and confirmed he gave the telephone order for to LN 43 Seroquel 25 mg po QHS prn x 14 days on 12/5/22. MD1 stated that he did not obtain informed consent from Resident 324's RR. A review of the facility's Informed Consent P&P, dated 07/5/22, defines 'Consent Form' as, a form which does not provide the actual Informed Consent, but which when signed by the patient/legal representative verifies that Informed Consent was obtained by the physician, and confirms that the patient has had an opportunity to have all his/her questions answered and wishes to proceed with the procedure. The P&P defined informed consent as, A process whereby the physician explains to the patient the nature of the treatment, the risks, possible complications and expected benefits or the effects of the treatment, as well as alternatives to treatment and their risks and benefits. After the patient is allowed to asked questions and understands the information to his/her satisfaction, he/she gives the physician 'informed consent. The P&P also indicated, The hospital may not permit treatment, unless the patient or person legally authorized to act on the patient's behalf, has consented to the treatment. 555216 Page 2 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 one resident (Resident 324) was free from physical restraint when a Geri-Chair (a chair with the ability to recline and designed to promote comfort) was used to stop the patient from getting up and restricted the resident's mobility. Residents Affected - Few These deficient practices had the potential to cause physical harm to Residents 324. Findings: A review of Resident 324's Record of Admission, indicated the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a disease that affects the brain ' s ability to think, remember and reason) with behavioral features, and weakness following an acute care hospital admission for a recent mechanical fall and fracture of the right ankle. A review of Resident 324's Minimum Data Set (MDS, a clinical assessment tool), dated 12/4/22, indicated Resident 324's needed extensive assistance and a two-person physical assist to transfer (move between surfaces) to or from: bed, chair, wheelchair, standing position. A review of Resident 324's Brief Interview and Mental Status (a screening tool to assess mental functioning) in the MDS, indicated severe cognitive impairment. A record review of Resident 324's [NAME] Fall Risk Criteria (a tool that determines a resident's risk of falling), dated 12/4/22, indicated a score of seven (7) for Resident 324 on admission. According to the [NAME] Fall Risk guidelines, a score of 3 or > indicated a resident was at high risk for falls. A record review of Resident 324's Safety Assessment Information Consent, dated 12/4/22, indicated Resident 324 was confused, impulsive, with episodes of getting up unassisted. During an observation on 12/13/22, at 12:20 P.M., Resident 324 was seen seated in a wheelchair facing the nursing station. During this observation, Resident 324 made multiple attempts to stand up from his wheelchair. A boot on Resident 324's right foot was visible during this observation. During the observation, staff approached Resident 324 and Resident 324 stated, stay away and I'm going home. A record review of the Nursing Assessment narrative notes, dated 12/13/22, at 12:30 P.M., indicated Resident 324 was alert but confused and had repeated episodes of being impulsive and getting up unassisted. Further review of the nursing narrative notes, dated 12/13/22, at 5 P.M., indicated that Resident 324 was up in chair and was not showing signs of distress, pain, discomfort or agitation but continued getting up unassisted. The following nursing narrative note dated 12/13/22, at 6 P.M., indicated, received new order from MD: Geri-chair for comfort & positioning, not a restraint. A record review of the interdisciplinary notes on Resident 324's Safety Assessment Information Consent form, indicated, Geri-Chair ordered for positioning & comfort on 12/13/22, at 6 P.M. A record review of physician orders, dated 12/13/22, at 6 P.M., indicated an order for Geri-chair for comfort & positioning (not a restraint) was obtained by telephone from MD 41 from licensed nurse (LN 43). 555216 Page 3 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 324's certified nursing assistant (CNA 41) on 12/14/22, at 3:59 P.M., CNA 41 stated, Resident 324 has dementia and gets confused. CNA 41 stated, yesterday (12/13/22), Resident 324 was bad about getting up. CNA 41 stated, he believes Resident 324 has anxiety because Resident 324 says he wants to go home. CNA 41 stated they tried to put him in a Geri-chair yesterday (12/13/22) but that Resident 324 tried to continue to get up from the chair. CNA 41 stated, the Geri-chair is a long chair that helps to prevent falls. CNA 41 stated that the resident did not seem to have an issue sitting in the wheelchair. During a concurrent observation and interview with Licensed Nurse (LN 41) on 12/15/22, at 2:30 P.M., Resident 324 was observed sitting in the hallway in a wheelchair near the nurse's station. LN 41 stated, Resident 324 did not seem to be uncomfortable sitting in the wheelchair. During an interview with LN 43 on 12/15/22, at 3:08 P.M., LN 43 stated she was the nurse who obtained the telephone order for the Geri-Chair on 12/13/22. LN 43 stated the reason she requested the order from MD 41 was because Resident 324 was repeatedly trying to get up. LN 43 stated Resident 324 did not complain of any discomfort when seating in the wheelchair. During an interview with the Director of Nursing (DON), on 12/16/22, at 2:01 P.M., the DON was informed of the order and use of the Geri-Chair to keep Resident 324 from getting up on 12/13/22. The DON stated she was not aware of the use of the Geri-Chair for Resident 324 and the Geri-chair should not have be used as a restraint. A review of the facility's policy and procedure (P&P) Restraints - Physical (In Sub Acute/Long Term Care), dated 6/3/20, defines physical restraints as, any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body. Use of a physical or mechanical device to involuntarily restrain the movement of the whole or a portion of a patient's body for the reason of controlling his/her physical activities in order to protect him/her or others from injury. Under section V.C.3(c) Restraint Type of the P&P, the policy lists, a Geri chair as a restraint and attempting to get out of chair as an example this type of restraint could be ordered. 555216 Page 4 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff reported to the facility's administration and to other agencies, including the California Department of Public Health (CDPH- the State Survey and Certification Agency) an injury of unknown origin as potential abuse for one of 18 resident (13) when Resident 13, a vulnerable resident who could not explain what happened, had bruising and swelling of his left eye. This deficient practice had the potential for incidents of abuse to go unreported and for residents to be unprotected from abuse. Findings: A review of Resident 13's face sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 13's History and Physical exam dated 5/29/22, indicated the resident had dementia (a group of thinking and social skills that interferes with daily functioning and is characterized by memory loss) with behavioral features. The document also indicated Resident 13 was receiving hospice care (end of life care). A review of Resident 13's Minimum Data Set Assessment (an assessment tool) dated 10/30/22, indicated the resident scored 6 out of 15 on the brief interview of mental status (a score of 6 indicated the resident was cognitively impaired). The MDS further indicated the resident required extensive assistance provided by one staff for bed mobility and required total assistance provided by one staff for performing activities of daily living (self-care activities such as grooming, eating, and toileting). On 12/14/22 at 9:16 A.M., an observation was conducted with Resident 13 while he was being brought to the shower room. Resident 13 was observed with bluish discoloration underneath his left eye that went from the inner eye and extended to the outer eye. A review of Resident 13's nursing notes dated 11/30/22 and authored by licensed nurse (LN) 1, indicated, Noted ecchymosis [bruising] on L [left] inner canthus of his eye: blackish bluish in color and slightly swollen. Per hospice nurse he [Resident 13] might have inflicted it himself LN 1 was not available for interview. On 12/14/22 at 9:46 A.M., an interview was conducted with hospice certified nursing assistant (HCNA). The HCNA stated Resident 13 was confused and seemed anxious at times. The HCNA stated he noticed bruising near Resident 13's left eye about two weeks ago and had reported it to the facility's charge nurse. The HCNA stated he could not recall the charge nurse's name. The HCNA stated Resident 13 had been unable to tell him what had happened to his eye. On 12/16/22 at 9 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she provided the staff with abuse prevention training. The DSD stated Resident 13 was confused and was not a reliable historian. The DSD reviewed Resident 13's 555216 Page 5 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical record and nursing note dated 11/30/22. The DSD stated bruising and swelling around a cognitively impaired resident's eye would be considered suspicious and that it was an injury of unknown origin. The DSD stated an injury of unknown origin should be treated as potential abuse. The DSD stated Resident 13's eye injury was a reportable injury. The DSD stated as a mandated reporter, LN 1 should have reported Resident 13's eye injury up the chain of the facility's administration immediately on 11/30/22 when it was first brought to her attention. The DSD stated the facility's administration would have then reported the incident to other agencies including CDPH. The DSD reviewed Resident 13's clinical record and stated there was no documentation that the resident's eye injury on 11/30/22 had been reported to the facility's administration or to other agencies. The DSD stated timely reporting of suspicious injuries was important in order to safeguard residents from abuse. The DSD further stated the facility did not have an abuse preventionist/coordinator and that everyone in the leadership position was considered the abuse preventionist/coordinator. On 12/16/22 at 9:15 A.M., an interview was conducted with clinical nurse lead (CNL) 1 who was in charge of Resident 13's unit. The DSD was also present. CNL 1 stated she had not been aware of the injury to Resident 13's left eye. CNL 1 stated the bruising around Resident 13's eye should have been reported to the facility's administration starting with the CNL. On 12/16/22 at 10 A.M., an interview was conducted with the director of nursing (DON). The DON stated the facility did not have an abuse preventionist/coordinator, and that the expectation was for staff to report allegations of abuse or injuries of unknown origin first to the CNL. The DON stated it could also be reported to the DON and clinical manager (CM). On 12/16/22 at 10:04 A.M., a joint interview and record review was conducted with CNL 2. CNL 2 stated she was also in charge of Resident 13's unit. CNL 2 stated she had not been aware of the injury to Resident 13's eye. CNL 2 stated Resident 13's eye injury was a reportable injury and that LN 1 should have reported up the chain of the facility's administration. CNL 2 stated, This did not happen to my expectation. CNL 2 further stated there was no documentation the registered nurse had done a complete assessment of Resident 13's eye injury on 11/30/22. CNL 2 stated this should have been done. On 12/16/22 at 10:26 A.M., an interview was conducted with LN 2. LN 2 stated if one of her cognitively impaired residents had bruising and swelling around the eye, she would investigate it herself and then decide it it was reportable. LN 2 was not able to verbalize that an injury of unknown origin would have been areportable incident as potential abuse. On 12/16/22 at 2:48 P.M., a joint interview was conducted with the DON and CM. The DON and CM both stated Resident 13 was cognitively impaired and the resident's eye injury was considered a reportable injury. The DON stated LN 1 should have reported the incident to the facility administration on 11/30/22 as potential abuse. The DON stated the facility administration would have then reported the incident to the various agencies including CDPH. On 12/16/22 at 3:22 P.M. a joint interview and review of facility documents was conducted with the DSD. Staff in-services related to abuse training were reviewed, including LN 1 and LN 2's attendance during the in-services. An undated lesson plan titled Dependent Adult & Elderly Abuse Prevention (Patient's Perspective) Prompt Reporting and Investigation Process/Resident Rights was reviewed. The DSD stated she utilized the lesson plan during the abuse in-services. The lesson plan did not include the facility's internal chain of reporting and did not include injuries of unknown origin as topics. The DSD stated those topics were not on the lesson plan, but that she did include them during the training. The DSD stated, I tell them [staff] report anything unusual. The DSD stated anything 555216 Page 6 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0609 unusual meant everything even a skin tear. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Abuse- Reporting of Elder and Dependent Adult, 01828.99, revised 7/15/20, indicated, . Possible indicators of adult abuse . Bruises, welts, discolorations, swelling, .injury is unexplained . all mandated reporters are responsible to immediately report abuse to the authorities as specified below and further are to refer the matter to Social Work for follow up . 6. If the suspected abuse does not result in serious bodily injury, a mandated reporter makes a report by telephone and in writing within 24 hours of the reporter observing, obtaining knowledge of, or suspecting the physical abuse, as specified Residents Affected - Few A review of the facility's policy titled Elder Abuse- Identification & Reporting, 39600.99, revised 12/12/18, indicated, . Any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source . shall be reported immediately to the facility administration and other officials in accordance with state law . will be investigated immediately by the supervisor and the facility's administrator, DON, or designee . The results of all investigations will be reported to the administration or designee and to other officials in accordance with state law (including to the State Survey and Certification Agency [California Department of Public Health]) 555216 Page 7 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0610 Respond appropriately to all alleged violations. 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 investigate one of 18 residents' (13) injury of unknown origin as potential abuse when Resident 13, a vulnerable resident who could not explain what happened, had bruising and swelling of his left eye. Residents Affected - Few This deficient practice had the potential for residents to experience abuse. Findings: A review of Resident 13's face sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 13's History and Physical exam dated 5/29/22, indicated the resident had dementia (a group of thinking and social skills that interferes with daily functioning and is characterized by memory loss) with behavioral features. The document also indicated Resident 13 was receiving hospice care (end of life care). A review of Resident 13's Minimum Data Set Assessment (an assessment tool) dated 10/30/22, indicated the resident scored 6 out of 15 on the brief interview of mental status (a score of 6 indicated the resident was cognitively impaired). The MDS further indicated the resident required extensive assistance provided by one staff for bed mobility and required total assistance provided by one staff for performing activities of daily living (self-care activities such as grooming, eating, and toileting). On 12/14/22 at 9:16 A.M., an observation was conducted with Resident 13 while he was being brought to the shower room. Resident 13 was observed with bluish discoloration underneath his left eye that went from the inner eye and extended to the outer eye. A review of Resident 13's nursing notes dated 11/30/22, indicated, Noted ecchymosis [bruising] on L [left] inner canthus of his eye: blackish bluish in color and slightly swollen. Per hospice nurse he [Resident 13] might have inflicted it himself On 12/14/22 at 9:46 A.M., an interview was conducted with hospice certified nursing assistant (HCNA). The HCNA stated Resident 13 was confused and seemed anxious at times. The HCNA stated he noticed bruising near Resident 13's left eye about two weeks ago and had reported it to the facility's charge nurse. The HCNA stated he could not recall the charge nurse's name. The HCNA stated Resident 13 had been unable to tell him what had happened to his eye. On 12/16/22 at 9 A.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated she provided the staff with abuse prevention training. The DSD stated Resident 13 was confused and was not a reliable historian. The DSD reviewed Resident 13's clinical record and nursing note dated 11/30/22. The DSD stated bruising and swelling around a cognitively impaired resident's eye would be considered suspicious and that it was an injury of unknown origin and should be treated as potential abuse. The DSD stated investigating Resident 13's injury of unknown origin would safeguard the resident and other residents and ensure abuse was not occurring within the facility. The DSD stated Resident 13's injury of unknown origin to his left eye on 11/30/22 had not been investigated by the facility and it should have been. 555216 Page 8 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/16/22 at 9:15 A.M., an interview was conducted with clinical nurse lead (CNL) 1 who was in charge of Resident 13's unit. The DSD was also present. CNL 1 stated she had not been aware of the injury to Resident 13's left eye. CNL 1 stated the bruising around Resident 13's eye required a thorough investigation into the incident. CNL 1 stated this should have been done to make sure there was not abuse. On 12/16/22 at 10:04 A.M., a joint interview and record review was conducted with CNL 2. CNL 2 stated she was also in charge of Resident 13's unit. CNL 2 stated she had not been aware of the injury to Resident 13's eye. CNL 2 stated a thorough investigation into the incident to make sure abuse had not occurred should have been done. CNL 2 stated, This did not happen to my expectation. On 12/16/22 at 2:48 P.M., a joint interview was conducted with the director of nursing (DON) and clinical manager (CM). The DON and CM both stated Resident 13 was cognitively impaired and the resident's eye injury should have been thoroughly investigated starting when staff noticed the injury on 11/30/22. The DON and CM both stated an investigation into the incident had not taken place. A review of the facility's policy titled Abuse- Reporting of Elder and Dependent Adult, 01828.99, revised 7/15/20, indicated, . Possible indicators of adult abuse . Bruises, welts, discolorations, swelling, .injury is unexplained . A review of the facility's policy titled Elder Abuse- Identification & Reporting, 39600.99, revised 12/12/18, indicated, . Any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source . shall be reported immediately to the facility administration and other officials in accordance with state law . will be investigated immediately by the supervisor and the facility's administrator, DON, or designee . The results of all investigations will be reported to the administration or designee and to other officials in accordance with state law (including to the State Survey and Certification Agency [California Department of Public Health]) 555216 Page 9 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 13's face sheet indicated the resident was admitted to the facility on [DATE]. Residents Affected - Few On 12/13/22 at 10:16 A.M., an observation of Resident 13 was conducted while inside the resident's room. Resident 13 was in bed, and was observed to have long fingernails on both hands. There was gray matter underneath Resident 13's fingernails. On 12/13/22 at 4:09 P.M., a joint observation was conducted with certified nursing assistant (CNA) 11 while inside Resident 13's room. CNA 11 observed Resident 13's fingernails and stated the nails were long on both hands. A review of Resident 13's written care plan titled ADL's (activities of daily living, Self- care activities such as grooming) Total Dependence (the resident depended on staff to provide the care), revised 10/19/22, indicated the resident was to be provided with nail care on bath days. On 12/15/22 at 11:45 A.M., a joint observation and interview was conducted with licensed nurse (LN) 2 while inside Resident 13's room. LN 2 stated nail care involved cleaning, cutting, or filing a resident's nails. LN 2 observed Resident 13's fingernails and stated, His nails are too long, and He needs nail care. On 12/15/22 at 11:48 A.M., a joint interview and record review was conducted with LN 2. LN 2 reviewed Resident 13's written care plan titled ADL's Total Dependence, revised 10/19/22, and stated it did not look like the resident's care plan had been followed. LN 2 further stated Resident 13's care plan intervention to provide nail care on bath days was not implemented and that it should have been. On 12/16/22 at 2:48 P.M., an interview was conducted with the director of nursing (DON) and the clinical manager. The DON stated Resident 13's written care plan for ADL care had not been implemented when nail care was not provided to the resident. 3. A review of Resident 224's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 224's dialysis (the process of removing toxic substances from the blood via machine when a person's kidneys no long function adequately) orders dated 12/7/22, indicated the resident had an arteriovenous (AV) fistula (the surgical joining of an artery with a vein to facilitate dialysis treatment) in her left arm and, .Remove dialysis dressing on AV [fistula] site 4-6 hours post treatment On 12/15/22 at 4:26 P.M., a joint observation and interview was conducted with Resident 224 while inside the resident's room. Resident 224 was seated next to her bed in her wheelchair. Resident 224 stated she had gone to her dialysis treatment yesterday (12/14/22) and had returned to the facility around 8 P.M. Resident 224's left upper arm was observed with two dialysis dressings over her access site. Resident 224 stated her dialysis dressings should have been removed last night. On 12/15/22 at 4:33 P.M., a joint interview and observation was conducted with licensed nurse (LN) 555216 Page 10 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4 while inside Resident 224's room. LN 4 observed Resident 224's left upper arm and dialysis dressings. LN 4 stated Resident 224's dialysis dressings should have been removed within 4-6 hours after returning to the facility. On 12/16/22 at 8:30 A.M., a joint interview and record review was conducted with LN 5. LN 5 stated the dialysis dressings should be removed within 4-6 hours after the resident returned from dialysis. LN 5 reviewed Resident 224's written plan of care titled, Hemodialysis dated 12/8/22, and stated it was important to include the physician's ordered care and treatment when the resident returned from dialysis. LN 5 stated the resident's care plan should have been developed to include checking the resident's AV fistula for any bleeding upon return to the facility. LN 5 stated if bleeding was noted, the dressings should be changed. LN 5 further stated Resident 224's hemodialysis care plan should have included the removal of the dressings within 4-6 hours after returning from dialysis treatment. On 12/16/22 at 2:48 P.M., an interview was conducted with the director of nursing (DON) and clinical manager. The DON stated Resident 224's hemodialysis written care plan should have been resident specific to include the appropriate assessment of the resident's AV fistula and removal of the dialysis dressings within 4-6 hours after returning from dialysis treatment. A review of the facility's policy titled Care Plan/interdisciplinary Care Conference, revised 12/1/22, did not provide guidance for developing and implementing resident-centered care plans for the long-term care resident. Based on observation, interview, and record review, the facility did not develop and/or implement patient centered care plans for 3 of 18 residents (46, 13, and 224). As a result, three residents did not receive care to meet their needs. Findings: 1. Per the facility face sheet, Resident 46 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident 46's plans of care were reviewed. Resident 46's plan of care for angry outbursts related to dementia, updated 11/20/22, did not identify the need to talk to the resident in his primary language, the resident's choices, or his daily routine. The interventions did not identify the need to find the cause of the outbursts or behaviors. Resident 46's plan of care for cognitive impairment, updated 11/20/22, stated to bring the resident back to reality. On 12/15/22 10:10 A.M., an interview and record review was conducted with LN 31. LN 31 reviewed Resident 46's plan of care and stated it did not identify the resident's language, daily routine, or interests. LN 31 acknowledged that Resident 46 needed to have staff talk to him in his native language. LN 31 stated the staff needed to know and support Resident 46's daily routine and interests such as cooking and taking care of his clothes. LN 31 stated it would help Resident 46 and the staff that took care of the resident. 555216 Page 11 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0656 Level of Harm - Minimal harm or potential for actual harm On 12/15/22 at 11:12 A.M., an interview was conducted with the DSD. The DSD stated the staff should be implementing resident centered care, including speaking to Resident 46 in his native language, promoting his daily routine, and interests. The DSD stated the staff should not be providing reality orientation for Resident 46's dementia. Residents Affected - Few 555216 Page 12 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 18 residents (13), whom was unable to carry out activities of daily living (self- care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). Residents Affected - Few As a result of this deficient practice, Resident 13's fingernails were long and had debris underneath the nails. Findings: A review of Resident 13's face sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 13's History and Physical exam dated 5/29/22, indicated the resident had dementia (a group of thinking and social skills that interferes with daily functioning and is characterized by memory loss) with behavioral features. The document also indicated Resident 13 was receiving hospice care (end of life care). A review of Resident 13's Minimum Data Set Assessment (an assessment tool) dated 10/30/22, indicated the resident scored 6 out of 15 on the brief interview of mental status (a score of 6 indicated the resident was cognitively impaired). The MDS further indicated the resident required total assistance provided by one staff for performing activities of daily living (self-care activities such as grooming, eating, and toileting). On 12/13/22 at 10:16 A.M., an observation of Resident 13 was conducted while inside the resident's room. Resident 13 was in bed, and was observed to have long fingernails on both hands. There was gray matter underneath Resident 13's fingernails. On 12/13/22 at 4:09 P.M., a joint observation was conducted with certified nursing assistant (CNA) 11 while inside Resident 13's room. CNA 11 observed Resident 13's fingernails and stated the nails were long on both hands. On 12/14/22 at 9:46 A.M., an interview was conducted with hospice certified nursing assistant (HCNA). The HCNA stated Resident 13 was confused. The HCNA stated CNAs could only file and clean the resident's nails while the licensed nurse (LN) could cut a resident's nails. The HCNA stated if nail care was provided or the resident refused, it would be documented in the resident's medical record. The HCNA stated Resident 13's fingernails were long and that it was a matter of getting around to filing them. The HCNA stated he would not want his own fingernails to be as long as Resident 13's were. The HCNA stated he would prefer his own nails to be kept short. On 12/15/22 at 10:53 A.M., a joint observation and interview was conducted with CNA 3 while inside Resident 13's room. Resident 13 was laying in bed and his fingernails were observed. CNA 3 stated Resident 13's fingernails varied from approximately one eighth of an inch long, to some that were approximately one fourth of an inch long and a couple nail that were close to a half an inch long. Resident 13's right hand was observed contracted (permanent muscle shortening) into a fist with the fingernails pressing into the palm of the hand. Resident 13 could not open his right hand. Resident 13's left hand had partially contracted fingers with his pointer finger extending straight out. Resident 555216 Page 13 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 13 stated, I ask them to cut it but they don't. Resident 13 stated he would not refuse having his nails cut and that he wanted them cut because they were too long. CNA 3 stated nail care was supposed to be provided to residents on shower days and that CNAs could file and clean the residents' nails. CNA 3 stated the LN was the one who cut residents' nails. CNA 3 stated CNAs did not have a place to document that nail care was offered and provided to residents. CNA 3 further stated that Resident 13 was not able to perform his own nail care and depended on staff to do it for him. On 12/15/22 at 11:28 A.M., a joint interview and record review was conducted with LN 2. LN 2 stated nail care was provided on shower days to the residents. LN 2 stated Resident 13 was cognitively impaired and was totally dependent on staff for his care. LN 2 stated the LN was responsible for cutting Resident 13's fingernails since the resident's hands had contractures. LN 2 reviewed Resident 13's clinical record and stated there was no documentation nail care had been provided to the resident or that the resident had refused nail care. LN 2 stated if the resident was refusing nail care that there should have been a care plan developed to address his refusal. LN 2 stated Resident 13's nail care was a shared responsibility with the hospice provider. On 12/15/22 at 11:45 a joint observation and interview was conducted with LN 2 while inside Resident 13's room. Resident 13 asked LN 2 to cut his nails. LN 2 stated, His nails are too long, and, He needs nail care. On 12/16/22 at 2:48 P.M., a joint interview was conducted with the director of nursing (DON) and the clinical manager. The DON stated nail care should have been provided to Resident 13. A review of the facility's undated document titled Activity of Daily Living-Hygiene indicated, .7. Nail care as needed is done every Sunday by the CNA/LN 555216 Page 14 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 324's Record of admission on [DATE] indicated the resident was admitted to the facility on [DATE], with a diagnosis of weakness following an acute care hospital admission for a recent mechanical fall and fracture of the right ankle. Residents Affected - Few A record review of Resident 324's skin assessment on admission, dated 12/4/22, indicated the resident was at risk of skin breakdown and had a intact, non-blanchable pressure ulcer on the left heel that was reddened and 4cm x 3cm in size. In an observation on 12/14/22, at 3:59 P.M., Resident 324 was seen lying in bed with both heels touching the bed with no offloading device (pillow, foam or boot used to keep heels or other body parts from touch bed) in place. In an interview with Resident 324's certified nursing assistant (CNA) 42 on 12/15/22, at 8:35 A.M.,, CNA 42 stated she was not aware that Resident 324 had a pressure ulcer. CNA 42 stated that when residents have a pressure ulcer the use elevation, positioning, boots and pillows to offload the affected area. In an interview and concurrent record review with licensed nurse (LN) 42 on 12/15/22 at 2:42 P.M., LN 42 looked through the chart and stated there was an order to offload Resident 324's heels. A record review of Resident 324's care plan titled, Skin Impairment: Pressure Injury, dated 12/4/22, indicated a Stage I pressure ulcer was present and indicated, keep heel/s off pressure when in bed as an action to implement to heal the pressure ulcer. In an interview with the Director of Nursing (DON) on 12/16/22, at 2:01 P.M., the DON was informed that CNA 42 was not aware Resident 324 had a pressure ulcer on the heel. The DON stated that CNAs should have been alerted to the pressure ulcer and offloading of the heel should have been implemented as ordered to avoid worsening of the pressure injury. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcer/Injury Prevention and Treatment, indicated the definition for a Stage 1 Pressure Injury as being Intact skin with a localized area of non-blanchable erythmea (redness). The P&P also indicated, Pressure Ulcer/Injury Prevention and Treatment, indicated that if a pressure ulcer is present on admission the facility should initiate and document a plan of care. Based on observation, interview and record review, the facility did not ensure two of three residents (Resident 45 and Resident 324) reviewed for pressure ulcers, received the necessary care and services related to pressure ulcer treatment in accordance with the physician's order and plan of care. This failure had the potential for pressure ulcer deterioration and infection. Findings: 1. Resident 45 was admitted to the facility 6/24/22 according to the resident's face sheet, with diagnoses that included weakness and history of CVA (Cerebrovascular Accident or stroke- a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain) per the 555216 Page 15 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0686 physician's progress note dated 11/29/22. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 45's Minimum Data Set (MDS-a process which provides a comprehensive assessment of each resident to help nursing home staff identify health problems, dated 12/5/22, the MDS indicated in Section M0300C. Number of Stage 3 pressure ulcers, 1. The MDS indicated, Section M1200C. Turning/repositioning program, E. Pressure ulcer/injury care, H. Applications of ointments/medications . Residents Affected - Few A record review of Resident 45's care plan was conducted. Resident 45's care plan titled, Skin Impairment: Pressure Injury, dated 5/24/22, indicated Impaired skin integrity R/T (related to) pressure as evidenced by: Stage 3 sacral wound. The care plan approaches indicated, Reposition q (every) 2 hrs (hours), and perineal (the space between the anus and scrotum in males) care after episodes of incontinency (the lack of voluntary control of the urine or stool). During an observation on 12/13/22 at 9:54 A.M., Resident 45 was lying in bed with his eyes closed. During an observation on 12/13/22 at 10:37 A.M., Resident 45 was lying in bed with his eyes closes. Resident 57's meal tray was untouched and was on the overbed table at foot of the resident's bed. During an interview on 12/13/22 at 11:16 A.M., Resident's wife stated Resident 45 was heavier and weighed 200 lbs. Resident 45's wife stated Resident 45 developed a stage 4 pressure ulcer (pressure injury reaching into muscle and bone) because Resident 45 was not repositioned at the hospital. An interview was conducted on 12/14/22 at 4:09 P.M., with certified nursing assistant (CNA) 11. CNA 11 stated Resident 45 had an open wound on Resident 45's coccyx (tailbone area). A concurrent review of Resident 45's physician orders was conducted with licensed nurse (LN) 11 on 12/15/22, at 9:51 A.M. LN 11 stated Resident 45 had a stage 3 pressure ulcer (pressure injury extending into the tissues) on the sacrum (tailbone area). LN 11 stated Resident 45's pressure ulcer was treated with wound cleanser, iodoform packing and covered with dry dressing. During an interview on 12/15/22, at 10:58 A.M., with the wound ostomy nurse, the wound ostomy nurse stated the wound ostomy team from the hospital conducted a monthly wound measurement for Resident 45. The wound ostomy nurse stated she will recommend an evaluation for a specialty mattress for the resident. During an observation on 12/15/22, at 10:58 A.M., Resident 45 was in high fowler's position in bed with overbed table and breakfast tray in front of Resident 45. An interview on 12/15/22, at 11:25 A.M., with the wound ostomy nurse was conducted. The wound ostomy nurse stated Resident 45's weekly wound measurements were completed on Wednesdays by either the medication nurse or the treatment nurse. The wound ostomy nurse stated residents with a stage 3 pressure ulcer should have a special mattress for pressure distribution. The wound ostomy nurse stated Resident 45 had a regular mattress like the other residents in the facility, and an incontinent pad was used for regular mattress. During an observation on 12/15/22, at 11:27 A.M., with LN 13, LN 13 provided incontinence care for Resident 45 due to presence of bowel movement. There was no dressing and packing on Resident' 45's pressure ulcer. Resident 45's pressure ulcer on the sacrum had white wound edges, and red with light 555216 Page 16 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few green slough on the wound bed. LN 13 stated the pressure ulcer was at stage 3. Resident 45's pressure ulcer was measured, and it was 2 cm x 1 cm x 0.75 cm. An interview was conducted on 12/15/22, at 2:10 P.M., with the assigned CNA 12 for Resident 45. CNA 12 stated she was assigned to the resident today,12/15/22. CNA 12 stated she did not provide morning care to Resident 45 prior to the wound treatment today. CNA 12 stated she was aware that Resident 45 had a wound on his sacrum. During an interview on 12/15/22, at 2:10 P.M., with LN 13, LN 13 acknowledged Resident 45 did not have a dressing on the sacrum to cover the pressure ulcer. LN 13 stated a dressing was necessary to protect the wound and not aggravate it. LN 13 stated without the dressing the wound could get worse and become infected. During an interview on 12/15/22, at 4:01 P.M., with CNA 11, CNA 11 stated Resident 45 required repositioning because Resident 45 had wound on the sacrum. CNA 11 stated Resident 45 was checked every hour because of the facility's hourly rounding program. CNA 11 stated if Resident 45 was not repositioned, Resident 45's wound would get worse. An interview was conducted with the Director of Nursing (DON) on 12/16/22, at 9:02 A.M., The DON stated the assigned CNA should have made rounds in the beginning of the shift to reposition, provide toileting and provide for Resident 45's needs. The DON stated they had every hour rounding program. The DON stated if rounding and wound treatment were not completed, Resident 45 could have further skin breakdown and infection. A review of the facility's undated guideline titled, Pressure Injury Prevention and Treatment, was conducted. The guideline indicated, .7. Turn and reposition patients at least every 2h (hour) . A review of the facility's P&P titled, Pressure Ulcer/Injury Prevention and Treatment, 30303.99, last revised on 2/25/20 was conducted. The P&P did not have information regarding providing incontinence care and repositioning residents with pressure ulcers. 555216 Page 17 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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: Residents Affected - Few 1. A peripheral intravenous line (PIV - a flexible tube inserted to a vein used to provide medication or hydration) dressing was changed according to facility's policy and procedure and, 2. The PIV assessment was done and documented consistently for one of one sampled resident (55). These failures had the potential for residents to be exposed to infections, and staff unaware of the PIV site condition. Findings: Resident 55 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection per the facility's Face Sheet. 1. On 12/13/22 at 9:38 A.M., a joint observation and interview was conducted with Resident 55. Resident 55's left wrist area had a PIV which had a handwritten date of, 12/6/22. The clear dressing on the PIV was peeling off the edges. Resident 55 stated he needed the PIV because he had, Blood infection and was taking antibiotics (medication to treat infection). On 12/13/22 at 3:37 P.M., a joint observation and interview with LN 25 was conducted of Resident 55. LN 25 stated Resident 55's PIV dressing was dated 12/6/22. LN 55 stated the PIV dressing should have a date when it was inserted and the initial of the staff who performed the procedure. On 12/13/22 at 4:05 P.M., an interview was conducted with LN 26. LN 26 stated PIV dressing was changed every seven days and as needed to prevent infection. On 12/15/22 at 4:05 P.M., an observation of Resident 55 was conducted. Resident 55's left wrist PIV dressing indicated 12/6/22, nine days since it was changed. On 12/15/22 at 9:06 A.M., an interview was conducted with LN 27. LN 27 stated PIV dressing should be changed every three days because, That's how we knew if the PIV was still okay to use. 2. On 12/13/22 at 3:37 P.M., a joint interview and record review of Resident 55 was conducted with LN 28. LN 28 stated the nurse who was doing the assessment should sign and date the assessment form to indicate the PIV site was assessed. LN 28 stated if it was not documented, it was never done because there was no evidence. On 12/13/22 at 3:48 P.M., an interview was conducted of LN 29. LN 29 stated every time a PIV was flushed and assessed, it should have been documented on the Intravenous Site Assessment form. On 12/15/22 at 9:06 A.M., an interview was conducted with LN 27. LN 27 stated the PIV assessment should be documented on the Intravenous Site Assessment form. LN 27 further stated that if it was not documented, it was never done. Per the facility's policy titled IV Therapy: Peripheral IV Insertion, Assessment, Maintenance and 555216 Page 18 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Removal, 30608.99, dated 9/14/21, B. Indicate the date, and initials of who performed the insertion on the dressing.Q. Peripheral IV catheter maintenance: 1. Change dressing every 6-7 days and prn if soiled, non-occlusive or wet: .d. Label with dressing change date and initials. Document in medical record . Per the facility's form titled SNF Nursing Documentation dated 2022, . 2. The purposes of the medical record documentation includes, but not limited to: a. communication between health care team members, b. written evidence of physician's orders, care provided and patient's response to care/services . 555216 Page 19 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 that pain management was provided in accordance with professional standard of practice for 1 of one resident (Resident 45) reviewed for pain management. Residents Affected - Few This failure resulted in Resident 45 to experience pain during pressure ulcer treatment. Findings: According to Resident 45's face sheet, Resident 45 was admitted to the facility on [DATE]. Resident 45 had a diagnosis of Sacral Stage 3 Pressure Ulcer (pressure injury that extends into tissues) per the physician's Progress Note, dated 11/29/22. During pressure ulcer treatment observation on 12/15/22 at 11:27 A.M., licensed nurse (LN) 13 provided incontinence care for Resident 45 due to presence of bowel movement. There was no dressing and packing on Resident' 45's pressure ulcer. Resident 45's pressure ulcer on the sacrum had white wound edges, undermining and red with light green slough on the wound bed. LN 13 stated Resident 45 had a stage 3 pressure ulcer. The wound ostomy nurse measured Resident 45's pressure ulcer. Resident 45 stated it was painful and started yelling out, Help, help. Resident 45 continued to yell out Help as the wound was being measured. During an interview on 12/15/22 at 11:48 A.M., LN 13 stated she asked the medication nurse to assess Resident 45 for pain before treatment. LN 13 stated Resident 45 should have routine pain medication. An interview was conducted on 12/16/22 at 8:28 A.M., with LN 15. LN 15 stated she completed Resident 45's dressing changes last week. LN 15 stated she treated Resident 45's pressure ulcer with wound cleanser, iodoform packing, then covered it with dry dressing. LN 15 stated Resident 45 had pain while sitting up in wheelchair. LN 15 stated Resident 45 requested for pain medication but Resident 45 was not able to verbalize the location of pain. During a review of Resident 45's care plan titled, Altered Comfort, dated 5/25/22 indicated, At risk for alteration in comfort related to: BPH, Brain Injury, Presence of Pressure Injury. The care plan approaches indicated, Administer pain medication as indicated . A review of Resident 45's Medication record, dated 12/1/22 - 12/31/22 was conducted. The medication record indicated Resident 45 received Tramadol (a pain medication) 50mg on 12/1/22 through 12/10/22, then Tylenol 325 mg 2 tablets on 12/14/22. During an interview on 12/16/22 at 9:02 A.M., with the Director of Nursing (DON), the DON stated residents were assessed for pain by asking them or by assessing their body language. The DON stated if a resident had a pressure ulcer with tunneling or undermining, there will be pain during measurement. The DON stated staff who were assigned to Resident 45 had been consistent and should anticipate that the resident would have pain during wound measurement. During a review of the facility's P&P titled, Patient Screening, Assessment and Management of Pain, 30327.99, last revised 3/5/21, the P&P indicated, III. TEXT: E. In patients who cannot self-report 555216 Page 20 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0697 the presence of pain or intensity, use one of the following to assess pain: 1. Assume pain present for conditions or procedures that are known to be painful. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555216 Page 21 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 two of two residents (Resident 224 and Resident 45) reviewed for dialysis (the process of removing toxic substances from the blood via machine when a person's kidneys no long function adequately) care, received care and treatment that followed the physician's orders and/or the residents' plan of care when: Residents Affected - Few 1. Resident 224's dialysis dressings (bandage applied over the access site to prevent bleeding) were not removed within 4-6 hours after dialysis treatment as was ordered by the physician. 2. Resident 45's dialysis access site was not accurately assess for bruit (the sound of blood flow) and thrill (vibrating sensation felt on the skin). As a result of these deficient practices, Residents 224 and 45 were at risk for developing dialysis access complications. Findings: 1. A review of Resident 224's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 224's dialysis orders dated 12/7/22, indicated the resident was to received dialysis treatments at the dialysis clinic on Mondays, Wednesdays, and Fridays, and that the resident had an arteriovenous (AV) fistula (the surgical joining of an artery with a vein to facilitate dialysis treatment) in her left arm. Resident 224's physician's orders further indicated, .Remove dialysis dressing on AV [fistula] site 4-6 hours post treatment A review of Resident 224's Minimum Data Set Assessment (an assessment tool) dated 12/14/22, indicated the resident scored 15 out of 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). On 12/15/22 at 4:26 P.M., a joint observation and interview was conducted with Resident 224 while inside the resident's room. Resident 224 was seated next to her bed in her wheelchair. Resident 224 stated she had gone to her dialysis treatment yesterday (12/14/22) and had returned to the facility around 8 P.M. Resident 224's left upper arm was observed with two dialysis dressings over her access site. Resident 224 stated her dialysis dressings should have been removed last night. On 12/15/22 at 4:33 P.M., a joint interview and observation was conducted with licensed nurse (LN) 4 while inside Resident 224's room. LN 4 observed Resident 224's left upper arm and dialysis dressings. LN 4 stated Resident 224's dialysis site should have been assessed to ensure it was not bleeding when the resident returned from dialysis and that the dressings should have been removed within 4-6 hours after returning to the facility. Resident 224 stated no one had checked her dialysis dressings last night. LN 4 stated she would remove the resident's dialysis dressings and that they had been on too long. LN 4 further stated dialysis dressings had to be removed in a timely manner or the resident's fistula could be affected negatively. On 12/16/22 at 8:30 A.M., a joint interview and record review was conducted with LN 5. LN 5 stated residents returning to the facility from dialysis, should have their access sites assessed for 555216 Page 22 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bleeding and have the dressings replaced if there was bleeding present. LN 5 stated the dialysis dressings should be removed within 4-6 hours after the resident returned from dialysis. LN 5 stated leaving the dialysis dressings on longer than 4-6 hours could cause clotting in the resident's access site and affect the patency of the AV fistula. LN 5 reviewed Resident 224's treatment administration record (TAR) and stated the TAR was blank on 12/14/22 related to removing the resident's dialysis dressings. LN 5 stated the TAR should have included removing the dialysis dressings on the night shift to ensure it was done within 4-6 hours after the resident returned to the facility. On 12/16/22 at 2:48 P.M., a joint interview was conducted with the director of nursing (DON) and clinical manager (CM). The DON and CM both stated Resident 224's dialysis dressings should have been removed from the resident's fistula within 4-6 hours after the resident returned from dialysis. The DON and CM stated it was a physician's order and it should have been followed. A review of the facility's policy titled Dialysis- Outside Services dated 10/96, did not provide guidance related to providing care and treatment to a resident's AV fistula after the resident returned from dialysis treatment. 2. According to Resident 45's face sheet, Resident 45 was admitted to the facility on [DATE] with the diagnosis of End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), per the physician's progress note, dated 11/29/22. During an observation on 12/13/22, at 9:54 A.M., Resident 45 was in bed laying on his back with his eyes closed. An interview with Resident 45's wife was conducted on 12/13/22, at 11:16 A.M. According to the resident's wife, Resident 45 was transported to the dialysis center on Tuesdays, Thursdays, and Saturdays. Resident's wife stated Resident 45 had a catheter on right chest, and a new graft on the right arm. Resident's wife stated Resident 45 has had the graft for 6 weeks. Resident's wife showed Resident 45's dialysis catheter on resident's right chest and the graft on resident's left upper arm. The dialysis catheter on the resident's chest and graft on resident's left arm were not covered with a dressing. During an interview on 12/15/22, at 4:09 P.M., with LN 14, LN 14 stated Resident 45 had a right upper arm graft. LN 14 stated she checked Resident 45's graft by feeling thrill and feeling bruit with 2 fingers. LN 14 stated if she did not feel bruit & thrill, she would report to the charge nurse. An interview was conducted with LN on 12/16/22, at 8:28 A.M. LN 15 stated Resident 45 had a graft on the left arm. LN 15 stated she listened to bruit and thrill. LN 15 stated she listened to the bruit which sounded like Tog, tog, and the thrill sounded like a swishing sound. LN 15 stated she used a stethoscope to listen to the bruit and thrill on Resident 45's dialysis graft. LN 15 stated she changed the gauze on Resident 45's graft site if there was bleeding. LN 15 stated if there was no bleeding from the graft, the dressing was left the entire shift on Resident 45's graft site. A review of Resident 45's Dialysis Communication Record, dated 12/1/22, 12/3/22,12/6/22, 12/8/22, 12/10/22, and 12/15/22 was conducted. The access site condition on the document did not have documentation by the licensed nurses. A review of Resident 45's physician orders, dated 12/1/22 through 12/31/22 was conducted. The 555216 Page 23 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician's orders indicated an order on 5/24/22, Monitor AV graft on left upper arm QS (every shift) for: thrill, bruit, redness, c/o (complaint of) pain, swelling, bleeding and notify MD for abnormals and document. A review of Resident 45's care plan for dialysis, dated 6/25/22 was reviewed. The care plan approaches indicated, Monitor access area for thrill, bruit, redness, c/o pain, swelling and notify MD for abnormal and document. During an interview on 12/16/22, at 9:02 A.M., with the Director of Nurses (DON), the DON stated Resident 45's graft should be assessed every shift to ensure it was not clotted. DON stated if the graft was clotted, the resident may need another procedure, will have delayed dialysis treatment, and the Resident 45 would have fluid buildup and become toxic. During a review of the facility's policy and procedure (P&P) titled, Dialysis-Outside Services, dated 10/96, the P&P indicated, 2. When a resident is in skilled nursing facility, that facility has direct responsibility for the care of resident including the customary standard care provided by the facility and the following: A. Assessment of Dialysis patient including: 2. Assessment of AV shunt every eight hours. B. Communication 1. Facility will notify dialysis center .any complications with AV access. 555216 Page 24 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 54's Face Sheet indicated the resident was readmitted to the facility on [DATE]. Residents Affected - Few A review of Resident 54's physicians orders antipsychotic medication (a medication that alters mood, thoughts, and behavior) order, dated 11/16/22, 11/30/22, and 12/14/22, indicated the resident had a diagnosis of dementia with behavioral disturbance. On 12/14/22 at 4:45 P.M., an interview was conducted with certified nursing assistant (CNA) 7. CNA 7 stated she was very familiar with Resident 54. CNA 7 stated Resident 54 was sometimes confused and did not speak English. CNA 7 stated Resident 54 would get frustrated when she could not understand the staff. CNA 7 stated when Resident 54 did not understand the staff trying to provide care, she would get agitated and try to hit the staff when they did not stop trying to provide care. CNA 7 stated there was a language barrier. CNA 7 stated she spoke the same native language as Resident 54 and, I don't have that problem [with Resident 54] because we speak the same language. CNA 7 stated Resident 54 could perform her own activities of daily living (ADL, self-care activities such as grooming and toileting) but required supervision. CNA 7 stated Resident 54 did not like for staff to watch her while she performed her ADL and would refuse if she was being watched. CNA 7 stated, I tell her it's time to get dressed, and then pretend to leave the room. CNA 7 stated she would stand outside Resident 54's privacy curtain or the door while the resident did her own ADL. CNA 7 stated Resident 54 thought her room was her apartment and would become surprised then agitated when staff were there in her room and would ask, Who gave me the key? CNA 7 stated she would tell Resident 54 that she was there to help her son take care of her and the resident accepted that and did not become agitated. CNA 7 stated, What I do [to manage Resident 54's behavior] usually works most of the time. On 12/15/22 at 10:35 A.M., an interview was conducted with CNA 8. CNA 8 stated she provided care to Resident 54 and knew the resident. CNA 8 stated, [Resident 54] doesn't speak English and I don't speak [Resident 54's language]. CNA 8 stated Resident 54 would get agitated when she did not understand. CNA 8 stated Resident 54 liked to be alone and would tell staff to get out of her room. CNA 8 stated Resident 54 was independent with her ADL but required supervision. CNA 8 stated there was an incident when she tried to walk with Resident 54, and explained in English that she would walk with the resident. CNA 8 stated Resident 54 did not understand her, became agitated, and threw the walker at her. CNA 8 stated a staff who spoke Resident 54's language told her that the resident had been telling her to go away. CNA 8 stated, The language barrier is big. On 12/16/22 at 10:36 A.M., a joint interview and record review was conducted with licensed nurse (LN) 9. LN 9 stated Resident 54 would get frustrated not being understood and not understanding staff. LN 9 stated Resident 54 would start yelling at staff in her native language. LN 9 stated, I don't speak [Resident 54's language]. LN 9 stated Resident 54 could perform her own ADL and required supervision for safety. LN 9 stated privacy was important to Resident 54. LN 9 stated she would keep Resident 54's bathroom door open a crack so she could see the resident while the resident could not see her. LN 9 stated, It works. LN 9 stated Resident 54 knew when she was finished in the bathroom and could use the call light to let staff know she was finished. LN 9 stated if Resident 54 was not provided privacy and she saw staff watching her use the bathroom, she would get upset and hit the staff. LN 9 stated, She hates being watched. LN 9 stated Resident 54 sometimes refused to take her medications. LN 9 stated Resident 54 would usually take the medication if staff tried again later. LN 9 stated having the resident speak with her son also helped with the resident's behavior. LN 9 stated using 555216 Page 25 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 54's native language to communicate with her, providing a sense of privacy to the resident, having the resident speak with her son, and providing time and/or trying the task again later, were effective in managing Resident 54's behavior about 95% of the time. LN 9 stated Resident 54 may still become agitated sometimes, but those interventions if consistently done, would help with her behavior by lessening the frustration and agitation. LN 9 reviewed Resident 54's clinical record and stated there were no assessments done related to the residents dementia behaviors. LN 9 stated there was no documentation of interdisciplinary team meetings or care conferences that discussed the resident's behavioral triggers as it related to her dementia. LN 9 reviewed Resident 54's written plan of care for dementia, dated 8/12/22, and stated it did not include interventions that worked for the resident. LN 9 stated Resident 54's dementia plan of care was not individualized to meet her needs and did not address the resident's dementia. On 12/16/22 at 1 P.M., a joint interview and record review was conducted with clinical nurse lead (CNL) 2 and the director of staff development (DSD). The DSD and CNL 2 reviewed Resident 54's clinical record. CNL 2 stated there was no documentation the facility investigated the cause of Resident 54's dementia behaviors to identify the possible triggers. The DSD stated there was no documentation of an assessment done for Resident 54's dementia behaviors. The DSD stated Resident 54's behavioral triggers identified by some of the direct care staff were not included in the resident's dementia plan of care. The DSD and CNL 2 both stated there should have been a dementia plan of care that met Resident 54's individualized needs and addressed the causes of her behavior. On 12/16/22 at 2:48 P.M., an interview was conducted with the director of nursing (DON) and clinical manager. The DON stated Resident 54's behavioral triggers should have been identified and should have been part of the resident's dementia plan of care. Per the facility policy, revised 7/2021, titled Dementia Care in LTC, .assess patient to determine habits, choices, .speak slowly and calmly limit reality checks - reasoning may not work . encourage staff to interact with the dementia patient with every opportunity and in a manner that meets their needs and preferences . Based on observation, interview, and record review, the facility did not assure that 2 of 18 residents (46 and 54) with dementia (impaired memory and reasoning) received the necessary treatment to promote their wellbeing. As a result, the residents became distressed, acting out because they felt misunderstood. Findings: 1. Per the facility face sheet, Resident 46 was readmitted to the facility on [DATE] with a diagnosis of dementia. Resident 46's records were reviewed. Per Resident 46's history and physical, dated 8/4/22, the physician determined the resident had dementia. Per Resident 46's psychiatric exam, dated 6/1/22, Resident 46 had memory issues, was able to verbalize his thoughts, and had the ability to answer questions correctly when given choices. The psychiatrist went on to say the assessment was conducted in the resident's native language as the resident 555216 Page 26 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0744 did not speak English. Level of Harm - Minimal harm or potential for actual harm Per Resident 46's quarterly assessment, dated 11/1/22, the resident was not assessed for dementia. Residents Affected - Few On 12/13/22 at 9:38 A.M., 12/14/22 at 8:31 A.M., and 12/15/22 at 9:02 A.M., Resident 46 was observed and interviewed. In all three observations and interviews, Resident 46 was highly active, walking back and forth, waving his hands, and speaking in his native language. Resident 46 stated the staff do not understand me because they do not speak in my native language, and they do not try understanding what I want. Resident 46 stated this upset him and sometimes when he did not like his food, he threw his tray on the floor. Resident 46 stated sometimes he cussed. Resident 46 went on to say he would like to cook and take care of his clothes. On 12/15/22 at 9:08 A.M., an interview was conducted with CNA 31 who stated Resident 46 became easily upset when he felt misunderstood. CNA 31 could not verbalize what Resident 46 liked to do but did state that Resident 46 usually calmed down when spoken to in his native language. On 12/15/22 at 10:10 A.M., an interview was conducted with LN 31. LN 31 stated that Resident 46 became easily upset and would often throw things. LN 31 could not verbalize what Resident 46 liked to do but did state Resident 46 usually calmed when staff spoke to him in his native language. LN 31 went on to say dementia patients who were disoriented like Resident 46 required reality orientation. On 12/15/22 at 11:12 A.M., an interview was conducted with the DSD. The DSD stated that residents with dementia often act out if they cannot understand others and the staff need to communicate in a language the residents can understand. The DSD stated the staff need to allow the resident to function in their own reality, because it might increase the resident's agitation, so the staff should not provide reality orientation for dementia residents. The DSD stated it is important for the staff to meet the resident's needs and know the activities they enjoy and food they want to eat. 555216 Page 27 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication was administered according to the physician's order for one of three residents (Resident 22) observed during medication administration. As a result of this deficient practice, the facility could not ensure pharmaceutical services were safely provided to its residents. Findings: A review of Resident 22's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnosis to included congestive heart failure (chronic condition wherein the heart cannot pump blood adequately). A review of Resident 22's physician's orders, dated 10/16/21, indicated the resident was to receive 125 micrograms of digoxin (medication that controls heart rate) daily, and that the nurse was to hold the medication if the resident's apical pulse (a measurement of the heart rate taken directly above the heart using a stethoscope) was less that 60 beats per minute. On 12/15/22 at 8:40 A.M., a medication observation was conducted with licensed nurse (LN) 11. LN 11 was observed preparing medication for Resident 22. At 8:50 A.M., LN 11 was observed asking certified nursing assistant (CNA) 6 for Resident 22's vital signs (respiration rate, heart rate, blood pressure, oxygen saturation, and temperature) and recorded it on a piece of paper. At 8:54 A.M., LN 11 stated she was ready to administer the medications to Resident 22. At 8:55 A.M., Resident 22 was administered his oral medications, including 125 micrograms of digoxin. On 12/15/22 at 3 P.M., an interview was conducted with CNA 6. CNA 6 stated when she started her shift in the morning, she would round on her assigned residents, and then take their vital signs. CNA 6 stated the vital signs measurements for her assigned residents were given to the LN. CNA 6 stated she took Resident 22's vital signs that morning using the vitals machine and reported the measurements to LN 11. On 12/15/22 at 3:06 P.M., an interview was conducted with LN 11. LN 11 stated she did not take Resident 22's apical pulse prior to administering his digoxin. LN 11 stated she should have as it was part of the physician's order. On 12/15/22 at 3:37 P.M., an interview was conducted with clinical nurse lead (CNL) 3. CNL 3 stated the LN giving digoxin was responsible to take the resident's apical pulse before giving the medication. CNL 3 stated checking the apical pulse prior to giving digoxin was done to make sure the medication was safe to give to the resident. CNL 3 stated checking the resident's apical pulse was part of the physician's order for giving digoxin and should have been followed. On 12/16/22 at 2:48 P.M., an interview was conducted with the director of nursing (DON) and clinical manager (CM). The DON stated LN 11 should have took Resident 22's apical pulse before administering digoxin. The DON stated the physician's order had not been followed. 555216 Page 28 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0755 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled Medication Administration revised 3/5/21, indicated, . Prior to any medication administration . 2. Right Medication: Validate the medication you are planning to administer [with the] provider order Residents Affected - Few 555216 Page 29 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 54's Face Sheet indicated the resident was readmitted to the facility on [DATE]. A review of Resident 54's physicians orders antipsychotic medication (a medication that alters mood, thoughts, and behavior) order, dated 11/16/22, 11/30/22, and 12/14/22, indicated the resident had a diagnosis of dementia with behavioral disturbance and was prescribed Seroquel (antipsychotic medication) 25 milligrams PRN (as needed) every eight hours as evidenced by hitting staff and refusing care. The appropriateness of the medication was to be reassessed after 14 days. A review of Resident 54's physician orders, dated 11/30/22, also indicated the resident was routinely prescribed Seroquel 25 milligrams at bedtime for dementia with behavioral disturbance. On 12/14/22 at 4:45 P.M., an interview was conducted with certified nursing assistant (CNA) 7. CNA 7 stated she was very familiar with Resident 54. CNA 7 stated Resident 54 was sometimes confused and did not speak English. CNA 7 stated Resident 54 would get frustrated when she could not understand the staff. CNA 7 stated when Resident 54 did not understand the staff trying to provide care, she would get agitated and try to hit the staff when they did not stop trying to provide care. CNA 7 stated there was a language barrier. CNA 7 stated she spoke the same native language as Resident 54 and, I don't have that problem [with Resident 54] because we speak the same language. CNA 7 stated Resident 54 could perform her own activities of daily living (ADL, self-care activities such as grooming and toileting) but required supervision. CNA 7 stated Resident 54 did not like for staff to watch her while she performed her ADL and would refuse if she was being watched. CNA 7 stated, I tell her it's time to get dressed, and then pretend to leave the room. CNA 7 stated she would stand outside Resident 54's privacy curtain or the door while the resident did her own ADL. CNA 7 stated Resident 54 thought her room was her apartment and would become surprised then agitated when staff were there in her room and would ask, Who gave me the key? CNA 7 stated she would tell Resident 54 that she was there to help her son take care of her and the resident accepted that and did not become agitated. CNA 7 stated, What I do [to manage Resident 54's behavior] usually works most of the time. CNA 7 further stated all residents had the right to refuse care. On 12/15/22 at 10:35 A.M., an interview was conducted with CNA 8. CNA 8 stated she provided care to Resident 54 and knew the resident. CNA 8 stated, [Resident 54] doesn't speak English and I don't speak [Resident 54's language]. CNA 8 stated Resident 54 would get agitated when she did not understand. CNA 8 stated Resident 54 liked to be alone and would tell staff to get out of her room. CNA 8 stated Resident 54 was independent with her ADL but required supervision. CNA 8 stated there was an incident when she tried to walk with Resident 54, and explained in English that she would walk with the resident. CNA 8 stated Resident 54 did not understand her, became agitated, and threw the walker at her. CNA 8 stated a staff who spoke Resident 54's language told her that the resident had been telling her to go away. CNA 8 stated, The language barrier is big. CNA 8 further stated Resident 54 had the right to refuse care. On 12/16/22 at 10:36 A.M., a joint interview and record review was conducted with licensed nurse (LN) 9. LN 9 stated Resident 54 would get frustrated not being understood and not understanding staff. LN 9 stated Resident 54 would start yelling at staff in her native language. LN 9 stated, I don't speak [Resident 54's language]. LN 9 stated Resident 54 could perform her own ADL and required 555216 Page 30 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision for safety. LN 9 stated privacy was important to Resident 54. LN 9 stated she would keep Resident 54's bathroom door open a crack so she could see the resident while the resident could not see her. LN 9 stated, It works. LN 9 stated Resident 54 knew when she was finished in the bathroom and could use the call light to let staff know she was finished. LN 9 stated if Resident 54 was not provided privacy, and she saw staff watching her use the bathroom, she would get upset and hit the staff. LN 9 stated, She hates being watched. LN 9 stated Resident 54 was not trying to hurt staff, and when she hit staff, it was because they would not go away. LN 9 stated Resident 54 was, Not hitting staff out of the blue, for no reason. LN 9 stated Resident 54 sometimes refused to take her medications. LN 9 stated Resident 54 would usually take the medication if staff tried again later. LN 9 stated having the resident speak with her son also helped with the resident's behavior. LN 9 stated using Resident 54's native language to communicate with her, providing a sense of privacy to the resident, having the resident speak with her son, and providing time and/or trying again with the task later, were effective in managing Resident 54's behavior about 95% of the time. LN 9 stated Resident 54 may still become agitated sometimes, but those interventions if consistently done, would help with her behavior by lessening the frustration and agitation. LN 9 reviewed Resident 54's clinical record and stated, It's not appropriate to have a Seroquel order because of dementia as evidenced by refusing care. LN 9 stated all residents had the right to refuse care. LN 9 stated, I don't think she [Resident 54] needs Seroquel. LN 9 further stated there was no documentation of interdisciplinary team meetings or care conferences that discussed the resident's behavioral triggers as it related to her dementia. LN 9 stated there was no documentation individualized, non-pharmacological interventions to address the resident's behavior were attempted prior to placing the resident on routine Seroquel, and prior to renewing the PRN order. LN 9 stated there was no documentation the physician reassessed and/or evaluated the resident prior to renewing the resident's PRN Seroquel order on 11/16/22, 11/30/22, and 12/14/22. On 12/16/22 at 1 P.M., a joint interview and record review was conducted with clinical nurse lead (CNL) 2 and the director of staff development (DSD). The DSD and CNL 2 reviewed Resident 54's clinical record. CNL 2 stated Resident 54's Seroquel was an order that came from the hospital when the resident was readmitted in September 2022. CNL 2 stated there was no documentation individualized non-pharmacological interventions were attempted prior to continuing the Seroquel and prior to reordering it. The DSD and CNL 2 both stated they did not think it was an appropriate indication for Seroquel to be administered for dementia as evidenced by refusing care. The DSD and CNL 2 both stated residents had the right to refuse care. The DSD stated there was no documentation the ordering physician had reassessed and/or evaluated the appropriateness of Seroquel prior to reordering it for another 14 days on 11/16/22, 11/30/22, and 12/14/22. On 12/16/22 at 2 P.M., a joint interview and record review was conducted with the facility's pharmacist consultant (PC). The PC reviewed Resident 54's physicians orders antipsychotic medication order, dated 11/16/22, 11/30/22, and 12/14/22 for Seroquel 25 mg PRN and stated that it was not an appropriate indication to have a Seroquel order for dementia as evidenced by refusing care. The PC further stated the facility should have identified Resident 54's dementia behaviors and triggers and attempted those individualized and non-pharmacological interventions prior to continuing the Seroquel orders. On 12/16/22 at 2:48 P.M., an interview was conducted with the director of nursing (DON) and clinical manager (CM). The DON stated it was not appropriate for Resident 54 to have an order for Seroquel for refusing care. The DON stated all residents had the right to refuse care. The DON stated Resident 54's dementia behavior triggers should have been identified and interventions developed to treat 555216 Page 31 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the behavior non-pharmacologically before renewing the resident's Seroquel orders. The CM stated she agreed with the DON's statements. A review of the facility's policy titled, Monitoring of Antipsychotic Medications, 39103, revised 5/11/22, indicated, .A. An antipsychotic medication should be used for the following condition/diagnoses as documented in the record and meets the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or subsequent editions: 1. Schizophrenia 2. Schizo-affective disorder 3.Schizophreniform disorder 4. Tourette's Disorder 5. Huntington disease 6. Hiccups (not induced by other medications) 7. Nausea and vomiting associated with cancer of chemotherapy . The policy did not include dementia as a condition/diagnoses. The policy further indicated, .C. The continued need for and the effectiveness of the antipyschotic medication is reassessed monthly by the responsible physician .F. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluate the resident for the appropriateness of the medication . Based on observation, interview and record review, the facility failed to ensure approved indications for the use of antipsychotic medications (drugs that affect brain activities associated with mental processes and behavior) were identified and documented for two of five residents (Resident 324 and Resident 54) reviewed for unnecessary use of psychotropic medications (medications that can affect the brain and nervous system). These deficient practices increased the potential for adverse consequences, such as injury and death, to occur for Resident 324 and Resident 54). Findings: 1. A record review indicated Resident 324 was admitted to the facility on [DATE] with a diagnosis of dementia (a disease that affects the brain's ability to think, remember and reason) with behavioral features and a past medical history of altered mental status (a change in mental function), according to the History and Physical dated 12/13/22. No indication or documentation of mental illness or psychiatric diagnosis was found in during Resident 324's clinical record review. A review of Resident 324's antipsychotic medication administration record (MAR) indicated Seroquel 25mg PO QHS PRN was ordered on 12/5/22 and administered on 12/7/22, 12/8/22, 12/9/22, 12/10/22, 12/11/22, 12/12/22, 12/13/22, 12/14/22. During an observation on 12/13/22, at 12:20 P.M., Resident 324 was seen seated in a wheelchair by the nurse's station eating lunch independently. Resident 324 made multiple attempts to stand up from his wheelchair which set off the wheelchair alarm. A staff member directed Resident 324 to sit down. Resident 324 stated, stay away and stated I'm going home. During an interview with Resident 324's certified nursing assistant (CNA 41) on 12/14/22, at 3:59 P.M., CNA 41 stated he was familiar with the resident and Resident 324's diagnosis of dementia (memory loss). CNA 41 stated Resident 324 was unable to walk because Resident 324 had a broken right ankle. CNA 41 stated Resident 324 was confused. CNA 41 stated Resident 324 tried to get up because the resident stated a desire to go home. CNA 41 stated she had not spoken to the family about what activities may help to decrease Resident 324's anxiety. CNA 41 stated a sitter had not been tried as an intervention for Resident 324's anxiety and attempts to get up. 555216 Page 32 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 Level of Harm - Minimal harm or potential for actual harm In a telephone interview with Resident 324's responsible party (RP) on 12/15/22, the RP stated that Resident 324 did not have a known history of behavior issues or disorders. The RP stated that she was called by a licensed nurse the day after Resident 324's admission to the hospital, 12/5/22, and was told Resident 324's behavior was erratic and the facility would like the RP's permission to give Resident 324 medication to treat this behavior. Residents Affected - Few During a concurrent interview and record review on 12/15/22, at 2:30 P.M., with the licensed nurse (LN 41), LN 41 stated the section for psychotropic medications (medicine used to treat psychiatric illness) was not marked in the interdisciplinary care conference (IDT) form. LN 41 stated the use of Seroquel (a psychiatric medication approved to schizophrenia and bipolar disorder) for Resident 324 was not reviewed or discussed. LN 41 stated Resident 324 had orders for Seroquel 25 milligrams (mg) PO (by mouth) QHS (daily at night) for 14 days prn (ask needed) for episodes of agitation, as evidenced by angry outbursts and getting out of bed unassisted. LN 41 stated the indication Resident 324 was placed on Seroquel was because the resident was hitting and being combative with staff. A concurrent interview and record review was conducted on 12/15/22, at 2:42 P.M., with LN 41 and a second licensed nurse (LN 42). Resident 324's behavior care plan, dated 12/9/22, and nursing notes from admission to 12/15/22 were reviewed and discussed. LN 41 and LN 42 stated the interventions listed on the behavior care plan were followed. LN 41 stated the non- pharmacological interventions were not documented. LN 41 stated it was something they do, but don't necessarily document in the chart. In a concurrent interview and record review, conducted on 12/15/22, at 3:08 P.M., with licensed nurse 43 (LN 43), LN 43 stated she was the nurse who obtained the telephone order from the medical doctor (MD 1) for the Seroquel for Resident 324. LN 43 stated Resident 324 was very agitated during the shift and that the resident was yelling and trying to get out of bed. LN 43 stated she thought the antipsychotic was needed because Resident 324 had a history of dementia. LN 43 stated she was not aware dementia was an approved diagnosis for the use of an antipsychotic. In an interview with MD 1 on 12/16/22, at 10:43 A.M., MD 1 stated he was called by LN 43 the night of 12/5/22 because Resident 324 was agitated. MD 1 stated LN 43 told him the staff was not able to control the residents behavior. MD 1 stated that he gave LN 43 the telephone order for the Seroquel 25 mg PO QHS PRN. MD 1 stated Resident 324 sundowns (a state of confusion that occurs late in the afternoon and into the night which is often associated with dementia) and he is very difficult to control. MD 1 stated he spoke to the RP this morning, 12/16/22, about the use of Seroquel for Resident 324 and the RP asked that the medication be discontinued. MD 1 stated that he has discontinued the order for Seroquel. 555216 Page 33 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner when; Residents Affected - Few A. An opened package of cheese wrapped in a clear plastic had a greenish-black fuzzy looking material inside and, B. Batter mixes, frostings, glaze, pastry toppings had no opened date or use by date. These failures had the potential to spread food-born illness to residents. Findings: On 12/13/22, an initial tour and interview with the Kitchen General Manager (KGM) was conducted of the kitchen. The KGM stated the kitchen prepared food for the residents in the skilled nursing facility. A. Inside the pastry refrigerator, the following food items were observed to be opened and used per the KGM: 1. Pecan sticky bun topping 2. Cream cheese icing 3. A container with an unknown white colored frosting 4. Blueberry muffin batter 5. Half gallon of milk All the food items listed did not have a use by date label. The KGM stated whenever staff opened a food product to use, a use by date label should be placed. B. Inside the pastry refrigerator was a tray bin that contained different kinds of opened cheese packages. One cheese product was wrapped with a clear plastic that had a handwritten use by date sticker. The sticker indicated, Use by 9/22/22. In addition, the cheese had a greenish- brown fuzzy looking material scattered on the cheese. The KGM stated, I have no excuse to this. This should have been thrown away to prevent cross contamination and infection. On 12/14/22 at 8:35 A.M., an interview was conducted with dietary aid (DA) 1. The DA 1 stated after chopping or preparing foods, the process was to put a use by sticker, put the name of the item, and date when it needed to be consumed. DA 1 stated that if there was no use by date label, the food should be thrown away because, It does not look good. 555216 Page 34 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/14/22 at 8:40 A.M., an interview was conducted with DA 2. DA 2 stated food items that were not labeled should be tossed away. In addition DA 2 stated foods that were prepared should have a use by date label to prevent infection. On 12/14/22 at 8:52 A.M., an interview was conducted with the cook (CK). The CK stated everyone who did food preparation should place a use by date label. The CK stated, There was no excuse for not putting one. Per the facility's undated document titled Procurements, Storage, Inventory, Floor Supplies, .Food Labeling. 1. All items will be labeled, covered and dated when placed in refrigerators or freezers using an established labeling rule . 555216 Page 35 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medical record was complete and accurate for one of one sampled resident (63). This failure had the potential to affect the treatment and coordination of care for residents. Findings: Resident 63 was sent back to the facility on [DATE] with diagnoses which included worsening ataxia (impaired balance and coordination due to damage on the brain) per the physician's history and physical note dated 11/21/22. On 12/13/22 at 11:49 A.M., Resident 63 was observed laying on his bed and moved constantly. On the wall was a sign that indicated, Offer q2 (every 2) hours urinal . On 12/15/22 at 3:00 P.M., an interview was conducted with CNA 21. CNA 21 stated Resident 63 was incontinent of urine and was not able to go to the bathroom independently. On 12/15/22 at 3:21 P.M., a joint interview and record review of Resident 63 was conducted with CNA 22 and CNA 23. CNA 22 stated staff documented the residents' fluid intake and output on the fluid intake and output form because nurses, Used the information for their knowledge. CNA 23 stated nurses used the information documented in the fluid intake and output form to do their weekly summary. CNA 22 and 23 both reviewed Resident 63's fluid intake and output documentation then stated it was incomplete and there were days and shifts that there was no amount of intake and output documented. Resident 63's clinical record was reviewed on 12/15/22. The following information was documented on the fluid intake and output form: 12/8/22, NOC shift (11 PM - 7 AM), there was no intake and output documented. 12/8/22 PM shift (3 PM - 11 PM), there was no intake and output documented. 12/10/22 PM shift, there was no intake and output documented. 12/11/22 AM shift (7 AM - 3 PM), there was no intake and output documented. 12/11/22 PM shift, there was no intake and output documented. 12/13/22 PM shift, there was no intake and output documented. There was an intake recorded and was marked as, Error. 12/14/22, AM, PM, and NOC shift, there were no intake and output documented. On 12/15/22 at 3:46 P.M., a joint interview and record review of Resident 63 was conducted of LN 555216 Page 36 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 24, and LN 25. LN 24 and 25 both stated that the fluid intake and output form should be completed every day on each shift. LN 25 acknowledged that the form had inconsistent documentation and there were some missing fluid intake and output values. On 12/16/22 at 7:52 A.M., an interview was conducted with the DON. The DON stated that the expectation for staff was to document the amount of fluid intake and output each shift. The DON further stated, I have no excuse for not having any documented fluid amount values on those shifts. On 12/16/22 at 10:34 A.M., an interview was conducted with the Medical Director (MD). The MD stated he would ask the nurse how much Resident 63 ate and voided to look at his overall general condition to have an appropriate treatment plan. Per the facility's undated form titled SNF Nursing Documentation, .3. Nursing Documentation Principles: (If not charted, it did not happen) a. must be entered in a timely manner, legible .f. document on procedure performed, results/outcome . Per the facility's form titled SNF Nursing Documentation dated 2022, . 2. The purposes of the medical record documentation includes, but not limited to: a. communication between health care team members, b. written evidence of physician's orders, care provided and patient's response to care/services . 555216 Page 37 of 38 555216 12/16/2022 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's QAPI/QAA (quality assessment performance improvement/quality assessment and assurance) committee failed to identify, develop, and implement action plans related to the use of unnecessary psychotropic medications (medications that alter mood, thoughts, and/or behavior) and abuse (cross reference F609, F610, and F758). This failure had the potential to affect the health and safety of the residents. Findings: On 12/16/22 at 3:38 P.M., an interview was conducted with the following members of the facility's QAPI/QAA committee: The director of nursing, the clinical manager, clinical nurse lead (CNL) 2, the director of staff development (DSD), and the pharmacy consultant. The members of the QAPI/ QAA committee stated they met quarterly and held their most recent QAPI/QAA committee meeting in November 2022. The QAPI/QAA committee stated the current issues that were identified and discussed during their November meeting included: bowel and bladder, pain management, pressure injuries and skin issues, pharmacology updates, falls, weight management, and vaccination rates. The DSD stated the QAPI/QAA committee reviewed the data collected from facility's quality indicators during the QAPI/QAA meetings. The QAPI/QAA committee stated resident abuse, reporting, and investigation had not been discussed nor identified as an area for improvement. The QAPI/QAA committee stated moving forward, abuse would be discussed. The QAPI/QAA committee stated residents' psychotropic medication use was reviewed as part of the facility's QAPI/QAA meeting held in November 2022. The QAPI/QAA acknowledged action plans related to incorrect indications for psychotropic use were not developed and had not been corrected. A review of the facility's policy titled QAPI Process in SNF (skilled nursing facilities), dated 9/21, indicated, .The QAPI process will be utilized to develop, implement, and maintain an effective, data driven on-going quality assessment program that focuses on indicators that foster quality of life and quality of care for our residents . Quality indicators are identified based on, but not limited to regulatory compliance needs, feedback from staff, resident's clinical care outcomes, risk management concerns, identified problem prone & high risk clinical issues . Priorities for action planning . will be based on the following considerations: impact of resident care and outcomes, duration of the problem, requirements for further investigation and resolution . Likewise, the elder abuse, neglect, and exploitation prevention process will be integrated with the [facility identifier] QAPI program through staff education and practices scrutiny . [facility identifier] has an established quality assurance performance improvement program that includes, but not limited to the following quality indicators: .c. Psychotropic drugs utilization .s. Elder & dependent adult abuse, neglect & exploitation prevention . 555216 Page 38 of 38