Health inspection·November 9, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, interviews and document review, the facility failed to provide an environment that promoted dignity for 3 of 5 residents during mealtime when, all three residents were not served their meal trays the same time as the other residents, in the multi-purpose room. This failure had the potential to affect the residents' dining experience and quality of life. Findings: On 11/6/23 at 12:09 P.M., a meal observation was conducted in the facility's multi-purpose room. Five residents and a family member (FM) were in the multi-purpose room. Staff served the lunch tray of two of the five residents in the multi-purpose room. On 11/6/23 at 12:15 P.M., the following activities were observed in the multi-purpose room: - Two family members came to the multipurpose room with food and started eating. - Two of the five residents were eating, while the rest were waiting to be served their lunch tray. - Two staff brought their food in the east side of the multipurpose room that was open to the rest of the room, while the three residents were waiting to be served their lunch tray. On 11/6/23 at 12:20 P.M., an interview with a FM that was in the multi-purpose room was conducted. The FM stated they could smell the food in the multi-purpose room and that the other residents were eating while the rest were not served. The FM stated it made her think that they have been forgotten. On 11/6/23 at 12:25 P.M., the three residents in the multi-purpose room were not served their meal tray, while the other 2 residents finished their lunch. On 11/6/23 at 12:45 P.M., an interview with certified nursing assistant (CNA) 50 was conducted. CNA 50 acknowledged that all the residents in the multi-purpose room should have been served their lunch around the same time. CNA 50 stated the resident may feel bad if they were not served while the rest were eating. A review of the facility's policy and procedure titled Resident/Patient Rights in Sub Acute/LTC (Long Term Care, revised on 5/18/23, indicated, Each resident has a right to a dignified existence, Page 1 of 23 555216 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0550 self-determination, and communication with, access to, persons and services inside and outside the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555216 Page 2 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0641 Ensure each resident receives an accurate assessment. 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 medical record review, the facility failed to accurately code the Minimum Data Set (MDS, a nursing assessment tool) for four of 21 residents (Resident 51, Resident 32, Resident 29 and Resident 12). This deficient practice had the potential to affect the residents by delaying resident care needs and provided inaccurate information to the Federal database. Residents Affected - Some Findings: 1. Resident 12 was admitted to the facility on [DATE] with diagnosis which included Cerebral Vascular Attacks (CVA, is a brain attack, that interrupts in the flow of blood to cells [basic living blocks of all living things] in the brain) per progress notes on 10/31/2023 by Medical Doctor (MD). Record review of resident 12's document titled, Physician's Orders dated 05/13/21 indicated, . Admit to [Hospice Name] on Routine Level of Care Terminal . Dx (diagnosis) Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) . Review of resident's care plan initiated 05/13/21 Admit to Hospice care .[Hospice Name] . A concurrent interview and record review was conducted on 11/07/23 at 10:13 A.M., with MDS Nurse 44. Resident 12's most recent completed MDS dated [DATE] was reviewed. MDS Nurse 44 stated, Resident 12 was admitted as a Hospice resident with a prognosis of six months or less and it should have been coded in MDS Section O0110K1 Hospice because Resident 12 was on hospice. MDS Nurse 44 stated, it was important to code accurately to avoid any delay of care for any residents and to make sure hospice was part of Resident 12's plan of care. MDS Nurse 44 stated, will modify MDS and re-submit to federal database. 2. Resident 32 was admitted to the facility on [DATE] with diagnosis which included CVA as noted in Resident 32's History and Physical (H&P) dated 07/29/2023. Record review of Resident 32's document titled, Physician's Orders dated 01/19/22 indicated, orders for RNA (Restorative Nursing Assistant, helps provide rehabilitative services to residents such as exercises to upper and lower body to prevent the decline in mobility) that include: • RNA program on standing exercise . • RNA ROM (range of motion) to BUE (bilateral upper extremities) Daily . A concurrent interview and record review was conducted on 11/09/23 at 10:20 AM, with MDS Nurse 44. Resident 32's most recent completed MDS dated [DATE] was reviewed. MDS Nurse 44 stated, RNA services provided during the look-back period (from 10/20/23-10/26/23) was coded for seven days. MDS 44 reviewed Resident 32's Restorative Nursing Progress Report that indicated RNA services were provided for three days (10/22/23 for 20 minutes, 10/23/23 for 20 minutes and 10/25/23 for 20 minutes) versus the seven days that was coded on Resident 32's MDS. MDS Nurse 44 confirmed that Resident 32's MDS 555216 Page 3 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated [DATE] was not accurate to code seven days of RNA services in MDS Section O0500 Restorative Nursing Program Section B range of motion (active). MDS Nurse 44 stated, Resident 32's MDS needs to be modified to reflect to provide accurate information to the federal database. 3. Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a gradual decline with memory, language, problem-solving and other thinking abilities) per Medical Doctor (MD) notes dated 09/12/23. Record review of resident 29's document titled, Physician's Orders dated 10/21/23 indicated, orders for restorative nursing services (restorative nursing assistant [RNA] is a program provided by nursing services for residents to restore or maintain physical function) that included: • RNA program 4x/week (four times a week) standing frame . • RNA program For SCI-FIT 3x/week (three times a week) . A concurrent interview and record review was conducted on 11/09/23 at 10:35 A.M., with MDS Nurse 53. Resident 29's most recent completed MDS dated [DATE] was reviewed. MDS Nurse 53 stated, RNA services during the look-back period (from 08/05/23-08/11/23) was coded as being done for seven days. MDS Nurse 53 reviewed Resident 29's Restorative Nursing Progress Report that indicated RNA services were provided on 08/07/23 for 15 minutes and 08/08/23 for 10 minutes. MDS Nurse 53 confirmed that the MDS dated [DATE] was not accurate to code seven days of RNA services in MDS Section O0500 Restorative Nursing Program Section A range of motion (passive) and should be modified to accurately reflect Resident 29's health status and prevent any delays in care. 4. Resident 51 was re-admitted to the facility on [DATE] with diagnosis which included coronary artery disease (A major blood vessel [coronary arteries]) that supply the heart with blood, oxygen, and nutrients to the heart muscle due poor circulation [the flow of blood]) and history of pressure ulcers to sacrum and upper back as documented per the progress note dated 08/22/23 written by a Nurse Practitioner (NP). Record review of resident 51's document titled, Physician's Orders dated 10/19/23 indicated, RNA program 5-7x/week for progressive ambulation . A concurrent interview and record review was conducted on 11/09/23 at 10:38 A.M., with MDS Nurse 44. Resident 51's most recent completed MDS dated [DATE] was reviewed. MDS Nurse 44 stated, RNA services during the look-back period (from 10/27/23-11/02/23) was coded as being done for seven days. MDS Nurse 44 reviewed Resident 51's Restorative Nursing Progress Report that indicated RNA services were provided only on 11/01/23 for 20 minutes. MDS Nurse 44 confirmed that the MDS dated [DATE] was not accurate to code seven days of RNA services in MDS Section O0500 Restorative Nursing Program Section B range of motion (active) and F walking. MDS Nurse 44 stated, Resident 51's MDS needs to be modified because MDS data was sent to federal database and drives the care to the residents for patient centered care. During an interview on 11/09/23, at 4:10 P.M., the Director of Nursing (DON) acknowledged 555216 Page 4 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0641 inaccurate MDS assessments and was verified of the above findings. Level of Harm - Minimal harm or potential for actual harm Review of Centers for Medicare and Medicaid Services (CMS, a federal agency) Resident Assessment Instrument (RAI, a standardized assessment tool for resident) RAI Manual 3.0 October 2019, (Page O-42) Section O0500: Restorative Nursing Program. Record the number of days each of the following restorative program was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily .A. Range of Motion (passive), B. Range of motion (active), .F. Walking. RAI Manual3.0 October 2023, (Pages O- Section O0110K Hospice Care. Code residents identified as being in a hospice program .) Residents Affected - Some 555216 Page 5 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide assistance for the hygiene for one (Resident 365) of five residents. This failure resulted in the resident not being provided a shower or bed bath for four days. This includes two regularly scheduled shower days and a day the resident had an offsite appointment (on day four). Residents Affected - Few This failure caused Resident 365 to feel unclean and embarrassed at the offsite appointment. Findings: Resident 365 was admitted on [DATE], for antibiotic therapy due to an ongoing infection per resident facesheet. Resident 365 had a BIMS (Brief Interview for Mental Status, an assessment tool to measure mental functioning and memory) score of 15. The resident was alert, oriented, and able to make needs known. An interview was conducted on 11/07/23 at 9:34 AM. Resident 365 was seated at bedside. Family was in Resident 365's room. Resident 365 stated she was offered a shower yesterday afternoon but had not received one since 11/3/23. Resident 365 stated she was going off site for a primary care physician (PCP) appointment within the hour and a shower at this time would not be possible. A record review was conducted of the Certified Nursing Assistant Flowsheet, for the week of 10/30/23 and 11/6/23. Resident 365's last documented shower/bath was on 11/03/23. A review of Resident 365's ADL (activities of daily living) care plan indicated Resident 365 was to have a shower twice a week (Monday and Friday) with bed baths in between. An interview was conducted on 11/07/23 at 1:53 PM, Resident 365 stated she did not have a shower on Friday, Saturday, or Sunday. Resident 365 stated, on Monday, she was told it would be later in the day, but it did not occur. Resident 365 said it was no good that she had to go to her PCP appointment without having bathed. Resident 365 stated she felt unfresh. An interview was conducted on 11/07/23 at 1:55 PM. with Certified Nursing Assistant (CNA) 13. CNA 13 stated, she was too busy to shower Resident 365. CNA 13 stated she informed the nurse that she was too busy and running behind. CNA 13 stated she informed Resident 365. CNA stated her expectation would be that the following shift would be able to complete Resident 365's shower. CNA 13 stated missing a shower would be hard on any resident. CNA 13 stated a resident would feel nasty and bad when they do not get a shower. An interview was conducted on 11/08/23 at 9:37 AM. with Charge Nurse (CN) 11 at the nursing station. CN 11 stated, if a CNA is unable to provide a shower on the scheduled shift it is passed on to the next shift. If a resident did not receive a shower for four days and one day being the scheduled shower day the resident would feel really bad and it would impact their quality of life. An interview was conducted on 11/08/23 at 1:48 PM with the Director of Restorative Care and Nursing (DON) in her office. The DON stated a missed shower should be passed down to the next shift. The DON stated a resident missing four shower days would feel dirty and that should not happen. 555216 Page 6 of 23 555216 11/09/2023 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record reviews the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) in accordance with the physician's order for one of six residents (Resident 51) reviewed for pressure ulcer. Residents Affected - Few As a result, Resident 51 developed a new pressure injury on the sacral area (area below the lower back). Findings: Resident 51 was re-admitted to the facility on [DATE], per admission record, with diagnosis which included Coronary Artery disease (A major blood vessel [coronary arteries]) that supply the heart with blood, oxygen and nutrients to the heart muscle due poor circulation [the flow of blood]) and history of pressure ulcers to sacrum (area below the lower back) and upper back as documented per the progress note dated 08/22/23 written by a Nurse Practitioner (NP). A record review of Resident 51's document titled Braden Risk Assessment Flowsheet (An assessment tool used to indicate pressure ulcer risk), dated 06/15/2023, indicated Resident 51 was at risk for developing pressure ulcers due to limited mobility .unable to make frequent or significant changes independently ., and chairfast .Cannot bear own weight and/or must be assisted into chair or wheelchair. A record review of Resident 51's document titled Physician's Orders dated 06/29/23 indicated, .Low Air Loss Mattress (LAL mattress - pressure relieving mattress that uses air that continues to flow through the mattress so that the user floats on the soft cushion of air relieving pressure to skin). for Wound Management ., and .Turn Patient Strict L/R (Left/Right) turns only every 2 hrs (hours) to remove pressure from sacral . A review of Resident 51's care plan related to pressure injury, dated 09/23/23, indicated, Stage 2 (an open wound with red or pink appearance sometimes may contain fluid filled blisters that are open or closed caused by pressure to the skin and is non-blanchable [reoccurrence]) location: sacrum . Reposition q (every) 2 hours . A record review on Resident's 51's document titled Physician's Orders dated 10/24/23 indicated, Cleanse with NS (normal saline is a mixture of table salt and water for medical use) wound on Sacral and L (left) inner buttock with NS, pat dry, apply Medi-honey (wound paste to treat wounds) and cover with adaptic (non-stick wound dressing) and 4x4 gauze (loosely woven cotton surgical bandage) daily and PRN (as needed) . Observations of Resident 51 were conducted on following dates and times: • 11/06/2023 at 10:56 A.M. and 1:00 P.M.- sat in an upright position in bed without a low air-loss mattress (LAL mattress - pressure relieving mattress that uses air that continues to flow through the mattress so that the user floats on the soft cushion of air relieving pressure to skin). 555216 Page 7 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0686 11/06/2023 at 2:51 P.M.- slightly turned to right (R) side while bottom half of the body laid directly on the bed. No LAL mattress. Level of Harm - Actual harm Residents Affected - Few 11/06/2023 at 3:00 P.M.- slightly turned to L side while bottom half of the body laid directly on the bed. No LAL mattress. • 11/07/2023 at 8:41 A.M.,10:41 A.M., and 12:53 A.M. - sat in an upright position in bed without a low air-loss mattress. 11/07/2023 at 1:57 P.M.- slightly turned to L side while bottom half of the body laid directly on the bed. No LAL mattress. • 11/08/2023 at 8:30 A.M.- slightly turned to R side with wedge pillow (triangular pillow used for positioning while bottom half of the body laid directly on the bed). No LAL mattress. 11/08/2023 at 10:12 A.M.- slightly turned to R side with wedge pillow (triangular pillow used for positioning while bottom half of the body laid directly on the bed). No LAL mattress. 11/08/2023 at 10:38 A.M.- slightly turned to L side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. 11/08/2023 at 12:30 P.M and 1:45 P.M.- sat in an upright position in bed with wedge pillow set aside without a low air-loss mattress. 11/08/2023 at 3:30 P.M.- slightly turned to L side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. • 11/09/2023 at 7:52 A.M.- sat in an upright position in bed with wedge pillow set aside without a low air-loss mattress. 11/09/2023 at 10:55 A.M- slightly turned to R side with wedge pillow while bottom half of the body laid directly on the bed. No LAL mattress. 11/09/2023 at 11:08 A.M.- CNA 50 repositioned Resident 51 to L side for wound treatment. An interview was conducted on 11/06/23 at 2:51 PM, with Certified Nurse Assistant (CNA) 42. CNA 42 stated residents who require extensive assistance with bed mobility such as Resident 51 should be turned every two hours and checked by all nursing staff. CNA 42 stated if there were skin issues or refusal of care, these issues would be reported to the licensed nurse (LN). A joint observation of Resident 51's wounds and interview of licensed nurse (LN) 46 was conducted on 11/07/23 at 2:52 PM. Resident 51's sacral area had two round open wounds. Below one of the open 555216 Page 8 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0686 Level of Harm - Actual harm Residents Affected - Few wounds, a round quarter-size reddish-purple discoloration was observed. LN 46 pressed on the reddish-purple discoloration and stated that the area was non-blanchable (a skin abnormality where the discoloration of the skin that does not turn white when pressed). An interview and joint record review of Resident 51's physician's order was conducted on 11/09/23 at 10:55 A.M., with LN 46. LN 46 stated Resident 51 was not on a LAL mattress because the resident had stage two pressure injuries. LN 46 stated that LAL mattresses were only ordered for stage three pressure injuries (an open wound caused by pressure that extends through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone and is non-blanchable). LN 46 reviewed Resident 51's physician's order and stated that the LAL mattress order was active and should have been provided to Resident 51. A joint observation of Resident 51's wounds and interview of LN 46 was conducted on 11/09/23 at 11:08 AM. A new open wound developed on Resident 51's sacral area, where the reddish-purple discoloration was observed on 11/07/23. LN 46 measured the new wound at 0.3 centimeters (cm) by 0.3 cm. LN 46 stated Resident 51 had histories of pressure ulcers and required assistance with bed mobility. LN 46 stated a LAL mattress would be beneficial due to Resident 51's high risk for developing pressure injuries. LN 46 stated it was important to reposition Resident 51 every 2 hours to help prevent the development of pressure ulcers. An interview with the Director of Nursing (DON) was conducted on 11/09/23 at 3:55 PM. The DON stated that the LAL mattress should have been provided to Resident 51 and that Resident 51 should have been repositioned every two hours as ordered to prevent skin breakdown. A review on the facility's policy, titled Pressure Ulcer/Injury Prevention and Treatment effective 07/12/23, was conducted. The policy defined a stage two pressure injury as .Partial-thickness skin loss with exposed dermis (the layer of skin just underneath the part you can see and touch). The wound bed is viable (alive), pink or red, moist, and may also present as an intact or ruptured serum (clear liquid or yellowish fluid that does not clot from blood) -filled blister . and defined a DTI (deep tissue injury) as . Persistent non-blanchable deep red, maroon or purple discoloration . The policy section III under Text indicated PUPT (Pressure Ulcer/Injury Prevention and Treatment) is designed to . 2. Define early interventions for prevention of pressure ulcer/injury. 3. Provide treatment options for Stages 1-4, Unstageable pressure ulcer/injury and DTI and 4. Define appropriate documentation of pressure ulcer/injury . 555216 Page 9 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 44 was admitted to the facility on [DATE] with an active diagnosis of amyotrophic lateral sclerosis (ALS, a progressive disease that breaks down nerve cells in the brain and spinal cord resulting in muscle weakness) per the resident's admission record. A review of Resident 44's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 9/14/23, section B, indicated Resident 44 was cognitively intact and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS, an assessment tool to measure mental functioning and memory). On 11/6/23 at 11:24 A.M., a concurrent observation and interview with Resident 44 was conducted. Resident 44 was sitting in a wheelchair watching television and had a electronic tablet, that used eye movements to point, click and type, set up on the bedside table for communication. Resident 44 indicated, via tablet, she received RNA services two to three times a week but that it was ordered every day. Resident 44 indicated, via tablet, she had communicated to staff she was not getting RNA services daily and indicated staff was always busy and in a hurry. On 11/8/23 at 2:08 P.M., an interview was conducted with RNA (restorative nursing assistant [RNA] is a program provided by nursing services for residents to restore or maintain physical function) 1. RNA 1 stated Resident 44's RNA therapy was ordered five to seven days a week for both upper and lower extremities. RNA 1 stated she had not been able to give Resident 44 RNA therapy as ordered because they had been short staffed. RNA 1 stated, Resident 44 had communicated, via tablet, that she is upset when she does not get her ordered RNA therapy. On 11/8/23 at 2:17 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 44 did not always get RNA therapy because of understaffing. LN 1 stated if a resident did not get RNA therapy as prescribed they were at risk of getting contractures (shortening and hardening of muscles and tissue that may result in a limb deformity), and increased pain from lack of mobility. A record review of Resident 44's Physician Orders, ordered on 7/28/23 indicated Resident 44 was to receive passive range of motion (PROM, movement of a body part without voluntary effort) to both upper and lower extremities five to seven days a week. A review of Resident 44's Restorative Nursing Progress Report (RNPR) for September 2023 and October 2023 was conducted with RNA 1. The weekly RNPR indicated Resident 44 received PROM from the RNA the following number of days per week: September 10-16th: three days September 17-21st: two days September 24-30th: three days October 1-7th: two days October 8-14th: three days 555216 Page 10 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0688 October 15-21st: one day Level of Harm - Minimal harm or potential for actual harm October 22-28th: one day Residents Affected - Some A review of the facility's Policy and Procedures titled, Restorative Nursing Program, revised 01/01/2016, indicated To establish a restorative program to ensure Sharp HealthCare Skilled Nursing Facilities assist each resident/patient to achieve and maintain the highest possible levels of independence . The RNA will implement the treatment programs following the written plan, documenting daily and weekly in each resident/patient's medical record. Based on observation, interview, and record review, the facility failed to provide Restorative Nursing services to 45 of 45 residents with orders for restorative nursing assistant (RNA) treatments, which included two residents (Resident 29 and Resident 44) reviewed for limited range motion (ROM, amount of joint's ability to move in any direction to its limits) when: 1. Resident 29 did not receive RNA services at the frequency ordered by the physician. 2. Resident 44 did not receive RNA services at the frequency ordered by the physician. This deficient practice could place all 45 residents with orders for RNA treatment at increased risk of further decline in range of motion ROM to resident's extremities (hands, arms, legs, and feet). Cross Reference F725 and F641 Findings: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a gradual decline with memory, language, problem-solving and other thinking abilities) per Medical Doctor (MD) notes dated 09/12/23. Record review of Resident 29's document titled, Physician's Orders dated 10/21/23, indicated orders for restorative nursing services that include: 1) RNA (restorative nursing assistant [RNA] is a program provided by nursing services for residents to restore or maintain physical function) program 4x/week (four times a week) standing frame and 2) RNA program for SCI-FIT 3x/week (three times a week). Review of Resident 29's Minimum Data Set assessment (MDS - a nursing assessment tool), dated 08/11/23, indicated Resident 29 had short- and long-term memory problems along with severely impaired (weakened or diminished) cognitive (the ability to understand, learn, process information, and react appropriately) skills for decision making. An observation and interview on 11/06/23 at 11:36 A.M., with CNA 42 was conducted. Resident 29 was in bed getting ready for lunch in upright position with two liters per minute (LPM) nasal canula (NC, a tube that delivers oxygen through the nose) with CNA 42. CNA 42 stated, resident requires limited assistance with meals. CNA 42 stated resident talks to self and is Spanish speaking. CNA 42 stated resident is forgetful and requires assistance with activities of daily living (ADLs) to be safe. An interview was conducted on 11/07/23 at 2:22 P.M., with CNA 45. CNA stated Resident 29 had one 555216 Page 11 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sided weakness and requires total dependence with care. Resident was also bowel and bladder incontinent and on an RNA program. During a concurrent interview and record review on 11/09/23 at 08:24 A.M., with RNA 51. RNA 51 reviewed flow sheets to include Resident 29 titled, Restorative Nursing Progress Report and stated if the report was undated or blank this indicated no RNA services were provided. RNA 51 stated providing RNA services had been a problem for a while, several months now. The fix was to hire more CNAs and RNAs to train but would resign retention wise is a problem. RNA 51 stated RNA services should be done to help residents with exercises that can prevent complications such as contractures and ADL decline. On 11/9/23 at 9:19 A.M., an interview with RNA 51 was conducted. RNA 51 provided a list of all the residents with orders for RNA treatment. Per the list, there were a total of 45 residents with orders to receive RNA treatments. RNA 51 reviewed the RNA documentation and stated that all residents with orders for RNA treatment, did not receive their treatments as ordered by their physicians. An interview was conducted in the conference room on 11/09/23 at 2:57 P.M., with the DON. The DON stated, the facility was not fully meeting RNA needs. An interview was conducted on 11/09/23 at 03:31 P.M., with licensed nurse (LN) 58. LN 58 stated, We made the decision to pull RNAs because CNA care tasks were deemed more important. A review of the facility's Policy and Procedures titled, Restorative Nursing Program, revised 01/01/2016, indicated To establish a restorative program to ensure Sharp HealthCare Skilled Nursing Facilities assist each resident/patient to achieve and maintain the highest possible levels of independence . The RNA will implement the treatment programs following the written plan, documenting daily and weekly in each resident/patient's medical record. 555216 Page 12 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents. There were a total of 45 residents in the facility receiving restorative treatment from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life. Findings: On 11/7/23 at 10:04 A.M., a confidential interview was conducted with the Resident Council (an organized group of residents who meet regularly to discuss and address concerns about their rights and their care). Nine residents attended the Resident Council meeting. During the meeting, five of the nine attendees stated that they were not receiving RNA treatments in accordance to their physician's orders. One of the residents stated that the RNAs were being removed from their duties to cover the certified nursing assistants (CNAs). On 11/7/23 at 2:48 P.M., an interview with RNA 1 was conducted. RNA 1 stated there used to be three RNAs to provide RNA treatments. RNA 1 stated currently there were two RNAs working and sometimes only one. RNA 1 stated the RNAs were being pulled from their duties to cover a CNA on the floor, when the floor was short of a CNA. RNA 1 stated that RNA treatments were not being provided for the residents when their was no RNA avaiable to provide the care. On 11/9/23 at 9:19 A.M., an interview with RNA 51 was conducted. RNA 51 provided a list of all the residents with orders for RNA treatment. Per the list, there were a total of 45 residents with orders to receive RNA treatments. RNA 51 reviewed the RNA documentation and stated that all residents with orders for RNA treatment, did not receive their treatments as ordered by their physicians. An interview with the Director of Nursing (DON) was conducted on 11/9/23 at 3:10 P.M. The DON stated the facility were not able to fully provide RNA services and that they were working on the plan. A review of the facility's document titled Staffing Plan for Birch [NAME] Convalescent Center, dated January 2023, was conducted. The document did not provide guidance regarding RNA staffing. 555216 Page 13 of 23 555216 11/09/2023 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** Based on observation, interview, and record review for one of six sampled residents (Resident 29), the facility failed to document an appropriate indication for the use of Seroquel (a medication used for mental/mood conditions that help regulate mood, thoughts, and behaviors). This failure placed Resident 29 at unnecessary risk for adverse consequences related to the use of Seroquel. Findings: Review of the clinical record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included dementia (a gradual decline with memory, language, problem-solving and other thinking abilities) per Medical Doctor (MD) notes dated 9/12/23. A record review of Resident 29's physicians orders, Antipsychotic Medication Order, dated 9/12/23, indicated the use of Seroquel 12.5 mg (milligrams) PO (by mouth) q (every) HS (bedtime) for Behavioral Disturbance secondary to dementia. Episode monitoring to include monitoring for Agitation QS (every shift) AEB (as evidenced by) a. continuous yelling, b. inability to sleep at night . A review of a nursing progress note, dated 9/14/23 at 8:30 P.M., indicated new orders to decrease Seroquel to 6.25 mg. Review of Resident 29's Minimum Data Set assessment (MDS; assessment tool), dated 8/11/23, indicated Resident 29 had short and long-term memory problems, along with severely impaired (weakened or diminished) cognitive (the ability to understand, learn, process information, and react appropriately) skills for decision making. An interview was conducted on 11/7/23 at 2:22 P.M., with certified nurse assistant (CNA) 45. CNA 45 stated Resident 29 had episodes of confusion with yelling out [MD Name] but did not recall episodes of Resident 29 hitting anyone or herself. CNA 45 stated Resident 29 was sleepier in the morning, but was more alert when family visited. An interview was conducted on 11/7/23 at 3:10 P.M., with CNA 47. CNA 47 stated Resident 29 was very talkative and refused to eat at certain times, due to customary preference of Mexican food, and that the family also brought food for the resident. CNA 47 stated that Resident 29 spoke Spanish, talked to self, forgets recent information, and had never seen Resident 29 have outbursts with other residents. CNA 47 stated Resident 29 was verbal but used body language, such as using arms to sway people away, but not in a harmful way. CNA 47 stated Resident 29 can be threatening by trying to scare CNAs off verbally, but never physically. CNA 47 stated Resident 29 was always looking for her kids, and that her behavior was calm when family was present. A telephone interview was conducted on 11/8/23 at 2 P.M., with RP 55. RP 55 stated Resident 29 was put into rehab after a fall two years ago, and was diagnosed with dementia. RP 55 stated that resident did not have symptoms of calling out at night for [MD name] until admitted to the facility and had not improved with the Seroquel and was still not asleep at night. RP 55 stated, Resident 29 slept 555216 Page 14 of 23 555216 11/09/2023 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 more during the day. RP 55 stated resident 29 was calmer when family visited and would be open to other options versus medication management. An interview with licensed nurse (LN) 49 was conducted on 11/8/23 at 3:22 P.M., LN 49 stated that Resident 29 was taking Seroquel for dementia due to behavioral episodes of yelling and for sleep that may indicate signs of psychosocial distress, pain, or infection. A review of the nursing progress notes dated, 9/15/23 at 1 P.M., indicated that RP 55 .verbalized that [Resident 29] is not aggressive and did not scratch daughter's hands last visit (referring to 9/11/23 nurse progress notes at 1414 [2:14P.M.] .episode of hitting staff when putting back pt to bed. Scratched daughter) . and only reacting to pain . During an interview on 11/9/23 at 2:29 P.M., with LN 57, LN 57 stated that Resident 29 was on Seroquel for dementia and agitation. Resident 29 was on medication due to resident's inability to sleep. A telephone interview with Resident 29's physician was conducted on 11/9/23 at 3:01 P.M., The physician stated that Resident 29 was taking Seroquel for dementia and develops agitations such as staying awake the whole night to cause disturbance when Resident 29 shares a room with somebody. During an interview on 11/9/23 at 3:40 P.M., with the Director of Nursing (DON), the DON stated psychotropic medications should have clear indications of appropriate use. Review of the facility's policy and procedure titled, Monitoring of Antipsychotic Medications, last revised 5/11/22 indicated, . Antipsychotic medications should be used for the following conditions/diagnosis . Schizophrenia, Schizo-affective Disorder, Schizophreniform Disorder, Tourette's Disorder and Huntington Disease, Hiccups (not induced by other medications), or Nausea and vomiting associated with cancer or chemotherapy . 555216 Page 15 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0759 Ensure medication error rates are not 5 percent or greater. 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 medications were administered correctly for 2 of 25 medication administration attempts, which resulted in an 8% medication error rate. Residents Affected - Few This failure had the potential to cause harm to the residents. Findings: A review of Resident 26's medical records indicated the resident was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), and had a gastrostomy tube (G-Tube, a tube inserted directly into the stomach to give medications, liquids and liquid food). On 11/08/23 at 9:33 A.M., a medication administration observation and interview was conducted with Licensed Nurse (LN) 21. LN 21 prepared Resident 26's medications which included: 1. Vitamin C 500 mg (milligram) 1 tablet; 2. Aspirin 81 mg (helps to prevent heart attacks) 1 tablet; 3. Calcium Carbonate 500 mg (dietary supplement) 1 tablet; 4. Vitamin D3 2000 u ([units] dietary supplement) 1 tablet; 5. Donepezil (for dementia [loss of cognitive thinking, remembering, and reasoning]); 10 mg 1 tablet; 6. Multivitamin with minerals 1 tablet; 7. Tylenol 650 mg/20.3 ml 20.3 ml (milliliter); 8. Senna (helps to prevent constipation) 8.6 mg/5 ml, 5 ml. On 11/08/23 at 9:50 A.M., LN 21 placed each tablet medication in a crushing container, crushed the medication, and poured each one into separate medication cups. LN 21 mixed and diluted each crushed medication with 5 ml of water. On 11/08/23 at 10:06 A.M., LN 21 was observed accessing the G-Tube to administer medications. LN 21 administered 30 cc (cubic centimeters) of air and confirmed tube placement. LN 21 flushed the G-Tube with 30 ml of water prior to administration of the medications. LN 21 flushed the G-Tube with 5 ml of water between medications. After administering the last medication, LN 21 stated she was done, and had administered all the medications of Resident 26. LN 21 removed the syringe and closed the G-Tube. LN 21 did not flush the G-Tube with water after the administration of medications. On 11/08/23 at 10:23 A.M., an interview was conducted with LN 21. When asked if she needed to flush the G-Tube with water after administering medications, LN 21 stated she did not but should have flushed with 30 ml of water, to ensure Resident 26 received all of the medications. On 11/08/23 at 10:24 A.M., an observation and interview with LN 21 was conducted. LN 21 was asked by the surveyor to look at the medication cup that the crushed calcium carbonate was diluted in. On the inside of the medication cup was a pink layer of undissolved medication. LN 21 acknowledged the wrong dose of the medication was administered when the undissolved medication in the cup was not given. On 11/08/23 at 2:04 P.M., a record review of the facility policy and procedures titled, Enteral Feeding Feeding Tube Site/s, G-J Tubes, dated 4/01/23, indicated that feeding tubes must be flushed .with 30 ml of water before and after meds . On 11/08/23 at 3:54 P.M., an interview was conducted with the director of nursing (DON). The DON acknowledged and agreed that it was important to flush a G-Tube with 30 ml of water before and after 555216 Page 16 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0759 Level of Harm - Minimal harm or potential for actual harm medication administration to ensure the resident received all of the administered medications. The DON agreed that medications crushed for G-Tube administration should be diluted enough to ensure the full amount of medication is drawn up and given. The DON stated LN 21 should have put more water into the medicine cup to dilute and ensure all of the medication was given. Residents Affected - Few 555216 Page 17 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, interviews, and record reviews the facility failed to ensure standardized recipes were used for preparing meals for skilled nursing home residents on regular and therapeutic diets. Residents Affected - Few This deficient practice had the potential to compromise the nutritional content of foods prepared for all skilled nursing facility residents. Findings: On 11/8/23 at 10:39 A.M., an observation and interview was conducted with [NAME] (CK) 1 in the main kitchen. CK 1 used a clear plastic cup to scoop a white powder from a clear plastic bin, labeled thickener, into a stainless steel food blender. CK 1 stated he was pureeing chicken soup for residents who had orders for a modified texture diet. CK 1 stated he did not follow a standardized recipe to add powdered thickener to pureed foods. CK 1 stated he just eyeballs the amount of thickener to add to a puree until it was velvety. CK 1 stated he did not use a standardized recipe to make chicken soup because he had been making chicken soup for 20 years. CK 1 stated he did not know where instructions on how to use the thickener were located, and there were no instructions on the container for the thickener. On 11/8/23 at 10:45 A.M., an interview and record review was conducted with CK 1 and the Registered Dietitian (RD). A review of the standardized recipe book for the week's menu indicated the facility did not have a standardized chicken soup recipe available for the regular or modified diet. The RD stated a standardized recipe with puree instructions should be available in the recipe book and followed by all cooks for regular and pureed items offered to residents, to ensure the nutritional content of the meal was preserved. The RD stated if a standardized recipe was not followed there was no way to ensure the nutritive value of the food served. A record review of the facility's menu items offered to residents on regular, therapeutic, and pureed diets indicated chicken noodle soup was a food item listed as available every day. A review of the facility policy titled, Meal Service Procedures; Recipes and Portions, revised 10/20/23, indicated, Policy: The Food and Nutrition Service Department will maintain strict food preparation procedures using standardized recipes . Guidelines: 1. All foods will be prepared in the best possible manner to maintain quality, nutritive value, and appearance, according to standardized recipes. 555216 Page 18 of 23 555216 11/09/2023 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 ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: Residents Affected - Some 1. Three walk-in refrigerators (Ref 1, 2 & 3) had TCS (time/temperature control for food safety foods - meats, produce, etc.) foods that were stored opened, unlabeled, and available for preparation beyond the use by date. 2. Multiple food items in the dry storage room were uncovered, mislabeled, and available for meal preparation beyond the use by date. 3. Holding temperatures for TCS foods were not recorded in the temperature log book. 4. Kitchen staff was observed working in the kitchen without a beard net. 5. A bag of expired enteral nutrition (EN, liquid nutrition placed directly into the stomach by a tube) was stored in the skilled nursing satellite kitchen and available for use. 6. Fruit cups in the trayline refrigerator (Ref 4) were stored and transported to the skilled nursing facility for lunch uncovered and undated. These deficient practices exposed the facility's residents to potentially hazardous and contaminated food which had the potential to cause foodborne illness and disease in 86 residents who receive food from the facility's kitchens. Findings: 1. On 11/6/23 at 10:14 A.M., an observation of the facility's walk-in produce refrigerator (Ref 1) was conducted in the main kitchen. Ref 1 contained a large bag of opened iceberg lettuce, 1/3 full, undated and unlabeled. On 11/6/23 at 10:25 A.M., an observation of the facility's walk in tray line refrigerator (Ref 2) was conducted in the main kitchen. A small metal container sitting on a storage rack, containing green sauce, 1/4 full, was unlabeled and undated covered in plastic wrap. In addition, the container had 555216 Page 19 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0812 a small, round, clear condiment cup lying in the green sauce. Level of Harm - Minimal harm or potential for actual harm On 11/6/23 at 10:30 A.M., an observation of the facility's walk in meat refrigerator (Ref 3) was conducted in the main kitchen. A large white foam container with frozen salmon filets was sitting on the bottom shelf of the meat rack. The label on the container indicated, Use by: Date: 9/25/23, Salmon w/Mizo. Residents Affected - Some 2. On 11/6/23 at 10:42 A.M., an observation of the facility's dry storage room was conducted in the main kitchen. In a large open and uncovered box, on the bottom shelf of a dry goods rack, laid a large open blue bag of unlabeled raisins. A use-by date of 8/13/23 was indicated on a large plastic bin with a red top containing small cream colored, oval-shaped beans labeled white beans, located on a separate dry goods rack. On 11/6/23 at 10:47 A.M., an interview was conducted with the Registered Dietitian (RD). The RD stated that a food item that has been opened should be sealed in a container, labeled with the correct name and date before re-storing the item on the shelf. The RD stated frozen foods should be cooked by the use by date on the use by label. RD stated the importance of labeling a food product with a date was to prevent foodborne illness and identify items correctly. According to the 2022 US FDA Food Code, Section 3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . A review of the facility policy titled, Infection Prevention for Food & Nutrition Services, last revised 8/31/23, indicated, I Purpose: To prevent the spread of microorganisms among patients, personnel and visitors and maintain effective Infection Prevention measures within the kitchen area and outlying areas stocked by food service personnel . III. Text .G. Food Storage/Disposal: 1. All foods are labeled, covered and dated when stored . Outdated foods are discarded . 3. On 11/8/23 at 9:46 A.M., a concurrent interview and record review was conducted with the RD and [NAME] (CK) 1. The facility's HACCP Critical Control Points Daily Temperature Log (T-Log), dated 11/7/23 was reviewed. The T-Log listed menu items for lunch on 11/7/23 at 11:30 AM. The T-Log included a space to record the final internal cooking temperature, the holding temperatures, cooling temperatures and reheating temperatures for each item. The holding temperature section for all the listed lunch foods on 11/7/23 was blank with no temperatures recorded. CK 1 stated holding temperatures should be recorded for all items available for consumption. CK 1 stated holding temperatures below 140 degrees farenheit and above 41 degrees farenheit could cause bacteria growth and foodborne illness. The RD stated the holding temperatures for all items served should be recorded in the temperature log book. A review of the facility policy titled, Infection Prevention for Food & Nutrition Services, last revised 8/31/23, indicated, . F. Food Preparation and Service . 3. All readily perishable foods or beverages capable of supporting rapid and progressive growth of microorganisms which can cause food infections shall be maintained at temperatures less than or equal to 40 degrees or greater than or equal to 140 degrees at all times . This is monitored by documentation of temperature logs . 555216 Page 20 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0812 4. Level of Harm - Minimal harm or potential for actual harm On 11/8/23 at 10:29 A.M., a concurrent observation and interview was conducted with kitchen Utility Worker (UW) 1 and the RD. During meal preparation for lunch, UW 1 was observed emptying trash bags from trash bins in the main kitchen area. An observation was made that UW 1 had a beard but was not wearing a beard net. UW 1 stated he was not aware he should be wearing a beard net. RD stated UW 1 should be wearing a beard net anytime he is in the kitchen because it is possible to contaminate resident foods with bacteria from any type of hair. Residents Affected - Some A review of the facility policy titled, Infection Prevention for Food & Nutrition Services, last revised 8/31/23, indicated, I Purpose: To prevent the spread of microorganisms among patients, personnel and visitors and maintain effective Infection Prevention measures within the kitchen area and outlying areas stocked by food service personnel . III. Text: A. Personnel . 5. Hair is kept clean and neat. Hairnets covering the entire hair are worn while working in food service or food preparation areas. Beards and moustaches that are not closely cropped or neatly trimmed are covered . 5. On 11/8/23 at 3:16 P.M., an observation, record review and interview was conducted in the satellite kitchen with the Director of Nursing (DON). Upon observation there was a large metal cart with multiple bags of EN formula for tube feeding available for use. The label on one 1000 milliliter (mL) bag of EN, labeled Glytrol, indicated a use by date of 7/6/23. The DON stated it was her job to remove expired EN bags and that she must have missed the expired bag. A review of the facility policy titled, Infection Prevention for Food & Nutrition Services, last revised 8/31/23, indicated, .G. Food Storage/Disposal: 1. All foods are labeled, covered and dated when stored . Outdated foods are discarded . 6. On 11/9/23 at 11:08 A.M., an observation and interview was conducted with Diet Checker (DC) 1 and the RD while lunch trays were being plated in the kitchen for residents in the skilled nursing facility (SNF). During an observation of the trayline refrigerator (Ref 4) canned peaches and applesauce were observed lined in rows in small plastic bowels, uncovered, unlabeled and undated. An observation of DC 1 plating meal ticket orders for the SNF was conducted and the uncovered, unlabeled, and undated bowels of peaches and applesauce from Ref 4 were placed on meal trays and put in the meal transportation carts uncovered. DC 1 stated it was not procedure for her to cover fruit side dishes with plastic wrap or anything else while being transported in the meal cart to the SNF. On 11/9/23 at 12:04 P.M., an interview was conducted with the RD. The RD stated it was the expectation that all foods being sent to residents for consumption be covered and have lids before being placed into the dietary cart and transported to the resident. RD stated this practice is to keep foods safe from contamination with insects and bacteria while being transported. A review of the facility policy titled, Infection Prevention for Food & Nutrition Services, last revised 8/31/23, indicated, I Purpose: To prevent the spread of microorganisms among patients, personnel and visitors and maintain effective Infection Prevention measures within the kitchen area and outlying areas stocked by food service personnel . III. Text: F. Food Preparation and Service .4. Food transported to patients will be covered or transported in an enclosed cart .and served as soon as possible after preparation . 555216 Page 21 of 23 555216 11/09/2023 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents, as indicated in the facility's Facility Assessment Report. There were a total of 45 residents in the facility with orders to receive restorative treatments from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life. (cross reference to F-tag 688 and F-tag 725) Findings: On 11/7/23 at 10:04 A.M., a confidential interview was conducted with the Resident Council (an organized group of residents who meet regularly to discuss and address concerns about their rights and their care). Nine residents attended the Resident Council meeting. During the meeting, five of the nine attendees stated that they were not receiving RNA treatments in accordance to their physician's orders. One of the residents stated that the RNAs were being removed from their duties to cover the certified nursing assistanst (CNAs). On 11/7/23 at 2:48 P.M., an interview with RNA 1 was conducted. RNA 1 stated there used to be three RNAs to provide RNA treatments. RNA 1 stated currently there were two RNAs working and sometimes only one. RNA 1 stated the RNAs were being pulled from their duties to cover the floor, when the floor was short of a CNA. RNA 1 stated that RNA treatments were not being provided for the residents when their was no RNA avaiable to provide the care. On 11/9/23 at 9:19 A.M., an interview with RNA 51 was conducted. RNA 51 provided a list of all the residents with orders for RNA treatment. Per the list, there were a total of 45 residents with orders to receive RNA treatments. RNA 51 reviewed the RNA documentation and stated that all residents with orders for RNA treatment, did not receive their treatments as ordered by their physicians. A interview with the Director of Nursing (DON) was conducted on 11/9/23 at 3:10 P.M. The DON stated the facility were not able to fully provide RNA services and that they were working on the plan. A review of the facility's Facility Assessment Report, dated August 2023, was conducted. The report indicated, The facility assessment determines what resources, services and the needs are to care for our residents competently during the day-today operations and in emergencies. The report also indicated, The Nursing Services department always maintains an adequate number of staff with different levels of skill mix (i.e., RNs [registered nurses], LVNs [licensed vocational nurses], Certified Nursing Assistants, Restorative Nursing Assistants, and other administrative support staff) who are responsible in rendering care for the residents on 3 shifts/24 hours, 7days/week [sic], and 365days/year [sic]. 555216 Page 22 of 23 555216 11/09/2023 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) failed to formally identify, investigate and act on staffing deficiencies in regard to the Restorative Nursing Assistant (RNA) program. (Cross reference F-tag 688 and F-tag 725) This failure placed residents who were ordered to receive RNA treatment at risk for a decline in mobility. Findings: On 11/9/23 at 1:55 P.M., a concurrent interview was conducted with the Director of Nursing (DON), the Clinical Manager (CM). The DON stated the issues the facility planned to monitor for QAPI were identified in the facility document during the quarterly QAPI meeting. The CM stated facility management was aware that insufficient RNA staffing was a problem, but it had not been identified as a formal issue to measure and monitor in QAPI meetings. On 11/9/23 at 3:31 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the facility had insufficient RNA staffing because RNAs were being pulled out of their assigned role to cover for Certified Nursing Assistants (CNA) who would call out. The DSD stated the QAPI committee had not identified measures to address insufficient staffing related to RNAs or monitor and collect data in an attempt to improve resident RNA care. The DSD stated the purpose of QAPI program was to address and monitor care areas that were identified as needing performance improvement. A review of the facility's QAPI meeting notes, dated October 2023, indicated the meeting agenda did not review insufficient staffing as an area of improvement that was discussed to measure and monitor. A review of the facility document titled, Charter: Birch [NAME] Skilled Nursing facility (SNF) Quality Assurance and Performance Improvement (QAPI) Committee (Charter) dated 7/30/23, indicated, .Scope: The scope of the QAPI program encompasses all segments of care and services provided by Birch [NAME] SNF that impact clinical care, quality of life, resident choice and care transitions with participation from all departments . In addition, insufficient staffing was not listed as an area of improvement to measure and monitor by the QAPI committee Charter. 555216 Page 23 of 23