Health inspection·October 10, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide activity preference per confidential group request timely. Residents Affected - Some As a result, residents' needs and choices were not met and accommodated. The facility census was 82. Findings: On 10/8/24 at 10 A.M., a confidential group meeting was conducted. Six out of six residents in attendance indicated complaints regarding the facility outings. According to the confidential group, the facility had bus outings before but it was temporarily discontinued during the COVID (a highly infectious respiratory disease caused by a virus) pandemic (global infection outbreak). The facility bus and bus driver were no longer available. The bus outings before would include residents and staff member, volunteers or family members. The bus outings activity before would include places like going to stores to buy what they needed, watching movies, walking in the park, sightseeing or just going out. According to the confidential group, their respective doctors would allow and give them out on pass. Currently there was discussion of the outings with the facility but until now the facility could not find a bus for the residents' outings. The confidential group stated it was too expensive to rent a transportation. The confidential group stated they would like outings together as a group because they wanted to get out of here and the facility have done bus outings before and then why stopped the outings now. The confidential group stated they wanted to go out in a group, want to get out of here to see the outside world. The confidential group stated bus outings was a distraction and we want our independence. The confidential group further stated they wanted do something and experience the outside world. On 10/8/24, a record review of Resident Council Minutes on Activity Program from February to September 2024 was conducted and indicated the following: 2/27/24 - canceled outings, transportation company has closed and will have to look for a new company. 3/26/24 - still looking for transportation. Most transportation buses only can take two wheelchairs. No transportation buses can take more than two at this time. 4/30/24 - continue to look for transportation to outings transports. Page 1 of 28 555216 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0558 5/29/24 - working on transportation for outings Level of Harm - Minimal harm or potential for actual harm 6/27/24 - transports 7/30/24 - still looking for bus. Residents Affected - Some 8/27/24 - still looking for bus. 9/24/24 - still looking for transport. On 10/8/24 at 11 A.M., an interview and record review with AA 1 was conducted. AA 1 stated he was aware of Resident Council Minutes for July, August and September 2024. AA 1 stated he wrote the resident council minutes for August and September 2024. AA 1 stated the facility was still working on the shuttle because the facility needed a bus that would accommodate six (6) or more with wheelchairs. On 10/8/24 at 11:15 A.M., an interview with AA 1 and AA 2 was conducted. AA 2 stated she had been here for 30 years, and the facility had a bus to go places like zoo, casinos, restaurants, parks and shopping. AA 2 stated we would bring five to six (5 to 6) residents in wheelchairs and a volunteer for each resident or a family members. AA 2 stated the hospital sold the bus during COVID. AA 2 stated when COVID ended in July 2022 the facility were still waiting for the bus service. AA 2 stated she understood how the residents felt regarding the bus outings and the residents wanted to go out. AA 1 stated going to bus outings would increase resident's self-worth, independence and honor resident's rights and choices. On 10/10/24 at 8:08 A.M., an interview and record review were conducted with the AC. The AC stated the facility received a grant for bus outings. The AC stated she was looking for a transportation that would accommodate four to six (4 to 6) residents with wheelchairs. The AC stated going on bus outings was important to make a home-like environment for residents and change of scenery. The AC stated they have not accommodated the residents bus outings. On 10/10/24 at 3:30 P.M., an interview was conducted with the DON. The DON stated during the pandemic the van was sold, and it was old and [hospital name] got rid of it. The DON stated the facility received a grant for outside activities amounting to approximately $27,000 dollars in November 2023. The DON stated the facility was looking for transportation but the transportation company went out of business. The DON stated the residents wanted to go out to see the Christmas lights and residents wanted to do things. The DON stated the residents have a right to go to outings and that the facility did not accommodate the outing. Per the facility policy entitled Scope of Care - Activity Program dated 12/14/23, indicated .Activities refer to endeavor, other than Activities of Daily Living (ADLs) in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical, cognitive and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence .Activity intervention which may include but is not limited to .community outings .facilitating opportunities for increasing socialization .facilitating community resources for leisure and recreation .the facility, to the extent possible, will accommodate an individual's needs and choices for how he/she spends time, both inside and outside the facility .A resident has right to participate in .community activities . 555216 Page 2 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and document review, the facility failed to give one of three reviewed residents (Resident 282) the Advanced Beneficiary Notice (ABN/CMS 10055: a form which gave the choice to continue services under private pay if Medicare did not provide payment) for discontinued skilled (rehabilitation and nursing) services who remained in the facility for custodial (non-medical assistance with daily tasks, such as bathing, dressing, eating, and toileting) services. Residents Affected - Few As a result, Resident 282 did not have the choice to appeal the decision or have knowledge of the costs to continue custodial care in the facility. Findings: A review of Resident 282's Medical Record indicated Resident 282 was admitted to the facility on [DATE] with diagnoses which included a history of arteriosclerotic cardiovascular disease (thickening or hardening of the arteries). On 10/9/24 at 9:26 A.M., an interview and document review was conducted with AD 1. AD 1 stated that Resident 282 last coverage day for skilled services ended on 7/31/24 and a Notice of Medicare Non-Coverage (NOMNOC: a notice given to a resident for discharge when plans are to discharge out of the facility) was discussed and mailed out to Resident 282's grandchild. AD 1 stated Resident 282 did not exhaust his Medicare skilled days when he transitioned to custodial services and still had Medicare days remaining. AD 1 stated she did not give an ABN because she gave a NOMNOC. AD 1 further stated Resident 282's discharge plan was to go back home with his family, but his family was not able to care for Resident 282. AD 1 also stated, that was the reason why Resident 282 remained at the facility for custodial care. AD 1 stated an ABN letter was supposed to be given because Resident 282 still had remaining Medicare days and remained at the facility for custodial care. AD 1 stated she would look for Resident 282's documents to see if the ABN form was completed. On 10/9/24 at 11:51 A.M., an interview and document review was conducted with AD 2. AD 2 stated the ABN given by AD 1 did not have a signature that Resident 282 or Responsible Party (RP) were notified. AD 2 the business office had not given them an ABN document prior to September 2024, that was why it was not signed. AD 2 stated that Resident 282 transitioned to custodial services in July 2024. AD 2 further stated, she was not aware that they had to issue an ABN because they have never used the document before. On 10/10/24 at 11:26 A.M., an interview with the DON was conducted, in the DON's office. The DON stated her expectations were that the ADs (AD 1 or AD 2) gave Resident 282 an ABN. The DON further stated because his Medicare days were not exhausted when Resident 282 transitioned to custodial care. The DON stated it was important to notify Resident 282 and his RP so they can make decisions regarding custodial services. The DON also stated so they know they have the right to appeal and know the costs of non-coverage during Resident 282's transition to custodial care. A review of the facility's policy and procedure titled, ADVANCED BENEFICIARY NOTICE (ABN) dated 2/15/24 indicated, . It is the policy of [Facility name] to complete an Advanced Beneficiary Notice of Noncoverage (ABN) and obtain the signature of the Medicare beneficiary or their authorized representative when there is reason to believe services will not be covered in accordance with Medicare 555216 Page 3 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0582 requirements. Medicare will only pay for services, which are determined to be reasonable and necessary . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555216 Page 4 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and clinical record review, the facility failed to ensure a significant change of status assessment (SCSA) was completed within 14 days after a significant change in the resident's physical or mental condition had been determined for one of 18 sampled residents (Resident 42). Residents Affected - Few This had the potential to delay necessary health services and updated plan of care based on the Resident 42's current health status. Findings: A review of Resident 42's Medical Record indicated Resident 42 was re-admitted to the facility on [DATE] with diagnoses which included a history of stroke (when the blood flow to the brain is blocked that could lead to muscle weakness, paralysis, or death). A review of Resident 42's Minimum data set (MDS: nursing facility assessment tool) dated 8/4/24 indicated Resident 42 was able to participate with the brief interview for mental status (BIMS) interview and had a BIMS score of 9 out of 15 to indicate moderate cognitive (mental process involved in knowing, learning, and understanding things) deficits. A record review of Resident 42's MDS dated [DATE] indicated that Resident 42's BIMS was unable to be conducted. On 10/9/24 at 8:16 A.M., an interview and record review was conducted with MDSC 1, in MDS office. MDSC 1 stated that Resident 42's previous admission was on 7/28/24 and that Resident 42 was verbal and able to participate with the BIMS interview. MDSC 1 stated Resident 42 was ambulatory, and participated with activities of daily living (ADL-personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating) such as: Maximal Assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with: - eating and was not on tube feeding (TF) - performed upper body dressing - personal hygiene, chair/bed-to-chair transfer Partial assistance (helper lifts or holds trunk or limbs and provides less than half the effort) with: - sit to stand and lying to sitting on side of bed. MDSC 1 stated Resident 42 returned to the facility with a new diagnosis of stroke on 8/26/24. MDSC 1 stated when Resident 42 returned to the facility on 9/24/24 she had declined in all ADLs as dependent. MDSC 1 also stated, Resident 42 was unable to feed self and had orders for TF and was unable to be interviewed for BIMS for cognition/mental process. 555216 Page 5 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/9/24 at 11:06 A.M., an interview and record review was conducted with MDSC 2, in the conference room. MDSC 2 stated Resident 42 did have a significant change of condition when Resident 42 was re-admitted to the facility on [DATE]. MDSC 2 stated Resident 42 was verbal and had the mental capacity to make decisions during her first admission on [DATE] and was not on TF. MDSC 2 stated Resident 42 then became dependent with all her ADLs when she returned from acute care. MDSC 2 stated that Resident 42 had a comprehensive admission's MDS dated [DATE] with the first admission but did not complete a SCSA MDS upon Resident 42's re-admission but instead did another comprehensive admission MDS dated [DATE]. MDSC 2 stated that they should have completed a SCSA MDS instead of doing another admission MDS. MDSC stated Resident 42 because was not expected to return to her prior levels within two weeks such because of the new stroke diagnosis and had a decline in more than two areas to include: - mental status - nutrition TF status - Dependent care with most ADLS MDSC 2 stated it was important for SCSA to be completed within the two-week period of Resident 42's re-admission to reflect the decline in Resident 42's health status. MDSC further stated they should have re-evaluated and re-setting Resident 42's comprehensive assessments with the updated plan of care that was reflective of Resident 42's current health status. On 10/10/24 at 11:40 A.M., an interview with the DON was conducted, in the DON's office. The DON stated Resident 42 had a decline in more than two areas (decline in ADLs relying on TF, mobility with ambulation, and non-verbal) after the stroke diagnosis. The DON also stated Resident 42 was not expected to return back to prior ADL and cognitive levels within the 2 weeks of re-admission. The DON stated MDSC should have completed the SCSA for Resident 42 per the Resident Assessment Instrument (RAI-Instructions on how to complete the MDS assessment) manual. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2024, was conducted. This RAI Manual 3.0 inidicated, .Comprehensive Assessments: Significant Change in Status Assessment (SCSA) (A0310A = 04) .An SCSA is appropriate when .The resident's condition is not expected to return to baseline within two weeks .If the condition has not resolved within 2 weeks, staff should begin a SCSA .An SCSA is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two . 555216 Page 6 of 28 555216 10/10/2024 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 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** Based on observation, interview and record review, the facility failed to implement care plans for three of seven sampled residents (1, 45 and 51) related to Restorative Nursing Assistant (RNA) range of motion (ROM- a measure of joint functionality and flexibility) exercises. This failure had the potential for residents to not meet their functional abilities. Cross Reference to F 688. Findings: a. Resident 1 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 1's history and physical (H & P) dated 6/18/24, indicated Resident 1 had diagnoses which included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) and was in vegetative state (residents may look like they are awake but have no awareness of their surroundings). The H & P also indicated Resident 1 had contractures in both upper and lower extremities. On 10/8/24, a review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 7/22/24, indicated Resident 1 was dependent to staff in his activities of daily living (ADL like eating, hygiene, toileting, bathing .) and functional abilities (like mobility). On 10/7/24 at 12:34 P.M., an observation of Resident 1 was conducted in his room. Resident 1 was lying in bed, looking up over the head light and did not respond when his name was called. Resident 1's hands were exposed and were contracted. On 10/9/24 at 10:05 A.M., an observation of Resident 1 was conducted in his room. Resident 1 was lying in bed, looking up the ceiling and did not respond to his name. On 10/9/24 at 10:39 A.M., an interview with CNA 11 was conducted. CNA 11 stated she was familiar with Resident 1. CNA 11 stated Resident 1 did not respond to verbal cues, and he was dependent to staff for all his ADLs and functional mobilities. CNA 11 stated Resident 1 had contractures in his hands, his legs were stiff and stretched. On 10/9/24 at 3:16 P.M., a concurrent record review and an interview with MDSC 2 was conducted. MDSC 2 stated Resident 1 was enrolled in RNA program for his upper and lower extremities. On 10/10/24 at 9:41 A.M., a concurrent review of Resident 1's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 2/26/24 for Resident 1 indicated RNAs to provide passive ROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities seven times a week (7x/wk). LN 11 stated the RNA weekly summary dated 10/8/24 indicated Resident 1 received five times (5x/wk) of PROM exercises. LN 11 stated Resident 1's care plan indicated RNAs to provide PROM on both upper and lower extremities daily for Resident 1 to prevent further contractures. LN 11 stated the physician's order should be carried out and the care plan should be implemented for Resident 1. 555216 Page 7 of 28 555216 10/10/2024 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 On 10/10/24 at 2:59 P.M., an interview with the DON was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician and the care plan should have been implemented for the residents to attain their maximum movement and functional ability. A review of the facility's policy titled Care Plan/ Interdisciplinary Care Conferences, revised on 1/12/22, indicated, I. Purpose: To establish guidelines for development, review .of resident plan of care . The policy did not indicate implementation of care plan. A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, .III .B. 3. The RNA will implement the treatment programs following the written plan . b. Resident 45 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 45's History and Physical (H & P) dated 4/3/24, indicated Resident 45 had a chief complaint of weakness. The H & P also indicated Resident 45 was confused. On 10/8/24, a review of Resident 45's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/12/24, indicated Resident 45 depended on staff for some of her activities of daily living (ADL like eating, hygiene, toileting, bathing .) and required maximum assistance from the staff when performing her functional abilities (like mobility). On 10/7/24 at 10:21 A.M., an observation and an interview of Resident 45 was conducted in her room. Resident 45 was up in bed and was asking to be moved. On 10/9/24 at 11:33 A.M., an interview with CNA 12 was conducted. CNA 12 stated Resident 45 required assistance in some of her ADLs and mobility. CNA 12 stated she had not seen RNAs provided ROM exercises to Resident 45. On 10/10/24 at 10:36 A.M., a concurrent review of Resident 45's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 4/19/24 for Resident 45 indicated RNAs to provide active (AROM - Movement of a joint provided entirely by the individual performing the exercise) and PROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities five times a week (5x/wk). LN 11 stated the care plan indicated Resident 45 had the potential for decreased in ROM and ROM exercises should have been maintained to prevent contractures and decline. LN 11 stated the care plan was not implemented for Resident 45. On 10/10/24 at 2:59 P.M., an interview with the DON was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician and the care plan should have been implemented for the residents to attain their maximum movement and functional ability. A review of the facility's policy titled Care Plan/ Interdisciplinary Care Conferences, revised on 1/12/22, indicated, I. Purpose: To establish guidelines for development, review .of resident plan of care . The policy did not indicate implementation of care plan. A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, .III .B. 3. The RNA will implement the treatment programs following the written plan . c. Resident 51 was admitted to the facility on [DATE], per the facility's Medical Record. 555216 Page 8 of 28 555216 10/10/2024 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 On 10/8/24, a review of Resident 51's History and Physical (H & P) dated 6/25/24, indicated Resident 51 had diagnoses which included stroke with right sided hemiparesis (weakness or the inability to move one side of the body). The H & P indicated Resident 51 responded to questions in the form of yes or no. The H & P also indicated the plan for Resident 51 was to continue RNA. On 10/8/24, a review of Resident 51's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/17/24, indicated Resident 51 was dependent to staff in most of her activities of daily living (ADL- like hygiene, toileting, bathing .). The MDS indicated Resident 51 was dependent to the staff in performing functional abilities (like mobility). On 10/7/24 at 12:25 P.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 lied in bed and responded yes and yeah to questions. On 10/9/24 at 8:04 A.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 was in bed and responded yeah to questions. On 10/9/24 at 11:01 A.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 51 responded yes to everything. CNA 11 stated Resident 51 was enrolled in RNA program but was not sure if she was getting the program five times per week (5x/wk) or every day. On 10/10/24 at 10:12 A.M., a concurrent review of Resident 51's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 3/13/24 for Resident 51 indicated RNAs to provide (AROM - Movement of a joint provided entirely by the individual performing the exercise) and PROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities daily. LN 11 stated the RNA weekly summary dated 9/28/24 and 10/4/24 indicated Resident 51 received (5x/wk) of ROM exercises instead of the 7x/wk exercises. LN 11 stated Resident 51's care plan indicated will maintain ROM daily . LN 11 stated the physician's order should be carried out and the care plan should be implemented to prevent Resident 51 from developing contractures and decline in performing her ADLs. On 10/10/24 at 2:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician and the care plan should have been implemented for the residents to attain their maximum movement and functional ability. A review of the facility's policy titled Care Plan/ Interdisciplinary Care Conferences, revised on 1/12/22, indicated, I. Purpose: To establish guidelines for development, review .of resident plan of care . The policy did not indicate implementation of care plan. A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, .III .B. 3. The RNA will implement the treatment programs following the written plan . 555216 Page 9 of 28 555216 10/10/2024 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 - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently provide Restorative Nursing Assistant (RNA) for range of motion (ROM- a measure of joint functionality and flexibility) exercises per physician's order for three of seven residents (1, 45, and 51), reviewed for limited ROM. This had the potential to worsen Resident 1's contractures (condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) and promote the development of contractures to Resident 45 and Resident 51. Cross Reference to F 656. Findings: a. Resident 1 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 1's history and physical (H & P) dated 6/18/24, indicated Resident 1 had diagnoses which included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head) and was in vegetative state (residents may look like they are awake but have no awareness of their surroundings). The H & P also indicated Resident 1 had contractures in both upper and lower extremities. On 10/8/24, a review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 7/22/24, indicated Resident 1 was dependent to staff in his activities of daily living (ADL like eating, hygiene, toileting, bathing .) and functional abilities (like mobility). On 10/7/24 at 12:34 P.M., an observation of Resident 1 was conducted in his room. Resident 1 was lying in bed, looking up over the head light and did not respond when his name was called. Resident 1's hands were exposed and were contracted. On 10/9/24 at 10:05 A.M., an observation of Resident 1 was conducted in his room. Resident 1 was lying in bed, looking up the ceiling and did not respond to his name. On 10/9/24 at 10:39 A.M., an interview with Certified Nursing Assistant (CNA) 11 was conducted. CNA 11 stated she was familiar with Resident 1. CNA 11 stated Resident 1 did not respond to verbal cues, and he was dependent to staff for all his ADLs and functional mobilities. CNA 11 stated Resident 1 had contractures in his hands, his legs were stiff and stretched. On 10/9/24 at 3:16 P.M., a concurrent record review and an interview with MDSC 2 was conducted. MDSC 2 stated Resident 1 was enrolled in RNA program for his upper and lower extremities. On 10/10/24 at 9:41 A.M., a concurrent review of Resident 1's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 2/26/24 for Resident 1 indicated RNAs to provide passive ROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities seven times a week (7x/wk). LN 11 stated the RNA weekly summary dated 10/8/24 indicated Resident 1 received five times (5x/wk) of PROM exercises. LN 11 stated the RNAs should have provided the PROM exercises for Resident 1 as ordered by the physician to prevent 555216 Page 10 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0688 worsening of his contractures. Level of Harm - Minimal harm or potential for actual harm On 10/10/24 at 9:50 A.M., a concurrent review of Resident 1's electronic record and an interview with RNA 11 was conducted. RNA 11 stated RNAs provided PROM exercises five times (5x/wk) for Resident 1 because there was not enough RNA the week of 10/1/24 to 10/8/24 to provide ROM exercises to all residents enrolled in RNA program. Residents Affected - Few On 10/10/24 at 2:16 P.M., an interview with the DON was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician for the residents to attain their maximum movement and functional ability. A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, I. Purpose: To establish a restorative care program to ensure [name of the facility] Skilled Nursing Facilities assist each resident to achieve and maintain the highest possible levels of independence .III .B. 3. The RNA will implement the treatment programs following the written plan . b. Resident 45 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 45's history and physical (H & P) dated 4/3/24, indicated Resident 45 had a chief complaint of weakness. The H & P also indicated Resident 45 was confused. On 10/8/24, a review of Resident 45's (MDS - a federally mandated resident assessment tool) dated 7/12/24, indicated Resident 45 depended on staff for some of her ADLs and required maximum assistance from the staff when performing her functional abilities (like mobility). On 10/7/24 at 10:21 A.M., an observation and an interview of Resident 45 was conducted in her room. Resident 45 was up in bed and was asking to be moved. On 10/9/24 at 11:33 A.M., an interview with CNA 12 was conducted. CNA 12 stated Resident 45 required assistance in some of her ADLs and mobility. CNA 12 stated she had not seen RNAs provided ROM exercises to Resident 45. On 10/10/24 at 10:36 A.M., a concurrent review of Resident 45's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 4/19/24 for Resident 45 indicated RNAs to provide active ROM (AROM - Movement of a joint provided entirely by the individual performing the exercise) and passive ROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities five times a week (5x/wk). LN 11 stated there were no ROM exercises provided to Resident 45 from 4/19/24. LN 11 stated the physician's order related to the RNA program for Resident 45 should have been carried out because it was important for Resident 45 to receive the ROM exercises to prevent her from developing contractures and decline in performing her ADLs. On 10/10/24 at 10:54 A.M., an interview with RNA 12 was conducted. RNA 12 stated Resident 45 was not enrolled in the RNA program. RNA 12 stated there were no ROM exercises provided to Resident 45. On 10/10/24 at 2:16 P.M., an interview with the DON was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician for the residents to attain their maximum movement and functional ability. 555216 Page 11 of 28 555216 10/10/2024 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 A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, I. Purpose: To establish a restorative care program to ensure [name of the facility] Skilled Nursing Facilities assist each resident to achieve and maintain the highest possible levels of independence .III .B. 3. The RNA will implement the treatment programs following the written plan . Residents Affected - Few c. Resident 51 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 51's history and physical (H & P) dated 6/25/24, indicated Resident 51 had diagnoses which included stroke with right sided hemiparesis (weakness or the inability to move one side of the body). The H & P indicated Resident 51 responded to questions in the form of yes or no. The H & P also indicated the plan for Resident 51 was to continue RNA. On 10/8/24, a review of Resident 51's minimum data set (MDS - a federally mandated resident assessment tool) dated 7/17/24, indicated Resident 51 was dependent to staff in most of her activities of daily living (like hygiene, toileting, bathing .). The MDS indicated Resident 51 was dependent to the staff in performing functional abilities (like mobility). On 10/7/24 at 12:25 P.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 lied in bed and responded yes and yeah to questions. On 10/9/24 at 8:04 A.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 was in bed and responded yeah to questions. On 10/9/24 at 11:01 A.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 51 responded yes to everything. CNA 11 stated Resident 51 was enrolled in RNA program but was not sure if she was getting the program five times 5x/wk or every day. On 10/10/24 at 10:12 A.M., a concurrent review of Resident 51's electronic record and an interview with LN 11 was conducted. LN 11 stated the physician's order on 3/13/24 for Resident 51 indicated RNAs to provide (AROM - Movement of a joint provided entirely by the individual performing the exercise) and PROM (PROM - Movement applied to a joint solely by another person) exercises for both upper and lower extremities daily. LN 11 stated the RNA weekly summary dated 9/28/24 and 10/4/24 indicated Resident 51 received (5x/wk) of ROM exercises instead of the 7x/wk exercises. LN 11 stated the RNAs should have provided the ROM exercises for Resident 51 as ordered by the physician to prevent her from developing contractures and decline in performing her ADLs. On 10/10/24 at 2:16 P.M., an interview with the DON was conducted. The DON stated the staff should have provided the ROM exercises to the residents as ordered by the physician for the residents to attain their maximum movement and functional ability. A review of the facility's policy titled Restorative Nursing Program, revised on 1/12/22, indicated, I. Purpose: To establish a restorative care program to ensure [name of the facility] Skilled Nursing Facilities assist each resident to achieve and maintain the highest possible levels of independence .III .B. 3. The RNA will implement the treatment programs following the written plan . 555216 Page 12 of 28 555216 10/10/2024 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 - Some 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** 3. Resident 51 was admitted to the facility on [DATE], per the facility's Medical Record. On 10/8/24, a review of Resident 51's history and physical (H & P) dated 6/25/24, indicated Resident 51 had diagnoses which included stroke with right sided hemiparesis (weakness or the inability to move one side of the body). The H & P indicated Resident 51 responded to questions in the form of yes or no. The H & P also indicated the assessment and plan for Resident 51 was to continue sertraline (antidepressant) and lorazepam (antianxiety) as needed for agitation and or anxiety. On 10/7/24 at 12:25 P.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 lied in bed and responded Yes and Yeah to questions. On 10/9/24 at 8:04 A.M., an observation and an interview of Resident 51 was conducted in her room. Resident 51 was in bed and responded yeah to questions. On 10/9/24 at 11:01 A.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 51 responded yes to everything. CNA 11 stated Resident 51 cried when she was wet or had bowel movement. CNA 11 stated Resident 51 was being monitored for her behavior and was documented in her chart when she scratched staff or pulled on something. CNA 11 stated it had not happened recently in her shift. On 10/10/24 at 10:12 A.M., a concurrent review of Resident 51's electronic record and an interview with LN 11 was conducted. LN 11 stated Resident 51's target behavior for antidepressant was for continuous crying and refusing care. LN 11 stated Resident 51's care plan indicated the antidepressant was indicated for depression as exhibited by low motivation and decreased interest. LN 11 stated the target behavior for Resident 51's antidepressant was not the same as to the target behavior for monitoring. LN 11 stated she was not sure how to measure depressive behavior of Resident 51 when she refused care or continuously cried. LN 11 stated the physician's order, and the care plan were not the same as to what was the target behavior being monitored. LN 11 stated there should be a clear target behavior that was monitored for Resident 51 to address her needs and problems. On 10/10/24 at 2:16 P.M., an interview with the DON was conducted. The DON stated there should be an appropriate target behavior monitoring for Resident 51 to ensure the effectiveness of the medication. A review of the facility's policy titled, Monitoring of Antidepressant Medications, revised 2/27/24, indicated, I. Purpose: To provide guidelines for safe and effective use of antidepressant medications .Antidepressant use is monitored to facilitate residents receiving the intended benefit of the medications .III. A .the necessity for the medication is documented in the resident's medical record and included in the care planning for the resident .B .the effect of pharmacologic behavioral modifiers are addressed .in the resident's care planning . 2. a) A review of Resident 35's Medical Record indicated that Resident 35 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities causing impairment in daily life) and non-Alzheimer's dementia (progressive state of decline in mental abilities). 555216 Page 13 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 A review of Resident 35's physician order dated 9/10/21 indicated the following order: Level of Harm - Minimal harm or potential for actual harm -Trazodone (a medication used to treat depression) with behavior monitoring for inability to sleep at night. Residents Affected - Some An interview on 10/9/24 at 4:39 P.M., with LN 12 was conducted. LN 12 stated there was no measurement on the hours of sleep, so if Resident 35 slept that night, it was counted as zero behaviors. LN 12 stated it would have been better if we have a number of hours she slept at night every day to be more accurate. An interview and record review with LN 12 on 10/10/24 at 12:16 P.M., was conducted. LN 12 stated Trazodone was ordered for depression with inability to sleep as its behavior monitoring. LN 12 stated however there was no way to evaluate or measure the behavior in Resident 35's medical record. LN 12 stated it would be better if staff can count the number of hours of sleep to be more accurate in monitoring the medication usage. LN 12 stated the MAR indicated zeros for a month of Trazodone use. A review of Resident 35's minimum data set (MDS: a nursing assessment tool) dated 9/6/24, with a brief interview of mental status (BIMS- developed by reviewing the resident's cognitive status during the prior seven day period) score of three out of 15 which indicated severe cognitive impairment. A review of the facility's policy and procedure titled, PSYCHOTROPIC MEDICATIONS dated 8/13/21, indicated .The practice of polypharmacy shall be reviewed by the Treatment Team. Review shall include the following, as appropriate: .b. Suspected adverse drug reactions and appropriate intervention strategies . 2. b) A review of Resident 58's Medical record indicated that Resident 58 was admitted to the facility on [DATE] with diagnoses which included Unspecified Depression and Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning) with psychotic (a mental condition with loss in reality) disturbance. A review of Resident 58's physician order dated 2/29/24 indicated the following order. - Trazodone with behavior monitoring of inability to sleep at night. - Quetiapine (unspecified dementia with psychotic disturbance)with behavior monitoring of hallucinations at night. An interview and record review with LN 12 on 10/10/24 at 12:16 P.M. was conducted. LN 12 stated Trazodone was ordered for depression with inability to sleep as its behavior monitoring. LN 12 stated however there was no way to evaluate or measure the behavior in Resident 58's medical record. LN 12 stated it would be better if staff can count the number of hours of sleep to be more accurate in monitoring the medication usage. LN 12 stated the medication administration record (MAR) showed zeros for a month's use. A review of Resident 58's minimum data set (MDS: a nursing assessment tool) dated 9/26/24 indicated a brief interview for mental status (BIMS- developed by reviewing the resident's cognitive status during the prior seven day period) score of eight out of 15 for moderate cognitive impairment. An interview on 10/10/24 at 2:10 P.M., with the DON was conducted. The DON stated behavior 555216 Page 14 of 28 555216 10/10/2024 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 - Some monitoring for psychotropic medications was important to evaluate medication effectiveness and monitoring the exact behaviors was detrimental to ensure progress of treatment. A review of the facility's policy and procedure titled, PSYCHOTROPIC MEDICATIONS dated 8/13/21, indicated .The practice of polypharmacy shall be reviewed by the Treatment Team. Review shall include the following, as appropriate: .a. Appropriateness of medications for diagnosis/indications. b. Suspected adverse drug reactions and appropriate intervention strategies . Based on observations, interviews, and record review, the facility failed to indicate the appropriate target behavior and monitor side effects for four of thirty residents (274, 35, 58, and 51) when: 1. Resident 274 was not being monitored for appropriate behaviors and side effects for two anti-depressants (medication used for feeling of sadness) and one anti-anxiety (medication used for worry and fear) medications. 2. Residents 35 and 58 did not have monitoring for behavior and side effects for anti-depressant medications. 3. Resident 51 did not have appropriate indications for the use of anti-depressant medications. These failures had the potential for unnecessary psychotropic (mind-altering medications) medication use and side effects to decrease therapeutic effects and a decline for residents psychological and mental well-being. Findings: 1. A review of Resident 274's Medical Record indicated Resident 274 was admitted to the facility on [DATE] with diagnoses which included a history of major depressive disorder (a mood disorder that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working). A record review of Resident 274's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 10/8/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's cognitive status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 274 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 10/8/24 at 11:49 A.M., an observation and interview was conducted with Resident 274, in 274's room. Resident 274 stated he takes medications for depression and anxiety to help alleviate his symptoms of depression and worry especially with current health status with a compressed back fracture (break in bone) from a fall he sustained prior to admission. On 10/9/24 at 3:50 P.M., an interview was conducted with CNA 3, outside of Resident 274's room in the west wing hallway. CNA 3 stated Resident 274 had episodes of mood changes and often gets anxious (irritable) for example gets up by himself at night without asking for help to get to the bathroom. CNA 3 stated Resident 274 needed reminders for safety to prevent falls but was a little hardheaded when he was reminded to use the call light prior to getting up. CNA 3 stated that Resident 274 took naps and woke up again in an hour during the night and was mostly anxious when it came to his 555216 Page 15 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0758 medications and wanting coffee. Level of Harm - Minimal harm or potential for actual harm On 10/9/24 at 3:55 P.M., an interview and record review was conducted with LN 4, in the west wing nursing station. LN 4 stated Resident 274 was on three psychotropic medications, two for depression and one as needed (PRN) for anxiety with a 14 day stop date and re-evaluation. LN 4 stated Resident 274's psychotropic medications were: Residents Affected - Some a. Trazodone (antidepressant medication) Trazodone for depression at bedtime as evidenced by inability to sleep at night. LN 4 stated the monitoring of inability to sleep at night was because the monitoring was not measurable (objective) but based on what Resident 274 said (subjective). LN 4 stated it should reflect what measure of sleep worked for Resident 274 to monitor the depressive behavior at night of what Resident 274 thinks was therapeutic. LN 4 stated Resident 274's clinical record did not indicate what side effects were being monitored and was not recorded in the medication administration record (MAR). b. Duloxetine (anti-depression medication): LN 4 stated Resident 274 had physician orders to be given in the morning for depression related to frequent complaints of pain with behavioral monitoring. LN 4 stated side effects should also be in the orders but was not included. LN 4 stated I don't see monitoring of side effects in the order. LN 4 stated it was important to document the side effects for the nurses to know what to look for and notify the physician to re-evaluate and update the psychotropic medication orders as appropriate. c. Lorazepam (anti-anxiety medication): LN 4 stated Resident 274 had physician's orders for anxiety PRN with behavior monitoring for increased irritability with a start date of 10/3/24 and stop date 10/17/24. LN 4 stated I don't see side effect monitoring for the orders . LN 4 acknowledged there was no evidence of side effects monitoring in Resident 274 record. On 10/10/24 at 10:23 A.M., a dual interview was conducted with LN 1 and Pharm 1, in the conference room. LN 1 stated that Resident 274's trazodone orders was for the inability to sleep. LN 1 furthers stated that was the behavior monitored for this medication. Pharm 1 stated the LN's assessment of Resident 274's behaviors was subjective and not objective. Pharm 1 and LN 1 both agreed it would have been better when the monitoring was objective instead of subjective to better monitor the effectiveness of medication. LN 1 and Pharm 1 both stated that side effect monitoring should have been included with Resident 274's psychotropic medications record. On 10/10/24 at 11:32 A.M., an interview with the DON was conducted, in the DON's office. The DON stated it was her expectations for the LNs to be aware of the psychotropic medication side effects. The DON also stated it was also her expectation for LNs to monitor the appropriate behaviors. The DON stated residents on psychotropic medications could have had adverse reactions and should have been monitored appropriately for side effects. A review of the facility's policy and procedure titled, PSYCHOTROPIC MEDICATIONS dated 8/13/21, indicated .The practice of polypharmacy shall be reviewed by the Treatment Team. Review shall include the following, as appropriate: .a. Appropriateness of medications for diagnosis/indications. b. Suspected adverse drug reactions and appropriate intervention strategies . 555216 Page 16 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to properly store and label house supply/stock medications with open dates. As a result, the facility could not ensure medications were safely stored to ensure their integrity. Findings: On 10/9/24 at 3:31 P.M., a concurrent observation and interview was conducted with LN 1, LN 21 and Pharm 1. During the medication storage observation, there were two boxes of insulin aspart (an injectable drug used to decrease blood sugar) stored in a tray inside a medication refrigerator. The two boxes contained one bottle each of insulin aspart. One box of insulin aspart was labeled with date open 9/21/24 and the bottle inside the box was not labeled with an open date. The other box of insulin aspart was labeled with expiration date 10/18/24 and the bottle inside the box was not labeled with an open date. The manufacturer's expiration date and lot numbers of the two insulin aspart in the tray were the same. LN 1 stated this had the potential for interchanging the bottles when returning to their boxes. On 10/10/24 at 3:26 P.M., an interview was conducted with the DON. The DON stated insulin have 28 days expiration upon opening. The DON stated the bottles were not labeled with the dates opened, LNs would not know for sure which was the appropriate bottle for the appropriate box with open dates and the medications would not be effective. Per the facility policy entitled Drug Storage/Security dated 9/19/2024 indicated .7. All medications .will be accurately labeled with .expiration dates 9. Look-Alike/sound-alike (LASA) medications will be stored in a manner that reduces the likelihood of error . 555216 Page 17 of 28 555216 10/10/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food can items were dented. 2. Food items were expired. 3. Opened food items were not properly labeled and dated. 4. Grains and dust on the lids, loose and cracked lids of the clear plastic bins with food in it. 5. Food items with molds in it, and wilted produce. 6. Dirty rugs on the floor in the dry storage room, trash found in the dry food storage room and in the freezer room. 7. Ready to eat food item on top of the raw meat, and metal bin with ready to cook condensed soup on top of the food rack. 8. Food utensils such as ladles, slotted spoons and [NAME] kitchen utensil stored as clean with crusted food debris. 9. Boxes on top of the food rack past the red line/mark. 10. The following items were stored inappropriately in a food preparation area: an employee cup of coffee, a pump-up foam unit, employee drinks with no lids, and a staff personal belonging. 11. Nutrition Assistant was preparing food items in a basket with no hair covering. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses. Findings: 1. On 10/7/24 at 8 A.M., an observation and interview was conducted with the FSM. There was a dented can of thyme and a dented can of hoisin sauce. The FSM stated, They should not be here. On 10/7/24 at 8:37 A.M., an interview was conducted with FOM. The FOM stated the dented cans should not belong there because they might be infected and could cause botulism (caused by a toxin that attacks the body's nerves and causes difficulty breathing, muscle paralysis, and even death). On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. 555216 Page 18 of 28 555216 10/10/2024 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 - Some According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 3-101.11 (Annex) According to the FDA dented, pitted, and rusted cans can potentially be a serious hazard, 3-202.15 (Annex) - damaged cans may allow the entry of bacteria or other contaminants and must be returned. 2. On 10/7/24 at 8 A.M, an observation and interview was conducted with the FSM. These observations included: - wonton chips in an opened plastic bag with expiration date of 6/18/24 - split peas in a clear container with a use by date of 9/11/24 - corn starch in a clear container with a use by date of 7/11/24 - barley in a clear bin with use by date of 9/20/24 - beans in a clear container with a use by date of 5/4/24 - dried red chili peppers in a clear bin with expiration date of 6/11/24 The FSM stated, We will take them out, we have to make sure we are not using outdated food items. On 10/7/24 at 8:37 A.M., an observation and interview was conducted with the FOM. These observations included: - 12 individual servings of mango mousse with a use by date of 9/27/24 - a bag of parmesan cheese with a use by date of 10/1/24 - shredded zucchini in a plastic container with a use by date of 10/6/24 The FOM stated, Those should be discarded. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .F. Food preparation and Service, 1. All food will be of good quality . 3. On 10/7/24 at 8:15 A.M., an observation and interview was conducted with the FSM. These observations included: - an opened box of pasta with no label - a brown box with opened graham crumbs with no use by date label - dried chili pepper in a bin with no label 555216 Page 19 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0812 The FSM stated the food items should have labels to ensure food were fresh and safe. Level of Harm - Minimal harm or potential for actual harm On 10/7/24 at 8:51 A.M., an observation and interview was conducted with the FOM. These observations were of unlabeled food items: Residents Affected - Some - bread and hash brown - opened plastic corn in a cob - opened plastic of crinkle sliced carrots - opened plastic of green beans - opened plastic of mixed vegetables - opened ready to serve fish puree - herbs in the produce refrigerator - 2 one-gallon lemon juice and 1 one gallon lime juice with no use by or opened date The FOM stated the food items should be labeled to make sure the food was fresh and safe for consumption. The FOM stated the opened plastic bags with food items should have been tightly sealed to prevent freezer burn. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 3-501.17 (A) (B) (C) (D), .required food labeling and dating .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .G. Food Storage .1. All foods are labeled, covered, and dated when stored . 4. On 10/7/24 at 8:15 A.M., an observation and interview was conducted with the FSM. These observations included: - cracked and loose container lids - dust and spilled split peas on top of the split peas container lids - spilled barley beans on top of the corn starch container's lids The FSM stated the kitchen staff should have ensured the bins were tightly sealed and cleaned to ensure food was fresh and prevent food contamination. 555216 Page 20 of 28 555216 10/10/2024 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 - Some On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 2017 4-601.11) Equipment .Non-food contact surfaces .Non-food contact surfaces of equipment shall be kept free from accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .F. Food preparation and Service, 1. All food will be of good quality . 5. On 10/7/24 at 9:14 A.M, an observation and interview was conducted with the FOM. There were two packs of strawberry with molds, a box of sweet potatoes and an opened box of wilted green onions. The FOM stated, They will be discarded. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .F. Food preparation and Service, 1. All food will be of good quality . 6. On 10/7/24 at 8:15 A.M, an observation and interview was conducted with the FSM. There were dirty rugs on the floor under the food racks. The FSM stated, There was an overflow from the drain and so they put some towels in there. The FSM stated the dry storage room should be kept dry and ensure the towels were taken out to prevent infestation. On 10/7/24 at 8:51 A.M., an observation and an interview was conducted with the FOM. There were crumpled paper trash in the clear bin in the food rack, an individual crumpled opened carton of protein shake, individual ice cream scattered on the floor, and old food debris on the floor. The FOM stated the kitchen and storage area should be cleaned and organized to prevent contamination and food borne illnesses to the residents. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure the kitchen area is cleaned and organized to prevent pest and pathogens that could breed in the debris that could cause a foodborne illness. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 2017 4-601.11) Equipment .Non-food contact surfaces .Non-food contact surfaces of equipment shall be kept free from accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food . Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .E. Equipment and Sanitation .9. Food services floors are cleaned according to cleaning schedule . 555216 Page 21 of 28 555216 10/10/2024 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 - Some 7. On 10/7/24 at 8:51 A.M., an observation and an interview was conducted with the FOM. There were 12 individual ready to eat mango mousse in a metal bin on top of the raw beef, and a ready to cook condensed soup in a metal tray on top of the rack. The FOM stated the mango mouse will be discarded and the ready to cook soup should not be on top of the food rack. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, We have to make sure we are compliant to ensure food is not compromised, they are secured, fresh and safe for consumption. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 2017 3-302.1 -Ready-to-Eat food storage: Food is to be protected from cross contamination by separating raw animal foods during storage, preparation, holding, and display from ready-to-eat food (raw and cooked). 8. On 10/8/24 at 10:15 A.M., an observation and an interview was conducted with the GMK. There was a worn out food tong (a tool used to grip something and lift it), a ladle (large deep spoon), a slotted spoon (spoon with narrow holes) and a [NAME] (is a hot water bath used for cooking delicate foods such as custards) utensil stored as clean with crusted food debris. The GMK stated, Those should not be there, and we will upgrade with our kitchen utensils. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 4-601.11, Equipment .Food-Contact Surfaces .indicate, (A) Equipment Food-Contact Surfaces .shall be clean .sight and touch . Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .E. Equipment and Sanitation .4. Cooking utensil are cleaned .according to procedures .6 . Defective or deteriorating equipment is .replaced . 9. On 10/7/24 at 8:51 A.M., an observation and an interview was conducted with the FOM. There were brown boxes and white boxes above the red mark in the storage area. The FOM stated boxes should not past the red line because that was a fire hazard. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated, the boxes should not past the red mark or above 18 inches because it was a fire hazard. 10. On 10/7/24 at 10:40 A.M., an observation and an interview was conducted with the FOM. These observations were: - an employee cup of coffee on top of the food rack - a pump-up foam unit in the dry food storage room - employee drinks with no lids - staff personal belongings in the kitchen area The FOM stated the coffee belonged to the kitchen staff, and the pump-up unit did not belong there. The FOM stated the process was for the kitchen staff to put lids to their drinks and the kitchen staff personal belongings should be in a locker room to prevent contamination and food borne illness. 555216 Page 22 of 28 555216 10/10/2024 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 - Some According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 6-305.11(B), .Storage of personal items: Lockers or other suitable facilities are to be provided for the storage of employee personal possessions, 6-403.11 (b) - lockers or suitable facilities are to be located in a designated area where contamination of food, equipment, utensils cannot occur . Per review of the facility's policy titled, Food Safety Management System, revised 4/1/22, .Personal items may not be stored in a way that could contaminate exposed food or clean equipment and utensils. Employee food in storage should be .segregated to avoid possible contamination of food and food contact surfaces .An employee may drink from a closed beverage container . 11. On 10/7/24 at 8:36 A.M., an observation and an interview was conducted with the NA. The NA with no hair covering was preparing individual crackers in a basket in the dry food storage room. The NA stated he forgot but he had them in his pocket. The NA stated it was important to prevent hair going to the food. On 10/10/24 at 11:39 A.M., an interview was conducted with the GMK. The GMK stated hair should be kept and a hair covering should be worn to prevent contamination and possible foodborne illness. Per review of the facility's policy titled, Infection Prevention for Food and Nutrition Services, revised 8/31/21, .A. Personnel .5. Hair is kept clean and neat. Hairnets covering the entire hair are worn while working in food service or food preparation area . 555216 Page 23 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and facility document review, the facility did not identify and address concerns that was in the residents council minutes meeting regarding transportation for the outdoor activities in quality assurance and performance improvement (QAPI). Residents Affected - Few This failure had the potential to effect all residents quality of life. Cross-Reference F558 Finding: On 10/10/24 at 3:49 P.M., an interview with the QAPI program members were conducted, in the conference room. The members of the QAPI team stated that they used information gathered from family, residents, pharmacy, national and state comparisons, best practices, clinical guidelines and CASPER report (a report for skilled nursing facilities used for quality improvement/assurance projects). The QAPI team further stated, these were used to track performance and to see what was not working to make changes with policies and procedures. On 10/10/24 at 3:51 P.M., an interview was conducted with the DON. The DON stated that the activities department participated in QAPI. The DON further stated, she and the AC discussed all concerns that the resident council brought to them, however they did not write it down and formalized it in to the QAPI plan. The DON further stated the activity outing concerns and the transportation issue was halted during the pandemic. The DON also stated the facility have been working on trying to bring back the transportation options to continue with outing activities pre-pandemic. The DON stated this could have effect the quality of life for the residents when their concerns were not being addressed. The DON stated the resident council feedback and concern regarding to the activities concerns should be formally addressed in QAPI but was not. A review of the facility's policy and procedure titled, CHARTER: [Facility Name] QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT (QAPI) dated 2024, indicated .Scope: The scope of QAPI program encompasses all segments of care and services provided by [Facility Name] that Impact clinical care, quality of life, resident choice, and transitions with participation from all department . 555216 Page 24 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 1 was admitted to the facility on [DATE], per the facility's Medical Record. Residents Affected - Few On 10/8/24, a review of Resident 1's history and physical (H & P) dated 6/18/24, indicated Resident 1 was in vegetative state (residents may look like they are awake but have no awareness of their surroundings). The H & P indicated Resident 1 had a gastrostomy tube (gtube - a tube inserted through the belly that brings nutrition and medication directly to the stomach). On 10/7/24 at 12:34 P.M., an observation of Resident 1 was conducted in his room. There was a sign by the door that indicated Resident 1 was on EBP. Resident 1 was lying in bed, looking up over the head light and did not respond when his name was called. There was a pole by the side of Resident 1's bed for tube feeding (TF-provides nutrition via tube). On 10/9/24 at 10:05 A.M., an observation of Resident 1 was conducted in his room. Resident 1 was lying in bed, looking up the ceiling and did not respond to his name. On 10/9/24 at 10:39 A.M., an interview with CNA 11 was conducted. CNA 11 stated she was familiar with Resident 1. CNA 11 stated Resident 1 did not respond to verbal cues, and he was on tube feeding. CNA 11 stated the LNs administered TF to Resident 1 at around 4 P.M. On 10/9/24 at 4:11 P.M., an observation of LN 12 preparing a TF for Resident 1 was conducted. LN 12 with no gown and gloves, spiked the tube feeding with an administration tubing set. Still with no gown, LN 12 put on a pair of gloves, pulled the curtain, auscultated (listened) Resident 1's stomach, opened the gtube port, pushed some air to the gtube and flushed some water to the gtube. LN 12 then connected the administration tubing to Resident 1's gtube. LN 12 did not change her gloves in between procedures. On 10/9/24 at 4:17 P.M., an interview with LN 12 was conducted. LN 12 stated she had worked with Resident 1 for a long period of time and was familiar with him. LN 12 stated Resident 1 was on EBP and the process was when a resident was on EBP, it was important to put on gloves. LN 12 stated wearing a gown was up to the discretion of the staff member. LN 12 stated she wore the same gloves completing the procedures. LN 12 stated she pulled the curtain, and the curtain was considered Dirty, and she should have changed her gloves to prevent infection to Resident 1. LN 12 was not able to verbalize a gown and gloves were to use during high contact activities with the resident on EBP. On 10/10/24 at 2:16 P.M., an interview with the DON was conducted. The DON stated the process when the residents were on EBP, the expectation was for the staff to wear a gown and gloves to prevent spread of infection to the residents, staff, and others. A review of the facility's policy titled, Enhanced Barrier Precautions in the Skilled Nursing Units, revised 8/5/24, indicated, I. Purpose: To establish appropriate infection prevention measures to reduce the spread of multidrug resistant organisms (MDROs) in the long-term care setting. Enhanced Barrier Precautions expand the use of gown and gloves during high contact resident care activities . Based on observations, interviews, and record reviews the facility failed to implement infection prevention and control practices with two of 18 sampled residents (Resident 52 and Resident 1) according to standards of practice and provide evidence of a tracking log of infections when: 555216 Page 25 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0880 Level of Harm - Minimal harm or potential for actual harm 1. A CNA did not wear appropriate personal protective equipment (PPE-use of gown, gloves, mask to prevent spread of infection) prior to entering a contact precautions (intended to prevent transmission of infectious agents) room. Cross Reference F881 Residents Affected - Few 2. A LN did not wear a gown for Resident 1 with enhanced barrier precautions (EBP -involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]). This failure had the potential to spread infection or outbreaks amongst all residents, staff, and visitors entering the facility. Findings: 1. A review of Resident 52's Medical Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses which included a history of methicillin-resistant staphylococcus aureus (MRSA- is a staph germ [bacteria] that does not get better with the type of antibiotics that usually cure staph infections. When this occurs, the germ is said to be resistant to certain antibiotics). A review of Resident 52's clinical record titled Urology Progress note dated 10/9/24 indicated Resident 52 had orders for CIPROfloxacin [broad-spectrum antibiotic], 400mg, intravenous every 12 hours. A record review of Resident 52's active orders indicated Resident 52 was on Contact Precautions as of 9/23/24 for MRSA in the nares. On 10/7/24 at 9:52 A.M., an observation was conducted in Resident 52's room. Prior to entering Resident 52's room a contact precautions sign was posted outside resident 52's room with PPE that included gowns and gloves hanging outside of Resident 52's door. The contact precautions sign had an image of gloves and a gown that indicated REQUIRED UPON ENTRY BY ALL HEALTH CARE WORKERS. Guests should check with the nurse before entering. Resident 52 was asleep on his bed wearing a hospital gown along with a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) drainage bag positioned hanging on the left side of the bed frame. On 10/7/24 at 11:54 A.M., an observation and interview was conducted with CNA 1, outside of Resident 52's room in the hallway. Resident 52 was in his bed asleep when CNA 1 entered his room without performing hand hygiene or applying PPEs. CNA 1 was interviewed after walking out of Resident 52's room and stated she did not know why Resident 52 was on contact precautions. CNA 1 stated she did not perform hand hygiene prior to entering Resident 52's room nor did she gown up or applied gloves. CNA 1 stated prior to entering rooms with contact precautions signs that it was mandatory to use PPEs and perform hand hygiene. CNA 1 stated it was important to follow the signs for contact precautions in case they have anything in their urine, poop, skin has open wounds to protect me and the resident and anyone else to prevent the spread of infection. On 10/8/24 at 8:12 A.M., an interview and record review was conducted with LN 3, outside of Resident 52's room. LN 3 stated Resident 52 was transferred during the evening/night shift on 10/7/24. LN 3 stated that Resident 52 was at risk for infection due to his urinary catheter along with a stage one pressure ulcers to his sacrum, buttocks and groin area. LN 3 stated Resident 52 was on contact precautions because of MRSA. LN 3 stated it was important to follow contact precautions for Resident 52 555216 Page 26 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because he had wounds and a urinary catheter that could be easily contaminated with germs that could spread from one person to another and bring about an outbreak when PPEs and hand hygiene were not properly performed for someone with contact precautions. On 10/9/24 at 1:11 P.M., an interview was conducted with LN 2, in the west wing hallway. LN 2 stated if any nursing staff went inside any contact precautions room without performing the proper hand hygiene and applying PPEs that they need to be stopped prior to entering a contact precautions room. LN 2 stated it was also important that any shared equipment used (examples such as blood pressure, temperature, oxygen saturation machines) need to be wiped down with an appropriate sanitizer to all equipment used. On 10/10/24 at 9:01 A.M., an interview and record review was conducted with the Infection Prevention (IP) nurse, in the conference room. The IP nurse stated she did not have a complete list of which residents were on infection control precautions except for residents with urinary tract infections (UTI-infection of the urinary system) or had an antibiotic stewardship log but confirmed that Resident 52 was on contact precautions per Resident 52's active orders. The IP nurse stated her expectations was for CNA 1 to follow the signs outside of Resident 52's room and performed proper hand hygiene and applied PPEs prior to entry. A review of the facility's policy and procedure titled, STANDARD PRECAUTIONS and TRANSMISSION-BASED PRECAUTIONS dated 5/31/24, indicated .Contact Precautions use contact precautions for patients with known or suspected infections .1. PPE Required Isolation Gown and Gloves . 555216 Page 27 of 28 555216 10/10/2024 Sharp Chula Vista Med Ctr Snf 751 Medical Center Court Chula Vista, CA 91911

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record reviews, the facility failed to follow its own policy and procedure to establish an antibiotic stewardship program when the Infection Preventionist (IP) did not track and monitor appropriate use of antibiotics. Residents Affected - Few This failure had the potential for lack of oversight and direction for staff. Cross reference F880 Findings. A concurrent interview and record review on 10/10/24 at 9:01 A.M., with IP was conducted. The IP stated the pharmacy helped with the antibiotics logging and tracking. The IP stated she did the urinary tract infection (UTI) tracking and the pharmacy helped with data collection and did the other infection tracking. The IP stated it was important to tracked antibiotic to make sure they are used appropriately and monitor patterns of infections and thus preventing outbreaks. An interview with the MDSC 1 on 10/10/24 at 9:12 A.M., was conducted. MDSC 1 stated a resident was coded for use of antibiotics on the MDS (a federally mandated resident assessment tool) but was not on the medication administration record (MAR) and resident was placed on contact precautions (measures to prevent infections disease). An interview with the Pharm 1 on 10/10/24 at 9:25 A.M., was conducted. Pharm 1 stated he did not track the antibiotic line list. Pharm 1 stated there was another pharmacist that probably tracked the antibiotic line list in the pharmacy. An interview with Pharm 2 on 10/10/24 at 9:44 A.M., was conducted. Pharm 2 stated she used escalation of the antibiotics but believed they should have a collaborative process so that all information was available. Pharm 2 stated, they would need to re-write the antibiotic tracking and all the information that goes with it, so that it would be reviewable and readily accessible for the healthcare team. There was no documented evidence of a line tracking list for an antibiotic stewardship program. A record review of the facility's long term care policy titled, antimicrobial stewardship program (LTC-ASP) 39135, indicated 1. purpose: develop a process for evaluating the judicious use of antimicrobials, the results of which shall be monitored jointly by appropriate .designate an appropriate antimicrobial stewardship committee . 555216 Page 28 of 28