Health inspection·November 29, 2018

F 0578 discussion, the parties, involved, the essence of the conversation, and plans for follow-up action if needed . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 2 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, one of four residents (28) received treatment for a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) without a physician's order. Residents Affected - Few This created the potential for Resident 28 to receive unsafe care. Findings: On 1/21/16, Resident 28 was admitted to the facility with a diagnoses which included hemiparesis (paralysis of one side of the body) following a stroke affecting the right dominant side per the facility admission Record. On 11/27/18 at 2:17 P.M., a concurrent observation of Resident 28's skin and interview with CNA 8 was conducted. CNA 8 stated Resident 28 did not have any skin issues. Resident 28's buttocks and tailbone (base of spine) area was observed with CNA 8. A Duoderm patch (used to treat pressure ulcers) was placed over the resident's tailbone area. On 11/27/18 at 2:25 P.M., a record review and interview was conducted with LN 10. LN 10 reviewed Resident 28's treatments and stated there were no orders for treatment to the buttocks and tailbone area. On 11/27/18 at 2:37 P.M., a concurrent observation of Resident 28's buttocks and tailbone was conducted with LN 10 and CNA 8. LN 10 observed the Duoderm placed on the resident's tailbone. LN 10 removed the Duoderm patch and revealed a reddened non-blanchable skin on the resident's tailbone area. LN 10 stated there was no physician's order related to the use of a Duoderm patch. LN 10 stated she placed the Duoderm patch on the resident's tailbone area a few days ago. On 11/29/18 at 8:25 A.M., an interview with LN 10 was conducted. LN 10 stated before a treatment was provided to a resident, there should be a physician's order present. LN 10 stated she should not have applied the Duoderm patch, without a physician's order. On 11/29/18 at 10:06 A.M., an interview with the DON was conducted. The DON stated if there were skin concerns, the nurses would have to call the doctor for the treatment orders, assess, and document the skin conditions. It is the standard of care. Per the facility's policy, revised 6/2013, titled Resident Assessment; Skin Management System, .a treatment order will be obtained from the attending physician for areas requiring treatment According to the Nurse Practice Act, Subsection (b)(4) of Section 2725, authorizes the nurse to implement appropriate standardized procedures or changes in treatment regimen in accordance with standardized procedures after observing signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determining that these exhibit abnormal characteristics. These activities overlap the practice of medicine and may require adherence to a standardized procedure when it is the nurse who determines that they are to be undertaken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 3 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers and hair washing for one of two sampled residents (187). Residents Affected - Few This failure had the potential for the resident to experience psychological stress and compromised hygiene. Findings: Resident 187 was admitted to the facility of 11/21/18 with diagnoses to include muscle weakness, per the admission Record. On 11/26/18 at 12:19 P.M., an interview was conducted with Resident 187 and his wife. Per Resident 187, his wife came in each morning to change his sheets and wash him in the bathroom. Resident 187 stated he had not washed his hair since admission, and he felt bad his wife had to help him. He also stated when his wife asked about washing his hair, the CNA responded to go ahead, but made no accommodations to assist her, and did not provide supplies. Per Resident 187's wife, the CNA never informed them of a shower room where hair could be washed while accommodating the resident in a wheelchair. On 11/29/18 at 9:09 A.M., a concurrent interview and record review was conducted with CNA 1. CNA 1 reviewed the shower assignment for Resident 187, and stated he was assigned the P.M. shift (3-11 P.M.) on Wednesdays and Saturdays for showers. CNA 1 reviewed the shower records for all residents in the hallway, but was unable to locate any documentation a shower had occurred for Resident 187 since his admission on [DATE]. Per CNA 1, refusal was the only reason not to shower a resident, and the refusal would be documented. CNA 1 stated the shower records were important to document any skin issues. CNA 1 looked at the EMR for the previous Wednesday and Saturdays when Resident 187 should have been showered, and found documentation from CNA 2, an evening shift CNA, that Resident 187 had a sponge bath, but not who provided it or when. Per CNA 1, That's not enough - there is no record of his skin condition. CNA 2 was not available for an interview. On 11/29/18 at 9:30 A.M., an interview was conducted with LN 10. Per LN 10, she was often assigned to Resident 187 and was familiar with his care. LN 10 stated she did not know he had refused showers or any other care, the CNA's had not communicated this to her. LN 10 stated there were several options for residents in wheelchairs, like Resident 187. LN 10 stated Resident 187 could use the shower while in a wheelchair, and showers were important for wound healing and resident satisfaction. On 11/29/18 at 9:45 A.M., an interview was conducted with LN 2. LN 2 stated hygiene was very important, especially for a resident with wounds, like Resident 187. LN 2 stated dignity was also an issue and not showering could affect how the resident felt about himself and his care. LN 2 stated the CNA's had been inserviced, but They need more, I guess. We can't fix what we don't know about. On 11/29/18 at 10:10 A.M., an interview was conducted with the DSD. Per the DSD, CNA's were inserviced on providing hygiene at least every six months, and more often if needed. The DSD stated, It is not acceptable for a resident to go eight days without a shower - it is an infection control issue, and affects the well-being of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 4 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Per a facility policy, revised 5/2017 and titled Bath, Shower, It is the policy of this facility to promote cleanliness and hygiene .Non-Ambulatory Residents: .3.shampoo hair .12. Document all appropriate information in medical record. Per a facility job description, undated, titled Certified Nursing Assistant (CNA), .Personal Nursing Care Functions .Assist residents with hair care functions (i.e., .shampooing . Event ID: Facility ID: 555873 If continuation sheet Page 5 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and manage pain for two of four residents investigated for pain management (24, 20). Residents Affected - Few As a result, the deficient practice had the potential for unmanaged pain. Findings: 1) Resident 24 was admitted on [DATE], with diagnoses which included hemiplegia (total or partial paralysis of one side of the body) affecting the right side, per the facility admission Record. An observation on Resident 24 was conducted on the following dates. - On 11/26/18 at 8:27 A.M., and at 9:24 A.M., Resident 24 was sleeping in bed lying on his back. At 9:47 A.M., Resident 24 was awake, lying on his back. At 1:16 P.M., and at 4:54 P.M., Resident 24 was noted lying at a 45 degree angle. - On 11/27/18 at 7:24 A.M., and at 3 P.M., Resident 24 was observed sleeping lying on his back. - On 11/28/18 at 9:01 A.M., Resident 24 was awake lying on his back. On 11/27/18 at 3:56 P.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 24 was totally dependent and cannot turn himself. CNA 11 stated Resident 24 yelled at the CNAs when the CNAs turned him. CNA 11 stated, Every time I turn the resident to change him, the resident shouted 'ahhhh' at me. CNA 11 stated Resident 24 yelled when his right leg was touched. CNA 11 further stated Resident 24 yelled more when turned on his left side, because his right leg was stiff. On 11/28/18 at 11:05 A.M., an interview with CNA 12 was conducted. CNA 12 stated Resident 24 yelled in pain during care. CNA 12 stated Resident 24 yelled at the CNAs when being turned or when his right leg was moved. CNA 12 stated Resident 24 had a stiff right leg and was unable to turn himself. On 11/29/18 at 7:26 A.M., an interview with LN 13 was conducted. LN 13 stated Resident 24 had a stiff right leg and was unable to turn himself. LN 13 stated Resident 24 usually screamed when CNAs changed him. LN 13 stated she was not aware Resident 24 was screaming due to pain. On 11/29/18, a review of the medical record indicated Resident 24 received one dose of Tylenol (a medication for pain) during the month of November 2018. No other pain medications were ordered. On 11/29/18 at 7:44 A.M., an observation and interview of Resident 24 was conducted. Resident 24 was lying slightly on his side, supported by a pillow. Resident 24 stated he did not get pain medication. Resident 24 stated he did not want to be turned because he was in pain. Resident 24 stated, It is more painful in my right leg. On 11/29/18 at 8:40 A.M., an interview with LN 14 was conducted. LN 14 stated she was not aware of Resident 24's pain during turning or care. LN 14 stated they should have assessed and managed Resident 24's pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 6 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm On 11/29/18 at 11:18 A.M., an interview with DON was conducted. DON stated Resident 24's pain should have been assessed and managed. A review of the facility's policy, titled Pain Management, revised on 11/2010, indicated, .Resident pain is assessed and managed by an interdisciplinary team .to achieve the highest practicable outcome. Residents Affected - Few 2. Resident 20 was admitted to the facility on [DATE] with diagnoses to include contracture (shortening or stiffening of muscles which causes deformity) of multiple sites as per the facility admission Record. On 11/26/18 at 9:27 A.M., an interview was conducted with CNA 13. CNA 13 stated, Resident 20 had a contracted right leg and complained of pain when repositioned or transferred. CNA 13 stated she believed the resident had pain because the resident moaned, groaned, and made faces when moved. On 11/27/18 at 9:21 A.M., a record review was conducted. A nursing progress note, dated 9/27/18, documented, . Resident with complaints of severe pain on the left knee upon touch and movement Multiple RNA progress notes, dated between 10/23/18 and 11/20/18, documented .Pt strongly refusing to do her right lower extremity due to pain,asked multiple times, but patient still refused. A care plan for chronic pain was created on 6/6/18. Interventions included pain assessment every shift and reposition for comfort. On 11/27/18 at 2:46 P.M., an interview was conducted with CNA 22 . CNA 22 stated Resident 20 complained of pain when repositioned or transferred. On 11/27/18 at 3:42 P.M., an interview was conducted with CNA 23. CNA 23 stated Resident 20 refused ROM when the resident had pain. On 11/28/18 at 10:30 A.M., a telephone interview was conducted with the responsible party (RP). The RP stated she spoke to the facility a month ago regarding Resident 20's increased pain when repositioned or transferred. On 11/28/18 at 11:40 A.M., an interview was conducted with LN 13. LN 13 stated Resident 20 yelled out when repositioned and transferred because of pain in her right leg. LN 13 stated she did not administer pain medication to Resident 20 this morning. On 11/28/18 at 2:58 P.M., an interview and record review was conducted with CM 1. CM 1 stated she had met with Resident 20's RP about Resident 20's leg pain. CM 1 stated Resident 20 had an order for Tylenol (pain medication) for pain. CM 1 stated no documentation of Resident 20's pain level was recorded for 11/28/18. Pain monitoring documentation showed Resident 20 had no pain since 11/1/18. No pain medication was administered for the month of November 2018. CM 1 stated she was aware Resident 20 frequently yelled out when repositioned or transferred, and the facility should have medicated Resident 20 for pain. On 11/29/18 at 11:27 A.M., an interview was conducted with the DON. The DON stated Resident 20's pain should have been assessed and managed. Per a facility policy, revised 11/2010, titled Pain Management .Resident pain is assessed and managed by an interdisciplinary team who work together .identifying circumstances when pain can be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 7 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 anticipated and developing and implementing a plan, using pharmacological and/or non- pharmacological interventions to manage the pain and/or try to prevent the pain consistent with the resident's goals Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 8 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure dialysis (the process of cleaning the blood through a machine) care was given according to professional standards of practice for two of five residents (287, 186). Residents Affected - Few This practice created the potential for: 1. Resident 287's temporary access site (central line located in the right upper chest) and AV fistula (artery and a vein surgical connection created for dialysis treatment) to become infected and for the AV fistula to clot. 2. Resident 186's access site to clot. Findings: 1. On 11/11/18, Resident 287 was admitted to the facility with Chronic Kidney disease (Kidney Failure) per the facility admission Record. On 11/26/18 at 10:57 A.M., an observation of Resident 287 was conducted. Resident 287 had a slightly reddened surgical site with sutures located in the left upper arm. Per Resident 287, the surgical site was an AV fistula, and until the AV fistula was healed, the temporary access site on his chest was to be used for dialysis. The temporary access site was uncovered and sutured in place. The two tubes protruding from the access site had gauze wrapped around them. On 11/26/18 at 10:59 A.M., an interview with LN 6 was conducted. LN 6 stated the left arm surgical site (AV fistula site) was a healing wound and did not know what it was. LN 6 stated Resident 287's temporary access site on his chest, was to be covered with a dressing at the dialysis center and removed by the facility after four hours. On 11/26/18 at 11:05 A.M., an interview was conducted with CNA 6. CNA 6 stated I have not been trained in care of a dialysis patient as a CNA. CNA 6 stated he stayed far away from the dialysis access sites. On 11/27/18 at 3:34 P.M., a concurrent observation of Resident 287 and interview with LN 7 was conducted. LN 7 stated Resident 287's temporary access site on the chest, was to be covered with a dressing by dialysis nurses and taken off 4 hours after Resident 287 returned to the facility. Resident 287 had just received a shower and the temporary access site on the chest was wet and uncovered. In addition, the gauze around the two tubes were wet. LN 7 stated she would not remove the wet gauze around the two tubes or apply a dry dressing to the access site. LN 7 stated she would wait for dialysis center to do the dressing and leave the access site alone. On 11/27/18 at 3:42 P.M., an interview was conducted with CNA 7. CNA 7 stated he had not been trained on how to care for dialysis residents. CNA 7 could not state how to care of the left arm AV fistula. On 11/28/18 at 3:45 P.M., a concurrent observation of Resident 287 and interview with LN 8 was conducted. LN 8 stated he stayed as far away as possible from the dialysis access site on the chest and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 9 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm he was not going to do anything with it. Resident 287's temporary access site on his chest was not covered with a dressing. On 11/28/18 at 4:01 P.M., a telephone interview was conducted with DLN 1 at Resident 287's dialysis treatment center. DLN 1 stated the standard of care for the dialysis access sites were as follows: Residents Affected - Few 1. The temporary access site on the chest should have been covered with a clean and dry dressing at all times to prevent infection. If it became wet, the facility should have contacted the dialysis center immediately. 2. The AV fistula on the arm should have been observed for redness and swelling as well as bleeding at the site and healing of the surgical site to prevent infection. In addition, the blood pressure should not have been taken on the left arm where the AV fistula was located because it could have caused a clot. On 11/29/18 at 8:42 A.M., an interview was conducted with the DSD. The DSD stated the temporary access site on the chest should have been kept clean and dry and the insertion site covered at all times. The nursing staff should have known to observe the dialysis access sites for redness and swelling or bleeding. If there were any issues or the dressing got wet, the staff were to contact the doctor and dialysis center immediately. In addition, CNAs and LNs should have known not to take a blood pressure on the arm where the AV fistula was located. On 11/29/18 at 9:29 A.M., an interview was conducted with the DON. The DON stated the temporary access site on the chest should have been covered and the dressing kept clean and dry. The DON stated the nursing staff should have observed the dialysis access sites for redness and swelling or potential bleeding and reported immediately to the doctor and dialysis center. In addition, The DON stated the nursing staff should have known not to take a blood pressure on the arm with an AV fistula. Per the National Kidney Foundation, copyright 2016, titled Hemodialysis Access What You Need to Know, .Call your dialysis care team at once if the area of the access is sore, swollen, red, or feels hot. This could be a sign of infection Be sure your catheter has a clean, dry dressing during and after every dialysis .Do not let anyone measure your blood pressure on your access arm. Your other arm should be used instead. Do not let anyone take blood from your access arm when you are not on dialysis . 2. Resident 186 was admitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (the process of cleaning the blood through a machine), per the facility's admission Record. On 11/26/18 at 9:06 A.M., an observation and interview was conducted with Resident 186. Resident 186 stated she goes to dialysis on Tuesdays, Thursdays, and Saturdays. Resident 186 had a pressure dressing (tightly fitted gauze, intended to prevent bleeding) on her left upper arm, with multiple layers of tape holding the dressing in place. When asked, Resident 186 stated the pressure dressing covered her fistula (an access site for dialysis), and should have been removed on Saturday night (two days prior) after she returned from dialysis. On 11/26/18 at 9:18 A.M., an interview was conducted with LN 3. Per LN 3, the pressure dressing should have been removed about four hours after the resident returned from dialysis, or Saturday night around 7 P.M. LN 3 removed the pressure dressing, and stated it was important to be able to assess (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 10 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the site. Per LN 3, We always observe the site for excessive bleeding, thrill and bruit (an assessment of the fistula's function) .well, obviously not this time. On 11/26/18 at 5:10 P.M., an interview was conducted with LN 4. LN 4 stated she was assigned to Resident 186 on Saturday evening. Per LN 4, the pressure dressing should have been checked for bleeding and then removed four hours after the resident returned from dialysis. LN 4 looked through the medical record but was unable to find any documentation of removal of the pressure dressing. LN 4 stated, The dressing should be removed in four to six hours, because it could occlude the fistula. I reinforced the dressing but I did not remove it. I made a mistake. On 11/29/18 at 12:02 P.M., an interview was conducted with the DON. The DON stated the pressure dressing covering Resident 186's fistula should have been removed on Saturday. An undated policy, titled Renal Dialysis, Care of Resident, Hemodialysis Access Site, did not address removal of the pressure dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 11 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to individualize behavioral interventions for one of three residents (43). Residents Affected - Few This failure had the potential to result in Resident 43's safety being compromised. Findings: Resident 43 was readmitted to the facility on [DATE], with a diagnosis of dementia (impaired memory) with behavioral disturbances, per the facility admission Record. On 11/29/18 a record review was conducted. Resident 43's MDS, dated [DATE], section C, indicated he had a BIMs of 9 meaning the resident had moderately impaired cognition. The MDS, section G, indicated Resident 43 ambulated with limited assistance. Resident 43's Fall Committee IDT note, dated 11/17/18, the resident had a fall on 11/15/18. The note indicated the resident had periods of severe confusion, was getting up unassisted, and did not use his call light to request assistance. Per the note, nursing interventions implemented to prevent falls included, .continue to remind to use his call light for staff assistance .room closer to nursing station Per the note, the IDT Fall Committee discussed the fall incident and no new recommendations were implemented. Resident 43's physician's orders, dated 9/20/18, indicated Resident 43 was given Seroquel for psychosis (loss of contact with reality). Resident 43's physician's orders, dated 9/20/18, indicated Resident 43 was to be monitored for akathesia (inability to sit still), every shift in relation to Seroquel dose. Resident 43's MAR, for the month of October 2018, indicated Resident 43 presented with akathesia behaviors 72 times. It also indicated with a + that akathesia occurred on 7 additional shifts without a numerical representation of times the behavior occurred. Resident 43's MAR, for the month of November 2018, indicated Resident 43 presented with akathesia behaviors 23 times. It also indicated with a + that akathesia occurred on 6 additional shifts without a numerical representation of times the behavior occurred. Resident 43's fall care plan, dated 11/17/18, had no individualized interventions to address his frequent standing up behavior. Resident 43's psychotropic medication care plan for Seroquel, dated 9/21/18, had no individualized interventions to address his frequent standing up behavior. Resident's restorative nursing notes, dated 11/19/2018, indicated Resident 43 was ambulating 80-100 feet with assistance and was tolerating ambulation and progressing toward goals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 12 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 43's psychiatric note, dated 11/26/18, did not mention his frequent behavior of standing up or interventions to address the behavior. Resident 43's psychiatrist's note, dated 11/27/18, indicated Resident 43 had behavioral disturbances and was constantly attempting to stand up with the risk of falling. The note stated, I believe that his Seroquel dosing is to diminish his psychotic and on-going attempts to fall + cause damage. During an interview on 11/29/18, at 11:25 A.M., with CNA 26, he stated he had cared for Resident 43 for two to three weeks. CNA 26 stated Resident 43 was usually calm but would occasionally become frustrated and speak nonsense. CNA 26 stated Resident 43 had recent falls and he walked with a RNA. During an observation and interview on 11/29/18, at 11:50 A.M., Resident 43 was sitting calmly at a table in the activities room. Resident 43 stated he enjoyed writing about observations and experiences. Resident 43 stated he had a very busy job for 20 years that involved a lot of writing and walking. Resident 43 further stated he enjoyed sports and physical activities including hiking. Resident 43 stated he liked to keep busy with activities. During an interview on 11/29/18, at 11:55 A.M., with AA 1, she stated Resident 43 tried to stand up frequently but was easily redirected. During an interview on 11/29/18, at 2:11 P.M., with CM 2, she stated Resident 43 should have been asked why he was standing. CM 2 stated the care team should have developed and implemented interventions that included activities he enjoyed, provided distractions and increased the frequency of his ambulation. CM 2 stated this was not done for Resident 43. CM 2 further stated, Standing up is not a psychotic behavior. It's not appropriate to medicate for standing up with Seroquel. The facility policy, untitled, revised 8/2015, indicated .Psychotherapeutic drug use .Policy: It is the policy of this facility to maintain every resident's right to be free from Psychotherapeutic drugs. The facility shall ensure .that behavioral interventions shall be attempted in an effort to discontinue these drugs The facility policy, untitled, revised 8/2017, indicated .Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 13 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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, the facility failed to ensure one of five residents (20) reviewed, received anti-anxiety medications for an approved indication and behaviors. As a result, Resident 20's distress was not accurately assessed or treated. Findings: Resident 20 was admitted to the facility on [DATE], per the facility admission Record with diagnoses to include dementia (impaired memory) and contracture (shortening or stiffening of muscles which causes deformity) of multiple sites. On 11/26/18 a record review was conducted. Per the history and physical note, Resident 20 did not have the capacity to understand and make decisions. Per a physician's order, dated 11/6/18, Resident 20 was to receive Xanax (an anti-anxiety medication) and be monitored for episodes of anxiety as evidence by calling out during care. On 11/26/18 at 9 A.M., Resident 20 was observed lying quietly in her bed. On 11/26/18 at 9:27 A.M., an interview was conducted with CNA 13. CNA 13 stated Resident 20 had a contracted right leg and had pain with movement. CNA 13 further stated that the resident moaned, groaned, and grimaced during repositioning and transfer. On 11/27/18 at 3:04 P.M., an interview with CNA 22 was conducted. CNA 22 stated Resident 20 cried/called out when repositioned or when care was being provided, because of pain. CNA 22 stated Resident 20 did not scream or call out if staff explained the care to the resident before actually providing the care. CNA 22 also stated if the resident was repositioned slowly and gently, the resident did not scream or call out. CNA 22 stated Resident 20 also expressed pain by facial grimacing and holding her right leg. On 11/27/18 at 3:42 P.M., an interview was conducted with CNA 23. CNA 23 stated Resident 20 yelled when she did not want to do any more exercises or when she was in pain. CNA 23 further stated when Resident 20 was up in the wheelchair and attended activities, the resident was distracted and had less episodes of yelling out. CNA 23 stated talking to Resident 20 before treatment or procedure helped the resident's anxiety. CNA 23 stated she had not noticed any combativeness from Resident 20. On 11/27/18 at 4:27 P.M., an interview with CNA 24 was conducted. CNA 24 stated Resident 20 was combative during the morning session of her ROM treatment. CNA 24 described combative behavior as manifested by Resident 20 holding the hand of CNA 24 and did not want CNA 24 to do any ROM therapy. On 11/28/18 at 8:55 A.M., an observation of CNA 22 was conducted while he provided care to Resident 20. CNA 22 spoke softly and in a calm manner to Resident 20. Resident 20 did not yell while CNA 22 provided care. On 11/28/18 at 10:20 A.M., a telephone interview was conducted with Resident 20's RP. The RP stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 14 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 20 cried out during care provided by staff. Per the RP, Resident had a history of leg pain, and had discussed the pain with facility staff about a month ago. On 11/28/18 at 11:40 A.M., an interview was conducted with LN 13. LN 13 stated Resident 20 was never combative or irritated. Resident 20 grimaced and called out during repositioning and transfers. Per LN 13, Resident 20 also called out because of pain on her leg. On 11/28/18 at 2:58 P.M., an interview and record review was conducted with CM 1. Per the physician's orders, dated 11/6/18, Resident 20 was to receive Xanax twice daily for anxiety related to calling out during care. CM 1 stated Resident 20's yelling was not because of anxiety but because of pain. CM 1 stated Resident 20 should have been assessed for pain prior to starting the anti-anxiety medication. On 11/29/18 at 11:19 A.M., a joint interview and record review was conducted with the CM 2 and the DON. CM 2 stated Xanax was ordered for anxiety, calling out during care and for pain. The DON stated the resident's probable cause of behavior (yelling during care) should have been assessed prior to the initiation of Xanax. The DON further stated Resident 20's behavior of yelling could have been due to other causes such as pain. Per a facility policy, revised 8/2015, and titled Psychotherapeutic Drug Use, .It is the policy of this facility to maintain every resident's right to be free from Psychotherapeutic drugs. The facility shall ensure that these drugs are used to treat specific condition as diagnosed by a physician, and that behavioral interventions shall be attempted in an effort to discontinue these drugs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 15 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor dietary preferences for one of four residents (78), which resulted in Resident 78 receiving foods she disliked. Findings: Resident 78 was readmitted to the facility on [DATE] per the facility admission Record. On 11/26/18, a record review was conducted of Resident 78's EMR. Resident 78 had a physician's order, dated 5/10/18, for mirtazapine (a medication for depression) at bedtime daily for depression. Resident 78 had a physician's order, dated 5/11/18, to monitor for episodes of depression as evidenced by poor appetite. On 11/26/18, at 1:11 P.M., an observation and concurrent interview was conducted in Resident 78's room. Resident 78 was sitting in bed with a meal tray in front of her. Resident 78 stated she was given zucchini and meatballs for lunch. Resident 78 further stated she did not like zucchini, meatballs or meatloaf and that she told facility staff numerous times but continued to receive them. The dietary slip on Resident 78's tray was reviewed and the field labeled dislikes was blank. On 11/27/18, at 2:39 P.M., an interview with CNA 22 was conducted. CNA 22 stated Resident 78 was unable to get out of bed. CNA 22 stated Resident 78 was a picky eater and disliked fish. CNA 22 stated if Resident 78's meal tray contained fish, he would get her a peanut butter and jelly sandwich instead of bringing her tray, with fish, to the room. On 11/27/18, at 3:28 P.M., a concurrent interview and record review was conducted with the DSS. The DSS stated she assessed resident's food dislikes upon admission and quarterly. The food dislikes were documented on the resident's diet slip (placed on a resident's meal tray) and in their initial and quarterly assessment notes. The DSS reviewed Resident 78's dietary notes and stated there were no food preferences documented. During the same interview, the DSS stated Resident 78 lost weight, which was a concern, and this was addressed in the IDT care conference. There were no food dislikes documented in the IDT conference note, dated 11/12/18. The DSS further stated meal alternatives were available and a resident who was bed bound or could not leave their room could have requested the list from nursing staff. On 11/27/18, at 3:47 P.M., a concurrent interview was conducted with Resident 78 and the DSS. Resident 78 stated she was not aware a meal alternative list was available. Resident 78 further stated she kept receiving foods she disliked after notifying staff. Resident 78 requested a peanut butter and jelly sandwich on her lunch and dinner trays in case she disliked the food she was served in the future. On 11/27/18, at 9:35 A.M., an interview was conducted with LN 2. LN 2 stated if a resident refused foods she would assess the residents likes and dislikes. She further stated nurses completed a diet communication slip or sent a message to dietary through the computer system, to let dietary know a resident disliked a particular food. LN 2 stated CNAs were the best source of information about resident's dislikes and care needs and should have been included in the IDT process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 16 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 11/28/18, at 9:59 A.M., an interview was conducted with CNA 22. CNA 22 stated he had never attended an IDT care conference. CNA 22 stated he did not know there was a dietary communication slip. CNA 22 stated he had already informed the nurses, the kitchen staff, and a cook of Resident 78's dislikes. Resident 78 continued to be served items she disliked despite his efforts. Per a facility policy, dated 2018, and titled Food Preferences, .Procedure: Food preferences will be obtained .through the initial resident screen .Updating of food preferences will be done as residents' needs change and/or during the quarterly review . Event ID: Facility ID: 555873 If continuation sheet Page 17 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, one of one resident (28) was not provided adaptive equipment for meals. Residents Affected - Few This failure created the potential for Resident 28 to limit her intake at mealtimes. Findings: On 1/21/16, Resident 28 was admitted to the facility with a diagnosis of hemiparesis (paralysis of one side of the body) following a stroke affecting the right dominant side per the facility admission Record. On 11/26/18 at 8:43 A.M., Resident 28 was observed lying in bed with the head of the bed elevated 60 degrees. Resident 28's breakfast tray was on the bedside table positioned over the resident's lower torso. Resident 28 was observed using a regular spoon, pushing food across the plate attempting to scoop up food. The food fell off the plate and landed on the tray. On 11/26/18 at 1:02 P.M., an observation and interview was conducted with Resident 28. Resident 28 stated, My right hand is paralyzed so I can only eat with my left hand. My right side is my dominant side. Resident 28 was observed, for the second time, pushing food with her spoon across the plate and onto the tray. On 11/28/18 at 8:09 A.M., an observation and interview with Resident 28 was conducted. Resident 28 stated she wanted to drink her coffee but was unable to because when she tried to drink the coffee with her left hand, she would burn herself. A standard coffee cup was observed with no lid, and full of coffee. On 11/28/18 at 8:15 A.M., an interview with CNA 9 was conducted. CNA 9 stated the process for residents receiving assistance starts when the CNA tells the nurse the resident needs help. CNA 9 stated Resident 28 may need an evaluation for assistive devices. On 11/28/18 at 11:53 A.M., an interview was conducted with LN 2. LN 2 stated Resident 28 would have benefited from an evaluation of her need for assistive devices when eating or drinking. LN 2 was unable to locate an evaluation of Resident 28's need for adaptive equipment in the medical record. On 11/28/18 at 1:47 P.M., an interview was conducted with CNA 9. CNA 9 stated Resident 28 was given ice tea with lid and straw and drank all of it. CNA 9 stated I am glad we caught that so we could offer her a safer alternative (to drink) with a lid and straw. On 11/29/18 at 9:40 A.M., an interview was conducted with the OT. The OT stated Resident 28 would have benefited from an evaluation. On 11/29/18 at 10:35 A.M., an interview was conducted with the DON. The DON stated an evaluation of Resident 28's need for adaptive equipment while eating would have been beneficial. Per the facility policy, revised 6/2017, titled Nutrition and Hydration Program . the facility is committed to ensuring that each resident .provided appropriate treatment to maintain and/or improve (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 18 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810 Level of Harm - Minimal harm or potential for actual harm .dining experience .Monitoring of meals .duties may include .3. Evaluate need for additional ADL assistance. 4. Evaluate need for referral to restorative feeding program. 5. Evaluate need for referral to OT/ST Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 19 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555873 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Bay Post Acute Care 553 F Street Chula Vista, CA 91910 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not implement infection control related to hand hygiene. Residents Affected - Few This practice created the potential for transmission of HAI (healthcare associated infections) to residents, staff, and visitors. Findings: On 11/26/18 at 12:33 P.M., an observation of CNA 13 was conducted. CNA 13 was holding two clear plastic bags with her bare hands. Inside the clear bags were incontinent briefs and wash cloths with brown material on them. CNA 13 went to the utility room and placed the clear bags in a plastic bin. CNA 13 then left the utility room, without performing hand hygiene, and went to the linen closet and took a clean wash cloth. CNA 13 then proceeded to a resident's room, took a pair of gloves from the wall, and went to the resident's bedside, without performing hand hygiene. On 11/26/18 at 12:37 P.M., CNA 13 came out of a resident's room with a clear plastic bag. Inside the bag was a wash cloth with brown stains. CNA 13 took the clear bag to the utility room and placed the bag in a plastic bin, inside the utility room. CNA 13 then proceeded to a resident's bedside, without performing hand hygiene. On 11/26/18 at 12:38 P.M., an interview with CNA 13 was conducted. CNA 13 stated the resident had a bowel movement. CNA 13 stated after changing the resident and the bed sheets, she placed the incontinent briefs and dirty linens in the clear bag, tied the bag with the dirty gloves, removed the dirty gloves, and threw the gloves in the trash. CNA 13 stated with her bare hands, she picked up the clear bags and dumped them in the utility room. CNA 13 stated she did not perform hand hygiene. CNA 13 stated she should have performed hand hygiene to prevent spread of infection. On 11/29/18 at 10:18 A.M., an interview with the DSD was conducted. The DSD stated CNAs were expected to perform hand hygiene before and after resident contact. The DSD stated hand hygiene was important to prevent the spread of infection. On 11/29/18 at 11:27 A.M., an interview with the DON was conducted. The DON stated CNA 13 should have washed her hands to stop the spread of infection. The facility's undated policy titled, Infection Control Prevention and Control Program- Hand Hygiene, indicated .This facility considers hand hygiene the primary means to prevent spread of infection .4. use an alcohol-based hand rub .or soap and water .b. before and after direct contact with resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 20 of 20