Health inspection·November 21, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a self-administration assessment was accurate for one of one resident (Resident 33) reviewed for self-administration of medication. Residents Affected - Few This failure increased the potential for the unsafe self-administration of medications, and the duplication of administered medications for Resident 33. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Asthma (a condition in which a person's airways become inflamed, narrow, swollen, and produce extra mucus, which makes it difficult to breathe), per the History & Physical, dated 2/10/22. On 11/14/22 at 9:16 a.m., Resident 33 was observed in her bed laying on her left side with a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask covering her nose and mouth. Resident 33's eyes were closed. The nebulizer cup was empty, and the nebulizer machine was on. On 11/14/22 at 10:18 a.m., Resident 33 was observed in her bed laying on her left side with the nebulizer mask on her chin. The nebulizer machine was on. On 11/14/22 at 11:50 a.m., Resident 33 was observed in her bed laying on her left side with her eyes closed, and the nebulizer mask was on her neck. The nebulizer machine was on. On 11/14/22 at 12:05 p.m., Resident 33 was observed in her bed laying on her back with her eyes closed, left leg was dangling off the bed, and the nebulizer machine was on. The resident's lunch tray was at the overbed table. On 11/14/22 at 1:00 p.m., Resident 33 was observed instilling the nebulizer liquid medication into the nebulizer cup through an opening attached to the mask. Resident 33 stated she administered her own breathing treatment because staff did not know what they were doing. Resident 33 stated the medication was left on her bedside table. There was no nurse at bedside. During an interview on 11/14/22, at 1:02 p.m., with LN 2, LN 2 stated she prepared the nebulizer treatment for Resident 33. Resident 33 stated she poured out what LN 2 put in the nebulizer cup and replaced it with the one that was left at her bedside. During an interview on 11/16/22, at 3:54 p.m., with LN 6, LN 6 stated he poured the Albuterol (a medication used to treat patients with Asthma, Bronchitis, Emphysema, and other lung diseases) for Resident 33. LN 6 stated, at times he would hand Resident 33 the Albuterol and she (Resident 33) poured it in the nebulizer cup herself. LN 6 stated he was not aware of Resident 33 keeping medications at bedside. LN 6 stated LN 7 informed him yesterday that an assessment and care plan were completed for Resident 33 to self-administer her medication. LN 6 stated LN 7 informed him that the physician was notified, and a lock box was given to the resident. LN 6 stated Resident 33 was to notify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 2 of 30 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 11/21/2022 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 0554 Level of Harm - Minimal harm or potential for actual harm nurse if she used the medication. LN 6 stated there should be a physician's order for self-administration, and this should be documented in the MAR. LN 6 stated he did not see a lock box in the resident's room. LN 6 stated Resident 33 had the capacity to recall the frequency of medication use. LN 6 stated Resident 33 could remember when to administer the medication, however Resident 33 would not follow the physician's order if she was to administer the medication herself. Residents Affected - Few On 11/17/22, at 9:36 a.m., LN 7 was interviewed. LN 7 stated she completed the Self-Administration of Medication assessment for Resident 33. LN 7 stated Resident 33 had COPD and always requested for a breathing treatment. LN 7 stated Resident 33 asked for the nebulizer at least every hour. LN 7 stated she did not review the facility's policy and procedure prior to completing the Self Administration Assessment. LN 7 stated she showed Resident 33 how to use the Advair (a prescription medication used to treat Asthma) inhaler (a hand-held, portable device that deliver medication to the lungs), and Resident 33 return demonstrated. LN 7 stated the order for the inhaler was one puff twice a day. LN 7 stated she showed Resident 33 how to use the nebulizer, how to twist the cup, place the medication mask on her face, turn on the machine, and place the mask in a plastic bag for infection control. The LN 7 stated she informed Resident 33 to keep the medications in the lock box, and to call for the nurse if she needed a breathing treatment. LN 7 stated LN 6 knew the combination for the lock box, and not Resident 33. LN 7 stated she determined Resident 33 had the capacity to self- administer medications. LN 7 stated she gave Resident 33 three medications to place in the box. LN 7 stated resident was not compliant with medication direction and will not follow physician's order. LN 7 stated she called the physician to inform him of Resident 33's request to have the medication at the bedside. LN 7 stated the IDT (a coordinated group of professionals from several different field), had the meeting on 11/15/22 which included the physician, DON, and herself (LN 7). During a concurrent record review and interview on 11/17/22, at 10:00 a.m., with LN 7, LN 7 stated the progress notes for Resident 33 dated 11/15/22 did not indicate IDT attendance on the notes. On 11/17/22, at 4:04 p.m., Resident 33 was observed in laying on her bed watching TV. A small white box with a light blue top, with a combination lock was observed on top of her overbed table. Resident 33 stated the box was to keep her medication for her breathing treatment. Resident 33 stated she did not request for the locked box, and only the nurses had the combination. The LN-Self Administration of Medications- Initial Evaluation, dated 11/15/22 was reviewed with the LN 7 on 11/21/22, at 11:12 a.m. LN 7 stated number 8 of the evaluation form was inaccurate. The assessment indicated Resident 33 was fully capable to correctly document self-administration of medications. LN 7 stated she did not observe Resident 33 document self-administration of her medication. LN 7 stated Resident 33 also did not demonstrate securing storage for the medication, as indicated on the assessment form. LN 7 stated Resident 33 did not demonstrate documenting the administration of PRN (as needed) medication, as indicated on the assessment form. During an interview with the DON, on 11/21/22 at 11:12 a.m., the DON stated she just gave the lock box to Resident 33 on 11/20/22. The DON stated an assessment was done for residents who requested self-administration, and an IDT meeting was held. The DON stated Resident 33 knew how often the medication should be taken. The DON stated she did not know if Resident 33 could follow directions. The DON stated the box had a padlock for Resident 33 to call for the nurse when she needed the medication. The DON stated the combination was not given to Resident 33 because she might self-administer more than what was needed. During a review of the facility's P&P titled, Care and Treatment, Self-Administration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 3 of 30 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 11/21/2022 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 0554 Level of Harm - Minimal harm or potential for actual harm Medications, without a date, the P&P indicated, 1. If a resident desire to participate in self-administration, the interdisciplinary team will assess .Nursing will be responsible for recording self-administered doses in the resident's medication administration record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 4 of 30 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 11/21/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), per History & Physical, dated 2/10/22. During observation and interview on 11/14/22, at 12:27 p.m., Resident 33 was in her room having lunch. Resident 33 stated she had no teeth but had dentures that were lost 3 months ago. Resident 33 stated she informed the head nurse and was told they will look for them. On 11/17/22, at 10:27 a.m., CNA 4 was interviewed. CNA 4 stated Resident 33 had dentures but refused to wear them. CNA 4 stated Resident 33 had no problems chewing. CNA 4 stated if a resident had missing dentures, she would report it to social services. CNA 4 stated she had not seen Resident 33 wear her dentures in the last 2 weeks. CNA 4 stated she never asked Resident 33 the reason for not wearing her dentures. On 11/17/22, at 10:42 a.m., a joint interview and record review of an undated Inventory of Personal Effects, document was conducted with CNA 4. CNA 4 acknowledged that the document indicated dentures were not marked as one of Resident 33's personal belongings. During a review of the Social Services Assessment/Evaluation V 2 document dated 2/5/21, the document indicated Resident 33 wore a partial, upper denture. During an interview on 11/17/22, at 11:22 a.m., with the SSD, the SSD stated Resident 33 had partial upper dentures upon admission to the facility. The SSD stated if a resident had missing dentures, she would start an investigation, instruct the nurses to check the medication carts, check the laundry, and refer the resident to the dentist. The SSD stated she was informed today (11/17/22) by the LN 7 that Resident 33's dentures were missing. During a review of the facility's undated P&P titled, Admission/Discharge/Transfer, Personal Effects, Inventory of, the P&P indicated The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Inventory of Personal Effects form. Based on observation, interview, and record review, the facility failed to ensure two of two residents' (241 and 33) belongings were inventoried and not lost. These belongings included: 1. Resident 241's right hearing aid was missing. 2. Resident 33's partial upper dentures were missing. These failures could affect the care of these residents by limiting Resident 241's hearing and communication abilities, limiting Resident 33's ability to eat, and increasing the resident's risk for weight loss. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 5 of 30 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 11/21/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Resident 241 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia per the facility's admission Record. Dementia is a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, or solve problems. On 11/14/22 at 9:32 A.M., Resident 241's family member (FM) was sitting in a chair beside the resident in bed. The FM stated Resident 241 had dementia that had recently been getting worse, and he was the responsible party (RP) who made decisions for the resident. The FM stated Resident 241 wore hearing aids and was admitted to the facility with only the right one because the left one had been out for repair. Resident 241's FM further stated the resident's right hearing aid was missing shortly after admission. The resident's FM stated it was reported to the staff, and the facility was investigating the loss. According to a review of Resident 241's Social Services Assessment/Evaluation, dated 11/8/22, .Summary: .wears hearing aids in the right ear . During an interview with certified nursing assistant (CNA) 11 on 11/16/22 at 9:18 A.M., CNA 11 stated Resident 241 was cognitively confused. CNA 11 stated Resident 241 lost her right hearing aid. Without hearing aids, the CNA had to be near the resident and speak loudly and clearly, and then the resident seemed to hear and understand. CNA 11 stated, Hearing aids are so small, and they are easily lost. CNA 11 further stated when residents went back to bed, she asked residents to put their hearing aids in a box labeled with their name and gave it to the nurses to lock up in the medication cart. During an interview with the social services director (SSD) on 11/17/22 at 9:15 A.M., the SSD stated she was notified on 11/14/22 that Resident 241's hearing aid was missing. The SSD stated that the hearing aid was not found after a thorough search of the resident's room, laundry, and the facility. The SSD stated after talking to the resident's FM, the hearing aid went missing on either 11/10 or 11/12/22. The SSD further stated the resident's FM was not interested in being reimbursed for the hearing aid, so the SSD entered a detailed note into Resident 241's medical record and did not complete a Theft/Loss report. According to a Social Services note, dated 11/16/22 at 4:59 P.M., .SS (social services) saw a hearing aid in the box and [FM] stated that hearing aid is for the left ear that was brought today after being repaired. SS continues to search room and did not find right hearing aid. SS made [FM] aware of the admission packet form Resident Hearing Aids, Dentures and Glasses. [FM] read the form with E-Signature of [resident]. [FM] stated that regardless of the form, [resident] hardly wears the hearing aids anyways stating that the left hearing aid has been in facility all day and [resident] does not care to have them on. [FM] requested for SS to drop the hearing aid case . During an interview with Resident 241's FM on 11/17/22 at 9:40 A.M., the FM stated a facility staff came in yesterday to look again in the room for the resident's missing hearing aid. The resident's FM stated the staff member showed him a form that the facility was not responsible for lost hearing aids, with the resident's signature. Resident 241's FM stated that the resident could not make decisions or sign any forms due to dementia. The FM stated he did not want to argue with the facility but would like to be reimbursed for the lost hearing aid. According to a review of Resident 241's undated Inventory of Personal Effects, only one shirt was added to the inventory and signed by the resident's FM. Additionally, there was no date or facility representative signature at the bottom of the document. In the Items Acquired After Original Entry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 6 of 30 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 11/21/2022 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 0584 section, the left hearing aid was added on 11/16/22. Level of Harm - Minimal harm or potential for actual harm During an interview with CNA 11 on 11/17/22 at 9:53 A.M., CNA 11 stated on admission, CNAs inventoried resident belongings with the licensed nurse (LN) and the resident or responsible party. Additionally, CNA 11 stated they looked for hearing aids and always asked residents if they were wearing hearing aids or dentures. CNA 11 further stated the CNA who did the inventory was to sign the form after the resident or RP signed it. Residents Affected - Few During an interview with the director of nursing (DON) on 11/21/22, the DON stated staff were expected to ask if residents had hearing aids and include them on the admission inventory. The DON stated staff were also supposed to sign the inventory after the resident or RP signed. The DON stated the SSD was following up on the replacement or reimbursement for Resident 241's lost hearing aid. During an interview with the SSD on 11/21/22 at 3:31 P.M., the SSD stated there had been no further follow-up since the last interview on 11/17/22. According to a review of the facility's undated policy titled Inventory of Personal Effects, Policy: It is the policy of the facility to take reasonable steps to protect the personal property of the residents. Purpose: To maintain an inventory for the personal effects of the resident. Procedures: 1. On Admission- A. When a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility. The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Inventory of Personal Effects form. B. Following completion of the inventory, the indicated form shall be signed by the resident and responsible party and by the staff member . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 7 of 30 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 11/21/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level II (PASRR II - an evaluation of the resident's psychiatric treatment requirements) was followed up and completed for one of one resident (Resident 17) reviewed for PASRR. As a result, there was potential for a failure to coordinate the PASRR recommendations to Resident 17's assessment and care planning. Findings: Resident 17 was readmitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder (a mental illness that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Post-Traumatic Disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and Major Depressive Disorder (a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), per the admission Record. A review of Resident 17's PASRR Level I (a screening tool for further psychiatric care) completed on 9/15/21 indicated a PASRR Level II was required. During an interview and concurrent record review on 11/21/22 at 3:20 p.m., with LN 7, LN 7 stated she was responsible for completing PASRRs. LN 7 stated a copy of the Level I was provided to the resident and sent to the PASRR agency. LN 7 stated a PASSR staff called her to verify Resident 17's diagnosis, any behavioral episodes, and if the resident had Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). LN 7 stated Resident 17 received a letter, dated 1/4/22 from PASRR which indicated, unable to complete due to isolation. LN 7 stated PASRRs were completed annually, and that she did not complete Resident 17 this year. LN 7 stated she did not follow up on Resident 17's PASRR Level II after the resident was removed from isolation. LN 7 stated it was important to follow up on the PASRR Level II to identify the resident's needs and properly place the resident if indicated. During an interview on 11/21/22 at 3:48 p.m., with the DON, the DON stated the purpose of completing the PASRR was to identify the care for the resident and meet the resident's psychosocial needs. During a review of the facility's undated policy and procedure (P&P) titled, Resident Assessment, PASRR, the P&P indicated, Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 8 of 30 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 11/21/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update or revise care plans for two of three residents reviewed for care planning (8, 78). This failure had the potential to result in delayed care, miscommunication among caregivers, and decreased physical well-being of the residents. Findings: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses to include dementia (a disorder causing memory problems and impaired reasoning) and muscle weakness, per the facility admission Record. On 11/14/22 at 11:19 A.M., a concurrent observation and record review of Resident 8 was conducted. Resident 8 was in bed, with a fall mat (a protective pad) on the floor next to the bed. The Resident Matrix (a document used to identify care needs) indicated Resident 8 had fallen within the past 90 days. According to a review of Resident 8s IDT (Interdisciplinary Team, a group of healthcare professionals), Resident 8 had fallen twice within the last year. On 5/1/22 Resident 8 was found on the floor, with new interventions of providing a safe and hazard free environment, with the call light within reach and the bed in the lowest position. On 10/29/22 Resident 8 had a fall when a staff member transferred him to a chair by lifting him manually without a mechanical device. An IDT note, dated 11/3/22, indicated, Resident requires mechanical device 2-person assistance in transfer .Continue plan of care and update the care plan. A Falls care plan, initiated 12/9/21, indicated a goal of, Will be free of falls through the review date of 1/21/23. The intervention of 2-person assistance in transfers was not listed as an intervention. On 11/21/22 at 10:25 A.M., an interview was conducted with LN 6. LN 6 stated care plans were used to focus care on the needs of the resident, and based on their goals and plan of action for achieving them. LN 6 stated it was important to have accurate care plans to provide good care and meet the resident's goals. On 11/21/22 at 12:20 P.M., a concurrent interview and record review was conducted with the DON. The DON stated the care plans need to be updated so staff know what interventions were required to keep the resident safe. Per the DON, the IDT was responsible for updating the care plan. The DON reviewed the Falls care plan and stated, I missed this one. My expectation is that updates to the care plan get done during the IDT meeting. We could have another fall if we don't put new interventions in place. 2. Resident 78 was admitted to the facility on [DATE] per the facility admission Record. On 11/14/22 at 11:08 A.M., a concurrent interview and record review was conducted with Resident 78. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 9 of 30 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 11/21/2022 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 78 stated he had been admitted to the facility with a catheter (a device inserted into the bladder to collect urine), but it had been discontinued to prepare him for discharge. The catheter was listed on the MDS Indicator section of the survey facility data. On 11/21/22 a record review was conducted. Resident 78's care plan listed the catheter as a current focus of care, with goals of no catheter-related trauma. On 11/21/22 at 10:25 A.M., a concurrent interview and record review was conducted with LN 6. Per LN 6, care plans were used to focus care on the needs of the resident, and based on their goals and plan of action for achieving them. LN 6 stated it was important to have accurate care plans to provide good care and meet the resident's goals. LN 6 reviewed Resident 78's care plans, and stated, We should have updated the care plan to match the discontinued catheter order. The nurses are responsible for updating the care plans, and this one was not updated. This might cause confusion among the health care providers. On 11/21/22 at 12:20 P.M., an interview was conducted with the DON. The DON stated care plans were used to identify patient needs, and if a catheter was removed, the care plan should have been resolved. Per the DON, If we don't resolve the care plan it could cause confusion among the caregivers. Per an undated facility policy, titled Care Planning/Care Conference, .4. Care plan will be revised as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 10 of 30 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 11/21/2022 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 develop a plan for discharge for one of four residents reviewed for care planning (Resident 49). Residents Affected - Few This failure had the potential to result in an unsafe discharge, and placed Resident 40 at risk for prolonged admission to the facility. Findings: Resident 49 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, per the facility admission Record. On 11/14/22 at 11:51 A.M., an interview was conducted with Resident 49. Resident 49 stated she had been at the facility almost a year, but still had no plans for discharging. Resident 49 stated she would like to be discharged back to her previous neighborhood but nobody had discussed finding her a place to live. According to Resident 49's Brief Interview for Mental Status (BIMS, an assessment tool, dated 9/1/22), Resident 49's score was 15, indicating intact cognition. On 11/30/21, an IDT met for Resident 49's initial care conference. Per the IDT, Resident 49's plan for discharge was for placement in the community. On 1/14/22, a Social Services admission assessment indicated Resident 49's discharge plan was to discharge to the community with home health needs to be determined upon discharge. On 2/4/22, a care plan was initiated, indicating Resident 49 wished to be discharged to her prior living arrangements. Goals were written for a pre-discharge plan to be established with the resident and caregivers, with revisions to the plan as needed. No discussion or revisions were documented. On 5/24/22, a Social Services quarterly assessment indicated Resident 49 now resided at the facility, and no discharge was anticipated. On 8/24/22, a Social Services quarterly assessment indicated Resident 49 resided at the facility and no discharge was anticipated. On 11/17/22 at 4:38 P.M., an interview was conducted with the SSD. The SSD stated discharge planning started when a resident was admitted to the facility. Per the SSD, the facility needed to evaluate the resident's abilities to live independently, and work with them to find an appropriate place to live upon discharge. The SSD stated the discussion about discharge should happen quarterly at the IDT meetings. Per the SSD, the IDT had not documented why Resident 49's discharge plan had changed or whether Resident 49 understood or not. The SSD stated she was not aware Resident 49 wanted to discharge elsewhere. On 11/17/22 at 5:05 P.M., an interview was conducted with the DON. The DON stated a discharge plan needed to reflect the resident's goals and staff interventions to help them meet their goals. The DON stated, I don't see the IDT discussed the discharge with the resident. This could cause an unsafe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 11 of 30 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 11/21/2022 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 0660 discharge. Level of Harm - Minimal harm or potential for actual harm Per an undated facility policy, titled Care Planning/Care Conference, .4. Care plan will be revised as needed . Residents Affected - Few Per an undated facility policy, titled Discharge Planning Process, It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals .c. Include regular re-evaluation of resident .to identify changes that require modification of the discharge plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 12 of 30 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 11/21/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide treatment and care according to professional standards of practice when: Residents Affected - Few 1. The need for a PRN (provided as needed) medication was not assessed for one of one residents reviewed for constipation (Resident 36), and 2. A physician's order to assist a resident up in a chair daily was not followed for one of three residents reviewed for care planning (Resident 49). 3. Blood sugar level checks were not performed before meal intakes for one of 3 residents reviewed for diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) care. These failures had the potential to place the residents at risk for further medical complications. Findings: 1. Resident 36 was admitted to the facility on [DATE], per the facility admission Record. On 11/14/22 at 1:13 P.M., a concurrent observation and interview with Resident 36 was conducted. Resident 36 was sitting in a wheelchair in her room, rubbing her abdomen with her hand. Resident 36 stated she had been constipated for three days, and her abdomen felt tight and painful. Resident 36 stated she had informed her nurse of the constipation, and in the past had needed to go to the hospital due to the painful constipation. On 11/16/22 at 9 A.M., a concurrent observation and interview with Resident 36 was conducted. Resident 36 was sitting in a wheelchair outside of a bathroom, and stated she still had not had a bowel movement. On 11/16/22 at 10 A.M., a concurrent interview and record review was conducted with CNA 1. CNA 1 stated she was assigned to Resident 36 often, and Resident 36 was able to tell staff whether she needed to have a bowel movement or not. CNA 1 reviewed an electronic document titled BM (bowel movement) Report. CNA 1 stated, per the BM Report, Resident 36 had a bowel movement on 11/13/22, three days ago. CNA 1 stated the nurses assigned had access to the BM report, and Resident 36 was able to tell nurses when she was constipated. On 11/16/22 at 10:19 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated the LN assigned to Resident 36 should assess her daily for constipation. Per LN 7, the nurses would assess for any pattern of constipation on the facility dashboard, and they should check the CNA Task list. LN 7 stated the nurse should write a progress note if constipation has occurred for several days in a row. LN 7 viewed all electronic documents, and stated, The assessment is not here. Her last bowel movement was three days ago. She (Resident 36) has an order for a prn medication for constipation. The LN should go to dashboard and check, and if nothing is documented for three days, that would trigger on the dashboard. The nurse should write a progress note. There's a hole in the process. The information didn't get documented anywhere. We can't administer a prn medication without asking about bowel movements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 13 of 30 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 11/21/2022 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 0684 On 11/16/22, a record review was conducted. Level of Harm - Minimal harm or potential for actual harm On 8/12/22, Resident 36's Brief Interview for Mental Status (BIMS, an assessment tool) score was 14, indicating intact cognition. Residents Affected - Few Resident 36 had four scheduled (given daily) medications ordered for constipation. In addition, Resident 36 had another medication ordered PRN, (as needed) for constipation. A care plan for constipation had been initiated on 1/29/22, and revised on 8/8/22. The Goal written was, Will have a normal bowel movement at least daily . Interventions implemented included following facility protocol for bowel management. On 11/16/22 at 4:50 P.M., an interview was conducted with Resident 36. Resident 36 stated she always informed the medication nurses when she was constipated. Resident 36 stated the nurses did not ask her about needing a PRN medication for constipation when bringing her morning medications. On 11/16/22 at 5:05 P.M., an interview was conducted with the DON. The DON stated all nurses should assess residents at risk for constipation to determine when the last bowel movement was, and to determine the need for a PRN medication. The DON stated, That would be an important part of the nurses' assessment during medication administration. Per an undated facility policy, titled Bowel Care Management, It is the policy of this facility to follow physician orders and implement bowel care interventions .1. Licensed Nurses will monitor bowel movements every shift through the Clinical Dashboard/Clinical Alerts . 2. Resident 49 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, per the facility admission Record. On 11/14/22 at 11:51 A.M., a concurrent observation and interview was conducted with Resident 49. Resident 49 was sitting up in bed, working on a word puzzle. Resident 49 stated the doctor had ordered for her to be up in her chair daily so she could get ready for discharge. Per Resident 49, staff did not get her up in the chair. Resident 49 stated, How can I get ready for discharge if I can't get into my wheelchair by myself? On 11/17/22 a record review was conducted. On 9/1/22, Resident 49's BIMS score was 15, indicating intact cognition. Per a physician's order, dated 3/3/22, Resident 49 was to be, Up to wheelchair daily. every day shift Per the November Treatment Administration Record (TAR, a list of physician-ordered treatments), LNs signed off the order of Up to wheelchair daily. every day shift every day in November. LN 6 had signed off the TAR for 11/15/22 and 11/16/22. LN 2 had signed off 11/13/22 and 11/14/22. LNs 2 and 6 were not available for interview. Per a facility care plan, initiated 2/6/22, Resident 49, I require assistance/potential to restore function to maximum self-sufficiency for mobility .Will demonstrate the appropriate use of adaptive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 14 of 30 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 11/21/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm devices to increase ability in mobility .I am at risk for ADL (activities of daily living, which include getting in and out of bed or a chair) Self Care .Will safely perform .Transfers .Monitor/document/report to MD .any reasons for self-care deficit . No care plan for noncompliance was identified for Resident 49. Residents Affected - Few On 11/17/22 at 10:32 A.M., an interview was conducted with CNA 1. CNA 1 stated she was usually assigned to Resident 49. CNA 1 stated Resident 49 only left the bed to take showers, but had refused to get up in the chair that day. CNA 1 stated she was aware Resident 49 was supposed to get up in the wheelchair daily but had never seen her out of the bed. On 11/17/22 at 11:50 A.M., an interview was conducted with Restorative Nursing Assistants (RNA) 41 and 42. RNA 41 and 42 stated their job was to provide range of motion exercises (ROM) three days a week for Resident 49. RNA 41 stated Resident 49 would complete the exercises, but when encouraged her to sit at the side of the bed she would refuse. RNA 41 stated Resident 49 stayed seated in bed to do her ROM exercises. RNA 42 stated they document the ROM exercises but transferring to a chair was not part of their role as RNAs. On 11/17/22 at 11:04 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated if a physician ordered transferring a resident to a chair daily, the CNAs were responsible for the task. Per LN 7, if the resident refused, the CNA should report this to the LN. The LN would then go and discuss the order with the resident and encourage them to complete the transfer. If the resident still refused, the nurse should write a progress note regarding the refusal. LN 7 searched the nurses progress note and stated, There is no documentation (about refusing the order), so we can assume it did not happen. On 11/17/22 at 11:24 A.M., an interview was conducted with LN 42. LN 42 stated if the physician ordered for a resident to be up in the chair daily, the CNA and the LN would be responsible for documenting it. Per LN 42, if a resident refused to comply, the nurse would document the refusal in the progress notes and contact the physician if there was a pattern of noncompliance. LN 42 stated the nurses should create a care plan the noncompliance so staff, including the physician, would be aware. On 11/17/22 at 11:50 A.M., an interview was conducted with the DON. The DON stated if a resident refused to comply with a physician's order, the nurse should inform the physician. The DON stated, We did not communicate that. The order is in the TAR so the nurse can sign it off when the resident has gotten up in the chair, but based on the TAR it would appear she got up in the chair daily. Nurses should not sign off treatments that did not occur. The risk of noncompliance could be a decline (in her health) or her skin integrity could be compromised. This is not our goal for the resident. Per an undated facility policy, titled Charting and Documentation, .The resident's clinical record is an account of treatment, care, response to care .Importance and use of the record: Provides a multidisciplinary record of the physical and mental status of the resident . 3. Resident 33 was admitted to the facility on [DATE] with diagnoses to include Diabetes type 2 ((a disease in which the body's ability to produce or respond to the hormone insulin is impaired), according to the History & Physical, dated 2/10/22. On 11/14/22, at 12:52 PM, LN 2 was observed checking Resident 33's blood sugar. LN 2 stated Resident 33's blood sugar was 206 and administered Humulin R insulin (a hormone created by the pancreas (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 15 of 30 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 11/21/2022 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 0684 that controls the amount of glucose in the bloodstream). Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 11/16/22, at 3:54 p.m. with LN 6, LN 6 stated Resident 33 had an order for insulin. LN 6 reviewed Resident 33's MAR and stated the physician's order indicated to Hold if BS (blood sugar) 80 or below, but there was no order to conduct fingerstick blood sugar checks. LN 6 stated he assumed the physician wanted a blood sugar check. LN 6 stated he checked Resident 33's blood sugar before the resident ate her meals. LN 6 stated if the resident's blood sugar was checked after a meal, it would be inaccurate and abnormally high. Concurrent review of Resident 33's blood sugar in the MAR, dated 11/14/22, indicated a result of 206 mg/dl (milligram per deciliter). Residents Affected - Few An interview and concurrent record review of Resident 33's physician's order was conducted on 11/21/22, at 10:20 a.m. with LN 2. LN 2 stated the resident's orders indicated inject 24 units of Regular insulin in the morning, and 18 units in the evening. LN 2 stated the order read to hold for blood sugar of 80 mg/dl or less. LN 2 stated she administered 2 units Regular insulin in addition to 24 units Regular insulin on 11/14/22 at 7:33 AM. LN 2 stated at 12:26 p.m., she administered 2 units of Regular insulin. LN 2 was not able to show in the computer what the resident's blood sugar was before administering the insulin. LN 2 stated blood sugars were checked based on the times indicated next to the medication in the MAR. Concurrent review of Resident 33's MAR indicated no physician's order for blood sugar check. LN 2 stated the standard of practice for checking blood sugar was before a resident ate. LN 2 stated the amount of insulin to be given to the resident was dependent on the resident's blood sugar level. LN 2 stated blood sugar check should have been done before breakfast for Resident 33. LN 2 stated the physician's order was not complete. LN 2 stated she should have asked the physician when to check the blood sugar. LN 2 stated It was important to know the resident's baseline of Diabetes, which was the normal sugar in the body before breakfast. LN 2 stated it was important to check blood sugars in order for the physician to review, and determine if resident was stable or not. LN 2 stated she assumed she had to check the resident's blood sugar before giving insulin, even though there was no order. LN 2 stated the insulin administered on 11/14/22 after meals was not accurate, and that it was her mistake. During a review of the facility's Consultant Pharmacist's Medication Regimen Review, for Resident 33, dated 4/21/22, indicated, Residents fingerstick readings show very high blood sugars, mainly >200 on most occasions. Please contact MD to adjust diabetic therapy. On 11/21/22 10:46 a.m. an interview was conducted with the DON. The DON stated blood sugar fingerstick should be completed before meals in accordance with the standard of practice. The DON also stated the nurses should follow the physician's order. A review of the facility's undated P&P titled, Nursing Clinical/Diabetes Mellitus Resident, indicated no guidance regarding when to perform blood sugar fingerstick. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 16 of 30 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 11/21/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a toilet seat was securely attached to the toilet bowl in a communal bathroom used by multiple residents. As a result, multiple residents were at risk for falls due to the instability of the loose toilet seat. Findings: Per the facility's admission Record, Resident 83 was admitted to the facility on [DATE] with difficulty walking. Resident 83's records were reviewed. Per the physician's history and physical, dated 10/17/22, Resident 83 had the capacity to make her own decisions. On 11/13/22 at 11:50 A.M., an observation and interview with Resident 83 was conducted. Resident 83 was sitting up on the side of her bed. Resident 83 stated she did not have a bathroom in her bedroom, so she used the bathroom down the hall, Resident 83 stated the bathroom was used by several residents on the hall. Resident 83 stated the toilet seat moved from side to side and when she tried to sit on it, she was afraid of falling because it threw her off balance. On 11/14/22 at 12:03 P.M., a concurrent interview with CNA 21 and observation of the toilet referenced by Resident 83 was conducted. CNA 21 observed the toilet seat and then moved it freely from side to side. CNA 21 stated the toilet seat was loose and could lead to a fall. On 11/14/22 at 12:06 P.M., a concurrent interview with the DON and observation of the toilet referenced by Resident 83 was conducted. The DON moved the toilet seat from side to side. The DON stated when the toilet seat was loose, someone could fall or slip off the toilet seat and land on the floor. Per the undated facility policy, titled Care and Treatment, Accident Intervention, .It is the policy of this facility that the resident environment remains as free of accident hazards as possible . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 17 of 30 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 11/21/2022 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of one residents (31) on intravenous (IV) antibiotic therapy had their PICC line monitored per professional standards and facility policy. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. Residents Affected - Few This failure could potentially increase the risk of infection and delay the identification of catheter-related complications for Resident 31. Findings: Resident 31 was admitted to the facility on [DATE] with diagnoses that included infective endocarditis (a bacterial infection that settles in the heart) and bacteremia (bacteria in the blood), per the facility's admission Record. During an interview with Resident 31 on 11/14/22 at 10:30 A.M., the resident stated he was receiving antibiotics through the IV in his arm because he had an infection in his blood. An IV site was observed in the resident's right upper arm, with a transparent dressing covering the site, which was labeled and dated. According to a review of Resident 31's Medication Administration Record (MAR), the PICC line was in the resident's right brachial vein (in the upper arm), and the dressing was to be changed every seven days. On 11/16/22 between 12:04 and 12:45 P.M., registered nurse (RN) 12 was observed while changing Resident 31's PICC line dressing. At 12:08 P.M., RN 12 placed a clean towel under Resident 31's arm on top of the bed. At 12:11 P.M., RN 12 put a package of sterile supplies on the resident's bedside table. The bedside table was not cleaned or sanitized before placing the supplies. RN 12 commenced removing the resident's dressing using clean gloves. At 12:22 P.M., RN 12 opened the sterile package on the bedside table and donned (put on) sterile gloves. RN 12 ripped the gloves while donning them. RN 12 removed the torn gloves and obtained a new sterile dressing change kit. RN did hand hygiene after placing the sterile equipment on the towel on the resident's bed. At 12:24 P.M., RN 12 opened the sterile kit, donned sterile gloves, and placed a sterile barrier under Resident 31's arm. At 12: 26 P.M., RN 12 removed a paper tape measure from the sterile kit, measured the PICC line from the insertion site to the cap, and then placed the tape measure back into the sterile kit. At 12:27 P.M., RN 12 removed alcohol wipes from the kit and wiped in a circular motion from the insertion site outward with three separate alcohol wipes. RN 12 cleaned the site in the same manner with a sterile antiseptic applicator from the kit. RN 12 discarded the used alcohol wipes and antiseptic on the bedside table with the other discarded items (dirty dressing, torn gloves, and empty sterile glove packages). At 12:29 PM, RN 12 picked up a closed package from the bedside table (next to the discarded items) and attempted to open the package containing the new dressing. At 12:30 P.M., RN 12, while struggling to open the dressing package, ripped one of the sterile gloves. RN 12 gathered the supplies from the bed, placed them on the bedside table, and removed the torn gloves. At 12:31 P.M., RN 12 placed another sterile dressing kit on the towel, did hand hygiene, opened the sterile package, placed the sterile gloves on top of the empty packages of the previous sterile gloves, and donned the sterile gloves. At 12:34 P.M., RN 12 put a sterile barrier under Resident 31's arm and cleaned the PICC line insertion site by wiping back and forth multiple times over the insertion site with the second alcohol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 18 of 30 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 11/21/2022 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wipe. RN 12 then cleaned the site with the antiseptic, starting at the insertion site, circling outward, then wiping toward the insertion site with the antiseptic. At 12:35 P.M., RN 12 picked up the package with the new dressing from the bedside table and opened the package, and placed the dressing on the insertion site. RN 12 completed the dressing change at 12:45 P.M. During an interview with RN 12 on 11/16/22 at 12:50 P.M., RN 12 stated, My big problem was the sterile gloves were too small. RN 12 further stated he did not do a proper job during the dressing change and did not maintain a sterile field. RN 12 stated he was not aware that he wiped back and forth across the insertion site while cleaning the site. During an interview with RN 13 on 11/17/22 at 11:25 A.M., RN 13 stated that a sterile field must be maintained during the dressing change for a PICC line to decrease the risk of infection. RN 13 further stated when doing a PICC line dressing change, they measured the PICC line but did not document the measurements anywhere in the chart. RN 13 stated they just visually monitored if the tubing was longer than last time. During an interview with the director of nursing (DON) on 11/21/22 at 12 P.M., the DON stated it was necessary to maintain a sterile field when changing a PICC line dressing to decrease the risk of infection. In addition, the DON stated measurements of the PICC line should have been documented on the MAR or progress notes during the dressing change to ensure that the PICC line was in the proper placement. According to a review of the facility's undated policy titled PICC line dressing change, Central Vascular Access Device: Peripherally Inserted Central Catheter (PICC) . Procedure: .F. Dispose old dressings and gloves appropriately. G. [NAME] sterile gloves . According to a review of the facility's undated policy titled Dressing Change for Vascular Access Devices [CVAD], Purpose: To prevent local and systemic infection related to the IV site . Equipment: .Dressing Kit (for midlines and central lines) .Sterile gloves (for midlines and central lines) . Procedure: .For Midlines and all CVADs: . 12. Clean site with three (3) alcohol swabs starting from the center moving outward in an increasing spiral pattern. Clean an area larger than dressing to be applied. 13. Prep site with three (3) povidone iodine swabs starting from the center moving outward in an increasing spiral pattern. Clean an area larger than dressing to be applied . 19. Suggested charting: Site assessment .External length, if indicated, for device . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 19 of 30 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 11/21/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of one resident (Resident 33) reviewed for respiratory care. Residents Affected - Few As a result, Resident 33 was provided with more oxygen than what the physician ordered, which had the potential to cause respiratory problems for the resident. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and Asthma (a condition in which a person's airways become inflamed, narrow, swollen, and produce extra mucus, which makes it difficult to breathe), according to the History & Physical, dated 2/10/22, and the Order Summary Report. On 11/16/22, at 4:31 p.m., a concurrent observation of Resident 33's oxygen concentrator (a medical device used to provide oxygen) was conducted with LN 6. The oxygen concentrator was observed at 3.5 liter/minute. LN 6 stated the physician's orders indicated 2 liters/minute. A concurrent record review of Resident 33's physician's order, dated 11/13/22 was conducted with LN 6 on 11/16/22. The order indicated Continuous O2 (oxygen) at 2 liters per minute via nasal cannula. During an interview on 11/21/22, at 11:45 a.m., with the DON, the DON stated staff was not following physician's order regarding Resident 33's oxygen. The DON stated, Resident 33 can have respiratory problems, and too much can harm the resident. During a review of the facility's undated P&P titled, Licensed Nurse Procedures, Oxygen Administration (Mask, Cannula, Catheter), the P&P indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 20 of 30 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 11/21/2022 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 failed to ensure one of four residents reviewed for dialysis (a process to remove waste products from the blood) had a dressing removed as ordered by the physician (Resident 36). Residents Affected - Few This failure had the potential to cause damage or injury to the dialysis site. Findings: Resident 36 was admitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (a need for dialysis due to kidney failure), per a facility admission Record. On 11/14/22 at 3:03 P.M., an interview was conducted with Resident 36. Per Resident 36, dialysis was scheduled on Tuesdays, Thursdays and Saturdays. Resident 36 stated the nurses usually removed the dressing from her dialysis access site when she returned at night. On 11/16/22 at 9:37 A.M., a concurrent observation and interview was conducted with Resident 36. Resident 36 stated she had returned from dialysis the previous night. Resident 36 stated the night nurse did not remove the dressing from her access site. Resident 36 pulled her arm from her shirt sleeve and demonstrated the intact dressing, with tape around the dressing and upper arm. On 11/16/22 at 9:40 A.M., an interview was conducted with LN 6. Per LN 6, the evening shift nurses would be responsible for removing the dressing from Resident 36's access site. LN 6 stated the order was for the dressing to be removed four to six hours after dialysis was completed. On 11/16/22 at 9:42 A.M., a concurrent interview and observation was conducted with LN 6 and Resident 36. LN 6 assisted Resident 36 in removing her arm from her shirt, and observed the dressing still in place. Per LN 6, The dressing is still here. The physician ordered for nurses to remove the dressing within four to six hours after dialysis, but the evening shift must have missed it. This could cause her access site to clot, and then she would not be able to receive her dialysis. On 11/16/22 at 10:31 A.M., a concurrent interview and record review was conducted with LN 7. LN 7 stated she was the charge nurse. Per LN 7, there was an order for the nurse to remove the dressing in the Treatment Administration Record (TAR). LN 7 viewed the TAR for the 11/15/22 dressing removal, and stated, It is signed off by (LN 41), he documented it was off. Leaving the dressing on could cause a clot. The nurses need to follow the physician's orders. On 11/16/22 at 4 P.M., an interview was conducted with the DON. The DON stated upon return from dialysis, the LNs were supposed to remove the dressing as ordered by the physician. The DON stated, It is my expectation the nurses follow all physician's order. LN 41 should not sign off something he did not do. On 11/16/22, a record review was conducted. On 5/18/21, the physician ordered to remove the pressure dressing four to six hours after dialysis. Per the order, Refrain from keeping pressure dressing more than 6 hours to minimize risk for access clotting and/or malfunction. Per the TAR, LN 41 had signed off the removal order for the dressing on 11/15/22, indicating he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 21 of 30 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 11/21/2022 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 followed the physician's order. Level of Harm - Minimal harm or potential for actual harm LN 41 was not available for an interview. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Per a facility policy, revised March 2009 and titled Dialysis (Renal), Pre and Post Care, It is the policy of this facility to: Assess or evaluate the resident's condition and monitor for complications before and after dialysis treatments .Post Dialysis Care: 1. Upon return to the facility, conduct a post-dialysis evaluation/assessment including but not limited to the evaluation/assessment of the dialysis access site and dressing .3. Post dialysis .access care as ordered . Event ID: Facility ID: 555873 If continuation sheet Page 22 of 30 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 11/21/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff promptly answered resident call lights and met resident's needs in a timely manner for two residents interviewed on the initial tour of the facility and three of seven residents from the confidential group interview. This failure could potentially affect these residents' physical and psychosocial well-being. Findings: 1. Resident 42 had a Brief Interview for Mental Status (BIMS) score of 12 (on a scale of 0-15, with 15 being the most cognitively intact), according to the resident's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 9/28/22. This MDS assessment also indicated Resident 42 required extensive assistance with bed mobility. During an interview with Resident 42 on 11/14/22 at 3:18 P.M., the resident stated that it took 30-40 minutes for staff to answer the call light on some night shifts. Resident 42 stated the long wait time had been on the weekends, but not all the time. Resident 42 stated she had called to be repositioned in bed when she had to wait so long. Resident 86 had a BIMS of 15, according to the resident's MDS assessment dated [DATE]. This MDS assessment also indicated Resident 86 required extensive assistance with transfers and toilet use. During an interview with Resident 86 on 11/15/22 at 9:22 A.M., the resident stated that when she used her call light, it took almost an hour to answer. Resident 86 stated she needed help to get to and from the bedside commode. The resident stated she had in the past soiled her brief with urine while having to wait for assistance. Resident 86 further stated yesterday, she had to wait a long time to be helped off the bedside commode, and it became uncomfortable because the bars pushed into her skin. During an interview with certified nursing assistant (CNA) 14 on 11/17/22 at 4:40 P.M., CNA 14 stated she usually worked the night shift. CNA 14 stated that depending on the shift, sometimes the night shift was understaffed. During an interview with the administrator and director of nursing on 11/21/22 at 5 P.M., the administrator stated that leadership did rounds with residents daily and concerns regarding call lights had not come up. The administrator further stated that they did not directly ask residents about call lights. 2. A confidential resident meeting was conducted on 11/15/22. Seven residents were in attendance, and stated they attended monthly meetings regarding areas of concern. Residents stated when they used their call lights, staff would call through the intercom and tell them to turn off their call light. Residents stated the more often the call light was used, the more the staff left residents alone. Residents stated when staff responded to call lights, some would say they were not assigned to them. Residents stated call light response had not improved since it was brought up in their monthly meetings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 23 of 30 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 11/21/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Per a review of the Resident Council meeting minutes from September, October and November of 2022, Residents had documented concerns regarding call light response. No response from Administration was documented on the minutes regarding the concerns. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 24 of 30 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 11/21/2022 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 behaviors related to the use of an antipsychotic was accurately monitored for one of 5 residents (Resident 33) reviewed for unnecessary use of psychotropic medications. As a result, Resident 33's documented behavior showed an increase in behavioral episodes which could potentially result in inappropriate dosing of the antipsychotic medication. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (a mental illness that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), according to Resident 33's face sheet. An interview was conducted with CNA 1 on 11/14/22, at 12:15 p.m. CNA 1 stated Resident 33 preferred to sleep in and not eat breakfast until she wakes up. CNA 1 also stated Resident 33 would get upset if breakfast tray was taken away without Resident 33's consent. On 11/14/22 at 1:00 p.m., Resident 33 was observed instilling the nebulizer liquid medication into the nebulizer cup through an opening attached to the mask. Resident 33 stated she administered her own breathing treatment because staff did not know what they were doing. During an interview on 11/16/22, at 8:38 a.m., with CNA 4, CNA 4 stated Resident 33 liked attention. CNA 4 stated if Resident 33 was given what she needed, she did not use the call light often. CNA 4 stated Resident 33 called a lot for a breathing treatment. CNA 4 stated she sympathized with her residents. CNA 4 stated she gave Resident 33 attention and talked to her prior to care. CNA 4 stated Resident 33 was meaner with other staff, cursed and yelled at them. CNA 4 stated Resident 33 yelled if something was loud or if she could not hear her TV. CNA 4 stated she was able to calm Resident 33 when she explained things. CNA 4 stated she did not observe any changes since admission. CNA 4 stated Resident's yelling would decrease if others talked to her. During an interview on 11/16/22, at 10:37 a.m., with Resident 33, Resident 33 stated that everyone at the facility was nice, but that she had yelled at staff and her doctor. Resident 33 stated, she yelled at them when they told her she could not do something. An interview was conducted on 11/16/22, at 3:54 p.m. with LN 6. LN 6 stated Resident 33 was hard to handle. LN 6 stated Resident 33 got upset if her food tray was taken away without her consent. An interview and joint record review of Resident 33's MAR was conducted on 11/17/22, at 11:00 a.m., with LN 6. LN 6 stated Resident 33 yelled at a CNA on 11/6/22 due to a missing blanket or crayon. LN 6 stated on 11/6/22 Resident 33 stated her blanket was given to another resident. LN 6 stated per the MAR, Resident 33 was being monitored for yelling for no apparent reason related to the use of Seroquel (antipsychotic medication). LN 6 stated there were 3 episodes of Yelling for no apparent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 25 of 30 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 11/21/2022 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 reason marked on the MAR for 11/6/22. LN 6 stated Resident 33's yelling on 11/6/22 should not have been considered as Yelling for no apparent reason because Resident 33 was yelling due to her missing blanket and crayon. LN 6 acknowledged that Resident 33's behavior was not monitored accurately. On 11/21/22, at 3:48 p.m., an interview was conducted with the DON. The DON stated Resident 33 was demanding and yelled at times. The DON stated she had observed Resident 33 yelling because she wanted her breathing treatment. The DON stated the physician's order for the use of Seroquel was for Yelling for no apparent reason. The DON stated that Resident 33's behavior for Yelling for no apparent reason was inaccurately monitored because Resident 33 yelled due to her missing items. The DON stated this inaccuracy caused inaccurate information for the physician which could lead to inaccurate medication dosing. A review of the facility's undated P&P title, Psychotropic Drug Use, indicated, .2. The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 26 of 30 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 11/21/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care conference documentation was accurate for one of 20 resident (Resident 33) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 33 and had the potential to cause confusion amongst care providers. Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), according to the History & Physical, dated 2/10/22, and the Order Summary Report. An interview and joint record review was conducted with the SSD on 11/17/22 at 11:22 a.m. The SSD stated that a care conference was scheduled for Resident 33 on 11/7/22. The SSD stated the care conference was canceled by Resident 33's daughter and was scheduled for a later date. The SSD reviewed the IDT (Interdisciplinary team - a coordinated group of professionals from several different field) Care Plan Review, dated 11/7/22, which indicated that a meeting was held, and the participants included Resident 33, the resident's representative, and the physician. The SSD stated that the documentation was inaccurate and that there was no meeting held on 11/7/22. During a telephone interview on 11/17/22, at 4:05 p.m., with Resident 33's daughter, the resident's daughter stated she canceled the IDT care conference scheduled for 11/7/22. The DON was interviewed on 11/21/22, at 3:34 p.m. The DON stated the inaccurate documentation in the IDT-Care Plan Review, did not reflect the events that occurred, and it caused confusion to health care providers. A review of the facility's undated P&P titled, Nursing Clinical/Charting and Documentation was conducted. The policy indicated, The resident's clinical record is an account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. It also includes data needed for identification and communication with family/responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 27 of 30 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 11/21/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During observation and interview on 11/14/22, at 2:52 p.m., CNA 3 was observed coming out of room [ROOM NUMBER] and carried a urinal filled with urine, while both hands were gloved. CNA 3 held the urinal with his right hand and closed the door to room [ROOM NUMBER] with his left hand. CNA 3 proceeded to enter the hall restroom and came out holding the urinal with his left hand. CNA 3 turned the doorknob with his right hand to enter room [ROOM NUMBER]. Residents Affected - Few An interview was conducted with the Infection Preventionist (IP) on 11/21/22, at 3:34 p.m. The IP stated staff used the restroom across the hall for room [ROOM NUMBER]. The IP stated he trained staff not to use gloves in the hallway. The IP stated he trained staff to use a barrier on holding a urinal. During a review of the facility's undated P&P, titled, Infection Prevention-Control of Transmission of Infection, the P&P indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Standard Precautions- Apply to all contact with resident's blood, body fluids, secretions and excretions . Based on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when one of five staff interviewed was unaware of a resident's (86) transmission-based precautions status. In addition, one staff did not adhere to proper hand hygiene. This failure could expose other residents to potential infection and multi-drug resistant organisms (MDROs). Findings: 1. Resident 86 was admitted to the facility on [DATE] with diagnoses that included sepsis (a potentially life-threatening complication of an infection), resistance to multiple antibiotics, and unspecified E.coli (a bacteria) as the cause of disease classified elsewhere, per the facility's admission Record. On 11/14/22 at 3:25 P.M., a sign outside Resident 83's room indicated Enhanced Barrier Precautions. According to the Centers for Disease Control and Prevention (CDC), Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. On 11/16/22 at 9 A.M., licensed nurse (LN) 15 was observed inside Resident 86's room, standing beside and talking with the resident. LN 15 was not wearing any personal protective equipment (PPE) while in the resident's room. A sign which indicated Enhanced Barrier Precautions and a cart with PPE were just outside Resident 86's door. During an interview with LN 15 on 11/16/22 at 9:39 A.M., LN 15 stated he was unsure of Resident 86's isolation status. At 9:58 A.M., LN 15 stated the resident was on Enhanced Barrier Precautions due to an MDRO in the urine. During an interview with the infection preventionist (IP) on 11/21/22 at 3 P.M., the IP stated Resident 86 was on Enhanced Barrier Precautions due to a urinary tract infection with an MDRO. The IP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 28 of 30 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 11/21/2022 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated residents with a history of MDROs required the use of gown and gloves for certain high-contact activities to reduce the risk of transmitting MDRO to other residents. In addition, the IP stated that all nurses and direct care staff needed to know why a resident was under precautions to mitigate MDRO transmission risks. According to a review of the facility's policy titled Transmission Based Precaution and Isolation, dated 9/29/17, It is the policy of [Facility] to implement infection control measures to prevent the spread of communicable diseases and conditions . Prevention and Control of MDRO Transmission: .G. Staff Education: is essential in reducing the transmission of MDROs. Healthcare workers should be informed concerning epidemiology of specific MDROs and the role they, the Healthcare worker, play in reducing the potential for transmission of these as well as other microorganisms. The facility will implement a system to alert staff, residents and visitors that a resident is on transmission based precautions . Event ID: Facility ID: 555873 If continuation sheet Page 29 of 30 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 11/21/2022 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 0949 Level of Harm - Minimal harm or potential for actual harm Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to ensure all staff were trained regarding behavioral health. Only 17 licensed nurses were in-serviced according to the in-service sign-in sheet. Residents Affected - Some As a result, there was a potential for staff to not have the knowledge to care for residents with behavioral health issues. Findings: An interview was conducted on 11/16/22, 9:52 a.m., with CNA 5. CNA 5 stated she was currently caring for a resident with diagnosis of post- traumatic stress disorder (PTSD - a mental condition that is triggered by a terrifying event). CNA 5 stated she did not receive training regarding how to care for residents who have PTSD. An interview was conducted on 11/21/22 at 9:50 a.m. with the Director of Staff Development (DSD). The DSD stated she was unsure if trauma training had been provided to staff. The DSD stated all staff including housekeeping, and maintenance should receive training on behavioral health to avoid triggering a resident's trauma. A record review of the facility's In-service Attendance Record, titled, Trauma & Informed Care/ Behavioral Monitoring Mgt, dated 2/20/22, was conducted. The record indicated that the in-service was provided to 17 licensed nurses and no other disciplines attended the in-service. On 11/21/22 at 3:48 p.m., the DON was interviewed. The DON stated all staff should be trained regarding trauma and PTSD. The DON stated it was important to know how to care for residents with a diagnosis of PTSD. During an interview on 11/21/22, 4:57 p.m. with the DON, the DON stated the facility did not have P&P specific for trauma and/or PTSD training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555873 If continuation sheet Page 30 of 30