Sharp Chula Vista Med Ctr SNF

Inspectors wroteBased on interview and record review, the facility failed to document that residents were informed of their right to formulate advance directives and failed to document provision of advance-directive information in the medical record for 9 of 18 sampled residents reviewed. (Residents #17, 95, 11, 38, 6, 52, 60, and 42). Failure to ensure documentation of advance-directive education has the potential to affect residents' ability to exercise their right to make informed healthcare decisions. FindingsOn 2/24/26 at 8:43 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 11. LN11 reviewed the medical record for Resident #17 and stated there was no documentation regarding advance directive discussion or that advance directive information had been provided to the resident or resident's representative in the medical record and there should have been. [...]

Inspectors wroteBased on interview and record review, the facility's QAA/QAPI (Quality Assessment and Assurance/ Quality Assessment Program Improvement) committee failed to identify, develop, and implement action plans related to advance directives (cross reference F 578). This failure had the potential for residents not to be informed of their right to formulate advance directives and make informed decision regarding their medical care and treatment preferences. FINDINGSOn 2/26/26 at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the admissions staff missed the opportunity to document advance directives information was provided to all residents. The DON stated his expectation was that the documentation should have been completed. The DON stated the facility's QAPI committee looked into facility issues that affected a high number of residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 52) was free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medication when Resident 52 was prescribed a psychotropic medication as needed for more than 14 days. This failure had the potential for Resident 52 to receive an unnecessary psychotropic medication which can lead to side effects, such as sedation, falls, and headaches.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the Long-Term Care Ombudsman for three of four sampled residents. (Resident #7, 89 and 91). This failure had the potential for the Ombudsmen to not be aware of the residents' transfers. FindingsOn 2/25/26 at 8:29 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 3. LN3 reviewed the medical record for Resident #7 and stated that Resident #7 was admitted to the facility on [DATE] with a past history of DVT (deep vein thrombosis- a blood clot (thrombus) in one or more of the deep veins in the body, usually in the legs). LN3 stated on 12/10/25, Resident #7 was assessed to have dark discoloration to right foot with severe pain and was transferred to the hospital. LN3 stated a written notification to the Ombudsmen was not documented. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a plan of care plan was developed for anticoagulant medications (medication to prevent blood clots) for 2 of 5 sampled residents. This failure had the potential to result in inadequate monitoring for complications of anticoagulant medications for residents (60, 95).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medication therapy in accordance with professional standards of practice for one of six sampled residents (Resident 1) when Licensed Nurse (LN) 14 did not flush (push water through) Resident 1's feeding tube (a device used to administer food and medications to individuals with difficulty swallowing) in between medication administration. This failure had the potential for Resident 1 not to get the full therapeutic benefit of his medications or to experience complications from his medications clogging in the feeding tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:A bag containing three inhaler (a device used to deliver medications to the lungs) mouthpieces for Resident 85 was found in one of two sampled active Medication Carts with the top part of the label missing. This failure had the potential for residents to receive the wrong inhaler or wrong dose, which could result in adverse resident outcomes and medication errors. An expired inhaler mouthpiece for Resident 85 was found in one of two sampled Medication Carts, andAn expired tube of white petrolatum was found in one of two sampled Treatment Carts. These failures had the potential to negatively alter the drugs' stability, physical properties (such as consistency) and effectiveness, which could result in adverse resident outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 11.43% when four medication errors occurred out of 35 opportunities during the medication administration for three of six randomly observed residents (Residents 92, 94 and 1). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control practices when Licensed Nurse (LN) 14 did not perform hand hygiene after touching a potentially contaminated surface during medication administration through a feeding tube (a surgically placed tube used to administer food and medications in individuals who have trouble swallowing) for Resident 1. This failure had the potential to put residents, staff and visitors at risk for infections due to cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activity preference per confidential group request timely. As a result, residents' needs and choices were not met and accommodated. The facility census was 82.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to indicate the appropriate target behavior and monitor side effects for four of thirty residents (274, 35, 58, and 51) when: 1. Resident 274 was not being monitored for appropriate behaviors and side effects for two anti-depressants (medication used for feeling of sadness) and one anti-anxiety (medication used for worry and fear) medications. 2. Residents 35 and 58 did not have monitoring for behavior and side effects for anti-depressant medications. 3. Resident 51 did not have appropriate indications for the use of anti-depressant medications. These failures had the potential for unnecessary psychotropic (mind-altering medications) medication use and side effects to decrease therapeutic effects and a decline for residents psychological and mental well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food can items were dented. 2. Food items were expired. 3. Opened food items were not properly labeled and dated. 4. Grains and dust on the lids, loose and cracked lids of the clear plastic bins with food in it. 5. Food items with molds in it, and wilted produce. 6. Dirty rugs on the floor in the dry storage room, trash found in the dry food storage room and in the freezer room. 7. Ready to eat food item on top of the raw meat, and metal bin with ready to cook condensed soup on top of the food rack. 8. Food utensils such as ladles, slotted spoons and [NAME] kitchen utensil stored as clean with crusted food debris. 9. Boxes on top of the food rack past the red line/mark. 10. [...]

Inspectors wroteBased on observations, interviews, and document review, the facility failed to give one of three reviewed residents (Resident 282) the Advanced Beneficiary Notice (ABN/CMS 10055: a form which gave the choice to continue services under private pay if Medicare did not provide payment) for discontinued skilled (rehabilitation and nursing) services who remained in the facility for custodial (non-medical assistance with daily tasks, such as bathing, dressing, eating, and toileting) services. As a result, Resident 282 did not have the choice to appeal the decision or have knowledge of the costs to continue custodial care in the facility.

Inspectors wroteBased on interview and clinical record review, the facility failed to ensure a significant change of status assessment (SCSA) was completed within 14 days after a significant change in the resident's physical or mental condition had been determined for one of 18 sampled residents (Resident 42). This had the potential to delay necessary health services and updated plan of care based on the Resident 42's current health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plans for three of seven sampled residents (1, 45 and 51) related to Restorative Nursing Assistant (RNA) range of motion (ROM- a measure of joint functionality and flexibility) exercises. This failure had the potential for residents to not meet their functional abilities. Cross Reference to F 688.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide Restorative Nursing Assistant (RNA) for range of motion (ROM- a measure of joint functionality and flexibility) exercises per physician's order for three of seven residents (1, 45, and 51), reviewed for limited ROM. This had the potential to worsen Resident 1's contractures (condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) and promote the development of contractures to Resident 45 and Resident 51. Cross Reference to F 656.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and label house supply/stock medications with open dates. As a result, the facility could not ensure medications were safely stored to ensure their integrity.

Inspectors wroteBased on observations, interviews, and facility document review, the facility did not identify and address concerns that was in the residents council minutes meeting regarding transportation for the outdoor activities in quality assurance and performance improvement (QAPI). This failure had the potential to effect all residents quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to implement infection prevention and control practices with two of 18 sampled residents (Resident 52 and Resident 1) according to standards of practice and provide evidence of a tracking log of infections when: 1. A CNA did not wear appropriate personal protective equipment (PPE-use of gown, gloves, mask to prevent spread of infection) prior to entering a contact precautions (intended to prevent transmission of infectious agents) room. Cross Reference F881 2. A LN did not wear a gown for Resident 1 with enhanced barrier precautions (EBP -involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]). This failure had the potential to spread infection or outbreaks amongst all residents, staff, and visitors entering the facility.

Inspectors wroteBased on interview and record reviews, the facility failed to follow its own policy and procedure to establish an antibiotic stewardship program when the Infection Preventionist (IP) did not track and monitor appropriate use of antibiotics. This failure had the potential for lack of oversight and direction for staff. Cross reference F880 Findings. A concurrent interview and record review on 10/10/24 at 9:01 A.M., with IP was conducted. The IP stated the pharmacy helped with the antibiotics logging and tracking. The IP stated she did the urinary tract infection (UTI) tracking and the pharmacy helped with data collection and did the other infection tracking. The IP stated it was important to tracked antibiotic to make sure they are used appropriately and monitor patterns of infections and thus preventing outbreaks. An interview with the MDSC 1 on 10/10/24 at 9:12 A.M., was conducted. [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of abuse for one of three sampled residents (1). As a result, Resident 1 had an increased risk of abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a care plan was developed to ensure one of three sampled resident's safety (Resident 1). As a result, restricted persons were able to visit the resident in the facility.

Inspectors wroteBased on observations, interviews, and medical record reviews the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) in accordance with the physician's order for one of six residents (Resident 51) reviewed for pressure ulcer. As a result, Resident 51 developed a new pressure injury on the sacral area (area below the lower back).

Inspectors wroteBased on observations, interviews and document review, the facility failed to provide an environment that promoted dignity for 3 of 5 residents during mealtime when, all three residents were not served their meal trays the same time as the other residents, in the multi-purpose room. This failure had the potential to affect the residents' dining experience and quality of life.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accurately code the Minimum Data Set (MDS, a nursing assessment tool) for four of 21 residents (Resident 51, Resident 32, Resident 29 and Resident 12). This deficient practice had the potential to affect the residents by delaying resident care needs and provided inaccurate information to the Federal database.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Restorative Nursing services to 45 of 45 residents with orders for restorative nursing assistant (RNA) treatments, which included two residents (Resident 29 and Resident 44) reviewed for limited range motion (ROM, amount of joint's ability to move in any direction to its limits) when: 1. Resident 29 did not receive RNA services at the frequency ordered by the physician. 2. Resident 44 did not receive RNA services at the frequency ordered by the physician. This deficient practice could place all 45 residents with orders for RNA treatment at increased risk of further decline in range of motion ROM to resident's extremities (hands, arms, legs, and feet).

Inspectors wroteBased on interview and document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents. There were a total of 45 residents in the facility receiving restorative treatment from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. Three walk-in refrigerators (Ref 1, 2 & 3) had TCS (time/temperature control for food safety foods - meats, produce, etc.) foods that were stored opened, unlabeled, and available for preparation beyond the use by date. 2. Multiple food items in the dry storage room were uncovered, mislabeled, and available for meal preparation beyond the use by date. 3. Holding temperatures for TCS foods were not recorded in the temperature log book. 4. Kitchen staff was observed working in the kitchen without a beard net. 5. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure that sufficient restorative nursing assistants (RNAs) were available to provide restorative treatments to the residents, as indicated in the facility's Facility Assessment Report. There were a total of 45 residents in the facility with orders to receive restorative treatments from the RNAs. This failure had the potential for residents on the RNA program to experience decline in their range of motions and affect their quality of life. (cross reference to F-tag 688 and F-tag 725)

Inspectors wroteBased on interview and record review, the facility failed to provide assistance for the hygiene for one (Resident 365) of five residents. This failure resulted in the resident not being provided a shower or bed bath for four days. This includes two regularly scheduled shower days and a day the resident had an offsite appointment (on day four). This failure caused Resident 365 to feel unclean and embarrassed at the offsite appointment.

Inspectors wroteBased on observation, interview, and record review for one of six sampled residents (Resident 29), the facility failed to document an appropriate indication for the use of Seroquel (a medication used for mental/mood conditions that help regulate mood, thoughts, and behaviors). This failure placed Resident 29 at unnecessary risk for adverse consequences related to the use of Seroquel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered correctly for 2 of 25 medication administration attempts, which resulted in an 8% medication error rate. This failure had the potential to cause harm to the residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure standardized recipes were used for preparing meals for skilled nursing home residents on regular and therapeutic diets. This deficient practice had the potential to compromise the nutritional content of foods prepared for all skilled nursing facility residents.

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) failed to formally identify, investigate and act on staffing deficiencies in regard to the Restorative Nursing Assistant (RNA) program. (Cross reference F-tag 688 and F-tag 725) This failure placed residents who were ordered to receive RNA treatment at risk for a decline in mobility.