Sharp Chula Vista Med CTR SNF

In the surveyor’s words

From the most serious findings on record at Sharp Chula Vista Med CTR SNF, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 9, 2023

  Based on observations, interviews, and medical record reviews the facility failed to provide interventions to prevent the development of pressure injuries (skin damaged by lack of movement for staying in a position for too long) in accordance with the physician's order for one of six residents (Resident 51) reviewed for pressure ulcer. As a result, Resident 51 developed a new pressure injury on the sacral area (area below the lower back). Findings: Resident 51 was readmitted to the facility on [DATE], per admission record, with diagnosis which included Coronary Artery disease (A major blood vessel [coronary arteries]) that supply the heart with blood, oxygen and nutrients to the heart muscle due poor circulation [the flow of blood]) and history of pressure ulcers to sacrum (area below the… […]

• No harm, potential for more than minimal, patternF578Feb 26, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF865Feb 26, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF558Oct 10, 2024

  Based 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. Findings: On 10/8/24 at 10 A.M., a confidential group meeting was conducted. Six out of six residents in attendance indicated complaints regarding the facility outings. According to the confidential group, the facility had bus outings before but it was temporarily discontinued during the COVID (a highly infectious respiratory disease caused by a virus) pandemic (global infection outbreak). The facility bus and bus driver were no longer available. The bus outings before would include residents and staff member, volunteers or family members. […]

• No harm, potential for more than minimal, patternF758Oct 10, 2024

  Based on observations, interviews, and record review, the facility failed to indicate the appropriate target behavior and monitor side effects for four of thirty residents (274, 35, 58, and 51) when: 1. Resident 274 was not being monitored for appropriate behaviors and side effects for two anti-depressants (medication used for feeling of sadness) and one anti-anxiety (medication used for worry and fear) medications. 2. Residents 35 and 58 did not have monitoring for behavior and side effects for anti-depressant medications. 3. Resident 51 did not have appropriate indications for the use of anti-depressant medications. […]