Health inspection·January 27, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 ensure discharge Minimum Data Set Assessments (MDS, an assessment tool) for two residents (Resident 18 and 5) were completed and/or transmitted to the Centers for Medicare and Medicaid Services (CMS) within acceptable timeframes. Residents Affected - Few This failure resulted in noncompliance with regulatory requirements. Findings: A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE]. A review of Resident 18's Face Sheet indicated the resident was admitted to the facility on [DATE]. On 1/27/23 at 8:26 A.M., a joint interview and record review was conducted with the MDS coordinator (MDSC). The MDSC reviewed Resident 18's discharge MDS assessment dated [DATE] and signed by the registered nurse on 10/7/22. The MDSC stated Resident 18's discharge MDS assessment had been completed but had not been transmitted/sent to CMS. The MDSC stated it should have been transmitted within 14 days of completion. The MDSC also reviewed Resident 5's discharge MDS assessment dated [DATE]. The MDSC stated the discharge MDS was incomplete. The MDSC stated it should have been completed within 14 days of the resident's discharge on [DATE] and then transmitted within 14 days of completion. The MDSC stated Resident 5's discharge MDS assessment had to be completed before it could be transmitted. The MDSC stated the resident's discharge MDS assessment had not been completed or submitted to CMS timely. On 1/27/23 at 9:17 A.M., an interview was conducted with the director of nursing (DON). The quality assurance nurse was also present. The DON stated it was her expectation that the guidance in the CMS Resident Instrument Assessment (RAI) manual be followed when completing and submitting resident MDS assessments. The DON stated resident MDS assessments should have been submitted within the required timeframes. A review of the facility provided document titled CMS's RAI Version 3.0 Manual, dated October 2019, indicated, .09. Discharge Assessment-Return Not Anticipated . Must be completed . within 14 days after the Page 1 of 10 056496 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to ensure that one licensed nurse (LN): 1. Checked residual (liquid feeding that is not absorbed) of tube feed (liquid feeding given through a tube directly to resident's stomach) prior to administering medication, 2. Flushed feeding tube (tube used for liquid feeding) according to facility policy, 3. Milked the line to unclog feeding tube according to facility policy for one resident (17). This failure to follow the facility's feeding tube policy and procedure, made it more likely for Resident 17 to experience : 1. Less medication absorbed via feeding tube, 2. Unwanted mixing of medications in feeding tube, and 3. A clogged feeding tube. Findings: 1. On 1/26/23 at 8:55 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. During administration of medications to Resident 17, LN1 was observed inserting tube feeding syringe to check placement of feeding tube. LN1 did not pull back on the syringe to check if there was residual tube feeding as per facility policy and procedure. On 1/27/23 at 9:30 A.M., an interview with LN1 was conducted. LN1 stated that she was not familiar with the Enteral Feeding Policy and Procedure which guided checking for residual tube feeding. On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with director of nursing (DON). The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .9. Check gastric content for residual feeding. Return residual volumes to stomach. Report any residual above 100 ml [milliters] . DON stated that LN1 should have checked residual as per facility policy. DON stated the importance of checking tube feed residual was to make sure patient absorbed and digested the formula. Furthermore DON stated, if resident did not absorb formula, he might aspirate. 2. On 1/26/23 at 8:57 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. LN1 was observed attempting to administer medication dissolved in water by gravity, but was unable to get medication through tubing. LN1 then stated, .I will give it a gentle flush . then flushed the feeding tube with water in her syringe. LN1 stated she flushed with 10 ml. On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with the DON. The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .11. Enteral tubes(feeding tubes) are flushed with 15 ml of water before administering any medications and after all medications have been administered . DON stated that LN1 should have flushed feeding tube with 15 ml as per facility policy. DON stated the importance of flushing the feeding tube with 15 ml of water was to make sure medications were not mixed, medications were absorbed, and to prevent clogging the length of feeding tube. DON stated without flushing with appropriate amount of water, Resident 17 might not get the full administration of medication. 3. On 1/26/23 at 8:59 A.M., a concurrent observation of medication administration and interview with LN1 was conducted. LN1 was observed flushing the feeding tube without milking the tube per facility policy. LN1 pinched the feeding tube in one spot, then attempted to flush with water, but was 056496 Page 2 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0693 unsuccessful in removing the blockage. Level of Harm - Minimal harm or potential for actual harm On 1/27/23 at 10:25 A.M., a concurrent interview and record review was conducted with the DON. The facility feeding tube policy and procedure entitled Medical Administration, Enteral Tubes dated January 2020 was reviewed. Policy indicated, .GUIDELINES .Managing Complications .3. Clogged tube-clogging can occur from internal blockage. A. If the clog is still present, gently milk the tube from top to bottom to release any clog that may be in this part of the tube . DON stated that LN1 should have milked the feeding tube as per policy. DON stated the importance of milking the line was that the method used less pressure than flushing, and it was gentler on the patient than trying to flush out a clog. DON stated that excess flushing can also give patient more fluid than necessary. Residents Affected - Few 056496 Page 3 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to : 1. Reconcile 2 of 3 sampled residents' (27 & 132) Controlled Drug Record (CDR) with Medical Administration Record (MAR), and PRN Pain Assessment Sheet (PPAS), 2. Administer controlled medication per physician order for 2 of 3 sampled residents' (27 & 132), 3. Administer Advair as per physician order for one sampled resident (13). This failure had the potential for the possibility of drug diversion and inadequate pain control. In addition Resident 13 missed multiple doses of an essential breathing medication. Findings: Resident 27 was admitted on [DATE] with diagnoses which include: Fracture of unspecified part and repeated falls per Face Sheet. Resident 132 was admitted on [DATE] with diagnoses which include: Spinal Stenosis, Fusion of Spine, Post Laminectomy Syndrome per Face Sheet. 1. On 1/26/23 at 2:05 P.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with LN1 for Resident 132. LN1 stated that there were missing entries on PPAS and MAR that were on the CDR for following dates and times on 1/21/23 at 3:10 A.M. and 1/22/23 at 3:30 A.M. LN1 stated the nurse should have documented pain medications on CDR, PPAS, and MAR when they are administered to patient, because if not documented, it is possible the patient did not receive controlled medication. On 1/26/23 at 2:10 P.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with LN1 for Resident 27. LN1 stated that there were missing entries on PPAS and MAR that were on the CDR for following dates and times on 1/21/23 at 9 P.M. and 1/22/23 at 9 P.M. LN1 stated the nurse should have documented pain medications on CDR, PPAS, and MAR when they are administered to patient, because if not documented, it is possible the patient did not receive pain medication. On 1/27/23 at 10:25 A.M., a concurrent interview and record review of CDR, MAR, and PPAS was conducted with DON for Residents 132 and 27. DON stated pain medications should be documented on CDR, PPAS, and MAR when they are administered to resident. DON stated if not documented, the controlled medication could not be reconciled, and there was a potential for medication diversion. Record review of facility policy and procedure entitled Medical Administration, General Guidelines dated January 2021 indicated, . Documentation: 1. The individual who administers the medication dose, records the administration on resident's MAR immediately following the medication being given. In no case should individual who administered the medications report off-duty without first recording the administration of any meds .5. When PRN meds are administered, the following documentation is provided: a. Date and time of administration, dose, route, b. Complaints or symptoms for which medication was given, c. Results achieved from giving the dose and time noted, d. Signature or initials of person recording administration and signature or initials of person recording effects. 2. On 1/26/23 at 2:05 P.M., a concurrent interview and record review of Resident 27's CDR, MAR, and PPAS was conducted with LN1. LN1 stated that according to the PPAS on 1/22/23 at 11 A.M. Resident 056496 Page 4 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0755 Level of Harm - Minimal harm or potential for actual harm 27 received Oxycodone 5 milligrams (mg) for pain 7/10 (self rated pain scale 0 is no pain, 10 highest level of pain). Review of order on CDR indicated, Give 1 Tablet (5 mg) .for mild pain .2 tablets(10 mg) for severe pain . LN1 stated she would consider 7/10 pain severe pain, so she would have given Resident 27, 10 mg of Oxycodone. LN1 stated the importance of giving pain medication as ordered, is to help treat the resident's level of pain accordingly. Residents Affected - Few On 1/26/23 at 2:10 P.M., a concurrent interview and record review of Resident 132's CDR, MAR, and PPAS was conducted with LN1. LN1 stated order read Oxycodone IR [Immediate Release] 5 mg tablet, give 2 tablets by mouth every 3 hours as needed for moderate pain & 3 tablets for severe pain . On the following dates and times: 1/21/23(No time written), 1/25/23 (6 P.M.), 1/25/23(10 P.M.) Resident 132 had pain recorded 7/10 on PPAS. Resident 132 received Oxycodone IR 10 mg by mouth each time. LN1 stated that since pain was 7/10, that would be considered severe and Resident 132 should have received 15 mg Oxycodone IR as ordered. LN1 stated the importance of giving pain medication as ordered is to help treat the resident's level of pain accordingly. On 1/27/23 at 10:27 A.M., a concurrent interview and record review of Resident 27's and 132's CDR, MAR, and PPAS was conducted with DON. DON stated that the LN's had not followed the physician's orders for administering correct dosage of pain medication in relation to residents' pain level for both residents. DON stated Resident not receiving correct amount of medicine for residents' level of pain might affect the residents' self-care activities, healing, and put them in unneeded distress. Record review of facility police entitled Medication Administration, General Guidelines date January 2021, indicated .Medication Administration: 1. Medications are administered in accordance with written orders of the the prescriber . 3. Resident 13 was admitted on [DATE] with diagnoses which include Chronic Obstructive Pulmonary Disease ( a lung disease) per Face Sheet. On 1/26/23 at 2:21 P.M., a concurrent observation, interview and record review was conducted with LN1. The medication cart was inspected with LN1. Resident 13's Advair inhaler (a breathing medication) had 28 of 60 doses used and was labeled, OPENED ON 12/17/22. LN1 stated that based on the unit doses in the inhaler, less than half the doses were given. LN1 stated she had been Resident 13's nurse for past 3 days and resident had not refused the medication on the day shift. Resident 13's Physician Orders read Advair HFA 50/250 mg 1 puff twice a day [9 A.M. & 5 P.M.]. On 1/26/23 at 2:25 P.M., an interview was conducted with Resident 13 inside the resident's room. Resident 13 stated she received her Advair treatment once a day in the morning. On 1/27/23 at 10:25 A.M., an interview was conducted with the DON. DON stated that the Advair inhaler should have less doses remaining if the patient was receiving all ordered doses. DON stated that the LN's need to follow physician's order and administer the medication twice a day. Record review of facility policy entitled Medication Administration, General Guidelines date January 2021, indicated, .Medication Administration: 1. Medications are administered in accordance with written orders of the the prescriber . 056496 Page 5 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were met in the kitchen when: Residents Affected - Some 1) Stored food was not consistently labeled and dated. 2) Stored food was not removed from storage when it was expired or reached its use by date. 3) Food preparation and cooking areas had food debris and trash on the shelving, inside the reach-in refrigerators, and on the floors. The cooking area's backsplash and stove hood was covered in a thin, brown, oily substance. 4) Clean water pitchers for resident use were stored wet. Baking sheets were stored directly on the floor. 5) Dented cans were stored in circulation among non-dented cans. 6) Kitchen cleaning schedules and logs were not maintained. These failures had the potential to place residents who consumed food from the kitchen, at risk for foodborne illness. Findings: On 1/24/23 at 8:35 A.M., a joint observation of the facility's kitchen and interview was conducted with the certified dietary manager (CDM). The head chef (HC) was also present. In the food preparation and cooking area, an unlabeled and undated opened bag of dry mashed potatoes was wrapped in clear plastic and was placed on a cooking shelf. The CDM stated the mashed potatoes should have been labeled and dated as to when it was opened and for how long it could be used. The shelves in the food preparation and cooking area had dried on liquid smears, crumbs and other food debris, empty plastic wrappers, and three empty soft drink cans. The flooring in the food preparation and cooking area was coated with a thin layer that felt tacky and slick underfoot. There was dried food debris, including objects resembling french fries, on the flooring. Two baking sheets were stored directly on the floor next to the stove. The CDM stated baking sheets should not have been kept on the floor. The backsplash behind the stove and wall which extended upward and onto the hood, was covered with a thin brown, oily layer. Dark brown, solid drippings hung from the hood and the tubing connecting to the hood. The CDM stated it looked like grease was on the backsplash and stove hood and that those areas needed to be cleaned. The line refrigerator had food debris and crumbs on the shelving. The walk-in refrigerator had an opened bag of spinach and a white bag which contained English muffins that were unlabeled and undated. The CDM stated the spinach should have been labeled with an opened date and use by date. The CDM stated the English muffins should have been labeled and dated. A tray of lunch prep (sliced vegetables for a salad bar) had a use by date of 1/18/23. The CDM stated the lunch prep should have been removed from the walk-in refrigerator and thrown away on 1/18/23. There was a box of coffee cakes with an expiration date marked 1/23/23. A container of sliced strawberries had a use by date of 1/19/23. A container of beef base was unlabeled and undated. A box of approximately 12 whole potatoes coated with an oily substance had a use by date of 1/20/23. Five 056496 Page 6 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some containers of cream had an expiration date of 1/23/23. The CDM stated all food items past their use by date and/or expiration date should have been removed from the walk-in refrigerator. In the dry storage area, there were approximately 36 stacked resident water pitchers that were visibly wet. The CDM stated the clean pitchers should have been fully air dried before being stacked and put into storage. A large can of sauerkraut had an approximate one inch dent along the top seam of the can. A large can of bean salad had an approximate three inch dent in the middle of the can. Both cans were in circulation among other non-dented cans. The CDM stated dented cans should have been removed from circulation and placed in the designated return area. On 1/26/23 at 8:33 A.M., an interview was conducted with the facility's registered dietitian (RD). The RD stated there should not have been a greasy layer on the kitchen floors, backsplash, or on the stove hood. The RD stated there should not have been dried food debris on the flooring and shelving in the food preparation and cooking areas. The RD stated food debris that was not promptly cleaned up could potentially attract pests to the kitchen. The RD stated it was her expectation for the food preparation, cooking areas, and the kitchen as a whole, to be wiped down after food was prepared and for the area to be cleaned daily in the evening when the kitchen closed. The RD stated the kitchen should not appear visibly soiled. The RD stated opened food should be labeled and dated. The RD stated the labels and dates should have been followed and expired food should have been removed from the food storage areas. The RD stated this was to have been done in order to ensure food safety, protect against foodborne illness, and to avoid contamination of the other stored food. The RD stated baking sheets should not have been kept on the floor. The RD stated water pitchers should have been fully air dried before being placed in storage. The RD stated all dented cans should have been pulled from circulation. On 1/26/23 at 2:45 P.M., a joint interview and record review was conducted with the CDM. The CDM reviewed the kitchen cleaning logs that included a check for food labeling and dating. The cleaning logs were blank. The CDM stated the cleaning logs had not been completed for some time. The CDM stated there was no staff assigned as being responsible for the various cleaning sections on the cleaning logs. The CDM stated it was his and the HC's responsibility to ensure dietary staff were cleaning the kitchen daily and signing the cleaning logs. The CDM acknowledged it could not be verified when the kitchen was last cleaned since the cleaning logs were blank. On 1/26/23 at 3:50 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that the facility's kitchen sanitation was maintained and cleaning was being done regularly to prevent residents from experiencing foodborne illness. According to the U.S. Department of Agriculture Food Safety and Inspection Service's article titled, Shelf-Stable Food Safety, dated 3/24/15, .Discard deeply dented cans. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam A review of the facility's policy titled Dining Services Sanitation, dated 1/1/20, indicated, . (a) All kitchens and kitchen areas shall be kept clean, free from litter and rubbish A review of the facility's policy titled Dining Services Daily Cleaning Schedule, dated 1/1/20, indicated, . Any food, which has spilled in the refrigerator, shall be wiped up at once . Floors shall be mopped after each meal .Clean and straighten all shelves, drawers and cupboards in the kitchen 056496 Page 7 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some area where food or other supplies are stored. Thoroughly wipe out interior and exterior surfaces to remove any grease and food particles . 4. Wipe out and clean the inside or the oven hoods and outside surfaces A review of the facility provided document titled Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, dated 5/30/19, did not provide guidance related to the facility's process for labeling and dating food items. 056496 Page 8 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) who received hospice services, had a person-centered written plan of care for the coordination of care between the facility and the hospice provider. In addition, Resident 1 did not have a physician's order to receive hospice service/care. This failure had the potential to affect the coordination and continuity of care for Resident 1. Findings: A review of Resident 1's Face Sheet indicated the resident was admitted on [DATE] with diagnoses to include heart failure. On 1/26/23 at 1:43 P.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated Resident 1 had been receiving hospice services for a while now. On 1/26/23 at 1:54 P.M., a joint interview and record review was conducted with the infection prevention nurse (IPN). The IPN reviewed Resident 1 clinical record and stated the resident did not have an order from his attending physician to receive hospice care and services. The IPN stated all residents admitted to hospice care were expected to have a physician's order to receive that type of care. The IPN further stated Resident 1 did not have a written plan of care for hospice. The IPN stated Resident 1 should have had a written plan of care for hospice so that everyone providing care to the resident would know what care was being provided by the facility and the hospice agency. The IPN stated this was to make sure Resident 1's care needs were coordinated between the facility and hospice provider. On 1/26/23 at 3:50 P.M., an interview was conducted with the director of nursing (DON). The DON stated there should always be an order from the attending physician to admit a resident into hospice care. The DON stated residents receiving hospice care/services should have a written plan of care to coordinate care between the hospice provider and the facility. On 1/27/23 at 9:17 A.M., an interview was conducted with the DON. The quality assurance nurse was also present. The DON stated the facility did not have a policy for hospice, and that it was her expectation for residents receiving hospice care to have a physician's order and a written plan of care for hospice. 056496 Page 9 of 10 056496 01/27/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that one licensed nurse (LN) disinfected a glucometer (machine that measures blood sugar) according to facility policy. Residents Affected - Few This failure had the potential to spread blood borne (from blood) infections among residents being tested with the glucometer. Findings: On 1/26/23 at 11:27 A.M., a concurrent observation, interview, and record review was conducted with LN2. LN2 was observed disinfecting a glucometer after taking a blood sugar reading. LN2 cleaned the glucometer with a disinfectant wipe and put wet glucometer in cup to dry. Within 10 seconds the glucometer was visibly dry. LN2 stated that she was not sure how long the glucometer needed to remain wet with the disinfectant or what wet time meant. LN2 stated the directions of disinfectant wipes indicated .For Use as One-Step Cleaner/Disinfectant Product .All surfaces must remain wet for 1 minute . On 1/27/23 at 9:35 A.M., an interview with infection prevention nurse (IPN) was conducted. IPN stated LN2 did not disinfect the glucometer correctly per the disinfectant wipes directions. IPN stated the glucometer had to stay wet with the disinfectant solution for one minute. IPN stated the importance of disinfecting the glucometer according to policy is to prevent the spread of blood borne infection between residents. On 1/27/23 at 10:30 A.M., a concurrent interview and record review was conducted with director of nursing (DON). Facility policy and procedure entitled DISINFECTION OF RESIDENT CARE ITEMS dated July 2021 indicated, .PROCEDURE .2. Glucometers will be cleaned with wipes designed to destroy both bacteria and viruses after each resident use according to manufactures guideline. DON stated that LN2 should have disinfected the glucometer according to facility policy and disinfectant wipes directions for use. DON stated the importance of disinfecting the glucometer according to policy is to prevent infections from spreading between residents. 056496 Page 10 of 10