Health inspection·December 14, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a policy for advanced directives (a written document that tells health care providers medical decisions to make when unable to speak for yourself) for four of 27 residents reviewed for advanced directives. (Residents 21, 133, 2 and 134) This failure resulted on staff's confusion regarding verifying residents' directives regarding care. Findings: Resident 21 was re-admitted to the facility on [DATE] with the diagnoses including paroxysmal atrial fibrillation (a type of irregular heartbeat) according to Resident 21's Face Sheet. Resident 133 was admitted to the facility on [DATE] with the diagnoses including unstable burst fracture (an injury to the spine) according to Resident 133's Face Sheet. Resident 2 was admitted to the facility on [DATE] with the diagnoses including atherosclerosis of coronary artery (thickening of heart's blood vessels caused by a sticky substance) according to Resident 2's Face Sheet. Resident 4 was admitted to the facility on [DATE] with the diagnoses including aftercare following joint replacement according to Resident 4's Face Sheet. An interview and joint record review was conducted with the Nursing Supervisor (NS) on [DATE], at 2:29 P.M. During a review of Residents 21, 133, and 2's records, the records included an Acknowledgement of Advanced Directive form. The completed Acknowledgement forms indicated Resident 21, 133 and 2 had advanced directives, but were unable to provide a copy. The NS stated Resident 21, 133 and 2's physician's orders also did not specify a code status (the type of resuscitation procedure when the heart stops beating and/or when a person stops breathing). The NS stated Resident 21, 133 and 2's code status should have been transcribed in the physician's orders according to the hospital records. The NS further stated it was important to know resident's code status to care for the resident during an emergency. During a review of Resident 134's records, the Acknowledgement of Advanced Directive form indicated Resident 134 did not have an advanced directive. An interview was conducted with Licensed Nurse (LN) 2 on [DATE], at 1:35 P.M. LN 2 stated a Page 1 of 3 056496 056496 12/14/2023 Carlsbad by the Sea 2855 Carlsbad Blvd Carlsbad, CA 92008

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's Physician's Order for Life Sustaining Treatment (POLST) will be checked if a resident's heart stopped. LN 2 further stated if a resident did not have a POLST or advanced directive, the physician or immediate family member will be called prior to performing Cardiopulmonary Resuscitation (CPR). During an interview on [DATE], at 1:40 P.M. with LN 1, LN 1 stated if a resident did not have a POLST or advanced directive, the resident was considered full code (full support, CPR). During an interview on [DATE], at 3:50 P.M. with LN 3, LN 3 stated residents were considered full code unless they had a Do Not Resuscitate (DNR) sticker outside of the resident's chart. An interview was conducted with the ADON on [DATE], at 11:45 A.M. The ADON stated it was important for staff to know resident's code status to provide immediate attention to the resident when needed. The ADON further stated the facility did not have a policy and procedure regarding advanced directives. 056496 Page 2 of 3 056496 12/14/2023 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. Based on observation, interview, and record review, the facility failed to reconcile discontinued controlled medications (medications that are regulated by the government due to the likelihood for being misused and high risk for abuse) received from licensed nurses. This failure had the potential for drug diversion (the illegal distribution or abuse of prescription drugs). Findings: An observation of the controlled medication storage was conducted on 12/14/23, at 9:40 A.M. with the Assistant Director of Nursing (ADON). According to the ADON, the Nursing Supervisor (NS) had the key to the controlled medication storage when the Director of Nursing (DON) was not in the facility. During an interview with the NS on 12/14/23, at 9:44 A.M., the NS stated he did not have the key for the controlled medication storage. The NS stated the key was kept in the DON's office. The NS stated Licensed Nurses (LN) gave him the discontinued controlled medications and placed them in the controlled medication storage until the DON and the pharmacist disposed the medications. The NS further stated there was no record maintained to account for the number of controlled medications received and the name of the LN who gave the controlled medications. During an interview with the ADON on 12/14/23, at 11:45 A.M., the ADON stated it was important to reconcile controlled medications given to the DON to prevent drug diversion. An interview was conducted with the Consultant Pharmacist (CP) on 12/14/23, at 12:29 P.M. The CP stated the DON accepted discontinued controlled medications. The CP stated the DON, and the LN should both sign the controlled medication count sheet prior to disposal with the CP. The CP stated it was important to verify the accuracy of the number of controlled medications for safety reasons. A review of the facility's Policy and Procedure (P&P) titled, Disposal of Medications, dated 1/2023 was conducted. The P&P indicated, .controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations .a controlled medication disposition log, or equivalent form shall be used for documentation . 056496 Page 3 of 3