Health inspection·March 3, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered, comprehensive care plan (describes the care and support provided to meet health needs), to two of 18 sampled residents, to address respiratory care needs (Resident 76) and dementia care needs (Resident 45). These facility failures had the potential for care and services not to be provided to residents to attain or maintain quality of life. Findings: 1. During a review of Resident 76's, Face Sheet (FS), dated 8/28/19, the FS indicated in part, Resident 76 is a [AGE] year-old male, who was admitted in the facility on 8/28/19. Resident 76's admitting diagnoses included, Hemiplegia (paralysis of one side of the body following injury to the brain) following Cerebral Infarction (Stroke) affecting left non-dominant side, Oropharyngeal Dysphagia (a disorder to which you can not properly swallow food, liquid or saliva), Muscle Weakness, and Gastrostomy Status (a tube placed into the stomach for nutritional support). During a concurrent observation and interview with Resident 76, on 2/28/22 at 3:40 p.m., Resident 76 was observed inside his room, lying in bed, awake and alert. Resident 76 had a left arm contracture (permanent shortening of a muscle or joint), a slightly mumbled speech, and occasionally struggled to cough and clear his throat effectively. On further observation, there was a suction machine on top of Resident 76's bedside table. When asked if the suction machine was used on him, Resident 76 stated, They're (referring to staff) supposed to suction me (pointing at his mouth, indicating increased oral secretions) but the nurses rarely use it because they're too afraid. After clarifying his statement, Resident 76 acknowledged that staff was supposed to suction his excessive oral secretions. During a concurrent interview and record review, on 3/2/22 at 10 a.m., with the Assistant Director of Nursing (ADON), Resident 76's, Treatment Orders (TO) and Care Plan (CP) Report, dated 8/28/19 present, were reviewed. Resident 76's, TO, indicated in part, Suction as needed (PRN for increased oral secretions), with an order date of 2/17/21. A review of Resident 76's, CP report, did not indicate, a care plan was initiated to manage the resident's ineffective cough, which could have included other appropriate goals and other care interventions aside from suctioning. The ADON verified the finding and acknowledged that a comprehensive care plan should have been initiated specific to Resident 76's respiratory care needs. 2. During a review of Resident 45's, Face Sheet (FS), dated 4/6/18, the FS indicated in part, Resident 45 is a [AGE] year-old male, who was admitted in the facility on 4/6/18. Resident 45's admitting diagnoses included, Dementia, Unspecified (loss of thinking, remembering, and reasoning due to advanced age), Unspecified Psychosis (a condition that affects the way your brain processes information), Oral Dysphagia (difficulty of swallowing), and Difficulty of Walking. During a concurrent observation and interview on 3/1/22 at 10:10 a.m., with a licensed nurse (LN1), Resident 45 was observed inside his room, lying in bed sleeping, with the height of the bed at its lowest position and on oxygen therapy via a nasal cannula (a flexible tube that has two open prongs intended to sit just inside your nostrils) running at 2 LPM (liter/s per minute). According to LN1, Resident 45 had a rough night and did not get too much sleep. LN1 described Resident 45 as confused, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 2 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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 0656 incoherent and anxious at times. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 3/2/22 at 10:30 a.m., with the Assistant Director of Nursing (ADON), Resident 45's, Care Plan (CP) Report, dated 4/6/18 - present, was reviewed. Resident 45's, CP report, indicated, goals and interventions to manage his current acute medical conditions (such as moderate hearing loss, nausea, vomiting, and weight loss) and psychosocial issues (such as anxiety and depression), without mentioning specific goals and interventions to address his dementia care needs. After further review of the report, the ADON verified and acknowledged that a comprehensive care plan should have been initiated to specifically address Resident 45's dementia care needs. Residents Affected - Few During a review of the facility's, policy and procedure (P&P), titled, Care Plans Procedure, revised 3/1/18, the P&P indicated in part, Purpose: The purpose of this procedure is to ensure that staff initiates care plans for identified problems of the resident. The P&P indicated further, Procedure: a) Complete Resident Comprehensive Assessment . b) Identify resident's needs and/or problems, c) Initiate care plans, and d) Care plans are developed and reviewed by the interdisciplinary team. During a review of the facility's, policy and procedure (P&P), titled, Develop/Implement Comprehensive Care Plan, revised 3/1/18, the P&P indicated in part, Each resident care plan shall include measurable objectives, the professional discipline responsible for each element of care and timeframes to meet the resident's needs identified in the comprehensive assessment. The P&P indicated further, The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 3 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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 interview and record review, the facility failed to ensure timeliness in the development and revision/update of the person-centered, comprehensive care plans (describe the care and support provided to meet health needs), to two of 18 sampled residents (Residents 76 and 45), when: 1. Care plan was not developed and initiated timely to address Resident 76's respiratory care needs, 2. Care plan to address Resident 76's care needs related to difficulty in swallowing was not updated to reflect current speech-language therapy recommendations, 3. Care plan was not developed and initiated timely to address Resident 45's dementia care needs. These failures had the potential for the provision of care and services to these residents not being provided timely which could affect residents quality of life. Findings: 1. During a review of Resident 76's, Face Sheet (FS), dated 8/28/19, the FS indicated in part, Resident 76 is a [AGE] year-old male, who was admitted in the facility on 8/28/19. Resident 76's admitting diagnoses included, Hemiplegia (paralysis of one side of the body following injury to the brain) following Cerebral Infarction (Stroke) affecting left non-dominant side, Oropharyngeal Dysphagia (a disorder to which you can not properly swallow food, liquid, or saliva), Muscle Weakness, and Gastrostomy Status (a tube placed into the stomach for nutritional support). During a concurrent observation and interview with Resident 76, on 2/28/22 at 3:40 p.m., Resident 76 was observed in his room, lying in bed, awake and alert. Resident 76 had a left arm contracture (permanent shortening of a muscle or joint), a slightly mumbled speech, and occasionally struggled to cough and clear his throat effectively. On further observation, there was a suction machine on top of Resident 76's bedside table. When asked if the suction machine was used on him, Resident 76 stated, They're (referring to staff) supposed to suction me (pointing at his mouth, indicating increased oral secretions) but the nurses rarely use it because they're too afraid. After clarifying his statement, Resident 76 acknowledged that staff was supposed to suction his excessive oral secretions. During a concurrent interview and record review, on 3/2/22 at 10 a.m., with the Assistant Director of Nursing (ADON), Resident 76's, Treatment Orders (TO) and Care Plan (CP) Report, dated 8/28/19 present, were reviewed. Resident 76's, TO, indicated in part, Suction as needed (PRN for increased oral secretions), with an order date of 2/17/21. A review of Resident 76's, CP report, did not indicate, a care plan was initiated to manage the resident's ineffective cough, which could have included other appropriate goals and care interventions aside from suctioning. The ADON verified the finding and acknowledged that a comprehensive care plan should have been initiated specific to Resident 76's respiratory care needs. 2. During a review of Resident 76's, SLP (Speech-Language Pathologist [assesses, diagnoses, treats, and helps to prevent communication and swallowing disorders]) Evaluation and Plan of Treatment (SLPPT), dated 9/10/21, the SLPPT indicated in part, Objective Progress/Short-term Goals .Patient will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 4 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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 increase oral phase swallow skills to Mild as evidenced by increased ability to safely swallow ice chips to promote swallow function and build swallow endurance The SLPPT also indicated, Recommendations . Additional Intake Recommendations = Ice Chips only. During a concurrent interview and record review on 3/2/22 at 10:15 a.m., with the ADON, Resident 76's, SLPPT dated 9/10/21, and CP report dated 8/29/19 - present, were reviewed. The ADON verified the SLPPT additional intake recommendations for Resident 76. On review of Resident 76's CP report, specific to tube feedings, the interventions section of the CP, indicated in part, past SLP evaluation/s. Interventions were not updated to reflect Resident 76's most recent SLPPT recommendations. The ADON verified the finding and acknowledged that the tube feeding CP should have been updated. 3. During a review of Resident 45's, Face Sheet (FS), dated 4/6/18, the FS indicated in part, Resident 45 is a [AGE] year-old male, who was admitted in the facility on 4/6/18. Resident 45's admitting diagnoses included, Dementia, Unspecified (loss of thinking, remembering, and reasoning due to advanced age), Unspecified Psychosis (a condition that affects the way your brain processes information), Oral Dysphagia (difficulty of swallowing), and Difficulty of Walking. During a concurrent observation and interview on 3/1/22 at 10:10 a.m., with a licensed nurse (LN1), Resident 45 was observed in his room, lying in bed sleeping, with the height of the bed at its lowest position and on oxygen therapy via a nasal cannula (a flexible tube that has two open prongs intended to sit just inside your nostrils) running at 2 LPM (liter/s per minute). According to LN1, Resident 45 had a rough night and did not get too much sleep. LN1 described Resident 45 as confused, incoherent and anxious at times. During a concurrent interview and record review on 3/2/22 at 10:30 a.m., with the Assistant Director of Nursing (ADON), Resident 45's, Care Plan (CP) Report, dated 4/6/18 - present, was reviewed. Resident 45's, CP report, indicated, goals and interventions to manage his current acute medical conditions (such as moderate hearing loss, nausea, vomiting, and weight loss) and psychosocial issues (such as anxiety and depression), without mentioning specific goals and interventions to address his dementia care needs. After further review of the report, the ADON verified and acknowledged that a comprehensive care plan should have been initiated to specifically address Resident 45's dementia care needs. During a review of the facility's, policy and procedure (P&P), titled, Care Plans Procedure, revised 3/1/18, the P&P indicated in part, Purpose: The purpose of this procedure is to ensure that staff initiates care plans for identified problems of the resident. The P&P indicated further, Procedure: a) Complete Resident Comprehensive Assessment . b) Identify resident's needs and/or problems, c) Initiate care plans, and d) Care plans are developed and reviewed by the interdisciplinary team. During a review of the facility's, policy and procedure (P&P), titled, Develop/Implement Comprehensive Care Plan, revised 3/1/18, the P&P indicated in part, Each resident care plan shall include measurable objectives, the professional discipline responsible for each element of care and timeframes to meet the resident's needs identified in the comprehensive assessment. The P&P indicated further, The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being During a review of the facility's, policy and procedure (P&P), titled, Care Plan Timing and Revision, revised 3/1/18, the P&P indicated in part, (name of organization) facilities will ensure the timeliness of each resident's person-centered comprehensive care plan .The comprehensive care plan will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 5 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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 be reviewed, evaluated, and updated by the interdisciplinary team and appropriately revised after each comprehensive and quarterly assessment, and more often if there is a change in the resident's condition. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 6 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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 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 store and label opened containers of food in the refrigerator and freezer as indicated in the facility policy and procedure. Residents Affected - Some This failure had the potential for food items to be stored for a duration that could cause the growth of microorganisms, which could lead to food borne illnesses in the facility's vulnerable population. Findings: During an observation on 02/28/22, at 9:30 a.m., in the facility kitchen, several opened containers of food were noted to be unlabeled: 1. Pineapple juice in the Walk in Refrigerator 2. Heavy Whipping Cream in the Walk in Refrigerator 3. Two containers of Ham base in the Refrigerator 4. Burger patties in the Walk in Freezer 5. Cheese Omelets in the Walk in Freezer During a concurrent observation and interview on 02/28/22, at 9:40 a.m., with the Director of Dietary Services (DDS), in the facility kitchen, the DDS confirmed the opened food stored in the refrigerator and freezer were not labeled. The DDS further stated this practice does not meet food safety practices. The DDS acknowledged the facility policy and procedure was not followed, but should have been. During a review of the facility policy and procedure titled, Food Storage, dated 2022, the policy indicated in section 13, Refrigerated Foods under f and g of Refrigerated foods, All foods should be covered, labeled, and dated and routinely monitored to assure that food will be consumed by their use by dates .All food in bulk containers that have been opened for partial use need to be labeled with an open date. Under section 14 Frozen foods, c and d, the policy and procedure indicated, All foods should be covered, labeled, and dated. All foods will be checked to assure that food will be consumed by their safe use by dates or discarded .All foods in bulk that have been opened for partial use needs to be put into a food safe container for storage. It needs to be labeled and dated with a Use By' date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 7 of 8 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 555371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayside Care Center 1405 Teresa Drive Morro Bay, CA 93442 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. Based on observation, interview, and record review, the facility failed to ensure one of 9 sampled residents (Resident 14), had an accurate Face Sheet ((FS) a document used by physicians and care givers to have quick access to essential facts about a resident). For Resident 14, this facility failure had the potential to result in life saving procedures being performed against their wishes. Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Records - Identifiable Information, dated 3/1/2018, the P&P indicated, Clinical records are maintained on each resident in accordance with accepted professional standards and practices. Clinical records are complete, accurately documented, readily accessible and systematically organized. During a review of Resident 14's Physician Orders for Life-Sustaining Treatment ((POLST) a medical order indicating end of life treatment wishes), the POLST indicated, if Resident 14 has no pulse and is not breathing, Do Not Attempt Resuscitation. During a review of Resident 14's FS, dated 3/1/22, at 7 a.m., the FS indicated, Resident 14's end of life wish was, Full Code [wishes all resuscitation procedures]; Do Not Resuscitate. During an interview on 3/1/22, at 11:42 a.m., with a licensed nurse (LN1), LN1 reviewed Resident 14's FS and stated the FS was not right because the end of life wishes listed, Are complete opposites. During an interview on 3/1/22, at 12:53 p.m., with the Director of Nursing (DON), DON reviewed Resident 14's FS and POLST and stated, They don't match, and they should. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555371 If continuation sheet Page 8 of 8