Health inspection·April 28, 2022

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect a resident (98) from financial abuse. Residents Affected - Few This failure had the potential to cause emotional and financial stress. Findings: Resident 98 was admitted to the facility on [DATE] per the facility's admission Record. On 4/26/22 at 8:39 A.M. a concurrent observation and interview was conducted with Resident 98. Resident 98 was sitting on the side of the bed, eating breakfast. Resident 98 stated her wallet had been missing and was found in the laundry room. Resident 98 stated, The wallet was returned, but $80 in cash was missing; no charges were made to my credit cards or debit cards. On 4/27/22 at 9 A.M., a review of Resident 98's Inventory of Personal Effects, dated, 4/18/22 was conducted. The section for credit cards, debit cards, checks was blank; the section for cash was blank. In addition, the section for other indicated a wallet, with no list of the contents. On 4/27/22 at 9:40 A.M. a joint interview was conducted with the Adm and the DON. The DON stated, We did not inventory in detail, just that she had a wallet. The amount of money was not clear. The wallet was found in the laundry, no cash in it. The Adm stated, We did not follow our policy. On 4/27/22 at 9:47 A.M. an interview was conducted with the BOD. The BOD stated, We did not detail the credit cards and the money on the inventory list. On 4/27/22 at 10 A.M. a review of the facility's policy, dated 4/2017, titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, indicated, .Policy Interpretation: 1. Residents have the right to be free from theft and/or misappropriation of personal property .3. Our facility will exercise reasonable care to protect the resident from property loss or theft, including: Inventorying resident belongings upon admission. Page 1 of 3 555745 555745 04/28/2022 Bayshire Carlsbad 3140 El Camino Real 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 interview and record review, the facility failed to administer medication according to a physician's order for one (41) of twelve sampled residents. This failure had the potential to cause side effects for Resident 41. Findings: Resident 41 was admitted to the facility on [DATE] according to the facility's admission Record. No observation of Resident 41 was conducted, as Resident 41 was no longer a resident of the facility. On 4/26/22 at 11 A.M., a review of Resident 41's medical record was conducted. Per a progress note, dated 4/1/22 at 8:30 P.M., .On 4/1/22, LN reported un-prescribed medication had been given to patient .resident was given medications identified as not being prescribed to this patient . Additionally, the progress notes, dated, 4/3/22 indicated, . On Sunday, 4/3/22, the resident starting to exhibit aggressive behaviors striking out at caregivers and staff .send patient to ED (emergency department) .blood pressure elevated, and 02 saturation (decrease in oxygen in the blood) decreased . An interview was conducted with the DON on 4/27/22 at 11A.M. The DON stated, The Resident received medications not prescribed for him, it should not have happened. The LN (who gave the medication) claimed she was distracted, and resigned. The Resident had changes in behavior and vital signs and was sent to the hospital. A review of the facility's policy, dated April 2019, titled, Administering Medications, indicated, .Medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescribers orders . 555745 Page 2 of 3 555745 04/28/2022 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based 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 5.71%. Two medication errors were observed, a total of 35 opportunities, during the medication administration process for two of four randomly observed residents (Residents 11, 151). Residents Affected - Few As a result, the facility could not ensure medications were correctly administered to all residents. Findings: 1. On 4/27/22 at 9:45 A.M., an observation of medication administration was conducted with LN 1. LN 1 prepared and administered medication to Resident 11, including a Salonpas Lidocaine 4% Gel-Patch (a pain patch). LN 1 removed a Gel-Patch (undated), and replaced it with a new patch, dated 4/27/22. 2. On 4/27/22 at 10:05 A.M., LN 1 prepared and administered medication to Resident 151, including a five percent lidocaine patch. Resident 151 stated the patch from the previous day had fallen off in the bed, and the previous shift nurse had not removed it. On 4/27/22 at 10:45 A.M., a record review was conducted of Resident 11 and Resident 151's electronic medical record (EMR). Per a physician's order, dated 4/28/22, Resident 11 was to have a Salonpas Lidocaine patch applied daily at 9 A.M., and removed at 9 P.M. daily. Per a physician's order, dated 4/24/22, Resident 151 was to have a lidocaine patch applied daily at 9 A.M., and removed daily at 9 P.M. On 4/27/22 at 11:59 A.M., a concurrent interview and record review was conducted with LN 1. LN 1 stated, It's important to follow the manufacturers' instructions, plus any orders from the physician. It could cause a problem if we do not follow the orders. On 4/27/22 at 2:19 P.M., an interview was conducted with the DON. Per the DON, The expectation is to follow the physician's orders, and to consider the manufacturers' instructions. If we fail to do that, it could cause a problem, such as a medication reaction. Per a facility policy, revised April 2019 and titled Administering Medications, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame .31 .Manufacturer's instructions .are kept with the devices or at the nurses' station. 555745 Page 3 of 3