Health inspection·April 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity, when a urine catheter drainage bag was not covered for one of three residents (Resident 3), reviewed for Resident Rights. As a result, there was the potential Resident 3 to experience a decline in dignity and self-esteem. Findings: Resident 3 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness on one side of the body) following cerebral infarction (stroke) affecting the left side, per the facility's admission Record. On 4/3/23 at 1:49 P.M. an observation and interview was conducted with certified nurse assistant 1 (CNA 1), of Resident 3, as he sat up in bed. Resident 3 had a urinary drainage catheter bag, attached to the right side of the bed frame, which was visible from the hallway. CNA 1 stated Resident 3's urine was visible, and he should have a dignity bag covering the urinary drainage bag, to provide the resident with dignity. CNA 1 stated Resident 3's dignity could be affected, because his privacy was not protected. On 4/3/23 at 1:53 P.M., an interview was conducted with CNA 2. CNA 2 stated all residents with urinary catheter drainage bags should be covered with a blue dignity bag, to protect the resident's dignity and privacy. On 4/3/23 at 1:55 P.M., an interview was conducted with the Director of Nursing, (DON). The DON stated she expected all residents with urinary catheter drainage bags to be covered, because it protected their dignity and was a privacy issue. On 4/3/23, Resident 3'a clinical record was reviewed: According to the Skilled Nursing (Brief Interview for Mental Status (BIMS-a cognitive assessment tool), dated 3/29/23, indicated a score of 11, indicating moderate impairment for cognition. According to the physician's order, dated 3/28/23, .Indwelling catheter care .every shift . There was no documented evidence a care plan had been developed for catheter care. According to the facility's policy, titled Resident Rights, dated December 2016, .1. Federal and Page 1 of 6 555745 555745 04/14/2023 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0550 state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .b. be treated with .dignity; .t. privacy . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555745 Page 2 of 6 555745 04/14/2023 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Responsible Party, (RP- a person selected to make medical and financial decisions on the resident's behalf), of room changes for one of three residents, (Resident 1), reviewed for resident rights. As a result, the resident and RP were not given the opportunity to accept or decline the facility-initiated room change. Findings: On 3/16/23, an interview was conducted with Resident 1's RP. The RP stated Resident 1's room had been changed about seven times, and the RP was never notified or asked if the room change was alright with them. The RP stated Resident 1 was moved one time, due to a Covid-19 outbreak (a highly contagious virus) and she was told about it after the fact, which she could accepted, but the other moves were unacceptable because they were never informed. On 3/27/23, and on 4/3/23, unannounced visits were made to the facility. Resident 1 had been discharged on 3/22/23, prior to the unannounced visits. Resident 1 was admitted to the facility on [DATE], with diagnoses which included aftercare for joint replacement of the right femur head (right hip), and fracture of lumbar 1-4 vertebra (lower spine) [NAME] the facility's admission Record. The RP was listed as the responsible party. The Minimum Data set (a clinical assessment tool), dated 1/20/23, listed a cognitive score of 11, indicating moderately impaired cognition. The Functional Status for activities of daily living, indicated a one-person staff assist was required for bed mobility, transferring, and toiletry. Resident 1's room change listed was reviewed. Resident 1 was re-admitted to the facility on [DATE] from the hospital after a fall. Room changes were conducted on 2/21/23, 2/22/23, changed on 2/25/23 due to covid outbreak, changed on 2/27/23, and again on 3/4/23. On 4/3/23 at 1:55 P.M., an interview and record review was conducted with the Director of Nursing (DON) regarding Resident 1's room change list. The DON reviewed Resident 1's room change list, and stated the resident was moved to five different room during February and March 2023, excluding the room change due to a COVID outbreak. The DON reviewed Resident 1's Progress Notes and stated she could not find any documentation indicating the resident or the RP were notified of the room changes, which goes against their policy. The DON stated the facility divided the notifications of room changes among the licensed nurses, the case managers, and the social services workers. The DON stated it was important to notify residents and their RPs of pending room changes, so they had the right to decline or refuse the room change. The DON stated if the RP had been notified, it would have been documented in the Progress Notes, that they agreed or declined the room change. The DON stated based on her review, the room notifications were not done, which violated the resident's right. According to the facility's policy, titled Room Change/Roommate Assignment, dated March 2017, .2. Prior to changing a room .all parties involved in the change/assignment (e.g., residents and/or their representatives (sponsors) will be given advance notice of such a change 5. Residents have the 555745 Page 3 of 6 555745 04/14/2023 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0559 right to refuse to move to another room .8. Documentation of a room change is documented . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555745 Page 4 of 6 555745 04/14/2023 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to safely store prescribed medication, when two tablets of medication were left at the bedside for one of three residents (Resident 2), reviewed for medication storage. As a result, there was the potential of misuse or diversion (theft) by staff, residents, or visitors. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included kidney failure (the inability to process and remove waste from the body), per the facility's admission Record. On 4/3/23 at 12:54 P.M., an observation and interview was conducted with Resident 2 as he sat up in bed, eating lunch. Next to the lunch tray on the bedside table, was a clear plastic medication cup. The medication cup contained two white tablets. Resident 2 stated he planned on taking his medication after he finished lunch. On 4/3/23 at 1 P.M., an observation and interview was conducted with licensed nurse 1 (LN 1), inside Resident 2's room. LN 1 observed the medication left unattended on Resident 2's bedside table. LN 2 stated she administered the medication to Resident 2 earlier and was unaware he had not taken it. LN 2 believed the medication to be Gabapentin (medication for nerve pain). LN 2 stated she should have stayed with the resident to ensure it was ingested. LN 2 stated by leaving the medication unattended on the bedside table, others could have taken the medication, or it could have fallen onto the floor and would never have been administered. On 4/3/23 at 1:17 P.M., an interview was conducted with LN 2. LN 2 stated it was never acceptable to leave medication at a resident's bedside unattended. LN 2 stated anyone could have accessed the medication and taken it, which might be harmful to them. LN 2 stated medication was always to be locked up or administered with a LN present, to ensure it was swallowed. On 4/3/23 at 1:19 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated medication should never be left unattended by a LN. The DON stated anyone could pick up the medication, or it could be dropped on the floor, and the resident would never receive their medication, both of which could cause injury. On 4/3/23, Resident 2's clinical record was reviewed: According to physician's order sheet, dated April 2023, Resident 1 was not prescribed Gabapentin medication. According to the medication administration record, dated 4/3/23, Resident 1 was administered variety of medications at 9 A.M., and one tablet of Sodium Bicarbonate (an antacid) at 1 P.M. It was unclear what the medication was previously left at the resident's bedside. 555745 Page 5 of 6 555745 04/14/2023 Bayshire Carlsbad 3140 El Camino Real Carlsbad, CA 92008

F 0761 Level of Harm - Minimal harm or potential for actual harm According to the facility's policy, titled Storage of Medications, dated October 2018, .C. Drugs shall be stored .in cabinets, draws or carts .F. Drugs shall be accessible only to personnel designated in writing by licensee. Residents Affected - Few 555745 Page 6 of 6