Health inspection·August 23, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Per the record titled Progress Notes dated 3/5/21 at 5:38 A.M., Resident 1 was difficult to arouse, blood pressure was 72/35 and he was non-verbal. Physician 2 (PH 2) ordered for Resident 1 to be transferred to the emergency room for further evaluation. On 4/18/22 at 4 P.M., an interview and concurrent record review was conducted with License Nurse (LN) 1 [in person] and the Director of Nurses (DON) [via phone]. LN 1 stated the physician's order, written for Resident 1 on 2/26/21 to bladder scan was a PRN (as needed) order and not a regular routine every 8-hour order. LN 1 was insistent and repeated that the order was PRN, and the bladder scanning did not need to be done every 8 hours. The DON stated the order clearly indicated the physician wanted Resident 1 to be scanned every 8 hrs. The DON stated the nurses did not follow the physician's order. The DON stated if Resident 1 was retaining urine and he needed the bladder scanning as ordered to prevent bladder and/or kidney infection and possible kidney failure. The DON stated the licensed nurses should have bladder scanned Resident 1 every 8 hrs. as ordered. The DON stated the nurses should have also contacted the physician when the resident was having that much urine retention at one time. On 5/2/22, a review of Resident 1's acute care hospital record was conducted. The record titled Hospital Medicine Discharge summary dated [DATE], indicated that Resident 1 was admitted to the acute care hospital on 3/5/21, from the facility with UTI, sepsis, acute renal failure (kidneys not functioning), and urinary retention. He was treated with IV antibiotics and was discharged to home on 3/10/21, with an indwelling catheter and a recommendation for outpatient urology follow up. On 5/17/22 at 12:09 P.M., a phone interview and concurrent record review was conducted with Physician (PH) 1. PH 1 stated it was his expectation that facility was going to bladder scan Resident 1 every 8 hours and then straight cath the resident if the bladder scan read more than 400 cc in the bladder per his 2/26/22 order. PH 1 stated his order was not a PRN (as needed) order. PH 1 stated Yes, that is a problem if the resident was retaining 1400 cc of urine and not straight cathed. PH 1 stated if continuous bladder retention was occurring and not addressed it could lead to bladder discomfort and could result in renal failure, UTI (urinary tract infection), or post obstructive nephropathy (kidney dysfunction). PH 1 stated he would have expected a phone call from the facility if resident was having continued amount of urine retention. A facility document review was conducted. The document titled Required Services revised 8/02/2021 indicated, .(f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated . 2. A review of a facility document was conducted. The document titled Catheterization, Intermittent, Male Resident with a revision date of 2010 indicated, .Do not remove more than 800 mL (milliliters) of urine at one time . On 4/18/22 at 4 P.M., a phone interview and concurrent record review was conducted with License Nurse (LN) 1 and the facility's Director of Nursing (DON). LN 1 stated she did not follow the policy when straight catheterizing Resident 1 when she removed over 1400 cc of urine from his bladder. LN 1 stated she should have stopped at 800 cc. LN 1 was unable to give a rationale as to why she should not remove more than 800 cc. The DON stated catheterizing someone for more than 800 mL could cause infection, pain, possible renal failure and was just too big of a shift in fluid at one time in the body. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555806 If continuation sheet Page 2 of 3 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 555806 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Development (DSD). The DSD stated the licensed nurses should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications. 3. On 5/9/22 at 7:07 A.M., a phone interview was conducted with License Nurse (LN) 3. LN 3 stated the facility had a new bladder scanner when Resident 1 was at the facility. LN 3 stated he did not receive formal training from the facility on the new bladder scanner. LN 3 stated he did not remember receiving any education from the facility on straight catheterization of a resident. LN 3 stated if the bladder scanner said a resident had 1500 cc in a resident's bladder, he would straight catheterize them and remove 1300 cc to 1500 cc from their bladder if there was an order to straight catheterize the resident. On 5/17/22 at 10:51 A.M., the facility's Director of Nursing (DON) confirmed via email that LN 1, LN 2, LN 3, and LN 4 who cared for Resident 1 while at the facility did not receive any education or competency evaluation on bladder scanning or straight catheterization of a resident prior to June 2021. On 6/2/22 at 8:50 A.M., a phone interview was conducted with the facility's Director of Staff Development (DSD). The DSD stated it was very important for the Licensed Nurses (LNs) to have education on bladder scanning and bladder catheterization. The DSD stated if the LNs do not catheterize a patient correctly it could lead to bladder infections and kidney problems. The DSD stated if the LNs do not know how to use the bladder scanner properly the LNs may not be able to identify if the resident is retaining urine. The DSD stated if the LNs do not identify if the resident is retaining urine it could lead to the resident getting a bladder infection and/or kidney problems. The DSD stated if the resident is retaining urine the nurse should call the doctor to let them know. The DSD stated the LNs should not be removing more than 800 cc of urine when straight catheterizing a resident because it is too much of a fluid shift for the resident and could cause medical complications. The DSD stated it is important to remove no more than 800 cc of urine from the bladder at one time when catheterizing a resident to prevent fluid shift complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555806 If continuation sheet Page 3 of 3