Bayshire Carlsbad

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent the formation of pressure injuries (wounds caused by sustained pressure to bony areas of the body) for one of three residents (Resident 1) reviewed for wounds. This failure resulted in Resident 1 sustaining pressure injuries to both heels.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order for pain management for one of three residents (Resident 1), for pain when: 1. Non-pharmalogical interventions (NPI- any intervention intended to improve the health or the well-being of individuals that do not involve the use of any drugs or medicine) were not consistently provided prior to pain medication being administered; and 2. Pain medication doses were not administered according to the pain scale ranges level (scale to indicate level of pain 0=no pain, 10 =greatest pain), indicated by the physician. These failures had the potential for pain medication to not necessarily be required and for pain medication doses to be over or under administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive assessment was completed accurately for one of 12 sampled residents (Resident 146) when Resident 146's Minimum Data Set (MDS, an assessment tool) did not reflect she had an indwelling catheter (a thin, flexible tube inserted and left in the bladder to collect and drain urine). This failure increased the risk for Resident 146 to not receive the appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 98), who were unable to carry out activities of daily living (ADL-self- care activities such as grooming), received assistance with nail care (cleaning, trimming and/or filing of nails) and removal of facial hair. This failure resulted in Resident 98 having long fingernails, and facial hair which had the potential to negatively impact the resident's self-esteem and comfort.

Inspectors wroteBased on interview and record review, the facility staff failed to document consistently the removal of lint from the drying machine trap after drying machine used in the laundry room. This failure had the potential to cause fire in the laundry room which could affect the safety of all residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 146) screened for an indwelling catheter (a thin, flexible tube inserted and left in the bladder to collect and drain urine) had a physician's order for an indwelling catheter, and catheter care was consistently provided. This failure had a potential for Resident 146 to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner. This failure had the potential for residents' needs to be unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A Kitchen manager took a thermometer and dipped it in a sanitizer bucket with food debris before checking the temperature of a food item. 2. Two Dietary Aides did not use proper food safety and sanitation practices to prevent cross-contamination. 3. A [NAME] (CK 1) did not properly verbalize the correct cool down process. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 41.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food storage methods and food sanitation equipment, according to standards of practice and facility policy when: 1. Food was not dated or stored correctly at the appropriate temperature, 2. The high temperature dish machine did not reach appropriate internal temperature, 3. The sanitizer in the satellite kitchen was not at the appropriate strength, 4. The floor around the dining room refrigerator had a thick layer of sticky dirt at the outside bottom, 5. Two kitchen cutting boards were observed discolored and overworn with several cuts and groves on them, 6. The ice machine was observed to have shiny black and red residue substances inside. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a sampled resident, (Resident 21) with an unintended, unplanned severe weight loss of 14.98% in one month, receive timely nutrition assessments and supplements according to facility policy and standards of practice. This failure had the potential to further impair sampled Resident 21's nutritional status, reduce lean body mass (body weight that includes muscles, bones, and organs; and excludes fat), and increase the risk of malnutrition. Cross reference:

Inspectors wroteBased on observation, interview and record review, the Licensed Nurses (LNs) failed to monitor oxygen (O2) concentrator (machine that delivers oxygen) humidifier (humidifies the oxygen delivered to the resident) per the physician's order for one of two sampled residents (14) reviewed for respiratory therapy. This failure had the potential for Resident 14 to develop dry mucus membrane, bleeding, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify one of one resident (42) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), and received care and services in accordance with professional standards when Resident 42's PTSD (post-traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past traumatic experience).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (42) was reviewed and assessed for overall psychosocial well-being, received a psychosocial assessment related to Post traumatic stress disorder (PTSD, an anxiety disorder that develops following distressing life events). As a result, Resident 42 did not receive appropriate and adequate psychosocial assessment, and mental health treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than five percent. Two medication errors out of 30 opportunities were identified during medication (med) administration, when Licensed Nurse (LN) 2: 1. Administered an aspirin tablet to Resident 147 compared to aspirin capsule ordered by the physician, and 2. Administered omeprazole (antacid) to Resident 197 after Resident 197 had her breakfast. These failures resulted in a medication error rate of 6.6%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication (med) was administered correctly when Licensed Nurse (LN) 3 did not check a resident's (Resident 198) heart rate prior to medication administration of metoprolol (Lopressor, anti-hypertensive medication, one side effect would slow down an individual's heart rate). This failure could cause harm to Resident 198 due to unsafe administration of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperature was monitored and documented consistently for two of two medication (med) refrigerators during med storage observation. This failure had the potential to affect the efficacy and effectiveness of the medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure the menus were followed for the diets as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not follow standardized recipes and ensure the food was palatable to the residents, according to facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents. The facility census was 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a food preference was honored for one sampled resident (Resident 21). This failure led to fewer caloric and nutrient intake and had the potential to increase the 14.98% unintended and unplanned weight loss experienced by Resident 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sampled resident (Resident 21) with a physician prescribed therapeutic dietary supplement order received the supplement as prescribed. This failure led to Resident 21's decreased nutrient intake and may have contributed to the resident's 14.98% severe weight loss in 30 days. Cross reference:

Inspectors wroteBased on interview and record review, the facility did not keep an accurate accounting of oxycontin (a prescribed schedule 2 controlled substance for moderate to severe pain). This failure allowed the medication to go missing from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident (98) from financial abuse. This failure had the potential to cause emotional and financial stress.

Inspectors wroteBased 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.

Inspectors wroteBased 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). As a result, the facility could not ensure medications were correctly administered to all residents.