Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayshire Carlsbad during CMS and state inspections, most recent first.
A resident with a femur fracture, moderate cognitive impairment, and high risk for pressure injuries required substantial to maximal assistance with bed mobility but was placed on a standard two-hour repositioning schedule rather than an individualized plan as required by facility policy. The resident frequently refused to get out of bed or be repositioned, and staff later observed black/purple blisters on both heels, which were not present on admission. An LN reported the use of Prevalon boots after the heel blisters developed, the DON acknowledged that the resident’s condition and refusals increased risk and should have been care planned, and the PCP stated the resident was high risk and that the facility probably had a duty to identify the risk early and use off-loading interventions.
A resident with lung cancer did not receive consistent non-pharmacological interventions before pain medication, as required by physician orders. Pain medication was also not administered according to prescribed pain scale ranges, leading to potential overmedication. Interviews with staff and the DON highlighted the importance of following physician orders to prevent risks such as dependency.
A facility failed to accurately complete a comprehensive assessment for a resident, as the MDS did not reflect the presence of an indwelling catheter. Despite documentation and physician notes indicating the catheter's presence, the MDS assessment was inaccurate, which the DON acknowledged should have been corrected to ensure proper care planning.
A resident with severe cognitive impairment and physical limitations did not receive necessary assistance with personal hygiene, including nail care and facial hair removal. Despite the care plan's directives, staff failed to notice and address the resident's grooming needs, as confirmed by observations and interviews with the CNA and DON.
The facility staff failed to consistently document lint removal from the drying machine trap in the laundry room, posing a potential fire hazard. Observations and log reviews showed multiple missed entries over several months. Interviews confirmed daily laundry operations and the importance of lint removal every two hours, as per the facility's fire safety policy.
A resident with an indwelling catheter did not have a physician's order for the catheter or consistent catheter care documented. Despite the presence of the catheter, there were no orders from January 8 to January 25, and toileting hygiene was not performed on all shifts on certain dates. The Director of Nursing confirmed these findings, and a physician's note later indicated the resident developed a UTI.
The facility failed to ensure timely responses to call lights, leading to potential unmet needs for residents. Interviews revealed significant delays, with one resident waiting over half an hour for assistance after an incontinence episode and another waiting over an hour for help to get ready for bed. The facility had a one-star staffing quality rating, and the DON expected call lights to be acknowledged within five to seven minutes. The facility's policy aimed to ensure timely responses to residents' needs.
Failure to Implement Individualized Pressure Injury Prevention Leading to Heel Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to implement individualized pressure injury prevention interventions for a resident at high risk for skin breakdown, resulting in pressure injuries to both heels. The resident was admitted with a left femur fracture and required substantial to maximal assistance with bed mobility, and the MDS documented that the resident was at risk for developing pressure ulcers/injuries and had moderate cognitive impairment. The facility’s policy required repositioning all residents with or at risk of pressure injuries on an individualized schedule based on risk factors and clinical guidelines. However, the resident was placed on a standard two-hour repositioning schedule used for multiple residents, with no individualized repositioning plan despite the resident’s specific risk profile. Staff interviews and observations showed that the resident later developed black/purple blisters on both heels, which were identified as pressure injuries that had not been present on admission. A CNA reported first noticing the heel blisters and notifying the treatment nurse, and stated that the resident frequently refused to get out of bed or be repositioned on her side. An LN confirmed that the resident was using Prevalon boots due to heel blisters caused by prolonged pressure and acknowledged that the resident had no wounds on admission. The DON stated that the resident’s fractured hip and refusals to get out of bed or be turned increased her risk and that nursing should have implemented a care plan to address these refusals. The PCP described the resident as high risk for pressure injuries and stated that, although the injuries were not entirely avoidable, the facility probably had a duty to identify the risk early and use off-loading interventions.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to adhere to a physician's order for pain management for a resident with a diagnosis of neoplasm of bronchus and lung. The resident, who had intact cognition and frequent pain with a high pain scale, was not consistently provided with non-pharmacological interventions (NPIs) before administering pain medication. The physician's order required monitoring for pain every shift and the use of NPIs, such as repositioning, emotional support, and relaxation exercises, before administering medication. However, NPIs were attempted only a few times out of numerous opportunities, and pain medication was administered frequently without documented evidence that NPIs were unsuccessful. Additionally, the facility did not administer pain medication according to the prescribed pain scale ranges. The physician's order specified different dosages of Oxycodone based on the resident's pain level, but the medication was not consistently given according to these guidelines. For instance, a half tablet was administered for a pain level of 8, and a full tablet was given for a pain level of 4, contrary to the physician's instructions. Interviews with nursing staff and the Director of Nursing (DON) confirmed the importance of following physician orders to prevent risks such as overmedication and dependency. The facility's policy on pain management emphasized the use of both non-pharmacological and medication interventions as ordered by the physician. Despite this, the facility did not consistently apply NPIs or adhere to the prescribed medication dosages, leading to a deficiency in the resident's pain management. The DON acknowledged the importance of following physician orders and the potential risks associated with not doing so, including the need to notify the physician if orders were not followed.
Inaccurate MDS Assessment for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed accurately for Resident 146, as the Minimum Data Set (MDS) did not reflect the presence of an indwelling catheter. Resident 146 was initially admitted with diagnoses including acute kidney failure and a urinary tract infection. An observation on February 3, 2025, confirmed that Resident 146 had an indwelling catheter, which was not documented in the MDS assessment dated January 15, 2025. Interviews and record reviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that nursing documentation from January 9, 2025, and a physician's note from January 13, 2025, both indicated the presence of an indwelling catheter. The DON acknowledged that the MDS should have accurately reflected Resident 146's status to aid in creating an appropriate plan of care. The facility's policy requires all individuals completing any portion of the MDS to attest to the accuracy of the information, which was not adhered to in this case.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for Resident 98, who was unable to perform self-care activities such as grooming. Despite being admitted with conditions including sepsis and muscle weakness, and having a severe cognitive impairment as indicated by a BIMS score of 7/15, Resident 98 did not receive adequate nail care or facial hair removal. Observations on multiple occasions revealed that Resident 98 had long fingernails and facial hair, which were not addressed by the staff. Interviews with the resident and staff, including a CNA and the Director of Nursing, confirmed the oversight. The CNA responsible for Resident 98's care admitted to not noticing the resident's long fingernails and facial hair, despite the care plan specifying that nail care should be performed on bath days and as needed. The Director of Nursing acknowledged the expectation for staff to maintain residents' hygiene and dignity by ensuring facial hair removal and nail trimming according to residents' preferences.
Inconsistent Lint Removal Documentation in Laundry Room
Penalty
Summary
The facility staff failed to consistently document the removal of lint from the drying machine trap in the laundry room, which posed a potential fire hazard. During an observation, it was noted that the laundry room was divided into clean and dirty areas, with the drying machine in use at a hot temperature. A review of the laundry dryers cleaning log revealed multiple missed entries from November 2024 through January 2025, indicating that the lint removal was not consistently documented on several specific dates. Interviews with the laundry staff and the Director of Nursing (DON) confirmed that the facility conducted laundry daily and that lint was supposed to be removed every two hours to ensure the dryer functioned effectively and to prevent fire hazards. The facility's policy on fire safety and prevention emphasized the importance of keeping dryer filters free of lint. However, the lack of consistent documentation of lint removal indicated a failure to adhere to this policy, potentially compromising the safety of residents and staff.
Lack of Physician Orders and Catheter Care for Resident
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a physician's order for the catheter and that consistent catheter care was provided. Resident 146, who was admitted with diagnoses including acute kidney failure and a urinary tract infection, had an indwelling catheter documented in their medical record. However, from January 8 to January 25, there were no physician orders for the catheter or its care, despite documentation indicating the presence of the catheter. The Director of Nursing confirmed the absence of orders and noted that catheter care should be performed every shift. Documentation revealed that toileting hygiene was not performed on all shifts on specific dates, and there was no specific documentation for catheter care during the period in question. A physician's progress note later indicated that the resident had developed a urinary tract infection, highlighting the potential impact of the lack of catheter care.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, which had the potential for residents' needs to be unmet. Interviews with residents revealed significant delays in response times. One resident reported waiting over half an hour for assistance after an incontinence episode, while another resident experienced a delay of over an hour when needing help to get ready for bed. Two other residents confirmed similar delays, with one resident specifically monitoring the response time with a watch. The facility's Payroll-based Journal Staffing Data Report indicated a one-star staffing quality rating for the fourth quarter of 2024. The Director of Nursing stated that the expectation was for call lights to be acknowledged within five to seven minutes, emphasizing the importance of timely responses to meet residents' needs. The facility's policy on answering call lights, revised in September 2022, was intended to ensure timely responses to residents' requests and needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 232 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carlsbad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlsbad By The Sea | 2 mi | ★★★★★ | 4 | 0 |
| La Paloma Healthcare Center | 2 mi | ★★★★★ | 0 | 0 |
| Pacific Villas Post Acute | 2 mi | — | 0 | 0 |
| Vista Knoll Specialized Care Facility | 2.6 mi | ★★★★★ | 18 | 0 |
| Vista View Post Acute | 3.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bayshire Carlsbad.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.