Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Carlsbad By The Sea during CMS and state inspections, most recent first.
Controlled Substance Documentation Did Not Reconcile: The facility failed to ensure the CDR matched the MAR for a resident receiving Lorazepam for anxiety. An LN found that the medication was documented with different times on the CDR and MAR on one occasion, and on another occasion it was signed out on the CDR but not documented on the MAR. The DON stated the dates and times should match and that accurate documentation was needed for accountability of narcotics.
Expired Food Stored in Refrigerator: An expired plastic container of canned black beans was observed stored in refrigerator number one during a kitchen tour. The SC stated it should have been discarded, and the HC, FSD, and DON all stated expired foods should be removed and thrown away because they could cause illness. Facility policy stated leftovers must be used within 72 hours or discarded.
The facility failed to store food safely, leaving food debris under a prep table for two days and not labeling foods with complete dates. Soy sauce and orange sauce were not refrigerated as required, and loose sugar was found in storage. Precooked shrimp was not properly covered in the refrigerator. The Director of Dining Services and Executive Director confirmed the importance of daily cleaning, accurate labeling, and proper storage to prevent foodborne illness and pest issues.
A facility failed to create a care plan for a resident with a history of falls, back pain, and hypertension who was hard of hearing (HOH). The resident's daughter raised safety concerns, and a licensed nurse confirmed that a care plan should have been initiated upon admission. The DON acknowledged the need for a care plan to address the resident's communication needs, as per the facility's policy.
A resident at risk for excessive bleeding due to blood thinners was observed shaving unsupervised with a disposable razor, contrary to her care plan which required an electric razor and supervision. The facility's policy mandates staff to assist residents with ADLs according to their care plans, but this was not followed, potentially affecting the resident's well-being.
A medication cart was left unlocked and unattended by an LN, allowing potential unauthorized access. The DON confirmed that carts should be locked when unattended to prevent unauthorized access and drug diversion, as per facility policy.
Controlled Substance Documentation Did Not Reconcile
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure the controlled drug record (CDR) reconciled with the medication administration record (MAR) for one resident. Resident 19 was admitted with a diagnosis that included a trochanteric fracture of the left femur. The physician order summary dated 2/20/26 showed an order for Lorazepam 0.5 mg tablet, with 0.25 mg by mouth daily for 14 days for anxiety. During interview and record review on 3/23/26, LN 3 reviewed Resident 19's CDR and MAR and stated Lorazepam 0.5 mg was removed from the locked box and administered on 3/17/26, but it was signed out on the MAR at 2140 and on the CDR at 2240, and the records did not match. LN 3 also stated Lorazepam 0.5 mg was removed from the locked box and signed out on the CDR on 3/20/26 at 2300 but was not documented on the MAR. On 3/25/26, the DON stated the nurse should have reviewed the physician order, identified the resident, removed the medication from the lock box, administered it, and documented it on both the CDR and MAR, and that the dates and times should match. The facility policy titled Medication Administration Controlled Substances stated that when a controlled medication is administered, the nurse immediately enters the date and time on the accountability record and documents the dose administered on the MAR.
Expired Food Stored in Refrigerator
Penalty
Summary
The facility failed to follow appropriate infection prevention and control practices when an expired plastic container of canned black beans was found stored in refrigerator number one. During an initial kitchen tour observation on 3/22/2026, the Sous Chef observed the container on the shelf with a discard date of 3/18/26 written on the label and stated it should have been thrown away. On 3/24/26, the Head Chef and Food Service Director stated that expired foods should be removed immediately and discarded because they could cause food borne illness. On 3/25/2026, the DON stated that the expired food should have been thrown away because it could cause residents to become sick. The facility policy titled Storage & Inventory - General Procedures, dated January 1, 2020, stated that leftovers shall be used within 72 hours and discarded if not used within that period.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store food safely, as evidenced by several observations during a survey. A vegan meatball, fruit, vegetables, and other food debris were left under a prep table for two days, indicating a lack of daily cleaning. This was confirmed by the Director of Dining Services (DDS), who acknowledged that the kitchen should be cleaned daily to prevent pest infestation. Additionally, the facility did not label dry, frozen, and refrigerated foods with the complete date, including the year, which is necessary to maintain food quality and prevent serving expired food. Further observations revealed that the facility did not refrigerate soy sauce and orange sauce after opening, contrary to the manufacturer's guidelines. The Chef (C1) and the DDS were unaware of the need to refrigerate these sauces, which were subsequently discarded. In the dry storage room, loose sugar was found at the bottom of a box of sugar packets, which C1 admitted should be contained to prevent attracting pests. The walk-in refrigerator contained precooked shrimp that was only half-covered, which C1 acknowledged should be stored in a sealed container to prevent contamination and foodborne illness. The Executive Director (ED) confirmed the expectations for food storage and cleanliness, emphasizing the importance of daily cleaning, accurate labeling, and proper storage according to manufacturer's guidelines. The facility's policies on food storage and inventory were reviewed, indicating that food storage areas should be clean at all times, and all foods should be covered, labeled, and dated. These deficiencies highlight a failure to adhere to established food safety protocols, potentially leading to foodborne illness and pest issues.
Failure to Develop Care Plan for Hard of Hearing Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who was hard of hearing (HOH) upon admission. The resident, identified as having a history of falls, back pain, and hypertension, was admitted without a care plan addressing their HOH condition. This oversight was highlighted during an interview with the resident's daughter, who expressed concerns about the resident's safety due to their hearing impairment. A licensed nurse confirmed that a care plan for HOH should have been initiated upon admission to address the resident's communication needs. The Director of Nursing also acknowledged that residents with sensory impairments should have a care plan to ensure their safety and proper care, as per the facility's care planning policy.
Failure to Supervise Resident During ADL
Penalty
Summary
The facility failed to provide adequate supervision during an Activity of Daily Living (ADL) for a resident who was observed using a disposable razor unsupervised. The resident, who was admitted with diagnoses including atrial fibrillation and congestive heart failure, was at risk for excessive bleeding due to the use of a blood thinner. Despite this risk, the resident was seen shaving her chin without staff supervision, which was contrary to her nursing care plan that specified the use of an electric razor and required supervision to prevent accidental cuts and bleeding. Interviews with the licensed nurse and the Director of Nursing confirmed that the nursing staff did not follow the resident's care plan. The facility's policy on ADL care required staff to assist residents with daily activities according to their individual care plans. The failure to provide the necessary supervision and appropriate shaving equipment as outlined in the care plan had the potential to affect the resident's well-being.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all medications were securely locked, as observed with Medication Cart #1. On the morning of December 4th, a surveyor noted that Medication Cart #1 was left unlocked and unattended in the hallway by the nursing station. A Licensed Nurse (LN) was inside the medication room at the time, leaving the cart accessible to unauthorized personnel. Upon returning to the cart, the LN acknowledged that the cart was left unlocked and unattended, and demonstrated that the cart could be opened without using a key, indicating that the key lock button had not been engaged. The Director of Nursing (DON) confirmed in an interview that medication carts should always be locked when not attended to prevent unauthorized access and potential drug diversion. The facility's policy on medication storage, dated January 2023, specifies that only authorized personnel should have access to medication carts and that these should remain locked when not in use. This incident highlights a breach in protocol, as the LN admitted to not locking the cart, which could have led to unauthorized access to medications.
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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.
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Nursing homes near Carlsbad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayshire Carlsbad | 2 mi | ★★★★★ | 1 | 0 |
| La Paloma Healthcare Center | 4 mi | ★★★★★ | 0 | 0 |
| Pacific Villas Post Acute | 4 mi | — | 0 | 0 |
| Vista Knoll Specialized Care Facility | 4.6 mi | ★★★★★ | 18 | 0 |
| Vista View Post Acute | 5.9 mi | ★★★★★ | 1 | 0 |
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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.