Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Capistrano Beach Care Center during CMS and state inspections, most recent first.
Inaccurate PICC line dressing documentation: A resident with a PICC in the right upper arm had the dressing and Stat-lock documented as changed in the MAR before the task was actually completed. RN 2 confirmed the dressing and Stat-lock were last changed a week earlier, and the DON verified the record did not match the actual care provided. RN 1 stated she documented the task as completed but forgot to update the record accordingly.
A resident with a PICC line had the dressing and Stat-Lock left unchanged beyond the ordered weekly schedule. RN and DON confirmed the dressing had been changed once and should have been changed again the following Friday, but it remained in place during observation, contrary to the physician’s order and facility P&P for central venous catheter care.
Food safety and sanitation failures were observed throughout the kitchen and nourishment storage areas. A dietary employee handled food without hand hygiene or changing gloves, test strips for the quaternary solution were unusable and the log was incomplete, and health shakes removed from frozen storage were not dated. Staff were observed with uncovered hair and facial hair, one aide ate in the food prep area, personal items were on food prep surfaces, expired and undated foods were stored in multiple areas, and equipment and utensils were dirty, worn, damaged, or not air-dried.
The facility failed to fully carry out its infection surveillance program because the IP only tracked residents who were prescribed antimicrobials and did not initiate McGeer’s criteria for residents with signs and symptoms of infection who were not on antimicrobials. The facility also lacked specific testing protocols and acceptable ranges in its Legionella water management program. In addition, an LVN used a BP cuff that had fallen to the floor without disinfecting it before applying it to a resident.
Kitchen Equipment and Floor Maintenance Deficiencies: The facility failed to keep essential kitchen equipment in proper working condition. The walk-in freezer had ice build-up that prevented the door from closing fully, with records showing ongoing issues with temperature maintenance and prior service work. The walk-in refrigerator fan cover had black debris and brown residue resembling rust, and the floor tiles under and next to the stove were chipped, missing, and peeling with exposed cement. The Dietary Manager, Maintenance Director, Administrator, DON, and RCDM acknowledged and verified the findings.
Kitchen sanitation was not maintained when flies were observed in the food prep area during multiple observations. The facility’s records showed 77 residents ate food prepared in the kitchen, and pest control documents reflected fly treatment/inspection. The Maintenance Director said an insect control box had been installed on the kitchen wall, but he did not know whether fly control had improved.
Failure to Document Advance Directive Information and Assistance: The facility did not document that written information or assistance on formulating an advance directive was provided to three residents who had no advance directive on file. Records showed each resident lacked an AHCD/advance directive, and the H&P/MDS reflected varying cognitive status, including moderate cognitive impairment for two residents and intact cognition for one resident. The SSD and DON acknowledged the missing documentation.
Failure to Provide Grievance Filing Information: Two residents, including one cognitively intact resident and one resident with decision-making capacity, stated they did not know how to file a grievance during a Resident Council meeting. Record review and staff interviews showed there was no documentation that grievance filing information was included in the admission packet or otherwise explained to them, and the DON acknowledged the findings.
A resident receiving paroxetine HCl for major depression disorder was not documented as being monitored for medication side effects or for depression-related behaviors after the antidepressant was started. The MAR and monitoring record did not show evidence of monitoring for adverse effects or episodes of sadness, and the DON acknowledged the missing documentation during interview and record review.
Failure to Document 72-Hour Monitoring After Change in Condition: A resident with no decision-making capacity had a change in condition evaluation showing low PO intake and minimal fluid intake. The chart did not show documented nutritional monitoring for the next 72 hours, and an RN verified the missing shift-by-shift documentation that was expected after the evaluation.
A resident was observed alone in a shower room shaving with a razor while the door was open, and the room had no call system available for assistance. The resident’s MDS showed he needed supervision or touching assistance for personal hygiene, and his care plan called for staff help with shaving and prompt access to a call light; the DSD confirmed the resident was shaving by himself and that no call light was in place.
Failure to Monitor Severe Weight Loss and Complete Timely Nutritional Assessments: A resident with DM, dysphagia, and NSTEMI experienced progressive severe weight loss from 200 lbs to 155 lbs. The record showed repeated change-in-condition reviews and MD notification, but the RD nutritional assessment was not completed when the resident first had significant loss, was delayed later, and intake was not consistently compared to estimated needs. The resident was also not weighed weekly as ordered, and the DON confirmed the missing monitoring and incomplete assessment documentation.
The facility failed to provide proper respiratory care for two residents receiving oxygen. One resident was observed with the nasal cannula off the nose and later had the oxygen concentrator set above the ordered rate, while staff could not explain who changed it. Another resident’s oxygen tubing was observed without the required date label, despite an order to change and label the tubing weekly.
Pharmaceutical services were not provided to meet the needs of three residents. Two residents receiving insulin had repeated injections in the same sites without rotation, contrary to the facility's insulin administration policy, and staff verified the sites were not rotated. Another resident ordered Zosyn IV for osteomyelitis had missing MAR documentation for two scheduled doses, and the DON confirmed the medication administrations were not documented.
Failure to Check Pulse Before Metoprolol Administration: An LVN checked a resident’s BP before giving metoprolol but did not assess the resident’s pulse, despite the order to hold the medication if SBP was below 110 mmHg or pulse was below 60 bpm. The resident’s MAR/order summary showed metoprolol tartrate 12.5 mg BID for HTN with those hold parameters, and the facility P&P required pre-administration assessments.
Improper storage of expired medications and supplies was found in Medication Room A and Medication Cart A. Expired Covid-19 Binax Now tests and expired 0.9% normal saline bottles were observed, and an enema was stored in the same cabinet as oral meds such as Geri-Lanta and calcium tablets. RN 2 verified the findings, and the DON and Administrator were later informed.
Dietary Manager Not Competent to Manage Food Services: Surveyors found multiple food service deficiencies, including improper hand hygiene, incomplete sanitizing logs, missing test strips, poor food storage, expired and uncovered food, unclean or poorly maintained equipment, incorrect food texture, menu noncompliance, and flies in the kitchen. The Administrator stated he relied on the RD for feedback on the Dietary Manager's job performance, and one kitchen employee was also found not competent in job duties.
Kitchen staff competency for manual dishwashing was not ensured when Cook 2 could not fully describe or demonstrate the required 3-compartment process. Although the cook identified the wash, rinse, and sanitize compartments and had attended a sanitation in-service, the cook could not state the minimum hot water temperature, gave an incorrect answer about sanitizing time, and dipped the sanitizer test strip for only one second instead of the required ten seconds.
A resident on a controlled carbohydrate, pureed diet did not receive the high caloric pudding or nectar-mildly thick whole milk listed on her meal ticket during a lunch tray observation. The MDS Coordinator verified the missing items, and the Administrator, DON, and RCDM were later made aware of the finding.
A resident with COPD and dysphagia was ordered a Regular Diet with Soft and Bite-Sized Level 6 texture, vegetarian, and no salad entree, but was observed being served a tossed salad with croutons and fresh chopped cantaloupe along with other lunch items. The RCDM acknowledged raw vegetables were not allowed on the texture diet and could not locate a physician order allowing fresh fruits and vegetables.
Substitute Meal Entree Did Not Match Nutritional Value: A resident with an order for a regular diet, Soft and Bite-Sized Level 6 texture, vegetarian, and no salad entree was served a grilled cheese sandwich instead of the planned baked chicken entree. Facility records showed the baked chicken would have provided more protein than the grilled cheese, and the substitute meal did not match the nutritive value of the main entree.
Adaptive eating equipment was not used properly for a resident during lunch. The resident’s meal ticket and MD order indicated a plate guard for all meals to support self-feeding independence, but staff observed the plate guard placed under the plate instead of on it. The RCDM confirmed the plate guard should have been on the plate.
Unsafe Handling of Food Brought by Visitors: The facility failed to ensure safe food handling for food brought in by family and other visitors. An LVN was unsure how long outside food could be stored in the refrigerator, the IP said staff training focused on dating the food, and the Dietary Mgr stated he was not involved in educating visitors or family members on safe food handling and had never been asked to provide such training.
Improper Storage of Refuse and Broken Equipment: The facility failed to keep dumpster lids fully closed and failed to dispose of broken equipment properly. Surveyors observed a recycling dumpster and two garbage dumpsters with lids propped open by a cardboard box and garbage bags, and found multiple broken items and equipment stored around the trash collection area and behind the facility, including wooden crates, a shower chair, a bedside table, tables, bed frames, and a front wheel walker. The Maintenance Director verified the findings and stated the dumpster lids should be fully closed and that the unused equipment needed to be discarded.
Incomplete Facility Assessment: The facility failed to ensure its Facility Assessment was complete. The assessment did not show active involvement of direct care staff, direct care representatives, residents, residents' representatives, or family members, and it lacked a plan to maximize recruitment and retention of direct care staff as well as a contingency plan for staffing needs. The Administrator reviewed the assessment and verified these omissions, stating she was not aware of the current CMS guidance.
A resident’s medical record contained conflicting documentation about whether an advance directive had been formulated. The AHD acknowledgement form indicated no advance directive had been completed, while the POLST stated the advance directive was not available. During record review, the SSD verified the inconsistency and said she would contact the resident’s responsible party to clarify whether an advance directive existed.
A resident with moderately impaired cognition experienced a dislodged nephrostomy tube and was transferred to a hospital for re-insertion. Upon return, facility staff did not develop a care plan to address the resident's needs related to the dislodged and replaced nephrostomy tube, as confirmed by medical record review and staff interviews.
A resident with advanced dementia was not properly represented in care planning when the responsible party was not informed in advance about psychological testing, psychiatric visits, or a new order for buspar following a behavioral incident. Facility staff and the psychiatrist confirmed that the responsible party was not notified as required by policy, resulting in a lack of informed consent for the resident's psychiatric care.
A resident with moderately impaired cognition did not receive timely blood pressure monitoring for hypotension, as required by facility policy, with BPs checked only twice per day despite low readings. Abnormal CBC results indicating infection were not promptly reported to the physician, with a delay of over three hours. Additionally, a stat order for a urine sample was not acted upon immediately, with collection occurring several hours after the order was placed.
A resident with confusion and no capacity experienced a change of condition, developing a cough. The physician ordered Tamiflu, but the medication was not transcribed into the medical record or administered. The IP admitted to the oversight, and the DON acknowledged the miscommunication between staff.
A facility failed to report an abuse allegation in a timely manner, as required by their policies and section 1150B of the Act. An LVN witnessed a resident with pillows over her face, allegedly placed by another resident. The incident was reported to the Administrator and other authorities, but the CDPH, L&C Program was not notified until seven days later. This delay was confirmed by interviews with the RN and Administrator, highlighting a deviation from the facility's protocol.
A facility failed to provide a resident with quarterly trust fund statements, as required by policy. The resident, who was cognitively intact, reported not receiving statements for years. The BOM claimed to have handed the statement in November but did not document the transaction. The Administrator could not provide evidence of the statement's delivery, indicating a deficiency in managing residents' personal funds.
The facility failed to follow food safety and sanitation guidelines, with undated and expired food items in the refrigerator, improper hair restraints worn by staff, and poor condition of kitchen equipment. A cleaning chemical was stored next to food items, and a handwashing sink was obstructed, posing contamination risks.
A facility failed to update informed consent for a resident's use of risperidone when the indication changed from suicidal ideation to racing thoughts. Despite the resident's capacity to understand and make decisions, the informed consent form was not updated, as confirmed by an LVN and an RN during interviews and record reviews.
A facility failed to assess a resident's ability to self-administer tetrahydrozoline eye drops, which were found at the resident's bedside without a physician's order. The resident lacked the capacity to make medical decisions and had not been approved for self-administration, contrary to facility policy.
The facility failed to ensure call lights were accessible for two residents, impacting their ability to request assistance. One resident's call light was placed out of reach on the bed, while another's was found on the floor. CNAs confirmed the call lights were not accessible and repositioned them.
The facility failed to address concerns from resident council meetings, including incomplete follow-up on OCTA Access forms and CNA mannerisms. The Resident Council Response Form was not properly utilized, leading to unresolved issues. Interviews revealed communication lapses and incomplete documentation, resulting in unaddressed resident concerns.
The facility failed to document and offer advance directive information to several residents, as required by policy. Medical records for multiple residents lacked evidence of being asked about advance directives or provided information on formulating one. Interviews with the SSD confirmed these documentation gaps, and the DON acknowledged the findings.
The facility failed to protect the confidentiality of two residents' medical records when computer monitors displaying sensitive information were left unattended at a nursing station. An LVN confirmed the oversight, and a CNA admitted to leaving a monitor unattended while assisting a resident, violating the facility's policy on safeguarding resident information.
A facility failed to provide written notification to a resident's representatives about a hospital transfer, as required by policy. The resident, who lacked decision-making capacity, was transferred without a signed Notice of Transfer/Discharge Form or documented written notification. The SSD confirmed that verbal notification was typical, but written notice was not given, risking the representatives' awareness of appeal rights.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled in hospice services. The resident was admitted to hospice on July 29, 2024, but no comprehensive assessment or SCSA was completed within the required timeframe. This was confirmed by the MDS Coordinator during an interview.
The facility failed to develop comprehensive care plans for three residents who experienced falls, resulting in deficiencies in addressing their specific needs. A resident had an unwitnessed fall and significant weight loss without a care plan to address these issues. Another resident slipped off the bed, and a third resident fell while transferring from a wheelchair, both without care plans. Interviews with staff confirmed the lack of appropriate care planning, indicating a failure to provide individualized care.
A resident with a cervical fracture was observed without a required cervical collar, contrary to a physician's order. The resident had stopped wearing the collar after a neurosurgeon appointment, but there was no documentation of order discontinuation. An LVN confirmed the order was still active, highlighting a failure in follow-up care.
A resident at high risk for pressure ulcers was found on a low air loss mattress set incorrectly to 250 pounds instead of their actual weight of 103 pounds. The resident was unable to communicate comfort levels due to cognitive impairment, and staff interviews confirmed the mattress should have been set according to weight. The MDS Coordinator adjusted the setting after the discrepancy was identified.
The facility failed to investigate and document the cause of a skin tear for a resident and did not ensure another resident wore a WanderGuard as ordered. Staff interviews revealed inconsistencies in reporting and documentation, and the WanderGuard was never applied despite the resident's risk for wandering. These deficiencies indicate non-compliance with facility policies and physician's orders.
The facility failed to monitor and address significant weight loss in three residents. A resident experienced severe weight loss without timely notification to their physician or an IDT evaluation. Two other residents did not receive weekly weight monitoring as ordered, leading to untracked weight changes. The DON confirmed communication lapses in implementing RD recommendations and physician orders.
The facility failed to provide necessary respiratory care for several residents, including improper oxygen administration and lack of adherence to physician orders. A resident received oxygen without a physician's order, while another had their oxygen tubing compressed by a door. Additionally, a resident was found on room air despite needing continuous oxygen, and another's oxygen titration order lacked specific parameters. Improper storage of a suction machine was also noted.
A resident with severe cognitive impairment received inadequate pain management due to unclear medication orders. The resident had overlapping orders for acetaminophen and hydrocodone-acetaminophen, leading to the administration of acetaminophen for a pain level of 5, when hydrocodone-acetaminophen was more appropriate. An LVN confirmed the lack of clear indications for use in the medication orders.
A facility failed to follow its protocol for administering medications through a G-tube for a resident. The policy required flushing the G-tube with water before and between medications, but an LVN used a syringe and plunger without flushing. The resident had a G-tube placement and an order to flush with 30 ml of water before and after medications.
The facility failed to monitor the behavior and side effects of a resident on risperidone and did not limit another resident's PRN lorazepam order to 14 days, as required by policy. Staff confirmed the lack of monitoring and documentation for extending medication use.
Inaccurate PICC Line Dressing Documentation
Penalty
Summary
The facility failed to ensure the medical record for one of four sampled residents was accurate when the PICC line dressing and Stat Lock were documented as changed on 5/22/26, but were actually last changed on 5/15/26. Resident 1 had a physician order for the right upper arm PICC dressing and Stat-lock to be changed every Friday, and the resident’s H&P showed the resident had the capacity to understand and make medical decisions, while the MDS showed moderate cognitive impairment. On 5/27/26, the resident was observed to have a PICC line in the right upper arm with a dressing dated 5/15/25. During concurrent observation, interview, and record review, RN 2 confirmed the dressing and Stat-lock had been changed on 5/15/25 and stated they should have been changed a week later on 5/22/26. The IV MAR showed the dressing and Stat-lock documented as changed on 5/22/26 by RN 1, and RN 2 stated documentation should be completed after the task is performed, not before. The DON verified the findings and stated the dressing and Stat-lock should have been changed every Friday and as needed to prevent infections; RN 1 later stated she had documented the task as completed but had forgotten to update the record accordingly.
PICC Dressing and Stat-Lock Not Changed as Ordered
Penalty
Summary
Provide and implement an infection prevention and control program was deficient for one sampled resident with a PICC line. Resident 1 had a PICC inserted in the right upper arm and was admitted to the facility with a history that included the capacity to understand and make medical decisions, although the MDS also documented moderate cognitive impairment. The physician’s order directed that the right upper arm PICC dressing and Stat-lock be changed every Friday. On observation, the resident’s PICC line was seen with a dressing dated 5/15/25. During concurrent interview and record review, RN 2 confirmed the dressing and Stat-Lock had been changed on 5/15/25 and stated they should have been changed one week later, on 5/22/26. The DON also confirmed the findings and stated the PICC line dressing and Stat-lock should have been changed every Friday and as needed to prevent infections.
Food Safety and Sanitation Failures in Kitchen and Nourishment Storage Areas
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed in multiple areas of the kitchen and nourishment storage areas. During observation in the kitchen, one dietary employee was seen wearing gloves while opening the refrigerator, touching multiple counter surfaces, and then cutting raw onions, lettuce, and tomato without performing hand hygiene or changing gloves. The Dietary Manager was informed and directed the employee to wash hands and put on new gloves. The facility also did not maintain required sanitation monitoring and storage practices. The quaternary ammonium test strips were unusable because the strips in the container were wet, and the Dietary Manager stated there were no extra test strips available. The Quaternary Ammonium Log also had missing entries for 9/28 and 9/29/25. In the nourishment refrigerator, health shakes removed from frozen storage were not dated when placed in the refrigerator, and the Dietary Manager stated there was no system in place to monitor the dates once thawed. The nourishment refrigerator also contained resident food items without dates or names, including fruit ice pops, a frozen meal, an ice cream tub with freezer burn, and canned beverages. Additional observations showed multiple storage and sanitation problems throughout the kitchen and unit refrigerators. Kitchen staff were observed with uncovered hair and uncovered facial hair, and one dietary aide was observed eating in the food preparation area. Personal items, including cell phones, were observed on food preparation surfaces. Expired orange juice was found in dry storage, food in the walk-in freezer was not covered and showed freezer burn, and dry storage bins were lined with black plastic liners that were not food grade safe. The nourishment refrigerator was also used to store personal care ice packs labeled for external use only alongside resident food. Food preparation equipment and utensils were found dirty, worn, chipped, or damaged, including pans, bowls, spatulas, a mixer holder, knife racks, and a can opener blade. A blender was observed stored wet with the lid on, and the Dietary Manager verified it had not been air-dried.
Infection Surveillance, Legionella Water Management, and Equipment Disinfection Failures
Penalty
Summary
The facility failed to implement its infection control surveillance program in accordance with its policy. The facility’s policy stated the infection preventionist was responsible for ongoing surveillance of healthcare-associated infections and other significant infections, and that nursing staff were to monitor residents for signs and symptoms of infection and report suspected infections. During interview, the infection preventionist stated the facility used McGeer’s criteria to determine whether a resident had an infection and that the licensed nurse who received an antimicrobial order would initiate the McGeer’s criteria form. Review of the monthly Infection Prevention and Control Surveillance Logs from January through October 2025 showed counts for healthcare-associated infections, community-acquired infections, and residents who did not meet McGeer’s criteria. The logs also showed that all residents included on the surveillance logs were prescribed antimicrobial medications. When asked whether residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications were included in surveillance, the infection preventionist stated the facility did not initiate the McGeer’s criteria form for those residents. The infection preventionist was unable to state how many residents had infections and were not prescribed antimicrobial medications during that period because the facility did not initiate the form for them. The facility also failed to establish specific testing protocols and acceptable ranges for control measures in its Legionella Water Management Program. The facility’s policy stated the water management program was intended to identify areas where Legionella could grow and spread and included specific measures, control limits, monitoring, and a plan when limits were not met. During interview and record review, the Administrator verified that the facility’s Water Management Program for Legionella Control did not show specific testing protocols or acceptable ranges for the control measures. In addition, during a medication pass observation, an LVN obtained a sphygmomanometer from the medication cart after it fell to the floor and did not disinfect it before using it on a resident. The LVN later verified that the device was not cleaned or disinfected before use. The DON and Administrator later acknowledged that any equipment used for residents needed to be clean or disinfected prior to use.
Kitchen Equipment and Floor Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure essential kitchen equipment was maintained in proper working condition. The kitchen walk-in freezer had ice build-up that prevented the door from closing completely, and facility records showed repeated concerns with the unit, including documentation that it could not maintain the temperature range and a third-party maintenance service report for repairs to the freezer system. During the kitchen tour, the Dietary Manager and Maintenance Director both observed and acknowledged ice build-up on the floor, ceiling, shelves, and around the interior and exterior bottom lining of the freezer door, with the Maintenance Director verifying that the door was not closing properly. The walk-in refrigerator fan cover was observed with black debris and brown residue resembling rust, and the Maintenance Director stated the fans were wiped down every six months while verifying the condition. In addition, the kitchen floor tiles under and next to the stove were chipped, peeling, missing in places, and had exposed cement and black residue. The Maintenance Director verified the floor condition, and later the Administrator, DON, and RCDM acknowledged and verified all of the findings.
Kitchen sanitation not maintained due to flies in food prep area
Penalty
Summary
The facility failed to ensure sanitation in the kitchen was maintained and failed to keep the kitchen free from flies. Review of the facility’s Matrix showed 77 residents consumed food prepared in the kitchen. The facility’s P&P titled Miscellaneous Areas stated that flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food and Nutrition Services Department. The facility’s P&P titled Sanitation stated that monthly a pest control company would inspect and service the Food and Nutrition Services department. Facility documents from a pest elimination company dated 6/18, 8/5, and 9/8/25 showed the pests treated and inspected for were flies. During an initial kitchen tour on 9/29/25, three flies were observed in the kitchen near the food preparation area, and during follow-up observations on 9/30/25 and 10/1/25, two flies and then one fly were observed in the same area. The kitchen door was adjacent to the back door of the facility leading to the trash dumpster in the parking lot. The Maintenance Director was informed of the findings and stated an insect control box had been installed on the kitchen wall in early September 2025, but he did not know if fly pest control had improved.
Failure to Document Advance Directive Information and Assistance
Penalty
Summary
The facility failed to inform and provide written information about the right to formulate an advance directive for three sampled residents who did not have an advance directive on file. Facility policy stated that prior to or upon admission, the resident or representative should be asked about the existence of any written advance directives, provided written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive, and offered assistance if no advance directive had been established. The policy also stated that nursing staff would document the offer to assist and the resident's decision to accept or decline assistance. For Resident 20, the record showed no AHCD and no advance directive on the POLST, and the H&P noted the resident had capacity to understand and make decisions, while the MDS showed moderate cognitive impairment. The SSD verified there was no documented evidence that information on how to formulate an advance directive had been provided after the resident's readmission. For Resident 46, the POLST showed no advance directive, the H&P noted capacity to understand and make decisions, and the MDS showed moderate cognitive impairment; the record did not show documented evidence that the facility provided information or assistance on formulating an advance directive to the resident or representative. For Resident 63, the POLST showed no advance directive, the H&P noted capacity to understand and make decisions, and the MDS showed the resident was cognitively intact; the medical record also failed to show documented evidence that the facility provided information or assistance on formulating an advance directive.
Failure to Provide Grievance Filing Information
Penalty
Summary
The facility failed to ensure that information on how to file a grievance was provided to two residents, including one final sampled resident and one nonsampled resident who attended the Resident Council meeting. During the meeting, when residents were asked who they would report concerns to, they stated they would bring concerns to administration and that administration would respond and resolve them. When asked whether they knew how to file a grievance, the two residents stated they did not know how to do so. Review of the medical record for one resident showed a BIMS score of 11, indicating the resident was cognitively intact. Review of the other resident's H&P showed the resident had the capacity to make decisions. Facility record review and interviews with the Admission Office Manager, SSD, and Activity Director showed there was no documented evidence that the grievance information was included in the admission packet or otherwise explained to the two residents. The DON was later informed and acknowledged the findings.
Failure to Monitor Psychotropic Medication and Depression Symptoms
Penalty
Summary
The facility failed to ensure Resident 46 was monitored for the side effects of paroxetine HCl, an antidepressant medication, after the resident began receiving paroxetine HCl 10 mg by mouth daily for major depression disorder manifested by verbalization of sadness. Review of the facility's psychotropic medication policy showed that residents receiving psychotropic medications are to be monitored for efficacy and adverse consequences, but the resident's Monitoring Record and MAR for November 2025 did not show documented evidence of monitoring for side effects after the medication was started on 11/7/25. Medical record review showed Resident 46 was admitted and later readmitted to the facility, and the H&P dated 8/25/25 documented that the resident had the capacity to understand and make decisions. The record also failed to show documentation that the resident's behavior was monitored for depression or for episodes of sadness. During an interview and concurrent record review, the DON acknowledged there was no documentation showing monitoring for side effects of the paroxetine medication or monitoring of the depression episodes to determine the effectiveness of the medication.
Failure to Document 72-Hour Monitoring After Change in Condition
Penalty
Summary
The facility failed to complete the required 72-hour monitoring after a change in condition for one resident. The resident was admitted to the facility and had no capacity to understand and make decisions, with an MDS assessment showing a BIMS score of 99, indicating the interview could not be completed. A Change in Condition Evaluation completed at 2347 hours on 8/16/25 documented low PO intake, with the resident consuming approximately 25% of meals and only sips of water. Medical record review did not show documented evidence that the resident’s nutritional status was monitored on 8/17/25 through 8/19/25 after the change in condition. During an interview and concurrent record review, the RN verified the missing documentation. The RN stated that after completion of the change in condition evaluation, licensed nurses were to complete 72 hours of documentation every shift to show the care provided and the resident’s well-being. The Administrator and DON were informed of the findings and acknowledged them, and the DON stated that after the evaluation, licensed nurses would monitor the resident’s condition and document in progress notes every shift for 72 hours.
Resident Left Unsupervised in Shower Room Without Call System
Penalty
Summary
The facility failed to ensure Resident 2 remained free from accident hazards and was adequately supervised in Shower room [ROOM NUMBER]. On 11/17/25 at 1122 hours, Resident 2 was observed in the shower room with the door open, shaving his face with a razor by himself in front of the bathroom mirror. The shower room was observed without a call system available for the resident to use if assistance was needed. At 1124 hours, the DSD confirmed that Resident 2 was shaving by himself in the shower room and that there was no call light or call system in place. Resident 2 was admitted to the facility and his MDS assessment showed he needed supervision or touching assistance from staff for personal hygiene tasks. His care plan identified a risk for unavoidable falls related to a history of falls and limited mobility, and included interventions for staff to assist with personal hygiene, including shaving, and to keep the call light within reach with prompt response to requests for assistance. Facility policy stated residents should never be left unattended in the tub or shower and should have an emergency call signal available for assistance, but the resident was observed alone in the shower room without that system available.
Failure to Monitor Severe Weight Loss and Complete Timely Nutritional Assessments
Penalty
Summary
The facility failed to ensure acceptable nutritional status was maintained for one resident who experienced progressive, severe weight loss. The resident was admitted with diagnoses including type 2 diabetes mellitus, dysphagia, and NSTEMI, and the H&P noted the resident had no capacity to make medical decisions and weighed 200 lbs at admission. The resident’s weight declined to 174 lbs, then 160 lbs, and later 155 lbs, reflecting severe weight loss over time. The record showed the resident was identified as high nutritional risk, with care plan interventions addressing poor or variable meal intake, recent weight loss, and risk for further weight loss. After the resident weighed 174 lbs, the record showed a Change in Condition Evaluation documenting a 10-lb monthly loss and notifying the MD, but the medical record did not show that the RD completed the ordered nutritional assessment. The facility’s IDT Weight Management documentation noted the resident’s weight loss and included encouragement of oral intake, extra portions, assist with meals, Glucerna BID, and Pro-Stat, but the record failed to show reassessment of weight or additional interventions after the severe loss was identified. The DON confirmed the resident had severe weight loss at that time, that the IDT met on multiple occasions, that the RD assessment with calorie, protein, and fluid needs could not be verified, and that the resident was not weighed weekly. When the resident later weighed 160 lbs, the Change in Condition Evaluation again documented weight loss and the MD was notified with a referral to RD, but the RD did not complete the nutritional assessment until later. The DON verified the RD assessment was not done in a timely manner and stated the resident did not have an order for weekly weights, which should have been ordered to monitor weight closely. When the resident weighed 155 lbs, the record showed another Change in Condition Evaluation and a Weight Variance entry with a recommendation for weekly weights for four weeks, but the record failed to show that the resident was actually weighed weekly as ordered. The DON verified the severe weight loss and acknowledged that the nutritional assessment could not be verified and that weekly weights were not documented as ordered.
Oxygen Therapy Not Provided and Tubing Not Dated
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents receiving oxygen therapy. Resident 13 was observed lying in bed with oxygen therapy via nasal cannula at three liters per minute, but the nasal cannula was on the resident’s chest rather than in the nose. During a later observation, the oxygen concentrator was turned on at five liters per minute, and the LVN verified the concentrator was set at that rate. The LVN also confirmed the resident had a physician’s order for continuous oxygen at two to four liters per minute via nasal cannula to maintain oxygen saturation above 90%, and stated she did not know who changed the oxygen rate to five liters per minute. Resident 13’s record also showed impairment in both upper extremities on the MDS assessment. Resident 14 was observed in the dining room using oxygen via nasal cannula, and the oxygen tubing had no date label. The resident’s record included an order for continuous oxygen at two to three liters per minute via nasal cannula and a separate order to change the oxygen humidifier and nasal cannula/tubing every week on Sundays and PRN, with the tubing labeled with the date. The IP verified the tubing was undated and stated the oxygen tubing was changed every Sunday and should be labeled with the date when changed.
Pharmaceutical Services: Insulin Sites Not Rotated and IV Antibiotic Administration Not Documented
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident for three sampled residents reviewed for unnecessary medications. The report states that the facility did not ensure insulin injection sites were rotated for Resident 2 and Resident 20, and did not ensure Zosyn IV medication was administered to Resident 69. The facility's policy on insulin administration required selecting an injection site, rotating injection sites preferably within the same general area, and documenting the injection site and any bruising, pain, redness, swelling, or unusual marks. Resident 20 had an order for Humalog insulin before meals and at bedtime for diabetes mellitus. Review of the September 2025 location of administration report showed repeated Humalog injections were given in the left lower quadrant of the abdomen on multiple occasions. During interview and record review, LVN 4 verified the injection sites were not rotated and stated that sites must be rotated because non-rotation could cause swelling, pain, bruising, and poor absorption of the medication. The Administrator and DON were informed and acknowledged the findings. Resident 2 had orders for Semglee insulin at bedtime and Humalog insulin before meals and at bedtime for diabetes mellitus. Review of the October 2025 location of administration report showed Humalog was repeatedly administered in the left lower quadrant of the abdomen, left deltoid, and left upper quadrant of the abdomen without rotation of sites as verified by LVN 2 and RN 2. Resident 69 had an order for Zosyn 3-0.375 gm/50 ml IV every eight hours for right foot osteomyelitis for 35 days, but the September 2025 MAR did not document administration on 9/18/25 at 1400 and 9/28/25 at 2200. The DON verified the MAR lacked documentation for those administrations and stated that any medication administration should be documented in the MAR.
Failure to Check Pulse Before Metoprolol Administration
Penalty
Summary
The facility failed to ensure that one resident observed during medication administration was free from a significant medication error. During an observation of medication pass for Resident 40, the LVN checked the resident’s blood pressure before preparing medications, including metoprolol 12.5 mg, but did not check the resident’s pulse rate before proceeding with administration. The metoprolol bubble pack directions required the medication to be held if systolic blood pressure was below 110 mmHg or pulse rate was below 60 beats per minute. Review of the resident’s order summary showed a physician’s order for metoprolol tartrate 12.5 mg by mouth twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was below 110 mmHg or pulse rate was below 60 beats per minute. The facility’s P&P for administering oral medications required verification of a physician’s medication order and performance of any pre-administration assessments. The LVN acknowledged that the pulse rate was not checked, and the DON and Administrator were informed of the findings.
Improper Storage of Expired Medications and Supplies
Penalty
Summary
The facility failed to ensure medications and supplies in Medication Room A and Medication Cart A were stored properly. During an inspection of Medication Room A, 20 individual packages of Covid-19 Binax Now were observed with an expiration date of 9/23/23, and an enema was stored in the same cabinet as orally administered Geri-Lanta and calcium tablets. RN 2 verified the expired supply and the mixed storage of external and internal medications, and stated expired supplies needed to be discarded and external and internal medications needed to be separated. During inspection of Medication Cart A, two sterile bottles of 0.9% normal saline 100 ml were found inside the cart, with one expired on 2/13/21 and the other expired on 4/1/22. RN 2 verified the findings and stated expired supplies needed to be discarded according to facility protocol. The DON and Administrator were later informed and acknowledged the findings.
Dietary Manager Not Competent to Manage Food Services
Penalty
Summary
The facility failed to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice in the food services department. The Dietary Manager was identified as not being competent in managing the day-to-day functions of the food services department, despite the position summary stating the role was to organize, plan, and supervise dietary department functions in accordance with applicable federal, state, and local standards and as directed by the Administrator and Dietitian. During the annual recertification survey, surveyors observed multiple kitchen and dietary issues, including improper hand hygiene during meal preparation, missing sanitizing test strips and incomplete sanitizing logs, improperly stored resident nutritional supplements, lack of hair restraints, food in the nourishment refrigerator that was not dated or stored at the proper temperature, employee personal items stored inappropriately, expired food not discarded, uncovered food in the walk-in freezer, a kitchen employee eating in the kitchen, improperly stored dry goods, food preparation equipment and utensils not clean or in good working condition, non-food contact surfaces not in good working condition, equipment not air dried, the wrong food texture served, the menu not followed, a meal substitute not equivalent in nutrient value to the main entree, one kitchen employee not competent in job duties, kitchen equipment not in good working order, and flies observed in the kitchen. The Administrator stated that all managers should be experts in their area of supervision and that he relied on the Registered Dietitian for feedback on the Dietary Manager's job performance.
Kitchen Staff Lacked Competency in Manual Dishwashing Procedure
Penalty
Summary
The facility failed to ensure one of 14 kitchen staff members, Cook 2, had the appropriate skill set necessary to safely perform manual dishwashing. The facility’s policy for 3-compartment manual dishwashing required the first compartment to be filled with detergent and hot water at 110 to 120 degrees Fahrenheit, the second compartment to be filled with clean, clear hot water at 110 to 120 degrees Fahrenheit, and the third compartment to contain Sani Tech solution tested with a strip dipped for ten seconds and reading 200 to 400 ppm, with items immersed for sixty seconds. The facility document for a sanitation procedures in-service dated 6/11/25 showed Cook 2 attended the training. During an observation and concurrent interview on 9/30/25, Cook 2 correctly identified the wash, rinse, and sanitize compartments, but was unable to state the minimum hot water temperature for manual dishwashing. When asked how long items needed to be sanitized, Cook 2 stated they could stay in the compartment for a long time. Cook 2 also demonstrated testing the sanitizing solution by dipping the test strip for one second instead of the required ten seconds. The RCDM verified and acknowledged these findings.
Diet Order Not Followed for Resident Meal Tray
Penalty
Summary
The facility failed to ensure the menu for a resident's prescribed diet was followed for Resident 23, who was on a controlled carbohydrate diet with pureed texture. During a dining observation, Resident 23's lunch meal ticket indicated she was to receive a high caloric pudding and 8 fluid ounces of nectar-mildly thick whole milk, but her lunch tray did not contain either item. The MDS Coordinator observed the tray and verified that Resident 23 was not provided with the high caloric pudding and whole milk. The facility's Matrix showed that 77 residents consumed food prepared in the kitchen, and the Administrator, DON, and RCDM were later informed of and acknowledged the findings.
Improper Diet Texture Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that Resident 12 received food prepared in the prescribed diet texture. Resident 12 was admitted with diagnoses including COPD and dysphagia, and the physician's order dated 9/15/25 specified a Regular Diet with Soft and Bite-Sized Level 6 texture, vegetarian, no salad entree, and permission for grilled cheese, regular bread, and toast. The facility's 2023/2025 Diet Manual for IDDSI Level 6 states to avoid all raw vegetables. During a dining observation on 9/29/25, Resident 12 was served a small tossed salad with croutons, fresh chopped cantaloupe melon, cooked green beans, a grilled cheese sandwich, and chocolate pudding for lunch. On 10/1/25, the RCDM acknowledged that raw vegetables were not allowed on a Soft and Bite-Sized texture diet and stated the resident had an order to allow fresh fruits and vegetables, but was unable to find a physician's order supporting that allowance.
Substitute Meal Entree Did Not Match Nutritional Value
Penalty
Summary
The facility failed to ensure Resident 12 received a substitute meal entree equivalent to the nutritive value of the main meal entree. Resident 12 had an order for a regular diet with Soft and Bite-Sized Level 6 texture, vegetarian, no salad entree, and permission for grilled cheese, regular bread, and toast. During the lunch meal observation, Resident 12 was served a grilled cheese sandwich instead of the three ounces of soft and bite-sized baked chicken listed as the entree for the meal. Facility records showed the lunch meal for the Soft and Bite-Sized diet was to include three ounces of baked chicken. The facility's nutritional analysis showed the baked chicken would provide 21 grams of protein, while the American cheese used in the grilled cheese sandwich provided 3 grams of protein per slice, for a total of 12 grams from four slices. The Administrator, DON, and RCDM were informed of the findings and acknowledged them.
Adaptive Eating Equipment Not Used Properly
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance was not ensured for Resident 23. During a dining observation on 9/29/25 at 1216 hours, Resident 23 was seen eating lunch in the dining room with the plate guard placed under the plate instead of on the plate. The resident’s meal ticket identified the plate guard as adaptive equipment. Medical record review showed a physician’s order dated 6/11/25 for a plate guard for all meals to increase independence with self-feeding. During a 9/30/25 observation and interview with the Dietary Manager and RCDM, the RCDM stated the plate guard was an OT order used when the resident had tremors and verified that the plate guard should have been placed on the plate to guard the food.
Unsafe Handling of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure safe food handling of food brought in for residents from outside sources. The facility’s policy titled "Food Brought by Family and Visitors," revised in 3/2022, stated that safe food handling practices are explained to family and visitors in a language and format they understand. However, during interview, LVN 6 stated that when visitors brought food from outside sources, staff would check the diet order and tell visitors the food must be labeled, but he was not sure how long the food could be stored in the refrigerator. LVN 6 also stated that the Dietary Manager provided training on safe food handling. The Infection Preventionist stated that the in-service training was about dating the food and that he provided the policy to employees. He further stated that the Dietary Manager would discuss safe food handling with family members upon admission or quarterly. The Dietary Manager stated he was not involved in educating visitors or family members on safe food handling related to food brought in from outside sources and said he had never been asked to provide such training for visitors.
Improper Storage of Refuse and Broken Equipment
Penalty
Summary
The facility failed to ensure refuse was stored in a sanitary manner. During observation, the outside recycling dumpster and two outside garbage dumpsters were found with lids not fully closed. The recycling dumpster lid was partially propped open by a cardboard box, and the two garbage dumpster lids were partially propped open by garbage bags, preventing them from fully closing. The Maintenance Director was interviewed at the trash collection area and verified that the dumpster lids should be fully closed. The facility also failed to ensure broken items and equipment were disposed of properly. At the trash collection area, more than five large wooden crates were observed adjacent to the recycling dumpster. Behind the metal storage container in the facility compound, a shower chair, bedside table, and two long wooden tables were observed. Behind the facility building, five bed frames and a front wheel walker were observed. The Maintenance Director verified these items were broken equipment, stated he would try to save the parts he could reuse, and stated the equipment behind the storage container was not being used and needed to be discarded.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure the Facility Assessment was complete. The report states that the assessment did not address or include the active involvement of required individuals in developing the Facility Assessment, including direct care staff members, direct care representatives, residents, residents' representatives, and residents' family members. It also did not include a plan to maximize recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and concurrent review of the Facility Assessment with the Administrator, the Administrator reviewed the assessment dated 8/21/25 and verified that there were no direct care staff, direct care representatives, residents' representatives, or family members actively involved in developing it. The Administrator further verified that there was no documentation of a plan to maximize recruitment and no contingency plan for staffing needs in the Facility Assessment, and stated she was not aware of the current CMS guidance. The Administrator acknowledged that the Facility Assessment was not complete and had not been updated based on the latest CMS guidance.
Conflicting Advance Directive Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for one of 23 sampled residents, Resident 5, because the record contained conflicting documentation about whether an advance directive for health care had been formulated. Review of Resident 5’s Advanced Healthcare Directive Acknowledgement Form dated 9/8/25 showed that Resident 5 had not formulated an advance directive, while the POLST dated 9/8/25 stated that the resident’s advance directive was not available. During an interview and concurrent medical record review with the SSD on 11/17/25 at 1449 hours, the SSD verified the conflicting documentation in the medical record and stated she would contact Resident 5’s responsible party to determine whether an advance directive had been formulated.
Failure to Develop Care Plan for Dislodged Nephrostomy Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the needs of a resident who experienced a dislodged nephrostomy tube. According to the facility's policy, a person-centered care plan with measurable objectives and timetables should be developed and implemented for each resident, including after a change in condition. Medical record review showed that the resident, who had moderately impaired cognition, had a nephrostomy tube dislodged and was transferred to an acute care hospital for re-insertion. Upon return to the facility with the tube replaced, there was no evidence that a care plan was created to address the dislodged and replaced nephrostomy tube. Interviews with facility staff, including an LVN and the DON, confirmed that no care plan was developed for the resident's nephrostomy tube incident. The staff acknowledged that a care plan should have been initiated following the change in condition, including interventions such as transfer to the hospital and care of the nephrostomy tube site. The absence of a care plan meant the resident's specific needs related to the nephrostomy tube were not formally addressed in the care planning process.
Failure to Inform Responsible Party of Psychiatric Care and Medication Changes
Penalty
Summary
The facility failed to ensure that the responsible party for one of six sampled residents was informed in advance about the care to be furnished and the type of provider who would be delivering that care. Specifically, the responsible party was not notified prior to psychological tests, psychiatric visits, or the prescription of buspar by the psychiatrist following a resident-to-resident altercation. The facility's policies require that residents and their responsible parties be included in care planning and notified of changes in care or treatment, but these procedures were not followed in this instance. The resident involved had advanced dementia and was readmitted to the facility prior to the incident. Documentation from a care conference with the responsible party did not mention upcoming psychiatric interventions or medication changes. Interviews with facility staff and the psychiatrist confirmed that the responsible party was not informed in advance about the psychiatric evaluation, follow-up visits, or the new medication order. The psychiatrist indicated that he believed it was the facility's responsibility to obtain informed consent, and the responsible party expressed concerns about not being notified about these aspects of the resident's care.
Failure to Monitor Hypotension, Delay in Reporting Lab Results, and Delay in Stat Urine Collection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident as required by physician orders, resident preferences, and established policies and procedures. Specifically, the facility did not adequately monitor the resident's blood pressure for hypotension, despite multiple readings below the defined threshold of 100/60 mmHg. Blood pressure measurements were only taken twice per day over two days, and staff interviews confirmed that more frequent monitoring was warranted but not performed. Additionally, the facility did not promptly report abnormal laboratory results to the resident's physician. A CBC test revealed an elevated white blood cell count, which was received by the facility at 1256 hours but not communicated to the physician until over three hours later. Both nursing staff interviewed acknowledged that the results, indicating a possible infection, should have been reported immediately upon receipt. The facility also failed to collect a stat urine sample in a timely manner after a physician's order was placed. The order for a UA with C&S stat was entered at 1747 hours, but the urine sample was not collected until 2218 hours the same day. Staff interviews confirmed that the sample should have been collected immediately following the order. These failures were verified through observation, interviews, and medical record review.
Failure to Administer Tamiflu as Ordered
Penalty
Summary
The facility failed to administer Tamiflu to Resident 2 as ordered by the physician, which was necessary to address a change in the resident's condition. Resident 2, who was admitted to the facility with confusion and no capacity, experienced a change of condition on January 22, 2025, when they developed a cough. The physician ordered Tamiflu 75 mg to be administered daily for seven days. However, the order was not transcribed into the resident's medical record, and the medication was not administered as required. Interviews and medical record reviews revealed that the Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP) were aware of the physician's order but failed to ensure it was documented and executed. The IP admitted to receiving the order but did not transcribe it into the medical record, acknowledging it as a mistake. The Director of Nursing (DON) confirmed the expectation for licensed nurses to notify physicians and family members of any changes in condition and to carry out physician orders, acknowledging the miscommunication between the charge nurse and the IP regarding the Tamiflu order.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse in a timely manner, as required by their policies and procedures and section 1150B of the Act. The incident involved two residents, where one resident alleged that another resident placed pillows over her face and told her to be quiet. This incident was witnessed by an LVN who responded to calls for help and removed the pillows from the resident's face. The LVN reported the incident to the RN, who then informed the Administrator and other relevant authorities, but failed to notify the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program immediately as required. The facility's policy mandates that any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the Administrator and other officials according to state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, and within 24 hours for other allegations. Despite this, the facility did not contact the CDPH, L&C Program until seven days after the incident, which was a clear deviation from the established protocol. Interviews conducted with the RN and the Administrator confirmed the failure to report the incident to the CDPH, L&C Program in a timely manner. The RN acknowledged the oversight, and the Administrator verified the lack of documentation regarding the immediate notification to the CDPH, L&C Program. This delay in reporting had the potential to leave the abuse allegation unreported and uninvestigated, contrary to the facility's policy and regulatory requirements.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly trust fund statements to a resident, identified as Resident 5, which is a requirement for managing residents' personal funds. The facility's policy, revised in March 2021, mandates that if the facility is appointed as the resident's representative payee, it must manage the funds in accordance with established policies and federal/state requirements. However, during an interview on January 2, 2025, Resident 5 stated she did not remember receiving any quarterly trust fund statements from the Business Office Manager (BOM) and mentioned not having received any statements for years, except possibly at the time of admission. The medical record review indicated that Resident 5 was cognitively intact and had the capacity to make medical decisions. Despite this, there was no documented evidence that Resident 5 received the quarterly trust fund statement for November 2024. The Account Receivable Consultant, who managed the resident's trust account offsite, confirmed that the statement was printed on October 31, 2024, but could not verify if it was handed to the resident. The BOM claimed to have personally handed the statement to Resident 5 in November 2024 but admitted to not keeping a copy or documenting the transaction. The Administrator, during an interview on January 3, 2025, was unable to provide documented evidence that Resident 5 received the quarterly statement in November 2024. The lack of documentation and verification of the delivery of the trust fund statement to Resident 5 highlights a deficiency in the facility's management of residents' personal funds, potentially leading to the loss and misuse of the resident's personal funds.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by several observations during a survey. In the walk-in refrigerator, food items such as beef and chicken were found undated and unlabeled, and other items like gelatin and grape juice were not discarded by their use-by dates. This lack of proper labeling and disposal could lead to foodborne illnesses. Additionally, staff in the kitchen, including the Dietary Services Supervisor (DSS) and cooks, were observed not wearing appropriate hair restraints, which is a violation of the USDA Food Code. Further inspection revealed that a bucket of cleaning chemical was stored next to food items, which poses a risk of contamination. The kitchen equipment and utensils were found to be in poor condition, with melted handles on spoons and spatulas, and baking sheets and cutting boards with residues and markings. These conditions make it difficult to maintain cleanliness and could harbor pathogens. The facility also failed to label a dry goods bin containing a white granulated powder, identified as a thickener, which is a breach of proper food storage protocols. The handwashing sink was obstructed by a trash can lid, making it inaccessible for staff use, which is against the FDA Food Code. This obstruction could prevent proper hand hygiene, increasing the risk of contamination. The facility's failure to maintain clean and properly labeled equipment, ensure staff wear appropriate hair restraints, and keep handwashing facilities accessible, highlights significant lapses in maintaining food safety and sanitation standards.
Failure to Obtain Updated Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the use of psychotropic medication, specifically risperidone, when the indication for its use was changed. The resident, who had the capacity to understand and make decisions, was initially prescribed risperidone for schizoaffective disorder manifested by suicidal ideation. However, the indication was later changed to address racing thoughts, and the facility did not obtain informed consent for this new indication. Interviews and medical record reviews confirmed that the informed consent form on file did not reflect the updated indication for the medication. Both an LVN and an RN verified that the informed consent should have been updated to include the new manifestation of racing thoughts as per the physician's order. This oversight had the potential to leave the resident uninformed about the medication and its effects.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for their ability to self-administer medications, specifically tetrahydrozoline eye drops. The facility's policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, but this assessment was not documented for the resident in question. The resident was observed with the eye drop medication at their bedside, which they had been self-administering without a physician's order or documented approval for self-administration. The resident's medical records indicated they lacked the capacity to understand and make medical decisions, and they had previously expressed a desire not to self-administer medications. Despite this, the eye drops were found at the resident's bedside, and a Licensed Vocational Nurse confirmed there was no physician's order for the medication to be self-administered or stored at the bedside. The Director of Nursing was informed and acknowledged these findings.
Inaccessible Call Lights for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, specifically regarding the accessibility of their call lights. For Resident 4, who had impairments in mobility of both upper extremities and one lower extremity, the call light was not within reach. On a specific observation, the call light was placed by the resident's left knee, making it difficult for the resident to reach the juice on the meal tray. A CNA later confirmed the call light was not accessible and assisted the resident by repositioning the call light and the juice. Similarly, Resident 72's call light was found on the floor, out of reach. When asked, the resident was unaware of the call light's location. A CNA verified the call light's position on the floor and subsequently sanitized and repositioned it within the resident's reach. The CNA acknowledged that the call light should not have been on the floor and should have been accessible to the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and follow through with concerns raised during resident council meetings, specifically regarding the completion of OCTA Access forms and the mannerisms of CNAs when interacting with residents. The facility's policy and procedure for Resident Council, revised in February 2021, mandates the use of a Resident Council Response Form to track issues and their resolution. However, the facility did not adhere to this policy, resulting in unresolved issues. In the first instance, the Resident Council Minutes from a meeting held in June 2024 indicated a request for OCTA Access forms, which are necessary for residents to obtain transportation access for outings. The Department Response Form noted a delay in addressing this concern due to a change in the Social Services Director. Although the form indicated the issue was resolved to the residents' satisfaction, there was no documentation of follow-up efforts to obtain the forms. Interviews with the Assistant Director (AD) and the new Social Services Director (SSD) revealed a lack of communication and awareness about the concern, leading to the forms remaining unprocessed. In another instance, the Resident Council Minutes from August 2024 highlighted concerns from residents in specific rooms about the CNAs' mannerisms. The Department Response Form documented investigations for some residents but failed to address all the concerns raised. The AD admitted to forgetting to follow through with two residents, and the Director of Staff Development (DSD) confirmed incomplete documentation and follow-up. The section of the form regarding resolution to the residents' satisfaction was left blank, indicating an incomplete investigation and lack of resolution for the concerns raised.
Failure to Document and Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that advance directive information was documented and offered to residents, as required by their policy and procedure. This deficiency was identified through interviews, medical record reviews, and facility policy reviews. Specifically, the facility did not document whether residents were asked about having an advance directive or if they were provided information on formulating one. This issue affected seven sampled residents and one non-sampled resident. For several residents, including Residents 4, 18, 35, and 72, their medical records lacked evidence that they were asked about having an advance directive or offered information on formulating one. Residents 2 and 19's records indicated they did not have an advance directive, but there was no documentation showing they were provided with information on how to create one. Resident 27's records did not indicate whether they had an advance directive, and Resident 76's advance directive was not available in their medical record. Interviews with the Social Services Director (SSD) confirmed these documentation gaps. The SSD acknowledged that the forms were incomplete or blank and should have been filled out to reflect whether residents had advance directives or were offered information. The Director of Nursing (DON) was informed of these findings and acknowledged the issues. These failures had the potential to impact the residents' ability to have their healthcare and treatment decisions honored.
Confidentiality Breach of Residents' Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of residents' medical records, specifically for two nonsampled residents, Residents 56 and 59. This deficiency was identified during an observation at Nursing Station A, where three computer monitors were left turned on and unattended. One monitor displayed the physician's orders for Resident 59, while another showed the care tracker/dashboard for Resident 56. These monitors were accessible to unauthorized users, compromising the residents' personal and health information. During an interview, LVN 6 confirmed that the monitors were unattended and acknowledged that they should not have been left in such a state. Additionally, CNA 6 admitted to leaving one of the monitors unattended to assist a resident, indicating a lapse in following the facility's policy on safeguarding resident information.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to the resident's representatives regarding the transfer of a resident to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews. The facility's policy on transfer or discharge, dated October 2022, requires that resident or representative notification and documentation be completed for facility-initiated transfers. However, in the case of Resident 2, who lacked the capacity to understand and make decisions, there was no written notification provided to the resident's representative when the resident was transferred to the hospital on July 27, 2024. The medical record review revealed that the Notice of Transfer/Discharge Form for Resident 2 was not signed by the resident or their representative, and the progress notes did not document any written notification being given. During an interview, the Social Services Director (SSD) indicated that nurses typically inform the resident or their representative of such transfers verbally, but acknowledged that no written notice was provided in this instance. This oversight posed a risk of the resident's representatives being unaware of their appeal rights regarding the transfer.
Failure to Complete Timely SCSA for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who was enrolled in hospice services. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a SCSA must be completed within 14 days when a resident enrolls in a hospice program. The medical record review for the resident, who was admitted to hospice services on July 29, 2024, showed that no comprehensive assessment or SCSA was completed within the required timeframe. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the assessment should have been completed within the specified period.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, which resulted in deficiencies in addressing their specific needs. Resident 13 experienced an unwitnessed fall on 7/27/24, and despite the incident being documented, no care plan was developed to address the fall. Additionally, Resident 13 experienced significant weight loss over a period of months, yet the care plan did not reflect any measures to address this issue. Interviews with the IP and DON confirmed these findings, indicating a lack of appropriate care planning for Resident 13's fall and weight loss. Resident 43 also experienced a fall on 7/29/24, where the resident was found sitting on the floor after slipping off the bed. Despite the incident being recorded in the progress notes, there was no care plan developed to address this fall. Interviews with the resident, LVN 7, and the DON confirmed that a care plan should have been initiated but was not, highlighting a failure to provide individualized care for Resident 43. Similarly, Resident 72 experienced a fall on 5/29/24 while transferring from a wheelchair to a couch. The incident was documented, but the care plan did not include any measures to address the fall. An interview with RN 1 confirmed the absence of a care plan for this incident, indicating a failure to develop a comprehensive care plan for Resident 72. These deficiencies suggest a pattern of inadequate care planning for residents who experienced falls, potentially compromising their well-being.
Failure to Follow Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to adhere to a physician's order for a resident who was required to wear a cervical collar at all times. The resident, who had a cervical fracture, was observed without the cervical collar during an interview and observation conducted on 09/18/24. The resident mentioned that she stopped wearing the collar after an appointment with her neurosurgeon on 9/6/24 and had given it to a friend for safekeeping. Despite this, there was no documentation in the medical records indicating that the order for the cervical collar had been discontinued. A Licensed Vocational Nurse (LVN) confirmed that the physician's order for the cervical collar was still active and that the care plan also required the collar to be worn at all times. The LVN acknowledged that there should have been a follow-up by the nursing staff after the resident's neurosurgeon appointment to verify any changes in the treatment plan. The lack of adherence to the physician's order posed a risk to the resident's well-being, as it was crucial for the resident's overall health and recovery.
Improper Mattress Setting for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set appropriately according to the resident's weight, which is crucial for preventing pressure ulcers. The resident, identified as being at high risk for developing pressure ulcers, was observed on two occasions lying on a mattress set to 250 pounds, despite the resident's actual weight being 103 pounds. The medical records indicated that the resident was totally dependent on staff for bed mobility and had severely impaired cognitive skills, making it impossible for them to communicate their comfort level. Interviews with the MDS Coordinator and LVN revealed that the mattress should have been set according to the resident's weight, as the resident could not verbalize comfort levels. The MDS Coordinator confirmed the incorrect setting and adjusted it to the correct weight. The DON acknowledged the findings, indicating a lapse in monitoring and adjusting the mattress settings as per the physician's order, which required checking the settings every shift.
Failure to Investigate Accident and Implement Safety Measures
Penalty
Summary
The facility failed to ensure adequate investigation and documentation of an accident involving a resident, identified as Resident 2, who sustained a skin tear on the right buttock. Despite the presence of a facility policy requiring thorough investigation and reporting of accidents, there was no documentation of the cause of the skin tear. Interviews with staff, including LVN 9, CNA 7, and LVN 3, revealed inconsistencies in the reporting and documentation process. LVN 9 was informed by CNA 7 about a fall incident involving Resident 2, but the focus remained on treating the skin tear rather than investigating the fall. The Director of Nursing (DON) and RN 1 confirmed the lack of documentation regarding the investigation of the skin tear's cause. The facility also failed to comply with a physician's order for Resident 86, who was at risk for wandering and elopement, to wear a WanderGuard on the left wrist. Observations and interviews with LVN 7 and RN 1 confirmed that Resident 86 was not wearing the WanderGuard as prescribed. Despite the care plan and physician's order indicating the need for the WanderGuard, it was never applied to Resident 86, leaving the resident without the necessary safety measure. These deficiencies highlight the facility's failure to adhere to its policies and procedures regarding accident investigation and the implementation of physician's orders. The lack of proper documentation and follow-through on safety measures had the potential to negatively impact the well-being of the residents involved.
Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional services to three residents, resulting in significant weight loss and lack of proper monitoring. Resident 13 experienced severe weight loss, with a 12% reduction in weight over three months and 11.2% over six months. Despite these alarming changes, the facility did not notify the resident's physician or responsible party in a timely manner, nor did they conduct an interdisciplinary team (IDT) evaluation to address the weight loss. This oversight was confirmed by both RN 1 and the Director of Nursing (DON), who acknowledged the failure to implement necessary interventions. For Resident 35, the facility did not adhere to the physician's order for weekly weight monitoring, which was recommended by the Registered Dietitian (RD) due to the resident's steady weight loss. The resident's weight decreased from 101 pounds to 95 pounds over a two-month period, yet no weekly weights were recorded after the initial order. The DON confirmed that the RD's recommendations were not effectively communicated to the nursing staff, resulting in the failure to monitor the resident's weight as ordered. Similarly, Resident 4's weight monitoring was not conducted as per the physician's order following an IDT meeting that recommended weekly weights. Although the resident's weight fluctuated, the facility did not perform weekly weigh-ins until a month after the order was given. The DON verified that the communication breakdown led to missed weight checks, which were crucial for monitoring the resident's nutritional status. This lapse in following the prescribed weight monitoring protocol was acknowledged during the review of the resident's medical records.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, as evidenced by multiple deficiencies in following physician orders and ensuring proper oxygen administration. Resident 442 was observed receiving oxygen at 4 liters per minute, but there was no documented evidence of the need for titration or the parameters for how high the oxygen could be titrated. The MDS Coordinator and DON confirmed the lack of documentation and the need for clarification of the physician's order. Resident 12's oxygen concentrator was found in the hallway with the door compressing the oxygen tubing, posing a risk of not receiving the necessary oxygen. Despite having a physician's order for continuous oxygen, the setup was not properly maintained, as verified by LVN 3. Similarly, Resident 27 was not receiving continuous oxygen as ordered, and was found on room air with a low oxygen saturation level of 84%. LVN 5 had not checked the resident's oxygen status that day, leading to a delay in administering the required oxygen. Additional deficiencies were noted for Resident 2, who was receiving oxygen without a physician's order, and Resident 72, whose oxygen titration order lacked specific parameters. Resident 4's suction machine and canisters were improperly stored on the floor, which could negatively affect the resident's medical condition. These observations highlight the facility's failure to adhere to physician orders and maintain proper respiratory care protocols, as outlined in their policy and procedure for oxygen administration.
Inadequate Pain Management Due to Unclear Medication Orders
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident with severe cognitive impairment. The medical record review revealed that the resident had orders for both acetaminophen and hydrocodone-acetaminophen, with overlapping indications for use based on pain levels. Specifically, acetaminophen was ordered for pain levels ranging from mild to severe (1-10 on a pain scale), while hydrocodone-acetaminophen was ordered for moderate to severe pain (4-10). On a specific occasion, the resident experienced a pain level of 5 and was administered acetaminophen instead of hydrocodone-acetaminophen, which was more appropriate for that level of pain. The Licensed Vocational Nurse (LVN) confirmed that the medication orders lacked clear indications for use, leading to the inappropriate administration of pain medication.
Failure to Follow G-tube Medication Administration Protocol
Penalty
Summary
The facility failed to administer medications according to its policy and procedure (P&P) for a nonsampled resident, identified as Resident 59. The P&P for administering medications through an enteral tube, revised in November 2018, required the removal of the plunger from the syringe before pouring medications into the syringe barrel and flushing the G-tube with water before and between administering medications. On September 19, 2024, during a medication administration observation, LVN 3 was seen using the syringe and plunger to push medications into Resident 59's G-tube without flushing it with 50 ml of water before and between the medications. LVN 3 acknowledged the failure to follow the procedure. Resident 59 had been readmitted to the facility with a post-status G-tube placement, and their September 2024 Medication Administration Record (MAR) included an order to flush the G-tube with 30 ml of water before and after medication administration.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as identified during a survey. For one resident, the facility did not accurately monitor behavior manifestations and side effects associated with the use of risperidone, an antipsychotic medication prescribed for schizoaffective disorder. Despite physician orders to monitor behaviors such as racing thoughts and side effects, the Medication Administration Records (MARs) for June, July, August, and September 2024 did not reflect any monitoring. Interviews with facility staff confirmed the lack of monitoring, which was required for residents receiving antipsychotic medications. Another resident was affected by the facility's failure to limit the PRN order for lorazepam, an antianxiety medication, to 14 days as per the facility's policy. The medical record review showed an ongoing PRN order for lorazepam without an end date or documented rationale for extending its use beyond 14 days. The Director of Nursing (DON) confirmed these findings and acknowledged the absence of documentation justifying the extended use of lorazepam. These deficiencies indicate a failure to adhere to the facility's policies regarding the use and monitoring of psychotropic medications, posing a risk of unnecessary medication use and potential negative impacts on the residents' health and well-being.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dana Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Juan Hills Healthcare Center | 3.7 mi | ★★★★★ | 21 | 0 |
| Orchards Skilled Nursing | 7.4 mi | ★★★★★ | 0 | 0 |
| Palm Terrace Healthcare & Rehabilitation Center | 11 mi | ★★★★★ | 27 | 0 |
| Villa Valencia Healthcare Center | 11.4 mi | ★★★★★ | 7 | 0 |
| Laguna Hills Health And Rehabilitation Center | 11.5 mi | ★★★★★ | 49 | 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.