Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 The Cove At La Jolla during CMS and state inspections, most recent first.
A resident with impaired mobility and a history of falls did not have fall mats properly placed as required by their care plan, with one mat left standing against the wall after a transfer. Additionally, multiple hallways had loose, water-damaged flooring with bubbles and separations, creating tripping hazards confirmed by the DES and acknowledged by the ADM.
Surveyors identified that multiple residents received food that was cold, bland, unappetizing, or not as described on the menu. Residents reported repeated meals, unidentifiable food, and issues with food allergies and preferences not being accommodated. Observations and interviews confirmed that food was often served at the correct temperature but lacked flavor and variety, and menu postings were difficult for residents to access or read.
A kitchen staff member was observed serving food with an uncovered beard and mustache during breakfast tray line, contrary to facility policy requiring beard restraints for all facial hair. The staff member believed trimmed facial hair did not require coverage, but both policy review and the RD confirmed that all facial hair must be covered to prevent food contamination.
Two residents were not provided with their requested meal preferences, including one who was served eggs despite a documented dislike and another who was denied a sandwich for dialysis appointments, contrary to facility policy and stated resident rights. Staff interviews confirmed that resident preferences were not properly accommodated or communicated.
A resident with obstructive sleep apnea who required a CPAP/BIPAP machine did not have a care plan developed or implemented upon admission, despite documentation of the need for the device. Staff interviews and record reviews confirmed the absence of a care plan addressing the use, maintenance, and infection control of the machine, contrary to facility policy.
A resident with obstructive sleep apnea used a CPAP/BIPAP machine without a physician's order, and staff were unaware of proper cleaning procedures for the device. The resident maintained the machine herself, and a physician's order was not obtained until several days after admission, contrary to facility policy.
A resident with a documented broccoli allergy was served broccoli at dinner after staff failed to follow established dietary verification procedures. The CNA delivering the meal did not check the tray for allergens, and the LPN responsible for tray accuracy did not notice the broccoli. The DON confirmed that multiple staff were responsible for ensuring dietary compliance, but the process failed, resulting in the resident being exposed to an allergen.
The facility failed to accurately code the MDS for three residents at high risk for elopement who required WanderGuard wristbands. Despite physician orders and care plans indicating the use of WanderGuards, the MDS assessments were incorrectly coded, leading to CMS being unaware of the residents' wandering behaviors. The MDSN acknowledged the oversight, and the DON highlighted the importance of accurate MDS coding for safety monitoring.
The facility failed to follow food safety standards, including improper storage of wet dishware, inadequate labeling of powdered thickener, and poor glove and hand hygiene practices during food service. These actions posed a risk of cross-contamination and bacterial growth, as observed by the CDM during a survey.
The facility failed to respond to call lights in a timely manner for several residents, leading to unmet needs and potential safety risks. Residents reported waiting 15 to 30 minutes or more for assistance, particularly during night shifts and weekends. Interviews with staff confirmed that call lights should be answered within five minutes, but the facility's policy lacked a specific timeframe.
A resident with significant femur fractures experienced severe hip pain, but the facility's care plan only included repositioning as a non-pharmacological intervention, despite physician orders for a broader range of methods. The resident reported that no other interventions were offered, and the DON confirmed the care plan did not reflect the resident's preferences, leading to a deficiency in pain management.
A resident with a urinary tract infection and an indwelling catheter had inaccurate fluid intake and output documentation, with non-numerical entries and incorrect calculations in their MAR. Staff interviews revealed that the process for measuring and reporting urine output was not followed, leading to discrepancies in the resident's clinical record. The DON confirmed the inaccuracies, highlighting the importance of precise documentation for assessing fluid balance.
The facility failed to address delayed call light responses identified by resident council meetings. Despite adding the issue to their QAPI plan and conducting staff in-services, the problem persisted due to lack of documentation and inadequate data analysis. The facility's QAPI compliance goal was inconsistently met, and the staff in-services did not emphasize keeping call lights on until residents' needs were met.
Failure to Maintain Safe Environment: Improper Fall Mat Placement and Unaddressed Flooring Hazards
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident with impaired mobility and a history of falls. According to the care plan, floor mats were to be placed on both sides of the resident's bed following a previous fall. However, during observation, one mat was found standing against the wall instead of on the floor, and staff confirmed it had not been returned after a transfer, rendering it ineffective in preventing injury. Additionally, the facility did not identify or address loose and water-damaged flooring in three hallways. Observations revealed multiple areas where the flooring was bubbling up and separating at the seams, creating tripping hazards under hand railings and near resident rooms. The Director of Environmental Services confirmed the presence of these hazards, and the Administrator acknowledged that hallways should be free of such risks to ensure the safety of residents, staff, and visitors.
Failure to Provide Palatable and Appropriately Served Food
Penalty
Summary
Surveyors found that the facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for fifteen of fifty-one sampled residents. Multiple residents reported receiving food that was cold, bland, unappetizing, or not as described on the menu. Specific complaints included cold sausage with brussels sprouts, dry and hard scrambled eggs, canned vegetables, tough chicken, and repeated servings of disliked items such as carrots. Some residents also noted that food was unidentifiable, lacked flavor, or appeared to be leftovers from previous days. Additionally, there were reports of residents not receiving requested items, such as sandwiches for dialysis appointments, and issues with food allergies not being accommodated. During a Resident Council Meeting, several residents echoed these concerns, citing rubbery pancakes, repeated meals, and difficulty accessing or reading the posted menu. Observations of the tray line and test trays confirmed that food temperatures were within facility standards but the food was consistently described as bland and in need of seasoning. The Registered Dietician acknowledged the importance of assessing and documenting residents' food preferences and dislikes, as well as providing alternatives, but the facility's practices did not align with these expectations. The facility's policy stated that residents' food preferences would be adhered to within reason, with substitutes and condiments available unless contraindicated, but these standards were not consistently met.
Failure to Ensure Beard Restraint Use by Kitchen Staff
Penalty
Summary
During a breakfast tray line observation, a kitchen staff member, specifically the Dietary Supervisor, was seen plating food while having an uncovered beard and mustache. The staff member stated that he believed it was acceptable to serve food without a beard restraint if his facial hair was trimmed and groomed. However, review of the facility's DRESS CODE policy indicated that all facial hair must be covered with a beard restraint. The Registered Dietician confirmed that the expectation was for any staff with facial hair to wear a beard restraint to prevent contamination of residents' food.
Failure to Honor Resident Preferences for Meals and Dietary Choices
Penalty
Summary
The facility failed to honor the rights of two residents regarding their preferences and choices in care. One resident, who had hemiplegia and hemiparesis due to cerebrovascular disease, expressed a dislike for eggs but was served an omelette for breakfast despite her meal ticket clearly indicating eggs as a disliked item. Staff interviews confirmed that meal trays were supposed to be checked for resident preferences by both dietary and nursing staff, but this process failed to prevent the resident from receiving food she did not want. Facility policy and admission documents also stated that resident preferences should be accommodated, but this was not followed in practice. Another resident, diagnosed with protein-calorie malnutrition, attended dialysis appointments three times a week and requested a sandwich, Nepro supplement, and napkins for these visits. Despite making this request to multiple staff members, including the dietician, the resident continued to receive only three cups of puree food and Nepro, which he discarded. The dietician acknowledged the request but did not document it or discuss it with the interdisciplinary team, and the resident's dietary preference was not accommodated. The facility's own documents indicated that residents have the right to reasonable accommodation of their needs and preferences, but this was not upheld in these cases.
Failure to Develop and Implement Care Plan for CPAP/BIPAP Use
Penalty
Summary
The facility failed to develop and implement a patient-centered care plan for a resident who was admitted with a diagnosis of obstructive sleep apnea and required the use of a CPAP/BIPAP machine. Upon observation and interview, it was found that the resident was using a BIPAP machine at the bedside and was responsible for cleaning and maintaining the device herself. However, a review of the electronic medical record by a licensed nurse confirmed that there was no care plan in place addressing the use of the CPAP/BIPAP machine. Further interviews with facility staff, including the Minimum Data Set Nurse and the Director of Nursing, revealed that the resident's hospital history documented the need for a CPAP machine, but no care plan was created until several days after admission. The facility's own policy required the interdisciplinary team to develop a comprehensive, person-centered care plan to address each resident's medical and nursing needs, which was not followed in this case.
Failure to Provide Physician Order and Proper Care for CPAP/BIPAP Use
Penalty
Summary
The facility failed to provide appropriate respiratory care services for a resident who used a CPAP/BIPAP machine. The resident, admitted with a diagnosis of obstructive sleep apnea, was observed using a BIPAP machine at her bedside and reported cleaning and maintaining the device herself. Upon review of the resident's electronic medical record, it was found that there was no physician's order for the use of the CPAP/BIPAP machine at the time of observation, despite documentation from a recent hospital history and physical indicating the resident's use of such a device. A physician's order was not obtained until several days after the resident's admission. Additionally, interviews with licensed nurses revealed a lack of knowledge regarding the proper cleaning procedures for the CPAP/BIPAP machine. One nurse stated she would need to consult the Director of Nursing about the facility's policy, while another admitted to not knowing how to clean the device. The facility's policy requires that CPAP/BIPAP devices be administered as ordered by a physician and that interventions be implemented to minimize associated risks, but these procedures were not followed in this case.
Resident Served Allergen Despite Documented Broccoli Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to broccoli was served broccoli with their dinner meal. The resident's allergy was recorded in the facility's Allergy Report, and the incident was confirmed through interviews with the resident, a CNA, and a licensed nurse. The CNA who delivered the meal admitted to missing the required check to ensure the meal matched the resident's dietary restrictions. The licensed nurse, who was responsible for verifying meal tray accuracy before delivery, stated she did not recall seeing broccoli on the tray. The Director of Nursing confirmed that three staff members—the kitchen staff, the licensed nurse, and the CNA—were responsible for ensuring dietary compliance, but the process failed at multiple points. Facility policy required that food preferences and allergies be adhered to and that food trays be checked by both the dietary department and nursing staff prior to delivery. Despite these policies, the resident received a meal containing an allergen, indicating a breakdown in the established verification process. The incident was substantiated through observation, interviews, and record review, and placed the resident at increased risk of an allergic reaction.
Inaccurate MDS Coding for WanderGuard Use
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for three residents who were at high risk for elopement and required WanderGuard wristbands. Resident 1, diagnosed with encephalopathy, had a physician's order for a WanderGuard and was categorized as high risk for elopement, yet the MDS was coded to indicate no alarm was in use. Similarly, Resident 5, with dementia, and Resident 103, with encephalopathy, both had physician's orders for WanderGuards and were also categorized as high risk for elopement, but their MDS assessments were inaccurately coded to show no alarms were in use. The Minimum Data Set Nurse (MDSN) acknowledged the oversight in coding for these residents, which resulted in the Centers for Medicare and Medicaid Services (CMS) being unaware of the residents' wandering behaviors. The Director of Nursing (DON) emphasized the importance of monitoring elopement and wandering behaviors as safety issues and expected the MDS to accurately reflect residents at risk for elopement. The failure to properly code the MDS assessments meant that CMS was not informed of the residents' current status and the interventions in place to prevent elopement.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. Firstly, dishware was improperly stored while still wet, which was noted during an initial kitchen tour. The Certified Dietary Manager (CDM) acknowledged that wet dishware poses a risk of bacterial growth, which could affect all residents consuming food from the kitchen. The facility's policy from 2018 mandates that dishes should be air-dried before stacking and storing, which was not followed. Additionally, the facility did not properly label powdered thickener containers with necessary dates, such as received, opened, and use-by dates, leading to potential confusion about the product's safety. Furthermore, during a lunch trayline observation, a kitchen staff member was seen not changing gloves or performing hand hygiene between tasks, which the CDM identified as a cross-contamination risk. The facility's sanitation policy requires that dishes be handled by the rim and that hands should not contact food surfaces, which was not adhered to in this instance.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for six residents, leading to unmet needs and potential safety risks. The issue was highlighted in Resident Council meeting minutes from March, April, and May, where slow call light responses were noted, and the administration's response was merely documented as 'Noted.' Interviews with residents revealed consistent complaints about delayed responses, particularly during nighttime, weekends, and after meals when staffing was perceived to be inadequate. Resident 10, who was admitted with acute cystitis, reported waiting over 20 minutes for assistance, especially after meals and during night shifts. Resident 4, with congestive heart failure, experienced similar delays, particularly at night and on weekends, affecting her ability to receive timely help for going to bed and using the bathroom. Resident 24, diagnosed with cellulitis, also noted staffing shortages on weekends, leading to delayed call light responses. Additional residents, including Resident 15 with chronic obstructive pulmonary disease, Resident 19 with acute respiratory failure, and Resident 7 with hemiplegia, reported waiting times of 15 to 30 minutes or more for call light responses. Interviews with CNAs and the DON confirmed that call lights should be answered within five minutes to ensure resident needs and safety, yet the facility's policy lacked a specific timeframe, only stating that lights should be answered within a 'reasonable time.'
Deficiency in Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident admitted with significant fractures in the left femur. Despite the physician's orders, which included a range of non-pharmacological interventions for pain management such as dim lighting, relaxation, distraction, music, and massage, the care plan only listed repositioning as an intervention. This oversight was confirmed during interviews with the resident and the Director of Nursing (DON), who acknowledged that the care plan did not reflect the resident's preferences or the full range of suggested interventions. The resident, who experienced severe hip pain, reported that the facility managed her pain solely with medication and repositioning, without offering any other non-pharmacological interventions. A review of the Medication Administration Record (MAR) corroborated this, showing that repositioning was the only non-pharmacological method attempted. The facility's policy mandates the development of a comprehensive person-centered care plan by the interdisciplinary team, but this was not adhered to in the case of this resident, leading to a deficiency in meeting her pain management needs.
Inaccurate Fluid Intake and Output Documentation
Penalty
Summary
The facility failed to accurately calculate and document the fluid intake and urinary output for a resident with an indwelling catheter, which is crucial for monitoring fluid balance. The resident, who was admitted with a urinary tract infection, had discrepancies in the recorded input and output values over several days. Observations revealed that the urine in the catheter tubing was dark yellow and cloudy, indicating potential issues with fluid balance. Interviews with staff, including a CNA and licensed nurses, highlighted that the process for measuring and reporting urine output was not followed correctly, leading to inaccurate documentation. The Medication Administration Record (MAR) for the resident showed incorrect calculations of fluid intake and output, with non-numerical entries such as 'x 2' and 'x 5' instead of measurable amounts. The Director of Nursing confirmed that the MAR was inaccurate and emphasized the importance of precise documentation for assessing the resident's fluid status. The facility's policy on charting and documentation underscores the necessity of accurate records to guide treatment and care, which was not adhered to in this case.
Failure to Address Delayed Call Light Responses
Penalty
Summary
The facility failed to adequately address root cause issues related to delayed call light responses, as identified by the resident council meetings. Despite adding call light responses to their Quality Assurance Performance Improvement (QAPI) plan in March 2024, the issue persisted in subsequent months. The facility conducted staff in-services and included call light responses in their morning Angel Rounds, but these efforts were not documented and only verbally communicated during stand-up meetings. Additionally, the facility had been conducting call light response audits since January 2024 using a computerized system, but the data was not analyzed by staff shifts or nursing units, which hindered the identification of specific problem areas. The facility's QAPI compliance goal was divided into three response time categories: under 5 minutes, over 5 minutes, and 30 minutes. However, the facility sometimes met the compliance goal and other times did not. The staff in-services did not emphasize the importance of keeping call lights on until residents' needs were fully met. The facility's policy on Quality Assurance and Performance Improvement, dated January 2022, outlined the use of tools such as Plan-Do-Study-Act cycles and the Five Why's to identify root causes, but these were not effectively utilized to resolve the ongoing issue of delayed call light responses.
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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 La Jolla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Jolla Post-acute | 1.6 mi | ★★★★★ | 0 | 0 |
| The Springs At Pacific Regent | 3.7 mi | ★★★★★ | 1 | 0 |
| Vi At La Jolla Village | 3.7 mi | ★★★★★ | 23 | 0 |
| Kearny Mesa Convalescent And Nursing Home | 6.3 mi | ★★★★★ | 1 | 0 |
| The Pavilion At Ocean Point | 6.4 mi | ★★★★★ | 25 | 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.