Inspection Reports for
Capistrano Beach Care Center
35410 Del Rey, Dana Point, CA 92624, United States, CA, 92624
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
22.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
470% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Routine
Deficiencies: 23
Date: Nov 19, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, medication management, nutrition, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to inform residents about advance directives, inadequate grievance information, improper monitoring of psychotropic medications, failure to monitor residents after change in condition, inadequate supervision in shower rooms, nutritional assessment and monitoring failures, respiratory care deficiencies, pharmaceutical service issues including medication administration and documentation errors, food service management and sanitation problems, incomplete facility assessment, infection control program deficiencies, and pest control issues.
Deficiencies (23)
Failed to inform and provide written information regarding advance directives to residents 20, 46, and 63.
Failed to ensure residents 16 and 48 were informed on how to file grievances.
Failed to monitor side effects and behavior related to psychotropic medication for Resident 46.
Failed to complete 72-hour monitoring following change in condition for Resident 4.
Failed to supervise Resident 2 in shower room and no call system available in shower room.
Failed to maintain acceptable nutritional status and timely nutritional assessments for Resident 72 with severe weight loss.
Failed to provide oxygen therapy as ordered for Resident 13 and failed to label oxygen tubing with date for Resident 14.
Failed to rotate insulin injection sites for Residents 2 and 20; failed to document administration of antibiotic Zosyn for Resident 69.
Failed to check pulse rate prior to administration of metoprolol to Resident 40.
Failed to remove expired Covid-19 test kits and expired saline bottles; failed to separate oral and external medications in storage.
Dietary Manager not competent in managing food services department and multiple food safety and sanitation violations observed in kitchen.
Dietary staff member not competent in manual dishwashing process.
Failed to follow menu and provide Resident 23 with high caloric pudding and whole milk as ordered.
Failed to provide Resident 12 with meal entree equivalent in nutritive value to main entree.
Failed to use adaptive eating equipment properly for Resident 23; plate guard not placed on plate during meals.
Multiple food safety and sanitation violations including improper hand hygiene, lack of sanitizing test strips, improper storage of nutritional supplements, uncovered hair and facial hair, improper refrigerator temperatures, personal items in kitchen, expired food not discarded, uncovered food in freezer, employee eating in kitchen, improper dry storage, and unclean equipment.
Failed to ensure safe food handling education for visitors bringing food from outside sources.
Failed to ensure garbage dumpsters and recycling dumpster lids were fully closed; broken equipment improperly stored on facility grounds.
Facility assessment incomplete; lacked involvement of direct care staff, residents, family; no plan for recruitment, retention, or staffing contingency.
Conflicting documentation regarding Resident 5's advance directive status.
Failed to implement infection control surveillance for residents with infections not prescribed antimicrobials; lacked Legionella water management testing protocols; failed to disinfect equipment prior to use on Resident 42.
Essential kitchen equipment not maintained properly: walk-in freezer door did not close due to ice build-up, walk-in refrigerator fan cover had debris and rust, floor tiles under kitchen oven damaged.
Failed to maintain kitchen sanitation; flies observed in kitchen near food preparation area.
Report Facts
Resident infections surveillance counts: 14
Resident infections surveillance counts: 21
Resident infections surveillance counts: 18
Resident infections surveillance counts: 11
Resident infections surveillance counts: 20
Resident infections surveillance counts: 4
Resident infections surveillance counts: 10
Resident infections surveillance counts: 16
Resident infections surveillance counts: 7
Resident infections surveillance counts: 9
Resident infections surveillance counts: 18
Resident infections surveillance counts: 2
Resident infections surveillance counts: 12
Resident infections surveillance counts: 13
Resident infections surveillance counts: 6
Resident infections surveillance counts: 4
Resident infections surveillance counts: 12
Resident infections surveillance counts: 10
Resident infections surveillance counts: 12
Resident infections surveillance counts: 26
Resident infections surveillance counts: 5
Resident infections surveillance counts: 11
Resident infections surveillance counts: 12
Resident infections surveillance counts: 8
Resident infections surveillance counts: 11
Resident infections surveillance counts: 21
Resident infections surveillance counts: 6
Resident infections surveillance counts: 12
Resident infections surveillance counts: 19
Resident infections surveillance counts: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 4 | Licensed Vocational Nurse | Verified insulin injection sites were not rotated for Resident 20. |
| LVN 2 | Licensed Vocational Nurse | Verified insulin injection sites were not rotated for Resident 2. |
| LVN 7 | Licensed Vocational Nurse | Failed to disinfect sphygmomanometer prior to use on Resident 42. |
| LVN 5 | Licensed Vocational Nurse | Did not check pulse rate prior to administering metoprolol to Resident 40. |
| RN 2 | Registered Nurse | Verified insulin injection sites were not rotated for Resident 2. |
| RN 4 | Registered Nurse | Verified insulin injection sites were not rotated for Resident 20. |
| Administrator | Acknowledged multiple findings including facility assessment incompleteness and equipment issues. | |
| DON | Director of Nursing | Acknowledged multiple findings including infection control and medication administration issues. |
| Dietary Manager | Acknowledged multiple food service and sanitation deficiencies; not competent in managing food services. | |
| Maintenance Director | Acknowledged issues with refuse storage and kitchen equipment maintenance. | |
| IP | Infection Preventionist | Described infection surveillance program and acknowledged deficiencies. |
| SSD | Social Services Director | Verified conflicting documentation on advance directives for Resident 5. |
| MDS Coordinator | Verified Resident 13 oxygen concentrator status and Resident 23 meal discrepancies. | |
| [NAME] 2 | Dietary Staff | Not competent in manual dishwashing process. |
Inspection Report
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to determine if a comprehensive care plan was developed for a resident with a dislodged nephrostomy tube.
Findings
The facility failed to develop a comprehensive care plan addressing the individual needs of Resident 4 following an episode of a dislodged nephrostomy tube, which posed a potential risk for inconsistent and inappropriate care.
Deficiencies (1)
Failure to develop a comprehensive care plan for Resident 4's dislodged nephrostomy tube.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Verified no care plan was developed for Resident 4's dislodged nephrostomy tube. |
| DON | Director of Nursing | Verified Resident 4 had an episode of dislodged nephrostomy tube and stated the care plan should have been developed including specific interventions. |
Inspection Report
Routine
Deficiencies: 4
Date: May 29, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, informed consent, and quality of treatment at Capistrano Beach Care Center.
Findings
The facility failed to ensure that the responsible party of Resident 1 was informed in advance about psychiatric treatments and medication orders, posing a risk to informed decision-making. Additionally, the facility failed to provide appropriate care for Resident 4 by not adequately monitoring blood pressure for hypotension, not promptly reporting CBC test results to the physician, and delaying urine sample collection.
Deficiencies (4)
Failed to ensure the responsible party of Resident 1 was informed in advance of psychiatric tests, visits, and medication orders.
Failed to ensure Resident 4's blood pressure was monitored for hypotension.
Failed to ensure the results of the CBC test were promptly reported to Resident 4's physician.
Failed to ensure Resident 4's urine sample was collected in a timely manner.
Report Facts
Medication dosage: 150
Blood pressure readings: 96
Blood pressure readings: 91
Blood pressure readings: 90
Blood pressure readings: 85
White blood cell count: 17.45
CBC test order frequency: 1
Urine analysis order time: 1747
Urine sample collection time: 2218
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Verified blood pressure monitoring and urine sample collection issues for Resident 4 |
| LVN 3 | Licensed Vocational Nurse | Verified blood pressure monitoring and lab result reporting for Resident 4 |
| SSD | Social Services Director | Interviewed regarding care conference and notification failures for Resident 1 |
| Resident 1's psychiatrist | Psychiatrist | Interviewed about informing responsible party and ordering buspar for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide necessary care and services to Resident 2, specifically the failure to administer Tamiflu as ordered by the physician.
Complaint Details
The complaint investigation found that Resident 2 had a change of condition with a cough and a physician ordered Tamiflu on 1/22/25, but the order was not transcribed into the medical record and the medication was not administered. The infection preventionist and licensed nurses acknowledged the failure and miscommunication.
Findings
The facility failed to ensure Resident 2 was administered Tamiflu as ordered by the physician, with the medication order not transcribed into the medical record and the medication not administered. Interviews confirmed miscommunication between staff regarding carrying out the physician's order.
Deficiencies (1)
Failure to provide necessary care and services to Resident 2 by not administering Tamiflu as ordered by the physician.
Report Facts
Medication dosage: 75
Date of physician order: Jan 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding Resident 2's condition and medication administration |
| DON | Director of Nursing | Interviewed and acknowledged findings and miscommunication regarding medication order |
| IP | Infection Preventionist | Interviewed and verified failure to transcribe medication order and administer Tamiflu |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide quarterly trust fund statements to a resident and failure to timely report an abuse allegation involving two residents.
Complaint Details
The complaint involved failure to provide quarterly trust fund statements to Resident 5 and failure to timely report an abuse allegation where Resident 1 stated pillows were put on her face by Resident 2. The abuse allegation was reported to law enforcement and ombudsman but not to the CDPH, L&C Program within the required timeframe. The facility notified the CDPH, L&C Program seven days later.
Findings
The facility failed to provide quarterly trust fund statements to Resident 5, risking potential loss or misuse of personal funds. Additionally, the facility failed to timely report an allegation of physical abuse involving Resident 1, delaying notification to the appropriate state agency by seven days.
Deficiencies (2)
Failed to provide quarterly trust fund statements to Resident 5, risking potential loss and misuse of personal funds.
Failed to timely report an allegation of physical abuse involving Resident 1, resulting in delayed notification to the CDPH, L&C Program.
Report Facts
Date of abuse incident: Dec 13, 2024
Date of facility notification to CDPH: Dec 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Reported abuse allegations to Administrator, law enforcement, and ombudsman but did not contact CDPH, L&C Program. |
| RN 2 | Registered Nurse | Verified facility contacted Administrator, law enforcement, physician, and ombudsman regarding abuse but no evidence of CDPH contact. |
| LVN 1 | Licensed Vocational Nurse | Removed pillows from Resident 1's face during abuse incident. |
Inspection Report
Routine
Deficiencies: 23
Date: Sep 20, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication management, resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication changes, inadequate assessment for self-administration of medications, failure to keep call lights within reach, incomplete follow-up on resident council concerns, incomplete documentation of advance directives, breaches in confidentiality, failure to notify representatives of transfers, incomplete significant change assessments, inaccurate MDS coding, incomplete care plans for falls and weight loss, failure to follow physician orders for cervical collar and oxygen therapy, inadequate pressure ulcer care, improper medication administration, failure to limit psychotropic PRN orders, food safety and sanitation violations, pest control issues, and failure to ensure hospice services visits.
Deficiencies (23)
Failed to ensure informed consent was obtained for change in indication of risperidone for Resident 7.
Failed to assess Resident 74 for self-administration of medications and no physician order for eye drops at bedside.
Failed to keep call lights within reach for Residents 4 and 72.
Failed to address and follow through on resident council concerns including OCTA access forms and CNA mannerisms.
Failed to document advance directive information or offer information to residents for seven sampled residents.
Failed to safeguard residents' medical records; monitors left unattended showing resident information.
Failed to notify resident's representative in writing of transfer to acute care hospital for Resident 2.
Failed to complete significant change MDS within 14 days after hospice enrollment for Resident 2.
Failed to ensure accurate MDS assessments for Residents 2 and 71 including hospice services and gender coding.
Failed to develop comprehensive care plans for falls and weight loss for Residents 13, 43, and 72.
Failed to follow physician's order for cervical collar at all times for Resident 7.
Failed to set low air loss mattress according to Resident 13's weight.
Failed to thoroughly investigate and document cause of skin tear for Resident 2; failed to apply WanderGuard for Resident 86 as ordered.
Failed to provide oxygen therapy as ordered for Residents 12, 27, 72, 442, and 2; oxygen tubing compressed in hallway; suction machine stored on floor.
Failed to ensure pain medication orders for Resident 62 included clear indication for use related to pain levels.
Failed to monitor behavior manifestations and side effects for risperidone use for Resident 7.
Failed to ensure daily nutritional and special dietary needs and preferences were met for Residents 62, 592, and 593.
Failed to follow food safety and sanitation guidelines including expired food, improper hair restraints, chemical storage, unclean utensils, and blocked handwashing sink.
Failed to dispose and store trash in a sanitary manner; trash and recycle bin lids not fully closed.
Failed to ensure resident with severe cognitive impairment (Resident 45) understood and voluntarily signed binding arbitration agreement.
Failed to notify hospice of significant weight loss and failed to ensure hospice nursing visits twice weekly for Residents 2 and 13.
Failed to maintain medication refrigerators and ice machine in safe operating condition.
Failed to maintain pest control; flies observed in Resident 10's room and kitchen areas.
Report Facts
Weight loss percentage: 12
Weight loss percentage: 11.2
Weight loss percentage: 5.45
Weight loss percentage: 23.5
Weight loss percentage: 9
Weight loss percentage: 20
Weight loss percentage: 9
Weight loss percentage: 32
Weight loss percentage: 12
Weight loss percentage: 11.2
Weight loss percentage: 9
Weight loss percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Verified failure to monitor behavior and side effects for risperidone for Resident 7 |
| RN 1 | Registered Nurse | Verified behavior manifestation monitoring failure for risperidone for Resident 7 |
| LVN 6 | Licensed Vocational Nurse | Verified Resident 74 had no physician order for eye drops at bedside |
| CNA 1 | Certified Nursing Assistant | Verified call light not within reach for Resident 4 |
| CNA 5 | Certified Nursing Assistant | Verified call light on floor for Resident 72 |
| AD | Activity Director | Verified resident council concerns not fully addressed |
| SSD | Social Services Director | Verified incomplete advance directive documentation |
| DON | Director of Nursing | Acknowledged multiple findings including failure to notify hospice and incomplete care plans |
| LVN 8 | Licensed Vocational Nurse | Verified Resident 7 not wearing cervical collar as ordered |
| MDS Coordinator | MDS Coordinator | Verified inaccurate MDS coding and mattress setting |
| RN 2 | Registered Nurse | Verified medication refrigerator ice buildup |
| Maintenance Supervisor | Maintenance Supervisor | Verified ice machine tape and residue |
| Corporate Dietary Supervisor | Dietary Supervisor | Verified food safety and sanitation violations |
| LVN 3 | Licensed Vocational Nurse | Verified hospice nursing visits not done as ordered |
| LVN 4 | Licensed Vocational Nurse | Verified pain medication orders unclear for Resident 62 |
| LVN 6 | Licensed Vocational Nurse | Verified Resident 2 receiving oxygen without order |
| LVN 9 | Licensed Vocational Nurse | Verified suction machine stored on floor |
| LVN 5 | Licensed Vocational Nurse | Verified Resident 27 not receiving oxygen as ordered |
| LVN 1 | Licensed Vocational Nurse | Verified Resident 27 oxygen administration |
| RN 1 | Registered Nurse | Verified Resident 27 oxygen administration and medication refrigerator ice buildup |
| RN 2 | Registered Nurse | Verified medication refrigerator ice buildup |
| LVN 7 | Licensed Vocational Nurse | Verified no care plan for Resident 43 fall |
| LVN 8 | Licensed Vocational Nurse | Verified Resident 7 not wearing cervical collar |
| CNA 7 | Certified Nursing Assistant | Reported Resident 2 fall incident |
| LVN 9 | Licensed Vocational Nurse | Reported Resident 2 fall incident and skin tear |
| LVN 3 | Licensed Vocational Nurse | Created eInteract Change in Condition Evaluation for Resident 2 skin tear |
| Admissions Director | Admissions Director | Acknowledged Resident 45 should not have signed arbitration agreement |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with resident rights regarding access to medical and billing records, specifically following a request for records for Resident 1.
Findings
The facility failed to provide the requested medical and billing records for Resident 1 as requested by the resident's representative, which had the potential to violate the resident's rights. Interviews confirmed the records had not been sent despite a timely request.
Deficiencies (1)
Failure to provide requested medical and billing records for Resident 1.
Report Facts
Date survey completed: Jul 22, 2024
Date medical records request received: Jul 8, 2024
Date Authorization for Release of Medical Information form: Jul 2, 2024
Resident discharge date: Sep 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records Director | Interviewed regarding receipt of medical records request | |
| Administrator | Interviewed and acknowledged medical records had not been sent |
Inspection Report
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess the safety and maintenance of the nursing home environment, specifically to ensure that the facility is safe, easy to use, clean, and comfortable for residents, staff, and the public.
Findings
The facility failed to ensure the broken shower bench in Shower Room C was removed, which posed a potential safety risk to residents. Observations and interviews confirmed the bench was broken and had not been reported or removed as required by facility policy.
Deficiencies (1)
The facility failed to ensure the broken shower bench in Shower Room C was removed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Interviewed and verified the broken shower bench in Shower Room C. |
| Maintenance Director | Maintenance Director | Verified the broken shower bench findings and stated broken shower chairs should be removed. |
| Administrator | Administrator | Informed and acknowledged the findings. |
| DON | Director of Nursing | Informed and acknowledged the findings. |
Inspection Report
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication administration policies and ensure residents are free from significant medication errors.
Findings
The facility failed to administer prescribed medications as ordered for one of six sampled residents due to delayed pharmacy delivery. The failure to notify the physician or follow up with the pharmacy potentially placed the resident at risk for adverse health effects.
Deficiencies (1)
Resident 1's evening medications were not administered on the admission day because they were not delivered by the pharmacy.
Report Facts
Date survey completed: Apr 2, 2024
Medication order entry time: 1342
Nursing progress note time: 2136
Pharmacy delivery window: 4
Pharmacy delivery window: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Conducted interview and medical record review regarding medication administration | |
| LVN 4 | Provided information about pharmacy delivery window and failure to notify physician | |
| DON | Confirmed pharmacy delivery expectations and potential resident risks | |
| Administrator | Commented on potential increased monitoring if physician had been notified |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food service, and equipment safety at Capistrano Beach Care Center.
Findings
The facility was found deficient in timely evaluation and intervention for significant weight loss in a resident, incorrect medication administration orders, serving meals at unsafe temperatures, and maintaining meal tray carts in proper working order. These deficiencies had the potential for minimal harm or potential actual harm to residents.
Deficiencies (4)
Failure to ensure timely RD and IDT evaluations and interventions related to weight loss for one resident.
Failure to ensure one resident did not receive unnecessary medication due to incorrect implementation of physician's order.
Failure to ensure residents' meals were served at desired safe and appetizing temperatures.
Failure to maintain five of six meal tray carts in proper functioning order, potentially causing unsafe food temperatures.
Report Facts
Weight loss percentage: 13.5
Medication dosage discrepancy: 10
Food temperature: 128
Food temperature: 110
Meal tray carts: 7
Meal tray carts malfunctioning: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Reviewed Infectious Disease Physician's recommendations and gave verbal order to LVN to follow. | |
| Infectious Disease Physician | Provided medication order and confirmed correct dosing schedule. | |
| DON | Director of Nursing | Verified RD assessments and medication order discrepancies. |
| DSS | Dietary Services Supervisor interviewed regarding food temperature complaints and meal tray cart issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 27, 2023
Visit Reason
The inspection was conducted following a complaint regarding an incident of sexual abuse involving two residents, Resident 1 and Resident 2, where Resident 2 was observed touching Resident 1 inappropriately.
Complaint Details
The complaint investigation found that Resident 2 was observed with his hands down Resident 1's pants making a jerking motion on 12/15/23. Resident 1 had severe cognitive impairment and could not consent. The facility failed to monitor Resident 1 consistently for 72 hours post-incident. Resident 2 had a history of inappropriate sexual comments and behaviors. The incident was substantiated with interviews of staff and review of medical records.
Findings
The facility failed to ensure Resident 1 was free from sexual abuse, placing him at risk for psychological and emotional harm. Resident 1 was not consistently monitored for 72 hours after the incident, and the facility did not document nursing staff monitoring as required. Resident 2 had a history of making sexual comments and was legally blind and dependent on staff.
Deficiencies (1)
Failure to protect Resident 1 from sexual abuse by another resident and failure to consistently monitor Resident 1 for 72 hours after the incident.
Report Facts
Duration of inconsistent monitoring: 72
Date of incident: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Reported observing Resident 2 with hands inside Resident 1's pants making a jerking motion |
| LVN 2 | Licensed Vocational Nurse | Reported Resident 2 had a history of making inappropriate comments to staff |
| LVN 4 | Licensed Vocational Nurse | Reported Resident 2 had behavioral problems and was not allowed near other residents |
| DON | Director of Nursing | Confirmed findings and stated nursing staff were required to document monitoring every shift for 72 hours after the incident |
| Administrator | Interviewed regarding the incident and Resident 2's condition |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 16, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care and treatment orders for residents, specifically focusing on wound care and laboratory testing for Resident 1 following admission from an acute care hospital.
Findings
The facility failed to provide appropriate wound treatment and apply wound VAC to Resident 1's bilateral feet on 8/5/23 and failed to obtain ordered laboratory blood tests on 8/7/23. These failures had the potential to negatively affect the resident's health and well-being.
Deficiencies (2)
Failed to provide wound treatment to Resident 1's bilateral feet and failed to apply wound VAC to right first toe amputation on 8/5/23.
Failed to obtain Resident 1's laboratory blood test on 8/7/23 as per physician's order.
Report Facts
Deficiencies cited: 2
Dates of missed treatments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse 1 | Treatment Nurse | Interviewed regarding wound care orders and documentation failures |
| Treatment Nurse 2 | Treatment Nurse | Interviewed regarding wound care assessment and failure to call physician for orders |
| DON | Director of Nursing | Verified findings related to wound care and laboratory testing deficiencies |
| Admission Nurse | Admission Nurse | Interviewed about wound assessment and treatment order responsibilities |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care and medication administration at Capistrano Beach Care Center.
Findings
The facility failed to ensure the call light was placed within reach for Resident 3, resulting in potential unmet care needs and feelings of helplessness. Additionally, the facility administered a stool softener to Resident 3 despite physician orders to hold the medication when loose stools were present, putting the resident at risk of adverse effects.
Deficiencies (2)
Failed to ensure the call light was placed within reach for Resident 3, limiting ability to call for assistance.
Failed to ensure Resident 3's drug regimen was free from unnecessary medication by administering stool softener despite loose stools.
Report Facts
Dates of loose stools: Resident 3 experienced loose stools on 7/3/23 at 2200 and 2201 hours, 7/4/23 at 1430 hours, and 7/6/23 at 0659 hours.
Medication administration times: Resident 3 received docusate sodium on 7/3/23 at 0900 and 1700 hours and 7/6/23 at 0900 hours.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Assigned to Resident 3 and involved in call light placement issue. |
| LVN 1 | Licensed Vocational Nurse | Administered medications to Resident 3 and involved in medication error. |
| DON | Director of Nursing | Verified medication administration error related to Resident 3. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 9, 2023
Visit Reason
The inspection was conducted due to a complaint alleging failure to timely report and investigate suspected sexual abuse involving two residents at the facility.
Complaint Details
The complaint involved an incident on 3/30/23 where Resident 2 was observed touching Resident 3's groin area without consent. The allegation was reported to the Administrator and Director of Nursing but was not reported to external agencies nor investigated thoroughly. Interviews with staff confirmed knowledge of the incident but no proper reporting or investigation was conducted.
Findings
The facility failed to report suspected sexual abuse of Resident 3 by Resident 2 to appropriate authorities and did not conduct a thorough investigation of the allegation as required by facility policies. The failure had the potential to result in ongoing and undetected abuse and put other residents at risk.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to thoroughly investigate the allegation of sexual abuse as per the facility's policies.
Report Facts
Date of survey completion: May 9, 2023
Number of residents involved: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator 1 | Administrator | Named in failure to report abuse finding |
| Administrator 2 | Administrator | Interviewed regarding lack of investigation |
| CNA 1 | Certified Nursing Assistant | Observed and reported the alleged abuse |
| LVN 2 | Licensed Vocational Nurse | Received report from CNA 1 and reported to RN |
| RN 1 | Registered Nurse | Aware of incident but not aware of reporting |
| Staffing Coordinator | Informed DON and Administrator of allegations | |
| DON | Director of Nursing | Had knowledge of the alleged incident but did not report |
Inspection Report
Deficiencies: 3
Date: Apr 18, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards for pain management in residents, specifically focusing on the administration of narcotic pain medications and the use of non-pharmacological interventions.
Findings
The facility failed to provide appropriate pain management for two sampled residents by administering narcotic pain medications not in accordance with physician orders and not consistently offering non-pharmacological interventions prior to medication use. This posed risks of underdosing or overdosing and ineffective pain management.
Deficiencies (3)
Resident 1 had two narcotic pain medications ordered with the same indication for use in two different forms (liquid and tablet).
Residents 1 and 2 were given narcotic pain medications not in accordance with the physician's orders.
Residents 1 and 2 were not consistently offered non-pharmacological interventions prior to the use of narcotic pain medication.
Report Facts
Medication administration instances: 8
Medication administration instances: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified medication administration discrepancies and lack of non-pharmacological interventions for Residents 1 and 2 |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding pain assessment and non-pharmacological interventions |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding pain assessment and physician order requirements |
Inspection Report
Deficiencies: 5
Date: Feb 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident activities and the safety, functionality, and sanitation of the nursing home environment.
Findings
The facility failed to provide a person-centered activities program for one resident, resulting in minimal harm or potential for actual harm. Additionally, the facility failed to maintain a safe, functional, and sanitary environment in multiple areas, including non-working television remote, damaged floor tiles, peeling paint, and cracked ceiling, all posing potential hazards to residents.
Deficiencies (5)
Failed to ensure one of six sampled residents was provided a person-centered activities program.
The channel button of the television remote control in Room A Bed B was observed not working.
The facility failed to maintain the integrity of the tiles in Hallway A in front of Room B, with tiles lifting off the floor creating an uneven surface and hazard.
Paint was observed peeling off from the wall in front of Rooms C and D in Hallway A.
The ceiling in Hallway A where the ceiling light and electric switch located was cracked and protruding due to water leaks.
Report Facts
Residents sampled: 6
Residents affected: Few
Dates of maintenance requests: 11/23/22, 12/6/22, 12/17/22 - related to television and tile issues
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interviewed regarding activities program and documentation | |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding Resident 1's activity participation |
| Maintenance Director | Interviewed and verified environmental deficiencies |
Inspection Report
Routine
Deficiencies: 15
Date: Dec 9, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident belongings, incomplete care plans, unsafe smoking practices, medication administration delays and errors, expired medication storage, food service deficiencies including improper food preparation and failure to honor dietary preferences, incomplete medical records, infection control lapses, and incomplete COVID-19 vaccination documentation.
Deficiencies (15)
Failed to safeguard Resident 74's personal belongings resulting in loss of irreplaceable personal pictures.
Failed to develop and implement comprehensive person-centered care plans for Residents 29, 74, and 425.
Failed to ensure Resident 425 was assessed for safe smoking and supervised while smoking, posing fire risk.
Failed to provide pharmaceutical services meeting residents' needs, including medication reconciliation errors and delayed medication administration.
Stored expired medications and supplies in medication carts and treatment carts.
Failed to ensure the CDM was competent to manage food service operations, resulting in multiple food safety and dietary compliance issues.
Failed to follow menus, recipes, therapeutic diets, and portion sizes, risking residents' nutritional needs.
Failed to ensure minced/moist and pureed vegetables were prepared to conserve nutritive value.
Failed to provide food prepared in a form consistent with individual resident dietary needs, risking aspiration.
Failed to honor religious food preferences for Resident 74, resulting in serving non-vegetarian food contrary to his beliefs.
Failed to ensure sanitary food procurement, storage, preparation, and kitchen maintenance, including expired foods, improper thawing, lack of cooling logs, improper labeling, spoiled produce, improper sanitizing, lack of air gaps, and unclean equipment.
Failed to provide training and enforce policy on safe food handling for food brought by family or visitors.
Failed to maintain complete medical records for Resident 7; POLST form was signed but blank.
Failed to implement infection prevention and control practices including hand hygiene lapses, dirty wheelchairs, and indwelling catheter tubing dragging on floor.
Failed to offer and document second dose of COVID-19 vaccine for Resident 7.
Report Facts
Residents sampled: 18
Residents affected: 3
Medication administration delay: 4
Expired items: 7
Residents receiving food prepared in kitchen: 77
Missing dietary profiles/preferences: 50
Portion sizes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Named in medication reconciliation and administration documentation deficiency |
| LVN 4 | Licensed Vocational Nurse | Named in medication administration hand hygiene deficiency and inhaler instruction deficiency |
| LVN 1 | Licensed Vocational Nurse | Named in medication administration delay and pharmaceutical services deficiencies |
| RN 1 | Registered Nurse | Named in medication administration and medical record review |
| MDS Coordinator | Named in care plan development and smoking assessment deficiencies | |
| DON | Director of Nursing | Named in multiple interviews verifying deficiencies |
| CDM | Certified Dietary Manager | Named in food service and dietary deficiencies |
| RD | Registered Dietitian | Named in dietary and menu deficiencies |
| IP | Infection Preventionist | Named in infection control deficiencies and COVID-19 vaccine documentation |
| LVN 2 | Licensed Vocational Nurse | Named in food brought by visitors policy deficiency and infection control |
| CNA 2 | Certified Nursing Assistant | Named in food brought by visitors policy deficiency |
| DSD | Dietary Services Director | Named in food brought by visitors policy deficiency |
| Pharmacist 1 | Pharmacist | Named in medication emergency kit deficiency |
| LVN 5 | Licensed Vocational Nurse | Named in expired medication storage deficiency |
| LVN 2 | Licensed Vocational Nurse | Named in expired medication storage and infection control deficiencies |
| RN 2 | Registered Nurse | Named in medication reconciliation interview |
| Cook 1 | Named in food portion size deficiencies | |
| LVN 6 | Licensed Vocational Nurse | Named in medication administration observation |
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