Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 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.
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.
The facility failed to provide appropriate dietary accommodations for three residents. A resident with a non-gluten diet did not receive gluten-free pasta, another resident requiring double portions received single portions, and a third resident did not consistently receive Ensure with meals as ordered. These deficiencies risked not meeting the residents' nutritional needs.
A resident with severe cognitive impairment signed a binding arbitration agreement at the facility. Despite having a BIMS score indicating severe cognitive impairment and a health examination confirming the lack of capacity to make medical decisions, the resident signed the agreement. The Admissions Director admitted to explaining the agreement but was unsure of the resident's understanding, acknowledging the resident should not have signed it.
The facility failed to notify hospice of significant weight loss for two residents and did not ensure hospice nursing visits occurred as per the care plan. This lack of communication and coordination posed a risk to resident care.
The facility failed to maintain essential equipment safely, with ice buildup in medication refrigerators and residue in an ice machine. Two RNs confirmed the ice buildup, and the Maintenance and Corporate Dietary Supervisors identified residue and improper repairs on the ice machine.
The facility failed to maintain a pest-free environment, with flies observed in a resident's room and the kitchen. In the resident's room, a fly landed on an uncovered cup of milk and an insulated water mug, with an open window lacking a screen. In the kitchen, flies were seen near the coffee machine, puree food preparation, and tray line areas, with one landing on a covered loaf of bread. These observations indicate a failure to prevent pests, potentially leading to foodborne illness transmission.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential risks in continuity of care. One resident's gender was incorrectly recorded, while another's hospice services and significant weight loss were not documented. These errors were confirmed by the MDS coordinator.
The facility failed to dispose and store trash in a sanitary manner, posing a threat for pest contamination. Observations revealed that the recycling bin had cardboard boxes piled above the rim, and two trash dumpsters had black trash bags preventing the lids from closing properly. The Maintenance Supervisor confirmed that lids should be fully closed to prevent pest access.
A resident's representative requested a copy of the resident's medical record, but the facility failed to provide it, potentially violating the resident's rights. The facility's P&P required written consent for releasing medical records and allowed access within 48 hours of a request. Despite receiving the request, the Medical Records Director and Administrator confirmed that the records were not sent.
A broken shower bench in Shower Room C was not removed, posing a safety risk to residents. The facility's maintenance policy requires equipment to be safe and operable, but the bench had uneven legs and a hanging metal piece. A CNA confirmed the bench was broken and stated that broken equipment should be reported to maintenance. The Maintenance Director verified the issue, noting missing and broken parts, and emphasized the need for removal to ensure resident safety. The Administrator and DON acknowledged the findings.
A resident's evening medications were not administered on the admission day because they were not delivered by the pharmacy. The LVN did not call the pharmacy or notify the physician after the expected delivery window had passed. The DON confirmed that the physician should have been notified, and the Administrator acknowledged that increased monitoring could have been ordered.
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.
Failure to Meet Residents' Nutritional and Dietary Needs
Penalty
Summary
The facility failed to meet the daily nutritional and special dietary needs of three residents, as observed during a survey. Resident 592, who had a physician's order for a non-gluten diet, did not receive gluten-free pasta with their lunch tray. The Corporate Dietary Supervisor acknowledged that the staff forgot to include the gluten-free pasta on the tray. Similarly, Resident 593, who had a physician's order for double portions, received only single portions during lunch. The Corporate Dietary Supervisor confirmed that the tray should have contained double portions as per the resident's dietary requirements. Additionally, Resident 62, who had a physician's order to receive Ensure with meals to aid in weight gain, did not have Ensure included with their lunch tray. The resident confirmed that they only received Ensure sometimes, not with every meal as prescribed. The IP verified the absence of Ensure on the lunch tray and acknowledged the physician's order for Ensure with every meal. These deficiencies posed a risk to the residents' nutritional needs not being met.
Resident with Cognitive Impairment Signed Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment did not sign a binding arbitration agreement. Resident 45, who had a BIMS score of 6 indicating severe cognitive impairment, was admitted and readmitted to the facility. Despite the resident's lack of mental capacity to understand the terms of the arbitration agreement, as confirmed by a health and physical examination, the resident signed the agreement. The Admissions Director admitted to explaining the agreement to the resident but was unsure if the resident comprehended it, acknowledging that the resident should not have signed the agreement.
Failure to Coordinate Hospice Care and Notify of Significant Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services for two residents who were receiving hospice care. For Resident 13, the facility did not notify the hospice provider about significant weight loss, which was documented as a 12% loss over three months and an 11.2% loss over six months. Despite being admitted to hospice services, there was no record of communication with the hospice regarding these changes. Interviews with the RN and DON confirmed the oversight in notifying the hospice of the resident's condition change. Similarly, Resident 2 experienced a significant weight loss of 5.45% in one month and 23.5% over six months, yet there was no documented evidence that the hospice was informed. The DON stated that the nursing supervisor was responsible for notifying the hospice of any changes, but could not provide documentation to support that this was done for Resident 2's weight loss. Additionally, the facility did not adhere to the hospice care plan for Resident 2, which required hospice nursing visits twice a week. The records showed that the visits were not conducted at the specified frequency, as confirmed by a review of the hospice's staff sign-in sheet and an interview with an LVN. This lack of coordination and communication between the facility and hospice services posed a risk to the residents' care.
Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, which could potentially affect residents' health and well-being. During an inspection, it was observed that the freezer compartments of two medication refrigerators had ice buildup. This was verified by two registered nurses during separate observations and interviews. Additionally, an inspection of the ice machine revealed black duct tape on the plastic ice harvester curtain and reddish-brown residue on a gray water pipe and a white insulated wire. The Maintenance Supervisor confirmed that the black tape was applied approximately a year ago by an outside vendor to repair a crack in the plastic. The Corporate Dietary Supervisor verified the presence of residue by wiping the wire with a clean paper towel, which transferred some of the residue onto the towel, and acknowledged that the ice machine needed cleaning.
Pest Control Deficiency: Flies in Resident's Room and Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies in both a resident's room and the kitchen. In the resident's room, a fly was observed landing on an uncovered cup of milk and the opening of an insulated water mug. The room's window was open without a screen, allowing the fly to enter. A Certified Nursing Assistant (CNA) verified the presence of the fly and the open window, subsequently closing it. In the kitchen, flies were observed on multiple occasions over two days. A fly was seen near the coffee machine, puree food preparation, and tray line areas. During a lunch tray line observation, a fly landed on a covered loaf of bread. The Corporate Dietary Supervisor confirmed the presence of the fly. These observations indicate a failure to ensure the facility was free of pests, potentially leading to the transmission of foodborne illness to residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to potential risks in continuity of care. For one resident, the MDS inaccurately recorded the resident's gender as female, despite medical records indicating the resident was male. This discrepancy was confirmed during an interview with the MDS coordinator, who acknowledged the error in the MDS coding for multiple dates. Another resident's MDS assessment failed to reflect their admission to hospice services and significant weight loss. The resident had a physician's order for hospice services, which was not documented in the MDS. Additionally, the resident experienced a 9% weight loss in one month and a 20% weight loss over six months, yet the MDS inaccurately indicated no significant weight loss. These inaccuracies were verified by the MDS coordinator during a review of the resident's medical records.
Improper Trash Disposal and Storage
Penalty
Summary
The facility failed to dispose and store trash in a sanitary manner, which posed a threat for pest contamination. During an observation conducted with the Maintenance Supervisor, it was noted that the facility's trash dumpsters and recycling bin were not properly covered. Specifically, the recycling bin had flattened cardboard boxes piled above the rim, preventing the lids from closing properly. Additionally, two trash dumpsters were observed with black trash bags that also prevented the lids from closing fully. The Maintenance Supervisor acknowledged that the lids should be closed fully to prevent pests from accessing the bins.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide the requested medical and billing records for a resident, which had the potential to violate the resident's rights. The facility's policy and procedure (P&P) on the release of information, revised in November 2009, stated that all information in a resident's medical record is confidential and can only be released with written consent from the resident or their legal representative. A resident may access their records within 48 hours of a written or oral request. In this case, the resident's representative requested a copy of the medical record on July 2, 2024, using an Authorization for the Release of Medical Information form. However, the Medical Records Director confirmed receiving the request by mail on July 8, 2024, and the Administrator acknowledged that the records had not been sent as requested by the representative.
Broken Shower Bench Not Removed
Penalty
Summary
The facility failed to ensure a safe environment for residents by not removing a broken shower bench in Shower Room C. The maintenance policy, revised in December 2009, requires that all building areas, grounds, and equipment be maintained in a safe and operable manner. During an observation on July 1, 2024, a broken shower bench was found in the shower room, with uneven legs and a hanging metal piece. CNA 1 confirmed the bench was broken and mentioned that typically, a rolling shower chair is used for residents, and any broken equipment should be reported to maintenance. On July 3, 2024, the Maintenance Director confirmed the findings, noting that two flat plastic saucers on the bench's legs were broken, and a metal piece was missing. The Maintenance Director stated that any broken shower chair should be removed for resident safety. The Administrator and DON were informed of these findings and acknowledged the deficiency.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident. On the admission day, the resident's evening medications were not administered because they were not delivered by the pharmacy. The medications included treatments for hyperlipidemia, glaucoma, high blood pressure, diabetes, nerve pain, and bowel management. The orders for these medications were entered in the system, but the nursing progress notes indicated that the medications had not been delivered by the pharmacy, and there was no documented evidence that the physician was notified or that follow-up with the pharmacy occurred. Interviews with the MDS Coordinator, LVN, and DON confirmed that the pharmacy was expected to deliver medications within four to six hours of the resident's arrival. The LVN admitted to not calling the pharmacy or notifying the physician after the six-hour window had passed. The DON confirmed that the physician should have been notified and that the resident had the potential for high blood pressure and increased blood sugar levels due to not receiving the medications as ordered. The Administrator also acknowledged that notifying the physician could have led to increased monitoring of the resident's condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 312 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near 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 | — | 18 | 0 |
| Orchards Skilled Nursing | 7.4 mi | — | 0 | 0 |
| Palm Terrace Healthcare & Rehabilitation Center | 11 mi | — | 25 | 0 |
| Villa Valencia Healthcare Center | 11.4 mi | — | 7 | 0 |
| Laguna Hills Health And Rehabilitation Center | 11.5 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.