A list of the most recent deficiencies for Capistrano Beach Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-27 | 2024-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-16 | 2023-09-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-06 | 2023-08-06 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-06 | 2023-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-09 | 2023-05-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-09 | 2023-05-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-18 | 2023-05-05 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-02-06 | 2023-03-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-06 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-23 | 2022-10-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-08 | 2022-10-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-22 | 2022-05-22 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Use approved construction type or materials. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-12-21 | 2022-01-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-09 | 2022-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-09 | 2022-01-06 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-09 | 2022-01-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-09 | 2022-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-06 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-12-09 | 2022-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-09 | 2022-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-09 | 2022-01-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-17 | 2022-01-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-17 | 2022-01-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-17 | 2022-01-06 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-17 | 2022-01-06 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-10-14 | 2021-11-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-14 | 2021-11-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-05 | 2021-11-05 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-05 | 2021-11-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-05 | 2021-11-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-25 | 2021-09-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-29 | 2021-08-29 | Y |
| Keep all essential equipment working safely. | Health | 2021-07-29 | 2021-08-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-07 | 2021-07-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-07 | 2021-07-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-07 | 2021-07-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-21 | 2021-05-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-21 | 2021-05-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-05 | 2021-03-21 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-05 | 2021-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-05 | 2021-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-03 | 2021-03-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-02 | 2021-03-11 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-04 | 2020-03-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-18 | 2020-03-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-18 | 2020-03-18 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-18 | 2020-03-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-18 | 2020-03-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-18 | 2020-03-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-18 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-18 | 2020-03-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-07 | 2019-06-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-20 | 2019-04-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-20 | 2019-04-20 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-03-20 | 2019-04-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-03-20 | 2019-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-20 | 2019-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-20 | 2019-04-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-20 | 2019-04-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-20 | 2019-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-20 | 2019-04-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-03-20 | 2019-04-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-20 | 2019-04-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-20 | 2019-04-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-03-20 | 2019-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-20 | 2019-04-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-03-20 | 2019-04-20 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-03-20 | 2019-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-20 | 2019-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-20 | 2019-04-20 | N |
| Keep all essential equipment working safely. | Health | 2019-03-20 | 2019-04-20 | N |
