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Deficiency Records for Capistrano Beach Care Center

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.

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?
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2024-07-22 2024-08-21 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-07-03 2024-08-02 Y
Ensure that residents are free from significant medication errors. Health 2024-04-02 2024-05-02 Y
Provide enough food/fluids to maintain a resident's health. Health 2024-02-29 2024-03-29 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-02-29 2024-03-29 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-02-29 2024-03-29 Y
Keep all essential equipment working safely. Health 2024-02-29 2024-03-29 Y
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
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

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