Centinela Grand Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. 14 of 17 residents reviewed (Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12, 13, 14, 15, 16, and 17) were supervised by the facility staff, as ordered by their physician, during leave of absence passes (LOA); and2. One resident reviewed (Resident 3) did not have sharp objects on the meal trays, as indicated in the residents' care plan. This failure had the potential for:1. Resident's 1, 2, 3, 4, 6, 7, 9, 10, 12,13, 14, 15, 16, and 17 to experience avoidable environment risks, hazards, and accidents; and 2. Placed Resident 3 at risk for self-harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure mental health services were provided when:1. The physician or psychiatrist was not notified for one resident (Resident 3) of Resident 3's concern regarding his methadone addiction and possibly experiencing a relapse; and 2. The facility did not arrange psychological evaluations for 12 of 12 residents reviewed (Resident's 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15). This failure had the potential for Resident's 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15 to have a delay in the necessary care and services to address their behavioral health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours to the State Survey Agency (SSA) and to the Long-Term care (LTC) Ombudsman for one of three sampled residents (Resident 1). The facility was made aware of Resident 1 ' s right arm fracture on May 23, 2025. This failure had the potential for state agencies and the LTC Ombudsman not to be able to advocate for the residents in protecting their rights to be free from abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate what could have caused one of three sampled residents ' (Resident 1) right arm fracture. The facility did not witness the source of the fracture, and the resident could not explain the source of the right arm fracture. This failure had the potential to delay provision of corrective action to ensure Resident 1 is free from potential abuse, neglect, and mistreatment.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #24) of 1 sampled resident reviewed for vision/hearing was provided their hearing aid when they were received in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of 95 residents (Resident 75) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant severe weight loss of 14 lbs (pounds, a unit of measurement), 6.7 percent (%) from October 14, 2021 to November 11, 2021, 17 lbs, 8% from September 14, 2021 to December 10 2021, 18 lbs, 8.6% from October 14, 2021 to January 18, 2022, 25 lbs, 11.9% from August 23, 2021 to February 8, 2022, and 34 lbs 16.2% from September 14, 2021 to March 2, 2022 were not addressed in the Interdisciplinary Team (IDT) which may include, Physician (MD), Registered Nurse (RN), Dietary Manager/Dietitian (Registered Dietitian, RD), Social Services, Activity Director/Coordinator .weight variance meeting; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. A full sheet deep metal pan of egg salad prepared on March 15, 2022, was found in the reach-in refrigerator without food temperature monitoring for the cool down process; 2. Three various sized cooking pans, readily available for use, had dry and heavy black residue buildup on the cooking surface; 3. Several various sized plastic containers and metal pans were stacked and stored wet; and 4. The kitchen staff did not utilize the correct manufacturer's directions to sanitize the dishes for the manual dishware washing using the 3-compartment sink. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ice machine in safe operating condition when the ice machine was not cleaned, and the manufacturer's manual was not followed. This failure had potential to cause food-borne illness in a highly susceptible population of 90 out of 95 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe smoking practices were observed and implemented for three of four residents reviewed for smoking (Residents 24, 3, 18 and 25), when: 1. Resident 24 was observed smoking inside the facility; 2. Resident 3 had his cigarettes and lighter in his possession, offered a cigarette to another resident, and smoked a cigarette himself without staff supervision; 3. Resident 18 stated he usually had his lighter in his possession; and 4. Resident 25 had a cigarette in his possession while inside the facility. These failures had the potential to result in accidents or injuries to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued and expired medications were not stored in the medication and treatment carts, readily available for use. This failure increased the risk for the licensed nurses to administer discontinued and expired medications to the residents which could result in medication and treatment errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when one [NAME] (Cook 1) did not monitor and did not know the process for ambient (current air temperature) cool down of Time/Temperature Control for Safety (TCS) foods (cross refer to F812, finding number 1). This failure had the potential to cause food borne illness in a potentially compromised population of 90 out of 95 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on March 15, 2022, when 11 residents with a CCHO (Consistent Carbohydrate to treat medical condition of diabetes) mechanical soft (food was broken down for easy chewing) diet and 21 residents with a CCHO regular (no modification made to food) diet received a whole piece of chocolate cake with whipped topping instead of a half piece. This failure had the potential to result in increased blood sugar levels of 32 residents with a CCHO diet.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a policy and procedure for Foods Brought by Family/Visitors, that included provisions on facility providing education and information about safe food handling (such as safe cooling/reheating process, hot/cold holding temperatures, preventing cross contamination, hand hygiene, etc.) practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who were involved in preparing, handling, serving, or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of residents who could consume food and receive food from family or visitors. The facility census was 95.

Inspectors wroteBased on interview and record review, the facility failed to provide written information on how to formulate an Advance Directive (AD-a written instruction related to the provision of health care when the resident can no longer make decisions), for two of 25 residents reviewed (Resident 54 and 25). This failure had the potential for Residents 54 and 25 to receive unnecessary care/treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of three residents reviewed for skin condition (Residents 19 and 5) received the proper care and treatment when: 1a. For Resident 19, the physician's order to give Doxycycline (type of antibiotic medication) for pressure ulcers (PU- an injury caused by prolonged pressure on the skin) was not carried out upon admission to the facility and was not administered to the resident. This failure resulted in Resident 19 not receiving the complete course of antibiotic treatment which may delay the healing process of the multiple infected pressure ulcers; 1b. The facility failed to develop and initiate a baseline care plan to address Resident 19's admitting diagnosis of multiple infected pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 57), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture for one resident (Resident 76) who was on a NAS (no added salt), CCHO (consistent carbohydrate that treats medical condition of Diabetes Mellitus), mechanical soft texture diet (a diet texture with a soft and chopped or ground texture for one who has difficulty chewing or swallowing) received a whole grilled quesadilla with cubed chicken for an alternate meal at lunch meal on March 15, 2022. This deficient practice had potential for Resident 76 to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) which could further compromise his medical status.

Inspectors wrote3. On November 5, 2019, at 3:57 p.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1 for Resident 83. CNA 1 stated he just gave Resident 83 a bedbath. Resident 83 was observed with multiple rashes on the right lower extremity (RLE). CNA 1 confirmed Resident 83 had rashes on the RLE. On November 6, 2019, at 1:36 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 6. LVN 6 confirmed Resident 83 had multiple rashes on the RLE. LVN 6 stated she was not aware of Resident 83's rashes. On November 6, 2019, Resident 83's record was reviewed. Resident 83 was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (also called stroke - a condition when blood supply to the brain is stopped either by a blockage or the rupture of a blood vessel). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure discontinued medications were not stored in the medication cart readily available for use. This failure increases the risk for the licensed nurses to administer discontinued medications to the residents and may result in medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and observe an infection control and prevention program when multiple residents were not provided withthe appropriate hand hygiene prior to eating lunch. This failure had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of seven residents (Resident 40) reviewed, to ensure the resident was afforded the right to receive or refuse medical care and/or treatment. Resident 40, who did not have the capacity to make decisions, sign the acknowledgements for advance directive (AD - written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself) and Bed Hold Notification. This failure had the potential for the resident to receive unnecessary care/treatment and services.

Inspectors wroteBased on obervation, interview, and record review, the facility failed, for one of 21 residents (Residents 16) reviewed, to ensure the medication hydrocortisone (corticosteroid hormone medication used to treat blood/hormone/immune system disorders, cancer and severe allergies) was given at breakfast, with food or milk, as ordered by physician. This failure had the potential for the resident to experience side effects of the medication if not given as ordered by the physician

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of four residents (Resident 23) reviewed for limited Range of Motion (ROM), to ensure the change in the resident's ROM on his right elbow was identified and addressed by the facility. This failure had the potential for the resident to develop further contracture (shortening or hardening of the muscles, tendons, or other tissues, often leading to rigidity and deformity of joints)on his right elbow if left untreated.

Inspectors wroteBased on interview, and record review, the facility failed, for one of 21 residents reviewed for unnecessary medications (Resident 51) to ensure monitoring for adverse consequences (such as signs and symptoms of bleeding and/or bruising) of anticoagulant medication (Apixaban- medications that reduce or prevent blood from clotting), since ordered on September 27, 2019. This failure had the potential for the resident not to be monitored for the adverse effect of Apixaban such as bruising and bleeding.

Inspectors wroteBased on interview and record review, the facility failed for two of six residents (Residents 55 and 40) reviewed for unnecessary medications to ensure: 1. For Resident 55 the physician failed to document the rationale for the continued use of Ativan, (a medication used to decrease anxiety), as needed (PRN) beyond the 14 days as required; and 2. Resident 40 the physician failed to document the rationale for the continued use of Ativan PRN beyond the 14 days as required. This failure had the potential for Residents 55 and 40 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for one of 21 residents (Resident 1), to ensure the medication Emtriva (anti-viral medication used to treat HIV {type of viral infection}) was available and administered to the resident in a timely manner as ordered by the physician. This failure resulted in a significant medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary practices for infection prevention for one of 21 residents reviewed (Resident 70) when an undated and unlabeled plastic jar containing brownish liquid and Jalapeno mixture was stored at the resident's bedside. This failure had the potential to result in the development of food-borne illnesses and the growth of microorganism in vulnerable residents.