Del Mar Convalescent Hospital

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure that the physician's order for docusate sodium included the prescribed dosage and that nursing staff clarified the missing dosage prior to administration. As a result, Resident 17 received docusate sodium without a verified dosage from 12/10/2025 to 12/16/2025. This deficient practice had the potential to cause medication errors, including constipation if underdosed or diarrhea if overdosed. 2. Ensure the accuracy of the Antibiotic and Controlled Drug Record Count log for Resident 33, who was receiving Cephalexin (Keflex, an antibiotic used to treat bacterial infections in various parts of the body). 3. Ensure the Controlled Substances Shift Count log was completed and signed for 12/17/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication label for one of one resident (Resident 3) had an expiration/use by date. This deficient practice had the potential for Resident 3 to be administered expired medication. 1. During a review of Resident 3's admission Record (AR), the AR indicated an admission on [DATE] with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (brain tissue death) affecting left non-dominant side, neoplasm (abnormal mass of tissue from uncontrolled cell growth) of unspecified behavior of brain, and hypertensive heart disease (problems with the heart that can develop if one has high blood pressure) with heart failure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store foods as evidenced by One open bag of dice broccoli in a freezer was not labeled and dated Two open cartons of milk in a refrigerator were not labeled and dated These deficient practices had the potential to result in residents being exposed to food borne illnesses (illnesses when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility. During a concurrent observation and interview on 12/15/2025 at 8:50 AM, one open bag of diced broccoli did not have a label with date in the facility kitchen freezer. The Dietary Supervisor (DS) stated the dietary staff opened and used the diced broccoli, but it was not labeled and dated on the bag. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation related to current Coronavirus 2019 (COVID-19, infectious respiratory disease easily spread from person to person) vaccination status for staff. This deficient practice had the potential to result in the facility's staff and residents contracting, transmitting, and experiencing complications related to COVID-19 such as difficulty breathing, persistent pain or pressure in the chest, or diarrhea. During a concurrent interview and record review of staff vaccination logs with the Director Staff Development (DSD) on 12/17/2025 at 11:30 PM, the DSD stated the only COVID-19 Vaccination log for the staff was from 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for one of one sampled resident (Resident 5) when certified nurse assistant (CNA) 3 was observed standing over Resident 5 and assisting Resident 5 to eat. This deficient practice had the potential to cause a decline in the resident's individuality, self-esteem, and self-worth. A review of Resident 5's admission Record (AR) indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (long-term condition when the kidneys are damaged and lose the ability to filter waste and fluid out of the blood), Alzheimer's Disease (type of dementia [loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life] that affects memory, thinking and behavior), and dementia. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) assessment was accurate for one of five sampled residents (Resident 43). Resident 43's MDS did not reflect Resident 43's current diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities). This deficient practice resulted in lack of monitoring Resident 43's signs and symptoms of depression. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that two of two sampled residents (Resident 8 and Resident 43) reviewed for comprehensive care plans had their care plan interventions implemented by failing to: Implement Resident 8's antiplatelet care plan interventions for monitoring for bleeding or bruising. 2. Implement Resident 43's mood problem care plan interventions for monitoring feeling of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits; change in sleep patterns' dimmish ability to concentrate; change in psychomotor skills. These deficient practices had the potential to negatively affect the resident's well-being and delay delivery of care and services to Residents 8 and 43. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a nutritional assessment was completed one of one sampled resident (Resident 4) when a significant weight loss (losing more than 5% of your body weight [around 10 pounds for many adults]within 6 to 12 months without trying) and a change in diet was identified. This deficient practice had the potential to result in Resident 4 to not receive the appropriate diet and nutritional needs required to address Resident 4's weight loss. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one of five sampled residents (Resident 8) was free from unnecessary drugs by failing to adequately monitor Resident 8's continuous need of Plavix (clopidogrel) (a medication used to treat and prevent blood clots) a medication that may increase the risk of bleeding. This deficient practice placed Resident 8 at risk of uncontrolled bleeding. During a review of Resident's 8 admission Record (AR), the AR indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (a stroke, loss of blood flow to a part of the brain), Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Pancytopenia (a blood condition where there's a significant drop in all three blood cell types: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedures to prevent food contamination and the spread of foodborne illness for one of one kitchen in the facility, when multiple food items in the kitchen ' s refrigerator were not labeled with the date and time the food was opened or prepared. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident bedrooms accommodate no more than four residents for seven (7) of eighteen (18) rooms (Rooms 16, 19, 20, 21, 22, 25, and 26) and did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs two of three sampled residents (Resident 21 and Resident 23) by ensuring the residents ' call lights (a device used to alert staff to the resident ' s room) were placed within the resident ' s reach, in accordance with the facility ' s policy and procedure [P&P] titled Call Lights: Accessibility and Timely Response. This deficient practice had the potential for the residents not to receive care and services that could result in accidents and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Resident 37 ' s Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment Form reflected Resident 37 ' s Advance Directive. 2. Resident 30 ' s POLST reflected Resident 30 ' s Advance Directive wishes and failed to provide Resident 30 with an Advance Directive Acknowledgment form. This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on observation, interview and record review for two of three sampled residents (Resident 24 and 54) the facility failed to ensure: 1. Ensure Resident 24 ' s family representative received a written notification of proposed transfer and/or discharge notification upon resident ' s transfer to the General Acute Care Hospital (GACH) in accordance with the facility ' s policy and procedure and have documented evidence Resident 30 ' s notice was sent to the Ombudsman 2. For Resident 54, the facility did not have documented evidence that notice of transfer was sent to the Ombudsman. This failure violated the resident ' s and resident representative ' s rights to make informed decisions and receive transfer/discharge information of their rights to appeal the transfer/discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents assessed at risk for falls received care and services, in accordance with their individualized level of risk to minimize the likelihood of falls, as indicated with the facility ' s policy and procedure [P&P] titled Fall prevention program for two of three sampled residents (Resident 6 and 30) by failing to: 1. Ensure the facility staff place the motion alarm on the bed when transferring Resident 6 from the wheelchair to the bed as indicated in Resident 6 ' s care plan for Falls. 2. Ensure to monitor the function and placement of Resident 30 ' s motion alarm when in bed and wheelchair. On 11/08/2024, Resident 30 ' s motion alarm was observed disconnected while in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 44) is free from significant medication errors when Resident' 44 ' s medication Droxidopa Oral Capsule (medication used to treat symptoms dizziness, lightheadedness or fainting sensation) route of administration did not match Physicians order on Resident 44 ' s Medication Administration Record (MAR) with route of administration (this means by which medication is introduced in the body such as orally, injection or topical application). This deficient practice had the potential to result in Resident 44 to receive medications through the wrong route.

Inspectors wroteBased on observation, interview and record review, the facility failed to reasonably accommodate the resident's needs as indicated in the facility's policy and procedure titled, Call Lights: Accessibility and Timely Response for 1 of two residents (Resident 104) who was observed with call lights (device used by a resident to signal his or her need for assistance from professional staff) not within the resident's reach. This deficient practice had the potential to in Resident 104 receive delayed care or not receive services and emergency care when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed maintain a homelike environment by ensuring the facility's wall clocks in the resident's bedroom were set in the current time for 2 of two sampled residents (Resident 1 and 105). This deficient practice had the potential for Resident 1 and105 to get disoriented with time, which could affect the resident's participation with daily activities and over all wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of resident's admission to the facility for one of 3 sampled residents (Resident 105) with a diagnosis of Type 2 Diabetes Mellitus (DM-an adult-onset disease in which the blood glucose or sugar levels are too high). This deficient practice had the potential for Resident 105 not to receive the appropriate interventions and treatments for DM and lead to complications such as hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 33) was assisted by two people during transfer from wheelchair to bed, and when using a Hoyer Lift (mechanical lift device with sling used to transfer residents between the bed and the chair or other location using electrical or hydraulic power). This deficient practice placed Resident 33 at risk for falls or accidents during transfers when using the Hoyer lift that could lead to injuries including possible fractures and a decline in the resident's wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 3) was free from significant medication errors. Resident's 3's heart rate was not assessed before administering Metoprolol Tartrate (a medication to treat high blood pressure and heart failure) based on physician's order to hold if Systolic Blood Pressure (SBP, measures the pressure of your blood in your arteries [tube like structure responsible for transporting blood]) less than (<) 110 milliliters per mercury (mmHg, unit of measurement) or heart rate (HR) < 60 beats per minute (bpm, unit of measurement). This deficient practice place Resident 3 at risk to experience adverse reaction (undesired effect) of Metoprolol that included dangerously low blood pressure and heart rate that could lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store foods in the refrigerator. 1. 15 Cups of poured milk were not labeled or dated. 2. 6 Prepared sliced peaches were not labeled or dated. 3. A cracked egg was observed saturating the egg crate. These deficient practices had the potential to result in residents being exposed to food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled Residents (Resident 51) and the resident's responsible party (RP) were informed and understood the concept of the proposed arbitration (solving disputes with a neutral third party instead of the court) and the Binding Arbitration Agreement (BAA, a binding agreement by the parties to submit to arbitration all or certain disputes between them in respect of a defined legal relationship, whether contractual or not) before having the resident/RP enter into a binding arbitration agreement. The deficient practice had the potential resulted in Resident 51 unknowingly giving up their right to resolve any disputes with the facility through a court of law before a jury.

Inspectors wroteBased on observation, interview and record review, the facility failed to label the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing with the date when it was first used for one of three sampled residents (Resident 204). This failure had the potential for Resident 204 to use contaminated or soiled NC tubing and result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a widespread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident bedrooms accommodate no more than four residents for five of 18 rooms (Rooms 16, 19, 22, 25 and 26) did not have more than four residents in one shared room. This deficient practice had the potential to limit care and services, and the ability to move easily in the room for residents and facility staff.