The Cove at La Jolla

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall mats were placed appropriately for one of 14 sampled residents (40), and ensure loose flooring was identified for three of three hallways. These failures placed residents at increased risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that palatable food was served to fifteen of fifty-one sampled residents. This failure had the potential to prevent residents from eating their meals and not receiving their daily nutrition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one kitchen staff wore a beard restraint during breakfast tray line. This failure had the potential to contaminate all residents' food with staff's facial hair and promote foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor two (Resident 1, 16) of 14 sampled residents reviewed for resident rights when: 1. The facility did not honor Resident 1's request not to have eggs for breakfast; 2. The facility did not honor Resident 16's request to have a sandwich during dialysis appointments. These failures resulted in not allowing residents to make a choice regarding their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a patient centered care plan for one of 14 residents reviewed for care plan. (Resident 209) Cross reference F695 This failure had the potential for Resident 209 to not receive appropriate care, treatment, and interventions for the use of a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services for one of one resident who used a continuous positive airway pressure machine (CPAP-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) when Resident 209 used a CPAP machine but did not have a physician's order. In addition, Licensed nurses did not know how to clean the CPAP machine. This failure had the potential for Resident 209 to receive inappropriate care and treatment to address Resident 209's respiratory problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a diet free of food they were allergic to for one of 14 sampled residents (6). This failure placed Resident 6 at an increased risk of allergic reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS-a clinical assessment tool) for three of four residents (1, 5, 103) reviewed for wander guards (a wrist band worn by residents that alarms and alerts staff when the resident get near or exit a specific area). As a result, the Centers for Medicare and Medicaid Services (CMS) was unaware of Resident 1, 5, and 103's current health status and wandering behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards for food safety when: 1. Dishware was not properly stored; and 2. Date on powdered thickener did not indicate open, discard, or preparation date; and 3. Gloves were not changed and hand hygiene was not conducted during food service. This failure had the potential to cause food-borne illness to all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner for six of 56 residents (Residents 10, 4, 24,15,19,7) reviewed for call lights response. This failure had the potential for resident needs to go unmet and at risk for safety. Findings. On 6/3/24 a review of the past three Resident Council (when residents meet once a month to discuss facility concerns) meeting minutes was reviewed. Resident Council minutes dated 3/5/24, 4/2/24, and 5/14/24 indicated slow call light responses. The ADM response to the concerns was documented as, Noted. 1. A review of Resident 10's admission Record indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included acute (sudden) cystitis (an infection of the bladder). An interview on 6/3/24 at 10:30 A.M., with Resident 10 was conducted. [...]

Inspectors wroteBased on interview and record review, the facility failed to create a person centered care plan related to pain management involving non-pharmacological interventions for one of five residents (Resident 2), reviewed for pain management. This outcome had the potential for Resident 2's pain to be managed only through pharmacological interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately calculate the fluid intake and urinary output (measurement of urine daily), for one of one resident (Resident 106), reviewed for accurate documentation. As a result, Resident 106's clinical record was not correct, which had the potential to affect his care for fluid balance.

Inspectors wroteBased on interview and record review, the facility failed to make a good faith attempt to address root cause issues brought forth by the resident council meeting in their Quality Assurance Performance Improvement (QAPI) committee meetings, related to timely call light responses. (Cross Reference F-558) This failure had the potential to affect the care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a laboratory (lab) test not being completed due to an expired specimen container for one of two sampled residents (1). As a result, there was an increased risk of Resident 1 not receiving the appropriate care and services they needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and implement policies and procedures for an allegation of abuse when: the alleged perpetrator returned to work and continued to enter the alleged victim's (Resident 5) room. This failure had the potential for Resident 5 to be vulnerable and exposed to the alleged perpetrator.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure essential kitchen equipment was maintained for the dish machine and a reach-in freezer according to food safety and sanitation standards of practice and facility policy. This failure had the potential to expose residents to contaminants that could cause foodborne illness.

Inspectors wroteBased on observation, interview and document review the facility did not ensure food and nutrition service staff were able to competently carry out their job duties when: 1. A Dietary employee did not air-dry clean dishes and stacked them wet. 2. A Dietary employee did not correctly label and date TCS (time controlled for food safety) foods in the kitchen. 3. A Dietary employee did not allow the dish machine to reach correct wash temperature while washing the dishes. As a result, this could have led to foodborne illnesses at the facility.

Inspectors wroteBased on observation, interview and document review the facility did not ensure that food was served at an appetizing and palatable temperature for 10 sampled residents. As a result, the 10 sampled residents were at risk for decreased food intake and the potential for nutritional deficits. In addition, this could have potentially affected all residents that receive meal trays from the kitchen at the facility.

Inspectors wroteBased on observation, interview and document review the facility did not maintain sanitary conditions for food safety in the kitchen according to standards of practice when: 1. The ice machine was not cleaned per manufacturer's guidelines. 2. The juice machine was not cleaned per manufacturer's guidelines. 3. The food was not dated per facility policy. 4. The food in 2 refrigerators and a dry storage room were expired. 5. The dietary staff did not follow proper cleaning and sanitizing of surfaces per facility policy. 6. The dietary staff did not air-dry clean dishes before stacking them and storing them. 7. Two staff members removed ice from ice machine in the kitchen without performing hand hygiene. 8. The refrigerators and freezer had food debris on bottom shelves and there were brown stains on the outside of one refrigerator. 9. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dining room space was able to safely accommodate non-feeding assistance residents who wanted to consume meals in the designated dining room space. This failure had the potential to lead to poor food intake among residents who want to eat meals in a communal dining room.