LA JOLLA, CA - Federal inspectors identified significant safety violations at The Cove at La Jolla nursing home during a May 2025 inspection, documenting failures to maintain proper fall prevention measures and provide appropriate respiratory care for residents with sleep apnea.
Fall Prevention Failures Create Safety Hazards
The facility faced multiple citations for failing to maintain a safe environment for residents, particularly those at high risk for falls. Inspectors found that safety protocols were not consistently followed, creating unnecessary risks for vulnerable residents.
One resident with a documented history of falls and mobility impairment had floor mats prescribed on both sides of their bed as a safety intervention following a fall on April 30, 2025. However, when inspectors observed the resident's room on May 15, they discovered that only one fall mat was positioned correctly on the floor, while the second mat was propped against the wall.
The licensed nurse present acknowledged the problem, stating that "staff moved the floor mat out of the way while transferring Resident 40, but it looked like they forgot to put the fall mat back down after the transfer." The nurse confirmed that "the floor mat would not have been effective while placed up against the wall instead of being on the floor."
This violation represents a breakdown in basic safety protocols. Fall mats are specifically designed to cushion potential falls from bed, reducing the risk of serious injury such as fractures, head trauma, or other complications that could be life-threatening for elderly residents. When these safety devices are not properly positioned, residents face the same injury risks as if no protective measures were in place at all.
The facility's own Fall Management System policy, established in June 2018, requires staff to "provide each resident with appropriate assessment and interventions to prevent falls." The Director of Nursing confirmed that the floor mat should have been returned to its proper position beside the resident's bed.
Widespread Facility Maintenance Issues
Beyond individual room safety concerns, inspectors identified extensive flooring damage throughout the facility's hallways that created tripping hazards for residents, staff, and visitors. The Director of Environmental Services confirmed that water damage had caused flooring to bubble and warp in multiple locations.
The documented hazards included: - Four areas with three-inch diameter floor bubbles in the center hallway directly under handrails - Three areas of one-inch bubbles near resident rooms, adjacent to recently repaired sections - A three-inch bubble with separated flooring seams creating a two-inch elevation change - Multiple additional bubble formations in high-traffic areas
These conditions violate the facility's own Physical Environment policy, which requires monthly environmental rounds to ensure "hallways free of potential environmental hazards." The Administrator acknowledged that hallways should be "free from any tripping hazards" and emphasized the importance of maintaining "a safe environment for the comfort and safety of the residents, staff, and the visitors."
Flooring irregularities pose particularly serious risks for nursing home residents, who often have compromised balance, use mobility aids, or take medications that affect coordination. Even minor flooring defects can result in catastrophic falls leading to hip fractures, which carry high mortality rates among elderly populations.
Respiratory Care Management Deficiencies
Inspectors also identified serious gaps in respiratory care management when they discovered a resident using breathing assistance equipment without proper medical oversight. The resident, diagnosed with obstructive sleep apnea, was using a CPAP machine but lacked a physician's order for the device and had no care plan addressing its use.
Sleep apnea affects breathing during sleep when airways become blocked, potentially leading to dangerous drops in blood oxygen levels. CPAP machines deliver continuous air pressure to keep airways open, preventing breathing interruptions that could otherwise result in heart rhythm problems, high blood pressure, or other cardiovascular complications.
The resident told inspectors they cleaned the machine and added water when needed, indicating they were managing the device independently. However, a Licensed Nurse confirmed during record review that "there was no care plan for a BIPAP or CPAP machine" until May 14, 2025 - well after the resident had been using the equipment.
The Minimum Data Set Nurse noted that hospital records from May 10, 2025, documented the resident's CPAP use, but the facility failed to establish appropriate care protocols upon admission. This represents a significant gap in continuity of care between hospital and nursing home settings.
Medical Standards and Care Planning Requirements
Proper respiratory care management requires comprehensive care planning that addresses equipment maintenance, infection control, and patient education. The Director of Nursing acknowledged that "there should have been a care plan for the CPAP machine to ensure that Resident 209's condition was treated, education was provided to Resident 209 and for staff to know how to clean the machine for infection control."
CPAP equipment requires specific cleaning protocols to prevent bacterial growth and respiratory infections. Inadequate maintenance can lead to serious complications including pneumonia, particularly dangerous for elderly residents with compromised immune systems. Additionally, improperly functioning equipment may fail to provide adequate respiratory support, potentially triggering life-threatening breathing episodes during sleep.
The facility's Comprehensive Person-Centered Care Planning policy, dated October 2024, requires the interdisciplinary team to "develop a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, mental and psychological need." This policy clearly applied to the respiratory care situation but was not implemented appropriately.
Industry Standards and Regulatory Requirements
Federal nursing home regulations require facilities to maintain safe environments and provide appropriate medical care based on residents' diagnosed conditions. Fall prevention programs must include proper use of safety equipment, while respiratory care requires physician oversight and structured care planning.
Environmental safety standards mandate regular facility maintenance to eliminate tripping hazards and other safety risks. These requirements recognize that nursing home residents are particularly vulnerable to injuries from environmental hazards due to age-related physical limitations and medical conditions affecting mobility and balance.
For respiratory care, regulatory standards emphasize the importance of physician-ordered treatments and comprehensive care planning to ensure appropriate monitoring and equipment maintenance. The involvement of multiple healthcare disciplines - including nursing, respiratory therapy, and environmental services - is essential for safe and effective treatment.
Additional Issues Identified
The inspection also documented related concerns about staff knowledge regarding medical equipment maintenance and infection control protocols. The failure to establish proper care plans upon admission suggests potential gaps in the facility's admission assessment procedures and interdisciplinary communication processes.
These violations highlight the interconnected nature of quality care in nursing homes, where environmental safety, medical management, and staff training must work together to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Cove At La Jolla from 2025-05-16 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.