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Complaint Investigation

Capistrano Beach Care Center

September 11, 2025 · Dana Point, CA · 35410 Del Rey
Citations 1
CMS Rating 1/5
Beds 93
Provider ID 055585
Healthcare Facility
Capistrano Beach Care Center
Dana Point, CA  ·  View full profile →
Inspection Summary

CAPISTRANO BEACH CARE CENTER in DANA POINT, CA — inspection on September 11, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for Minimal Harm

Review of Resident 4's MDS assessment dated [DATE], showed the resident's cognition was moderately impaired.

Review of Resident 4's eINTERACT Change in Condition Evaluation - V 5.1 dated 8/19/25, showed the resident had dislodged nephrostomy tube.

Review of Resident 4's Progress Notes showed the following:- dated 8/19/25 at 1421 hours, showed the resident's nephrostomy tube was dislodged, the physician was notified and ordered to transfer the resident to the acute hospital for nephrostomy tube re-insertion;- dated 8/19/25 at 1907 hours, showed the resident was transferred to the acute care hospital, and- dated 8/19/25 at 2222 hours, showed the resident arrived at the facility at 2000 hours, with a replaced nephrostomy tube from the acute care hospital.

Review of Resident 4's plan of care failed to show a care plan was developed to address the resident's dislodged and replaced nephrostomy tube. On 9/11/25 at 1020 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified there was no care plan developed to address Resident 4's dislodged nephrostomy tube. LVN 3 stated whoever initiated the change of condition should have done the care plan for Resident 4's dislodged nephrostomy tube. On 9/11/25 at 1055 hours, an interview and concurrent medical record review was conducted with the DON.

The DON verified Resident 4 had an episode of dislodged nephrostomy tube.

The DON stated a care plan was being initiated when the resident was admitted to the facility of if there was a change of condition.

The DON stated the licensed nurse should have written Resident 4's nephrostomy tube was dislodged and the intervention should include the transfer to the acute care hospital.

The DON further stated the care plan intervention should have included keeping the nephrostomy tube site clean and intact.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DANA POINT, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CAPISTRANO BEACH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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