Centinela Grand Inc

In the surveyor’s words

From the most serious findings on record at Centinela Grand Inc, in the surveyor’s own words.

• Actual harm, isolatedF692Mar 18, 2022

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Mar 18, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF908Mar 18, 2022

  Based 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. Findings: A review of facility document titled, Physician Orders List, dated March 14, 2022, indicated 90 residents were on diets and received food from the kitchen. […]

• No harm, potential for more than minimal, patternF689Aug 4, 2025

  Based 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.Findings:On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.1a. […]

• No harm, potential for more than minimal, patternF742Aug 4, 2025

  Based 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. Findings:1.On July 30, 2025, an unannounced visit was conducted at the facility to investigate a complaint.On July 30, 2025, at 12:17 p.m., Resident 3 was interviewed. […]