Capistrano Beach Care Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of four sampled residents (Resident 1) was accurate. * Resident 1's PICC line dressing and Stat Lock were documented as being changed on 5/22/26; however, they were last changed on 5/15/26. This failure contributed to delay in Resident 1's PICC line dressing and Stat-lock to be changed as ordered by the physician.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were implemented for one of four sampled residents (Resident 1). * Resident 1's PICC line dressing and StatLock were not changed as ordered by the physician. This failure placed Resident 1 at increased risk for developing a central line-associated bloodstream infection related to the PICC line.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. 1. One of 14 kitchen employees did not perform hand hygiene during food preparation.2. The sanitizing test strips were not available to test the sanitizing solution and sanitizing solution log was incomplete.3. The residents' nutritional supplements were not stored appropriately.4. The hair restraints were not utilized by kitchen staff.5. The food stored in the nourishment refrigerator was not stored at the proper temperature.6. The employee's personal items were not stored appropriately.7. The expired food was not discarded and food was not dated.8. The food in the nourishment refrigerator was not dated.9. The food was not covered in the walk-in freezer.10. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of January through November 2025. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the essential equipment was maintained in proper working condition. * The kitchen walk-in freezer had ice build-up which prevented the door from closing completely. * The walk-in refrigerator fan cover had black debris and brown residue resembling rust. * The floor tiles under the kitchen oven were not intact and clean. These failures had the potential for the equipment to not function the way it was intended.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitation in the kitchen was maintained. * The facility failed to ensure the kitchen was free from flies. This failure posed the risk for the pests to contaminate the residents' food.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directives for three of 23 final sampled residents (Residents 20, 46, and 63). * The facility failed to provide documented evidence if the written information and assistance on how to formulate an advanced directive were provided Residents 20, 46, and 63 when the residents did not have an advance directive. This failure had the potential for the residents to not receive the treatment and services based on the residents' wishes.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one final sampled resident (Resident 16) and one nonsampled resident (Resident 48) who participated in the Resident Council meeting. * The facility failed to ensure Residents 16 and 48 was informed on how to file a grievance. This failure had the potential to cause the residents feeling hopeless and may negatively affect their emotional well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six final sampled residents (Residents 46) reviewed for the unnecessary medications were free from the unnecessary medications. * The facility failed to ensure Resident 46's was monitored for the side effects of paroxetine HCl (antidepressant medication). In addition, the facility failed to show documentation of the behavior monitoring for depression. These failures had the potential for the resident to not receive the necessary care due to the delay in the detection of adverse effects and determination of the effectiveness of the psychotropic medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the resident to attain or maintain the highest practicable well-being for one of two final sampled residents (Resident 4). * The facility failed to ensure the 72 hours monitoring following a change of condition for Resident 4 was completed. This failure posed the risk of the residents not receiving the appropriate care and potential for the delay in providing the necessary care to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident remained free from accident hazards for one of 23 final sampled resident (Resident 2). * The facility failed to ensure Resident 2 was supervised in Shower room [ROOM NUMBER]. In addition, Shower room [ROOM NUMBER] had no call system available to call the staff for assistance if needed. These failures had the potential to place the resident at risk for accidents and serious injury.

Inspectors wroteBased on observation, interview, facility document and P&P review, the facility failed to ensure the acceptable parameters of nutritional status were maintained for one of four final sampled residents (Resident 72) ) reviewed for nutrition status. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weighed 174 pounds (lbs) on 4/8/25. In addition, the facility failed to monitor Resident 72's weight and implemented interventions to address Resident 72's severe weight loss. * The facility failed to conduct a nutritional assessment in a timely manner when Resident 72 weighed 160 lbs on 8/4/25. In addition, the facility failed to closely monitor Resident 72's weight. * The facility failed to ensure the nutritional assessment was completed when Resident 72 weight 155 lbs on 10/3/25. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 14) reviewed for oxygen therapy. * The facility failed to ensure Resident 13 received oxygen therapy as ordered by the physician's order. * The facility failed to ensure the oxygen tubing for Resident 14 was labeled with the date. These failures had the potential for the residents not to receive the appropriate respiratory care and may negatively impact the residents' medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for three of three final sampled residents (Resident 2, 20, and 69) reviewed for the unnecessary medications. * The facility failed to ensure the insulin (medication to lower the blood sugar) injection administration sites were rotated for Residents 2 and 20. * The facility failed to ensure the Zosyn (antibiotic) IV medication was administered to Resident 69. These failures had the potential for the residents to not receive the necessary medications and could negatively affect the residents' well- being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (nonsampled resident, Resident 40) observed for medication administration was free from the significant medication errors. * LVN 5 did not check the resident's pulse rate prior to the administration of the metoprolol (a medication to lower blood pressure) to Resident 40. This failure had the potential to negatively impact the resident's health and well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications/supplies in the medication room and medication cart were store properly. * The facility failed to ensure the expired Covid-19 Binax Now (a test to detect Covid-19) were removed from Medication Room A. In addition, the facility failed to ensure the oral medications were stored separately from the externally used medications. * The facility failed to ensure the expired bottles of the 0.9% normal saline solutions were removed from Medication Cart A. These failures had the potential for medication errors and the use of the expired medications/supplies which could negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to employ a staff with the skills and abilities to effectively implement the departmental processes in accordance with standards of practice in the food services department. * The facility failed to ensure the Dietary Manager was competent in managing the day-to-day functions of the food services department. This failure had the potential to jeopardize the health and well-being of the 77 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one of 14 kitchen staff members (Cook 2) had the appropriate skill set necessary to safely perform the manual dishwashing. * The facility failed to ensure [NAME] 2 was competent to describe or demonstrate the manual dishwashing process. This failure had the potential for the residents' dishes to not be washed correctly which could lead to sanitation concerns.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu to meet the resident's nutritional needs was followed for one of 77 residents (Resident 23). * The facility failed to ensure Resident 23 was provided with the high caloric pudding and whole milk on her lunch tray. This failure had the potential to not meet the resident's nutritional needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served was in accordance with the prescribed diet texture to one of 23 final sampled residents (Resident 12). * The facility failed to provide Resident 12's diet was according to the physician's order. This failure posed a risk for the resident to not tolerate the food texture and choke.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the resident was served a substitute meal entree that was equivalent to the nutritive value of the main meal entree for one of 23 final sampled residents (Resident 12). * The facility failed to ensure Resident 12 received a substitute meal entree equivalent to the main meal entree of three ounce baked chicken. This failure had the potential for the resident to not receive a meal to meet the resident's needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the adaptive equipment was used properly for one nonsampled resident (Resident 23). * The facility failed to ensure the plate guard was placed on Resident 23's plate during meals. This failure posed the risk for Resident 23 to not reach her maximum level of independence.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure safe food handling of the food brought for the residents from the outside sources. * The facility failed to ensure the visitors who brought food for the residents from outside sources and employees who handled the outside food were educated on safe food handling. This failure poses the risk of food contamination which could lead to food borne illnesses to all 77 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the refuse was stored in a sanitary manner. * The facility failed to ensure the two of two garbage dumpsters' lid and one of one recycling dumpster's lid were fully closed. * The facility failed to ensure the broken items/equipment were disposed of properly. These failures had the potential for pest contamination.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the active involvement of required individuals in developing the Facility Assessment, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs. These failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview and medical record review, the facility failed to maintain an accurate medical record for one of 23 final sampled residents (Resident 5). * Resident 5's medical record had conflicting documented information as to whether Resident 5 had formulated an advance directive for health care. This failure had the potential for not meeting Resident 5's requests specific to his healthcare.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of six sampled residents (Resident 4). * The facility failed to develop a care plan when Resident 4 had an episode of dislodged nephrostomy tube. This failure had the potential for the residents to not receive the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the responsible party of one of six sampled residents (Resident 1) was informed in advance of the care that was going to be furnished and of the type of provider who would be furnishing the care to Resident 1. This failure posed the risk of Resident 1's responsible party not being able to make the informed decisions about Resident 1's care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of three sampled residents (Resident 4). * The facility failed to ensure Resident 4's BP was monitored for hypotension. * The facility failed to ensure the results of the CBC test were promptly reported to Resident 4's physician. * The facility failed to ensure Resident 4's urine sample was collected in a timely manner. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 was administered Tamiflu (a medication used to treat the flu or can reduce the chance of getting the flu) as ordered by the physician. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to develop and/or implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an abuse allegation in a timely manner for one of two residents sampled for abuse (Resident1). * The facility failed to ensure an allegation of physical abuse was reported timely when Resident 1 stated the pillows were put on her face by Resident 2. This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the quarterly trust fund statements to one of two residents reviewed for personal funds (Resident 5). This failure had the potential for loss and misuse of Resident 5's personal funds.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The food and beverages in the walk-in refrigerator were not discarded by the use-by date. * The appropriate hair restraints were not worn by four staff in the kitchen (The DSS, Cooks 1 and 2, and the Maintenance Supervisor). * One uncovered bucket of cleaning chemical was stored next to two containers of broth base and one container of oil. * The cooking utensils, cutting boards did not have cleanable surfaces. * One rubber spatula had white residue on the spatula and handle. * 12 baking sheets had black residue. * The trash can lid was on top of the handwashing sink * One dry goods bin with white granulated powder was unlabeled. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six final sampled residents (Resident 7) reviewed for psychotropic use was informed of the indication for the use of psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 7's informed consent was obtained when the indication for the use of risperidone (an antipsychotic medication used for mental illness that causes disturbed or unusual thinking) was changed to racing thought. This failure had the potential for Resident 7 to not be informed of the medication and potential effects of risperidone.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to assess one of 21 final sampled residents (Resident 74) for their self-administration of the medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for two of 21 final sampled residents (Residents 4 and 72). * The facility failed to ensure Residents 4 and 72's call lights were kept within the residents' reach. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care and services to the residents.

Inspectors wroteBased on interview, facility P&P review, and facility document review, the facility failed to address and follow through with the concerns brought up in the resident council meetings (a group of residents gathered to discuss interests and issues noted in facility). * The facility failed to complete the request for the OCTA Access forms for the residents. * The facility failed to thoroughly address regarding the concerns about the CNAs' mannerisms when answering the residents. These failures had the potential for the residents' identified issues to go uncorrected.

Inspectors wrote6. Medical record review for Resident 2 was initiated on 9/17/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Physician's Orders for Life-Sustaining Treatment (POLST) dated 7/28/24, showed Resident 2 did not have an advance directive. Review of Resident 2's Advanced Healthcare Directive Acknowledgement Form, undated, showed Resident 2 did not have an advance healthcare directive; however, there was no documentation to show the resident or the resident's representative was offered information regarding the formulation of an advance directive. On 9/20/24 at 1327 hours, an interview and concurrent medical record review for Resident 2 was conducted with the SSD. The SSD verified the Advance Healthcare Directive Acknowledgement form for Resident 2 was incomplete and stated it should have been completed. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' medical records were safeguarded to protect their confidential health information for two nonsampled residents (Residents 56 and 59). This failure had the potential for the residents' personal and health information to be accessed from the unauthorized users.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident's representatives of the resident's transfer and reasons for the transfer to the acute care hospital in writing for one of three final sampled resident (Resident 2) reviewed for hospitalization. This failure posed the risk of the resident's representatives not being aware of their appeal rights.

Inspectors wroteBased on interview and medical record review, the facility failed to complete a significant change MDS within 14 days after a significant change for one of two final sampled residents reviewed for hospice services (Resident 2). This failure resulted in a delay in a comprehensive reassessment of the resident's changing health status and plan of care, in the effort to attain the resident's highest level of well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the plan of care was developed for three of 21 final sampled residents (Residents 13, 43, and 72). * The facility failed to develop a comprehensive person-centered care plan to address Resident 13's fall incident on 7/27/24, and Resident 13's significant weight loss. * The facility failed to develop a plan of care to address the actual fall for Resident 43. * The facility failed to develop a comprehensive person-centered care plan to address Resident 72's fall on 5/29/24. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of 21 final sampled residents (Resident 7). * The facility failed to follow the physician's order for Resident 7 for cervical collar at all times every shift. This failure posed the risk of adverse effects to Residents 7's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the resident's low air loss mattress was set appropriately according to the resident's weight for one of two final sampled residents reviewed for pressure ulcer (Resident 13). This failure had the potential for Residents 13 not receiving the appropriate care and services to prevent the development of the pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 2 and 86) received the necessary care and services to prevent accident hazards. * The facility failed to thoroughly investigate and document Resident 2's cause of skin tear on the right buttock. * The facility failed to ensure the physician's order for Resident 86 to wear WanderGuard at all times was followed. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of six final sampled residents reviewed for weight loss (Residents 4, 13, and 35) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to implement interventions to maintain Resident 13's nutritional status when the resident experienced severe weight loss. The facility failed to notify Resident 13's physician and responsible party in timely manner and failed to ensure the IDT analyzed and implemented the necessary interventions to address Resident 13's severe weight loss. * Residents 4 and 35's weekly weights were not completed as ordered by the physicians. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of six final sampled resident (Residents 2, 4, 27, 72, and 442) and one nonsampled resident (Resident 12) reviewed for respiratory care and services. * The facility failed to ensure the physician's order for oxygen therapy was followed for Resident 442. In addition, the facility failed to clarify the physician's order when the order did not show how high the oxygen could be titrated for Resident 442. * Resident 12's oxygen concentrator was observed in the hallway, and the door was closed with compressing oxygen tubing. This failure posed the risk of Resident 12 not receiving her oxygen. * Resident 27 was not administered continuous oxygen as ordered by the physician. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of three final sampled residents (Resident 62) reviewed for pain management had the pain medication orders to include clear indication for use as evidenced by: * Resident 62 had the orders for acetaminophen (analgesic) and hydrocodone-acetaminophen (opioid analgesic) with the same pain levels for use. This failure posed the risk of the resident's pain not being managed appropriately.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the medications were administered according to the facility's P&P for one nonsampled resident (Resident 59). This failure posed the risk of Resident 59's medications not being administered according to accepted practices.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 2 and 7) reviewed for psychotropic medications (medication affecting brain activities associated with mental processes and behavior) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 7's behavior manifestation and side effects were monitored accurately for the use of risperidone (an antipsychotic medication used for mental illness that causes disturbed or unusual thinking). * The facility failed to ensure the PRN order for lorazepam (antianxiety medication)was limited to 14 days for Resident 2. These failures posed the risk of unnecessary medications for these residents and negatively affects the residents' health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure daily nutritional and special dietary needs, and preferences were provided for one of 21 final sampled residents (Resident 62) and two nonsampled residents (Residents 592 and 593). * Resident 592's lunch tray did not include gluten free pasta. * Resident 593's lunch tray did not include double portions. * Resident 62 did not have Ensure (supplement) to his lunch tray as per the physician's orders. These failures posed the risk for the residents' foods and nutritional needs not being met.

Inspectors wroteBased on interview, medical record review, and the facility document review, the facility failed to ensure one of three nonsampled residents (Resident 45) reviewed for arbitration, who had no mental capacity to understand the terms of the facility's binding arbitration agreement (an agreement that allows parties to resolve disputes and lawsuits privately rather than going to the court) did not sign the Arbitration Agreement. This failure posed the risk for the resident to not have a clear understanding of the arbitration process.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of two final sampled residents reviewed for hospice services (Residents 2 and 13). * The facility failed to ensure the hospice was notified regarding significant weight loss for Residents 2 and 13. * The facility failed to ensure Resident 2 received the hospice nursing visits two times per week as per the plan of care. These failures posed the risk for delays in the communication between the hospice provider and the facility which may affect resident care.

Inspectors wroteThe facility failed to ensure the equipment was maintained in the safe operating condition when: * The facility's freezer compartments had ice buildup for two of two medication refrigerators. * One of one ice machines had black tape, a non-cleanable surface, and brownish-red residue inside. These failures had the potential to affect the resident's health and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure the facility was free of pests in one resident's room, and the kitchen. * A fly was observed in Resident 10's room and on their uncovered cup of milk and on the opening of their bedside insulated water mug. * A fly was observed in the kitchen on multiple occasions over two days, by the coffee machine, puree food preparation and tray line areas. These failures had the potential for transmission of foodborne illness to the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessment was accurate for two of 21 final sampled residents (Residents 2 and 71). * The facility failed to ensure Resident 71's gender was coded accurately. * The facility failed to ensure Resident 2's hospice services and weight loss was coded accurately. These failures placed the residents at risk for lack of continuity of care.

Inspectors wroteBased on observation and interview, the facility failed to dispose and store trash in a sanitary manner. This failure posed a threat for pest contamination.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the requested medical and billing records for one of two sampled residents (Resident 1). This failure had the potential to violate the resident's rights.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure a safe environment was provided for the residents. * The facility failed to ensure the broken shower bench in Shower Room C was removed. This failure had the potential to affect the safety of the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of six sampled residents (Resident 1). * Resident 1's evening medications were not administered on the admission day because they were not delivered by the pharmacy. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the RD and IDT evaluations and interventions related to weight loss were conducted timely for one of two sampled residents (Resident 1). This failure had the potential for a delay in providing care and interventions and continued weight loss for the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) did not receive the unnecessary medication when the licensed nurse failed to enter or implement the physician's order correctly. This failure had the potential for the resident to experience adverse effects and negatively impact the resident's well-being.

Inspectors wroteIntakes: CA00882864 Based on observation, interview, and medical record review, the facility failed to ensure the resident's meals were served at the desired temperatures for two of two sampled residents (Residents 1 and 2). This failure had the potential for the undesirable food temperatures to result in decreased oral meal intake and undesirable weight loss for the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure five of six meal tray carts used for meal distribution to the residents were maintained in the proper functioning order. This failure had the potential for undesirable food temperatures and unsafe food temperatures.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse. This failure placed Resident 1 at risk for psychological and emotional harm. * On 12/15/23, Resident 2 was observed with his hands down on Resident 1's pants and making a jerking motion. Resident 1 had severe cognitive impairment and did not have the capacity to consent. Resident 1 was not consistently monitored for 72 hours after the incident.

Inspectors wroteBased on observation, interview, facility document and P&P review, the facility failed to ensure the CDM was competent to manage the day to day operations of the food service department as evidenced by: 1. The CDM failed to provide food in a manner that was in accordance with current food safety guidelines. 2. The CDM failed to ensure recipes were followed and correct portion sizes were served. 3. The CDM failed to ensure therapeutic diets were followed. 4. The CDM failed to ensure foods were prepared to conserve nutritive value. 5. The CDM failed to ensure mechanically altered diets were served food consistent with the prescribed texture. 6. The CDM failed to follow and document the residents' food preferences. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the menu was followed. * The facility failed to ensure the recipes were followed. * The facility failed to ensure the therapeutic diets were followed. * The facility failed to ensure the correct portion sizes were followed. These failures had the potential for resident's nutritional needs not to be met which could further compromise their medical status.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure proper thawing of frozen food in the refrigerator. * The facility failed to ensure a cooling log was in place. * The facility failed to ensure proper covering, labeling, and dating of foods in the kitchen. * The facility failed to ensure the proper storage of produce. * The facility failed to ensure the proper use of the sanitizing solution in the sanitizing sink. * The facility failed to ensure proper backflow prevention of two of three air gaps. * The facility failed to ensure proper sanitary condition of the hood over the stove. * The facility failed to ensure proper sanitary condition of the drain sink under the tray line table. [...]

Inspectors wroteBased on observation and interview, the facility failed to safeguard one of the 18 final sampled residents (Resident 74)'s personal belonging from loss or theft. * Resident 74's irreplaceable personal pictures were lost when he was moved to another room in the facility. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for three of 18 final sampled residents (Resident 29, 74, and 425). * The facility failed to develop a care plan to address Resident 425's smoking. * The facility failed to develop a care plan to address Resident 29's use of antidepressant medication. * The facility failed to develop a care plan to address Resident 74's religious food preferences. These failures had the potential to negatively impact the care needed for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide an environment free from accident hazards for one of 18 final sampled residents (Resident 425). * The facility failed to ensure Resident 425 was assessed for safe smoking. This failure posed the risk of fire and injury to the residents and staff in the facility.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of each resident when: * The facility failed to ensure Resident 6's lorazepam (anti-anxiety medication) was accurately reconciled. Five tablets for lorazepam had been removed from Resident 6's medication bubble pack after it had been discontinued on 11/24/21. The number of tablets of lorazepam removed showing on the Antibiotic or Controlled Drug Record did not match the number of tablets in the electronic MAR as administered to Resident 6. This failure had the possibility of diversion of controlled medications. * The facility failed to ensure the oral medications emergency kit was replaced in a timely manner. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe medication storage was observed in three of seven medication carts (Medication Cart 4, Treatment Cart 2, and IV Cart 1). * An expired bottle of vitamin E was stored in Medication Cart 4. * An expired acetic acid solution was stored in Treatment Cart 2. * Two bags of expired IV fluids were stored in IV Cart 1. These failures had the potential for the residents to be exposed to the expired medications.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure the nutritive value of minced/moist and pureed vegetables were conserved when minced/moist and pureed vegetables were prepared with additional liquid and held in a hot oven for more than an hour and a half prior to meal service. This failure placed four residents who received a minced/moist diet and seven residents who received a puree diet at risk for compromised nutritional status.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure one sampled resident (Resident 18) and one nonsampled resident (Resident 58) received food prepared in a form to meet their individual dietary needs. This failure placed Resident 18 and Resident 58 at risk for aspiration (accidental breathing in of food or fluid into the lungs).

Inspectors wroteBased on observation, interview and facility document review, the facility failed to honor religious food preferences for one sampled resident (Resident 74). This failure posed the risk of Resident 74's religious and nutritional needs not to be met.

Inspectors wroteBased on interview and facility record review, the facility failed to ensure the policy regarding food brought to the facility for the residents by the family or visitors was followed. This failure posed the risk for potential unsafe food handling practices.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of 18 sampled residents (Resident 7) was complete. * Resident 7's POLST (Physician Orders for Life Sustaining Treatment is a medical order that helps give people control over their care during a medical emergency) form was blank, but was signed and dated by the physician. This had the potential for the resident's emergency care needs not being met because his medical information was incomplete.

Inspectors wroteBased upon observation, interview, and facility document review, the facility failed to follow the infection control practices for three of 18 final sampled residents (Residents 52, 56, and 578): * LVN 4 failed to perform hand hygiene during the medication administration for Resident 56. * Resident 52's indwelling urinary catheter drainage tubing was observed dragging on the ground under the wheelchair. * Resident 578's wheelchair was dirty and had brown stains on the seat. These failures had the potential to cause growth and the spread of microorganisms.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 7) was offered the second dose of COVID-19 vaccine. This failure had the potential for the resident not being fully vaccinated against COVID-19.