Del Rosa Villa

development of an individualized comprehensive care plan for each resident.

555195 02/12/2026

Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

of 20 sampled residents (Resident 6) with personal hygiene specifically nail care.

This failure resulted

maintain personal hygiene.

Findings:During a review of Resident 6's face sheet (demographic data), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia (decline in memory function).During a review of Resident 6's quarterly Minimum Data Set (assessment tool) dated 1/14/26, Resident 6 required assistance in her personal hygiene.During a concurrent observation and interview on 2/8/26, at 10:56 a.m. with Resident 6 in the dining room, Resident 6 was observed with long, visibly dirty fingernails.During a meal observation on 2/8/26 at 12:02 p.m., Resident 6 was seen eating and touching food with both hands.

When asked about the condition of her fingernails, Resident 6 stated I know.During a concurrent observation and interview on 2/9/26 at 11:02 a.m. in Resident 6's room, with Certified Nursing Assistant (CNA 1), Resident 6 fingernails remained long and dirty. CNA 1 stated she did not notice the condition of Resident 6's fingernails.

During an interview on 2/9/26 at 9:52 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated CNAs were responsible for cutting/cleaning residents' fingernails.During a concurrent observation and interview on 2/10/26 at 8:50 a.m. with CNA 2, Resident 6 remained with visibly long dirty fingernails. CNA 2 stated she did not observe the condition of Resident 6's fingernails.

During an interview on 2/12/26 at 9:05 a.m. with Director of Nursing (DON), DON stated CNAs were responsible for maintaining and providing ADL assistance to the residents.During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting dated March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care).

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Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

prevent accidents.

observation, interview and record review, the facility failed to keep the environment safe and free

were not implemented.

These failures placed Resident 28 at risk for potential falls and injuries.

During a review of Resident 28's Face Sheet (Demographics), the Face Sheet indicated Resident 28 was readmitted to the facility on [DATE] with diagnoses which included Encephalopathy (brain dysfunction that often results in altered mental state), Multiple Sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord).During an observation on 2/8/26 at 10:30 AM, in Resident 28's room, Resident 28 was resting in bed, with the bed elevated in a high position from the ground. Resident 28 was wearing a wristband that indicated Fall Risk.During a concurrent observation and interview on 2/9/26 at 9:30 a.m. with Certified Nursing Assistant (CNA) 4 in Resident 28's room, Resident 28 was resting in bed which was again raised in a high position from the floor.

The Resident's call light was found underneath the bed on the floor. CNA 4 confirmed bed was in a high position and stated Resident 28 was considered a high risk for fall and the bed should be lowered to prevent injury. CNA 4 stated the call light should be within the resident's reach and was not when it was found under Resident 28's bed.

During an interview on 2/10/26 at 10 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 28 was a fall risk and safety interventions should be in place to prevent falls, including keeping her bed in a low position and having the call light within reach.During a review of Resident 28's care plan Falls dated 12/18/24, the care plan indicated goals were to minimize risk for falls and the interventions included, Keep bed in low position.

Keep call light within reach.During a review of the facility's policy and procedure (P&P) titled, Falls/Fall Risk Management, dated September 2012, the P&P indicated, . the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

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Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

During a review of Resident 107 face sheet (demographic data), Resident 107 was readmitted to the facility on [DATE] with diagnoses which included fluid overload, and hypoxemia (low oxygen levels in the blood).During a review of Resident 107's admission Minimum Data Set (MDS- assessment tool) dated 11/13/2025, MDS assessment indicated Resident 107 was cognitively intact.During a review of the physician's order dated 2/4/26 indicated [name of medication] to inhale orally via nebulizer (medical device that turns liquid medicine into a mist that can be inhaled) every 6 hours as needed for shortness of breath, hypoxia (a condition where body tissues do not receive enough oxygen); Initiate Incentive Spirometer (medical device used to measure lung volume and speed of air in between respiration) three times a day for 5 to 10 breath cycle or as tolerated for 10 days.

During a concurrent observation and interview on 2/8/26 at 10:10 a.m. and 2/9/26 at 9:30 a.m. with Resident 107, a nebulizer machine was observed without set-up and there was no Incentive Spirometer found at bedside. Resident 107 was observed to have coughs and stated he was experiencing slight shortness of breath in between his activities.

During an interview on 2/10/26 at 9:20 a.m. with Resident 107, Resident 107 stated he had not received any breathing treatments since his readmission. Resident 107 further stated the Incentive Spirometer was not provided since returning from the acute hospital.

During an interview on 2/10/26 at 9:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 107 had orders of respiratory treatments; however, LVN 1 stated the respiratory prescribed treatments were not administered/provided on 2/9/26 to 2/10/26 during her shift. LVN 1 also confirmed the nebulizer machine had no set up and there was no Incentive Spirometer equipment at bedside,During a review of the Medication Administration Record (MAR) dated February 2026, there was no documentation indicated that the prescribed respiratory medication via nebulizer were administered, offered, attempted or refused by Resident 107.

During an interview on 2/12/26 at 9:05 a.m. with Director of Nursing (DON), the DON stated all respiratory medications should have been administered according to physician's order.During a review of the facility's policy and procedure titled Respiratory Treatment dated 8/1/24, indicated It is the policy of this center that residents receive respiratory treatments and monitoring per their physician's orders, standards of practice and plan of care.

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Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

appetizing for two of 20 sampled residents (Resident 67 and Resident 116).This failure had the

an interview on 2/8/26 at 11 a.m. with Resident 67 in the resident's room, Resident 67 stated the food was not good and she did not like to eat the food served. Resident 67 stated the food would also be delivered cold, which did not make it appetizing to eat and she would often not finish her meal because of it.

During an interview on 2/8/26 at 3:30 p.m. with Resident 116 in the resident's room, Resident 116 stated she did not like the food that was served because it was not palatable when the food tray was cold by the time it was delivered to her room.During a review of the facility's menu titled, February 9-15, 2026, the menu for Monday 2/9/26 indicated the lunch meal of Regular diet included Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, and Fruit Bavarian Cream.During a test tray observation and interview on 2/9/26 at 12:28 p.m. with the Dietary Supervisor (DS) in the dining room, a food tray of the regular diet was removed from the last meal cart for delivery to the residents' rooms and the temperatures of the food were taken. On the regular tray, the entree of Fish with Tarragon was 126.8 degrees F and the Cajun Country [NAME] was 127.8 degrees F when the temperature was taken with a thermometer.

The DS acknowledged the low food temperatures of the food and stated it should be served warmer.During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-501.16 titled, Time/Temperature Control for Safety.

Holding, FDA Food Code indicated, Food shall be maintained. held at a temperature of 54 degrees Celsius (130 degrees F) or above.During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, undated, the P&P indicated, Proper hot and cold temperatures are maintained during food distribution and service.

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Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

comfortable environment for one of 20 sampled residents (Resident107) when Resident 107 did not

had the potential to place Resident 107 at risk for infection, and contamination that could affect his overall health condition.Findings: During a review of Resident 107's face sheet (demographic data) and admission Minimum Data Set (MDS- assessment tool), Resident 107 was readmitted to the facility on [DATE] with diagnoses which included fluid overload, and hypoxemia (low oxygen levels in the blood). MDS assessment indicated Resident 107 has intact cognition.During a concurrent observation and interview on 2/8/26 at 10:10 a.m. with Resident 107, Resident 107 was observed with urinary drainage bag with covering attached to his wheelchair and he stated the staff were not coming in to empty the urinary bag and had been emptying the urine by himself. Resident 107 was observed removing the drainage port, showing how to empty it, and replacing the port without gloves or performing hand hygiene before and after the task.

During an interview on 2/9/26 at 9:43 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 107 was not his regular assigned resident, and he was not aware of the urinary bag.

During an interview on 2/9/26 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNAs were responsible for emptying urinary bags. LVN 1 could not state if Resident 107 was screened to perform self-emptying the urinary bag.During an interview on 2/11/26 at 10:08 a.m. with Infection Preventionist (IP), IP could not confirm if there was documentation indicating Resident 107 was assessed as capable of managing his own catheter care, nor any documentation of resident education, supervision or competency evaluation related to catheter-bag emptying.During a review of the facility's policy and procedure titled Infection Prevention and Control Program with revised date of October 2018, indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection.

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Del Rosa Villa 2018 N Del Rosa Ave San Bernardino, CA 92404

program, when staff failed to report the presence of flying insects in room [ROOM NUMBER] shared

staff.Findings:

During an interview conducted on 2/9/26 at 10:56 a.m. with Resident 14, Resident 14 stated there was a lot of bugs inside his bathroom. Resident 14 stated he informed staff about the bugs last week but they did nothing about it. Resident 14 stated he could not remember the staff name or the specific date when he told staff.During an observation on 2/9/26 at 10:57 a.m. in room [ROOM NUMBER] shared bathroom, there was large amount of small dark colored flying insects inside the bathroom and large amount that were resting around the toilet seat.During a concurrent observation and interview on 2/9/26 at 11 a.m. with the Administrator and Environmental Service Director (ESD) in room [ROOM NUMBER] bathroom, the Administrator and the ESD stated they were unaware of the bugs issue inside the bathroom.

The Administrator and the ESD confirmed the large amount of flying insects.During a concurrent interview and record review on 2/10/26 at 9:56 a.m. with the ESD, the ESD stated he was not notified by any staff regarding the insects inside room [ROOM NUMBER] bathroom.

The ESD provided a communication folder (a folder used by facility staff to report maintenance issues) for review.

The folder indicated there was no documented evidence that staff reported or communicated the issue.During a review of the facility's policy and procedure (P&P) titled, Pest Control with a revision date of May 2008, the P&P indicated, Our facility shall maintain an effective pest control program.