Inspection·June 20, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that food provided to a resident on a puree diet ( a type of texture-modified diet where all foods are blended to a smooth, pudding-like consistency) was given as ordered by the physician, when a cotton candy was given for consumption for one of three sampled residents (Resident 1). This failure had the potential to place Resident 1 at risk for choking or aspiration. Findings: On May 13, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficult swallowing). A review of Resident 1's History and Physical dated March 15, 2024, indicated, Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Physician Order, dated June 13, 2024, indicated, Fortified diet [additional nutrients have been added to foods] Puree texture, Nectar/Mildly Thick Liquids consistency, LARGE PORTIONS. A review of Resident 1's Care Plan, dated June 13, 2025, indicated, .swallowing difficulty requiring altered texture diet: pureed foods, thickened liquids .Goal .Resident will safely consume prescribed diet with no signs of aspiration .Interventions .Offer choices within diet .Provide diet per order . A review of Resident 1's Nurses Progress Note, dated May 5, 2025, indicated, .STAFF NOTED THAT RESIDENT WAS CONSUMING COTTON CANDY, SPOKE WITH RESIDENT THAT RES IS CURRENTLY REGULAR DIET WITH PUREE TEXTURE AND MILD THICKENED FLUID . A review of Resident 1's Dietary Profile dated May 5, 2025, indicated, .Diet Texture .PUREE TEXTURE .RESIDENT IS TO REMAIN ON AN FORTIFIED DIET, PUREE TEXTURE . On May 13, 2025, at 11:19 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, she worked on May 5, 2025, at around 1:30 p.m., and saw Resident 1 eating cotton candy, and the container was about half full. LVN 1 stated, Resident 1 was on a puree diet and was at high risk for aspiration. LVN 1 stated, the Business Manager gave the cotton candy to the resident and had done so in the past. (continued on next page) 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 TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056315 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056315 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citrus Grove Post Acute 9025 Colorado Avenue Riverside, CA 92503 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)