Inspection·August 15, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that nurses were not yet treating his wounds, but he was receiving mobility therapy. The left foot had several metal pins and a stabilization device, with clean and dry wound edges, showing no signs of bleeding or drainage. A review of Resident 3's record was conducted. Resident 3 was admitted to the facility on [DATE], with diagnosis which included fracture (broken) left foot with routine healing, non-pressure chronic ulcer of other parts of unspecified foot with unspecified severity. A review of Resident 3's Minimum Data Set (MDS an assessment tool), dated July 30, 2025, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact). A review of Resident 3's Body Check dated July 17, 2025, indicated, Resident 1 had multiple wound issues, including a diabetic foot ulcer (DFU - open sore or wound on the foot) to the left great toe and an external fixation device with pins. A review of Resident 3's Daily Documentation from July 30, 2025, indicated No wound, with no descriptive notes. There was no documentation that the nurse's daily documentation identified current skin conditions with ongoing treatments. A review of Resident 3's Care Plan initiated July 29, 2025, indicated: .LLE ste [site] with multiplanar external fixation device 25 pins.interventions.administer treatments as ordered by MD [medical doctor] .treatment nurse to evaluate every week.keep site clean and dry.report any signs of infection to MD.DFU treatments to left great toe. interventions.administer treatments as ordered by MD.treatment nurse to evaluate every week.keep site clean and dry.report any signs of infection to MD.Further review of Resident 3's record indicated there was no evidence in daily documentation that the current wounds and treatment were consistently recorded.On July 31, 2025, at 12:30 p.m., during observation and interview, Resident 2 was found lying upright in bed with gauze fabric wrapped around both her left and right feet. Resident 2 stated she was receiving wound treatments daily. A review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnosis which included, encounter for orthopedic aftercare following surgical amputation (removal of a part of a limb or portion of the body), Diabetes Mellitus type 2 (inability to regulate blood glucose (sugar) in the body). A review of the History and Physical dated July 17, 2025, indicated that Resident 2 has the capacity to understand and make decisions. A review of Resident 2's admission Progress Note July 16, 2025, at 11:30 p.m. indicated, .Surgical sites on both lower extremities. Bruising on left arm from hospital stay. Scabs present from self-report of acne. Excoriations underneath bilateral breast. A review of Resident 2's Body Check dated July 17, 2025, indicated, . Amputation tma (Trans metatarsal amputation - surgically removing the front part of the foot) right foot 17 staples mild dehiscence (small opening) noted slight drainage with discoloration noted.DFU to left heel 15 x 1.5 x utd (depth unknown) dry skin noted 3 x 4 masd (moisture associated skin damage - skin irritation or breakdown caused by moisture on the skin) to all bilateral folds/bilateral axillary abscess (a pocket of pus that forms under the skin) mid abdominal 1.5 x .5. A review of Resident 2's Weekly Documentation, for July 23, 2025, and July 30, 2025, indicated: .7/23/2025.skin integrity.resident has skin issues.NO. Prevention.Offloading turning and positioning.7/30/2025.skin integrity .resident has skin issues.No. Prevention.Offloading turning and positioning.A review of Resident 2's Daily Documentation, from July 26, 2025, to July 31, 2025, indicated the following: .7/31/2025.skin integrity.resident has a wound.No.No other notes .7/30/2025.skin integrity.resident has a wound.No.No comments .7/29/2025.skin integrity.resident has a wound.No.No comments.7/28/2025.skin integrity.resident has a wound No.No comments.7/26/2025.skin integrity.resident has a wound.No.No comments A review of Resident 2's Care Plan initiated July 22, 2025, indicated, .DFU L plantar (foot).resident will have no further complications.administer treatment as ordered by md (physician).tx (treatment) nurse to evaluate every week.keep site clean and dry.report any signs of infection to md.TMA to right foot with slight dehiscence.resident will have no further complications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056315 If continuation sheet Page 2 of 7 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 08/15/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administer treatment as ordered by md (physician).tx nurse to evaluate every week.keep site clean and dry.report any signs of infection to md.DFU to left great toe. resident will have no further complications. administer treatment as ordered by md (physician).tx nurse to evaluate every week.keep site clean and dry.report any signs of infection to md.Further review of Resident 2's record indicated daily, and weekly nursing notes did not reflect the progress of wounds or the interventions in place. On July 31, 2025, at 1:06 p.m. during an interview, Resident 4 was alert and stated he had a skin ‘thing' with his ear and was receiving treatments.A review of Resident 4's record was conducted. Resident 4 was admitted to the facility on [DATE], with diagnosis which included, acute kidney failure and osteoporosis (weakening of the bone density),A review of the History and Physical dated March 10, 2025, indicated that Resident 4 has the capacity to understand and make decisions. A review of the Body Check documentation from July 11, 2025, to July 25, 2025, indicated the following: .July 25, 2025. Ongoing tx administered. no new skin alterations noted at this time. Body check completed with skin issues. (no additional description of the skin).July 18, 2025. Ongoing tx administered. no new skin alterations noted at this time. Body check completed with skin issues. (no additional description of the skin).July 11, 2025.Ongoing tx in place, no new skin issues noted. Body check completed with skin issues. (no additional description of the skin).A review of body check documentation did not describe the current status of the skin for ongoing treatments.A review of the physician orders summary indicated the following: .Active.July 30, 2025. Treatment to scab right ear cleanse with n/s (normal saline) pat dray apply betadine lota x 14 days reassess notify Md if any coc. start date 7/30/2025.Active.July 15, 2025.Maintenance to right buttocks cleans with n/s pat dry and apply Calmoseptine x 14 days and reassess. Notify md of any further changes everyday shift for 21 days until finished start dated 7/15/2205.A review of the Weekly Documentation was reviewed for July 8, 2025, and July 29, 2025, indicated the following: .7/8/2025.Skin integrity.resident has skin issues .No.no additional information).7/15/2025.Skin integrity .resident has skin issues.No. no additional information.7/22/2025.Skin integrity .resident has skin issues.No is checked. no additional information.7/29/2025.Skin integrity .resident has skin issues.No is checked. no additional information There was no documented evidence that the Weekly Documentation identified an ongoing status of the resident's skin condition.A review of Resident 4's Care Plan revised dated July 14, 2025, indicated:- Has higher risk/potential for pressure ulcer development r/t: impaired mobility.risk for skin impairment.interventions.monitor/document/report to MD (physician) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length x width x depth, stage.) - Maintenance Excoriation to right buttocks .resident will have no further complication.interventions.treatment as ordered.reposition every 2 hours.keep site clean and dry.notify MD or change in condition.monitor for pain.- Resident may have open lesion on right ear .resident will be free from any further complications.interventions.monitor resident pain level.treatment as ordered. On July 31, 2025, at 1:33 p.m. an interview was conducted with Licensed Vocational Nurse (LVN 2). LVN 2 stated she was a treatment nurse. LVN 2 explained the duty of the treatment nurse is to conduct a thorough body assessment each week for residents with treatment orders, document in the medical record, note and report changes. LVN 2 stated the nurses assigned to the residents should check the Braden scale (skin breakdown risk), body check assessments and conduct their own assessments each shift and document in the medical record. LVN 2 stated The section for skin integrity for the skilled daily and weekly charting should reflect the current treatments and skin status because that shows there was a head-to-toe body assessment was completed. During a concurrent review of sample resident records with LVN 2, she said that all orders should be clarified if there are changes in skin assessments, as seen with Resident 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056315 If continuation sheet Page 3 of 7 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 08/15/2025 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete LVN 2 mentioned that skin condition updates should align with appropriate treatments and reflect the current skin status. Additionally, LVN 2 observed that the weekly summaries and daily documentation for sampled residents did not accurately reflect their skin conditions.On July 30, 2025, at 2:53 p.m. an interview was conducted with the Assistant Director of Nursing (ADON), and The ADON stated the following:a. The nurses were expected to document the wounds and the current skin status;b. The physician's orders should reflect the wounds;c. The daily and weekly documentation should reflect the current skin conditions as indicated in the skin sections of the assessments. d. There was a risk for residents not to receive accurate assessments, treatments, changes and monitoring of the skin if the current skin conditions were not reflected in the nurses' charting, which could cause a change or worsening of a skin condition.e. The nurses should be charting to match the current conditions with full head to toe assessments that accurately reflect the conditions of the resident which included the skin. f. All nurses are provided with training for skin care competencies and should provide the services according to the training received.A review of the facility document titled, Licensed nurse orientation checklist (Licensed Nurse Training module), undated, indicated, .Skin Delivery Care Process.skin assessment (upon admission then weekly x 4) .skin care plan with revision, review, resolve.pressure injury staging guide.wound terminology guide.weekly wound MD rounds and recommendations.writing orders for skin problems/wound.A review of the facility policy and procedure titled, Nursing Documentation dated, June 2022, indicated, .Purpose.to communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided.documentation.clear, concise, pertinent, and accurate based on the resident's/patient's condition, situation, and complexity.nursing assessment and interventions.evaluation of the patient's outcomes. Event ID: Facility ID: 056315 If continuation sheet Page 4 of 7 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 08/15/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to conduct an ongoing monitoring and supervision for use of bed rails for four of six residents reviewed, (Residents 1, 2, 5 and 6)This had the potential to cause Residents 1, 2, 5, and 6 to be at risk for entrapment or injury for falls.Findings:On July 31, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], readmitted [DATE], and discharged on July 22, 2025, with a diagnosis which included hemiplegia and hemiparesis following cerebral infarction (loss of function of one side of the body with brain dysfunction) affecting the right dominant side, and traumatic brain injury.A review of the History and Physical dated March 13, 2025, indicated, .Resident 1 does not have capacity to understand and make decisions.A review of the Physicians order dated June 14, 2023, indicated, .side rail one half x 2 up in bed as enabler to assist with bed mobility -nonrestraint.active.A review of the Bed safety assessment dated July 21, 2023, indicated, .Res currently has 1/4 rails for mobility and positioning.A review of assessments records for Resident 1 did not indicate documented bed safety assessment for Resident 1 after July of 2023 or prior to his discharge on [DATE].A review of the Change of Condition dated July 14, 2025, indicated, .07/14/2025 3:15 a.m., .Resident seen sitting on side of bed with (R) arm inside rail. RN (Registered Nurse) supervisor provided head to toe assessment with excoriation noted to (R) side of back upper and lower & (R) arm.MD (physician) notified with orders in place.Recommendation is for resident to have bed in low position for safety measures and cont. (continue) with call light within reach.A review of the Nurse Progress Note, dated July 15, 2025, at 3:15 a.m. indicated, .resident was found on the floor in his room. this writer immediately proceeded to resident's room to assess the situation.3:17 upon entry, resident was observed lying on the floor next to his bed on the right side. The resident was found in a semi-fetal position with his right arm caught within the side rail. environmental safety checks performed: bed observed in low position with right side rail up, left side rail down. floor free of clutter or liquid. lighting adequate. The call light was on the bed but not activated by resident. call light noted on in room for resident's roommate.3:19 rn supervisor initiated head-to-toe assessment.noted superficial excoriations to the right lateral arm and right mid-back region. no active bleeding. no hematoma, swelling, or visible deformities noted. resident denied pain verbally and also responded nonverbally by shaking head no when asked if he had pain to back, arm, hips, or head.3:22 range of motion assessment conducted.resident able to move lue (left upper extremity) and lle (left lower extremity) extremities within baseline with no signs of guarding, facial grimace, or vocal complaints of pain. passive range of motion provided to rue (right upper extremity) and rle (right lower extremity) no signs of guarding, facial grimace, or vocal complaints of pain. no decrease in strength noted outside of resident's baseline. neurologically, resident alert and oriented to self and place within place. skin warm and dry. respirations even and unlabored.3:25 hours: vital signs obtained. (vital signs were within normal limits according to the record) .3:27: pa (physician assistant) notified of incident.neurologic monitoring protocol per fall policy. fall risk precautions maintained.3:30.resident safely assisted back to bed. repositioned for comfort. call light placed within reach. bed in lowest position, brakes engaged. floor mats are implemented for safety. resident remains without signs of distress at this time. no signs of acute change in condition.3:35 responsible party and spouse.notified via phone of fall incident and current condition.5:04 . provider responded with new orders for stat xrays to rt (right) forearm, rt shoulder and pelvis.A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056315 If continuation sheet Page 5 of 7 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 08/15/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review of the IDT (interdisciplinary team) meeting notes, dated July 14, 2025, indicated, .Cognitive changes since last review: No.Communication/speech/hearing pattern changes since last review: No.Physical functioning changes since last review: No. Spouse present. New or interim disease/conditions/infections that impact the resident's ability to care for self and adds a risk for care/treatment: fall 7/14/25 minor injury 7/11/2025. Rehab Screen note. Rehab Screen: Current Therapy Orders or Restorative Programs: Restorative Program.Areas reviewed: No changes in function since last assessment.Comments: RNA has reported R hip pain in Pt but family has not expressed any concerns and states pain is chronic. Pt has no active ROM of RUE and RLE and may be at baseline function. There is no need for therapy at this time as pt maintains RNA program.Evaluation order requested: No evaluation indicated.Further review of the IDT notes indicated no documentation that the IDT discussed the need for an assessment and/or evaluation of the use of side rails for Resident 1 for the year of 2024, and after the fall that occurred on July 14, 2025.A review of the Care Plan, Risk for injury related to side rail use, initiated April 20, 2021, revision July 11, 2023, and then again December 7, 2023, indicated, .Goal. Resident will not have side rail injury through review date. May have 1/4 side rails to assist with bed mobility and repositioning.A review of the Care Plan, Resident using side rails for enablers, initiated September 9, 2019, revised May 1, 2025, indicated, .Interventions. Assess and reassess the need for side rails at least quarterly. Remind resident to call for assistance. Instruct the resident not to try to get out of bed while side rails are in use.A review of the Care Plan, The resident is Moderate risk for Falls r/t confusion, gait/balance problems incontinence, initiated January 20, 2022, indicated, .The resident will not sustain serious injury through the review date.Revision May 1, 2025. Interventions. Anticipate and meet the residents needs. Be sure the residents call light is within reach and encourage the resident to use it. Resident needs prompt response to all requests for assistance.Educate family resident caregivers about safety reminders and what to do if a fall occurs.Follow facility fall protocol evaluate and treat as ordered PRN (as needed), Resident needs working call light, bed in low position, Side Rails as ordered, handrails on walls, personal items within reach.A review of the Operative Note, for Resident 1 dated July 16, 2025, indicated, .proposed primary procedure.closed reduction internal.patient presented to the ED (emergency department) after being found down at his nursing facility.imaging studies demonstrated an acute right displaced intertrochanteric hip fracture.risks and benefits explained.operative findings. displaced intertrochanteric hip fracture.Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnosis which included osteoporosis (bone deterioration)A review of Resident 2's The Bed safety assessment, dated January 5, 2023, indicated, .Res currently has 1/4 rails for mobility and positioning.A review of Resident 2's Physicians order dated May 24, 2023, indicated, active.side rails one quarter x 2 up in bed as enabler to assist with bed mobility-non-restraint.A review of Resident 2's assessments indicated no documentation of an ongoing assessment and evaluation for the use of side rails.Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with a diagnosis which included hemiplegia (loss of use of one side of the body). Resident 5's Physicians order dated August 19, 2023, indicated, active.side rails one quarter x 2 up in bed as enabler to assist with bed mobility-non-restraint.The Bed safety assessment dated August 19, 2023, indicated, .Res currently has one quarter x 2 rails for mobility and positioning.A review of Resident 5's assessments indicated no documentation of an ongoing assessment and evaluation for the use of side rails. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnosis which included, dementia (cognitive decline in memory).Resident 6's Physicians order dated August 1, 2023, indicated, active.side rails one quarter x 2 up in bed as enabler to assist with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056315 If continuation sheet Page 6 of 7 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 08/15/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete bed mobility-non-restraint.The Bed safety assessment dated August 1, 2023, indicated, .Res currently has one quarter x 2 rails for mobility and positioning.A review of Resident 6's assessments indicated no documentation of an ongoing assessment and evaluation for the use of side rails.On August 15, 2025, at 1:18 p.m. an interview and record review were conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). A review of the Bed Rail policy was conducted along with a full review of the sampled resident bed rail assessments for Residents 1, 2, 5 and 6. The ADON stated the current policy for bed rails was updated as of February of 2025. The ADON stated the process regarding bed rails was that upon admission a bed rail evaluation would indicate the use of the rails as enablers for mobility and should have an MD order, consent for use, and appropriate according to the manufacturer's specifications. The ADON stated the bed rail evaluation would be done during a change in condition and during the quarterly IDT meetings. The ADON indicated the previous policy was for the bed rails to be reviewed quarterly but that there were new annual changes to that protocol that were not indicated in the policy.A concurrent record review with the ADON for Resident 1 was conducted. The ADON stated Resident 1 did not have a bed rail assessment since 2023 and should have to determine the need and safety for use of bed rails. The ADON stated the side rails were not discussed in the IDT meeting after the fall that occurred on July 14, 2025, and should have been. The ADON stated, The side rails were not in the right position which would have placed the resident at risk for a fall during that time when the fall occurred. The ADON stated there was a potential for a fall if the side rails were not in the proper position. Further review of the bed rail assessments was conducted for Residents 2, 5 and 6 were conducted with the ADON. The ADON further stated Residents 1, 2, 5 and 6 did not have updated bed rail assessments since 2023 and the care plans for the use of side rails were not updated to reflect the current use of the side rails and they should have to prevent the risk of falls and injury.A review of the facility policy titled Bed Rails dated February 21, 2025 indicated, .Bed rails.utilize a person-centered approach when determining the use of bed rails.variety of types one-half, one quarter.bed rails, side rails, safety rails, grab bars and assist bars.as part of the comprehensive assessment, the IDT will review and determine the residents needs, and whether or not the use of bed rails meets those needs.acute medical or surgical interventions.risk for falling.the facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice. Event ID: Facility ID: 056315 If continuation sheet Page 7 of 7