Inspection·December 17, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided timely incontinence care consistent with the resident's care needs for one of two sampled residents (Resident B).This failure resulted in Resident B remaining in a soiled brief for approximately an hour, placing the resident at risk for skin breakdown, infection, discomfort, and compromised dignity.Findings:A review of Resident B's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included hereditary spastic paraplegia (weakness with stiffness of legs).A review of Resident B's Minimum Data Set (MDS - an assessment tool), dated October 31, 2025, indicated:- Brief Interview for Mental Status (a standardized cognitive screening tool) score of 15 (cognitively intact).- Functional Abilities-Self Care-Toileting Hygiene-Substantial /Maximal assist [Helper does more than half the effort Bladder-Urinary Continence- Always incontinent.On November 19, 2025, at 4:12 p.m., during an observation in Resident B's room, a strong urine odor was noted. In a concurrent interview with Resident B, Resident B stated she had been changed at approximately 3 p.m., became wet again about 30 minutes later, and remained wet despite notifying staff. On November 19, 2025, during a concurrent observation and interview with CNA 1, the following was observed:-At 4:15 p.m., CNA 1 stated Resident B was wet. CNA 1 was observed to leave Resident B's room without providing incontinence care or explanation to the resident. -At 4:30 p.m., CNA 1 was observed to return to Resident B's room and stated he would change the resident. CNA 1 was observed placing a clean brief on the bedside table and exiting the room again without providing incontinence care. -At 4:33 p.m., CNA 1 returned to Resident B's room and provided incontinence care, approximately one hour after Resident B reported being wet and notifying staff. On November 19, 2025, at 4:40 p.m., an interview with Licensed Vocational Nurse (LVN) was conducted. LVN stated CNAs were required to provide incontinence care every two hours and as needed, and if delayed, staff were expected to communicate this to the resident. On December 2, 2025, at 1:33 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the CNA to provide incontinence care every two hours and as needed, and not doing so placed residents at risk for skin breakdown and infection. A review of the facility policy and procedure titled Dignity, dated February 2021, indicated .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.promptly responding to a resident request for toileting assistance. Residents Affected - Few 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 12/17/2025 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)