Other·June 19, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of one complaint. Complaint number CA00524663. Representing the California Department of Public Health: Surveyor 33841, HFEN; and Surveyor 37626, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00524663.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 05/19/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UL1311 Facility ID: CA240000057 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056315 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS GROVE POST ACUTE 9025 Colorado Ave Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UL1311 Facility ID: CA240000057 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056315 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS GROVE POST ACUTE 9025 Colorado Ave Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to report a resident's (Resident A) injury of unknown source to California Department of Public Health (CDPH) in accordance with the State law. This facility failure increased the potential for additional residents' incidents to go not reported or investigated in order to prevent further incidents and injuries. Findings: On March 14, 2017, at 11:45 a.m., an unannounced visit to the facility was conducted to investigate a complaint. On March 14, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on March 6, 2015, with diagnoses which included dementia (cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning), and periprosthetic fracture (broken bone that occurs around the components of implants). Resident A's SBAR (situation, background, appearance and request- communication of nursing to physician related to change of condition) dated February 28, 2017, indicated right tibia and fibula (shin/leg bone) fracture. The document indicated Resident A's right leg was swollen and had purple discoloration. The document indicated Resident A was transferred to the acute hospital due to fracture. On March 14, 2017, at 3:30 p.m., Resident A FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UL1311 Facility ID: CA240000057 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056315 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS GROVE POST ACUTE 9025 Colorado Ave Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was interviewed. Resident A had a cast on her right leg. Resident A stated she broke her leg. She stated she felt somebody hit her leg when asked how she broke it. Resident A was unable to provide other information on what caused the fracture. On March 14, 2017, at 5:20 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed and stated Resident A was not able to state what happened to her right leg. On March 16, 2017, at 3:35 p.m., RN (Registered Nurse) Supervisor was interviewed. She stated she did not know what caused the swelling and bump on Resident A's right leg. RN Supervisor stated Resident A was unable to provide pertinent information of what caused the swelling. She stated Resident A's x-ray indicated fracture, and Resident A was transferred out to the hospital after obtaining the result. On March 21, 2017, at 8:45 p.m., Resident A's family member stated Resident A did not have any complaint on February 27, 2017. She stated she did not know of any incident which could have caused the fracture. The above interviews indicated none of the staff and family member involved with Resident A knew of how and when Resident A's fracture occurred. Resident A's Emergency notes at the acute hospital dated February 28, 2017, indicated,"...Medics state that patient (Resident A) woke up this morning complaining of right leg pain. Per medics, staff states at this point they noted a deformity to right leg, as well as bruising..." Resident A's orthopedic consult at the acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UL1311 Facility ID: CA240000057 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056315 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS GROVE POST ACUTE 9025 Colorado Ave Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospital dated February 28, 2017, indicated Resident A was assessed with a displaced spiral fracture right distal tibia and fibula. According to American Academy of Orthopedic Surgeons, the tibia or shin bone is the most common fractured long bone in your body. It takes a major force to break a long bone, and other injuries often occur with these types of fracture. Spiral fracture is a type of fracture caused by a twisting force. On April 5, 2017, at 2 p.m., the Administrator was interviewed. He stated Resident A's case was not reported because it did not meet the criteria for an injury of unknown source since it was located in an area vulnerable to trauma which was the shin area. According to Code of Federal Regulations 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. According to Code of Federal Regulations 483.12, Injuries of unknown source was defined as an injury which met the following criteria: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: UL1311 Facility ID: CA240000057 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056315 (X3) DATE SURVEY COMPLETED 04/20/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS GROVE POST ACUTE 9025 Colorado Ave Riverside, CA 92503 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: UL1311 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000057 (X5) COMPLETE DATE If continuation sheet 6 of 6