Other·July 11, 2019

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: CA00609398 Representing the California Department of Public Health: Surveyor 37569/3134, HFEN The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. The allegation was substantiated, with violations of the regulations. Three deficiencies were issued for complaint number CA00609398.

F580 SS=G Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 03/02/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or 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: QMKX11 Facility ID: CA240000057 If continuation sheet 1 of 31 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 01/31/2019 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 (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three residents (Resident A) change of condition was immediately reported to the resident's physician when the resident had a change in his mental status after a fall from his bed and was found face down on the floor; and Resident A's physician was not notified after the resident's enteral feeding pump ( a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 2 of 31 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 01/31/2019 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 mechanical pump used to give liquid feedings at a specific rate through a tube that has been placed into the resident's stomach) was found laying on his chest for an unknown period of time. These failures caused delays in the medical care and treatment for Resident A and could have contributed to the decline in the patient's overall health. Findings: On October 29, 2018, at 12:55 p.m., the complainant, a family member (FM) 1 of Resident A was interviewed by telephone. FM 1 stated Resident A had a history of multiple strokes, was bedbound, and his left side was paralyzed. FM 1 stated Resident A was sent to the facility for rehabilitation, with a plan for Resident A to return home. The family member stated the family requested side rails for Resident A's bed but was told "no." FM 1 stated she received a call from a facility nurse on November 23, 2017, about 10 p.m., who said Resident A "fell out of bed face first," and that he was okay. FM 1 was told his vital signs (temperature, heart rate, blood pressure, and respiratory rate) were "fine." FM 1 stated she asked the nurse if the facility called 911 to have Resident A sent to the hospital for further evaluation and was told "no." FM 1 stated she went to see Resident A at the facility the next day and found him more confused and not responding. FM 1 stated Resident A's doctor came to the facility, told the family he was not aware of Resident A's fall, and ordered the nurse to call 911. FM 1 further stated Resident A was treated at ( name of HOSP [Hospital] 2) for injuries related to the fall and later returned to the facility. FM 1 stated several days later Resident A was sent to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 3 of 31 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 01/31/2019 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 (name of HOSP 3) and passed away on December 7, 2017. On October 30, 2018, at 9 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding Resident A. On October 30, 2018, at 9:55 a.m., Resident A's facility medical record was reviewed, and indicated Resident A was admitted to the facility on November 19, 2017, from (name of HOSP 1) with a diagnosis of generalized muscle weakness,and was to receive short term rehabilitation. The Physician's Order summary for November 2017 indicated Resident A's medications included Aspirin and Plavix (medications given to prevent stroke or heart attack can cause prolonged bleeding) Keppra (to prevent seizures) and Nitroglycerin (for acute chest pain). The "Physical Therapy Plan of Care," dated November 19, 2018, untimed, indicated Resident A was "...Unable to maintain balance without mod/max (moderate/maximum) support...dependent for all functional mobility..." The "Occupational Therapy Plan of Care, " dated November 20, 2018, untimed, indicated, "...left sided weakness, left hand splint, + foley (sic) catheter, fall risk...Bed mobility...dependent 100% assist..." Resident A's medical record from HOSP 1 was then reviewed. The record from HOSP 1 indicated Resident A was admitted to HOSP 1 October 14, 2017, with diagnosis of acute stroke, and had a tracheostomy (surgical opening in the airway to assist breathing), PEG tube (percutaneous gastrostomy tube or G tube), and a Foley catheter (catheter placed in to the bladder to drain urine) placed at HOSP FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 4 of 31 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 01/31/2019 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 1. The record indicated Resident A's tracheostomy site was surgically revised and the cannula (tube) was removed before Resident A was discharged. The Physician's discharge summary indicated Resident A was alert and oriented x 3 (normal is person, place, time, situation), could verbalize his needs, and had left side paralysis when he was discharged from HOSP 1. Resident A's record from the SNF (skilled nursing facility) was further reviewed. The SBAR Note (communication form used to document physician notification of changes in condition) indicated, "...unwitnessed fall...11/23/2017... Doctor was notified we started neurochecks..." There was no documented indication the RN or LVN immediately assessed and evaluated Resident A's level of alertness, oxygen level, heart and lung sounds, range of motion, speech, status of his tracheostomy site, PEG tube, or Foley catheter for changes or injuries. There was no documented indication what information was given to Resident A's Physician, the Physician's response, or if any new orders were given. The document, titled "Neuro Check Flow Sheet," dated November 23, 2017 to November 25, 2017 was reviewed. The Flow Sheet indicated neuro checks (neurological assessment rating scale used to check for changes in mental status/signs of head injury scored 3 lowest to 15 highest) were not initiated until 11:50 p.m. (1 hour and 50 minutes after Resident A was found face down on the floor at around 10 p.m.). The Flow Sheet further indicated Resident A's neuro check scores were abnormal with a score of 11 (opened his eyes to command, was confused, and moved to withdraw from pain) at that time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 5 of 31 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 01/31/2019 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 There was no documented indication nursing staff called to notify Resident A's Physician of the abnormal neuro signs or at what time they were initiated. The medical record notes titled, "Functional Rehab Documentation..." dated November 22 and 23, 2017, completed by the RNs, indicated, "Resident alert, awake, verbally responsive and able to make needs known..." The "Functional Rehab Documentation..." form, dated November 24, 2017, at 1515 (17 hours and 15 minutes after Resident A was found on the floor) indicated, "Resident is awake, on bed, non-verbal, total care rendered..." The Nurse's Notes for November 19, 2017 to November 24, 2017, were reviewed. There was no documented evidence in the notes of Resident A's fall on November 23, 2017, notification of Resident A's Physician or if any orders were given to address Resident A's fall. There was no documented indication in the Nurse's Notes to indicate when Resident A was last provided care prior to the fall or assessments or interventions done for Resident A after he fell. There was no documented indication that nursing staff initiated 72 hour monitoring to assess Resident A for further changes in condition. There was no documented indication of Resident A's transfer to HOSP 2 on November 24, 2017, the time, or his condition at the time he was transferred. On October 30 , 2018, at 9:30 a.m., the Director of Nursing (DON) was interviewed. The DON stated when a resident had an unwitnessed fall, the Physician and family should be immediately notified, and neuro checks should be done for 72 hours. During a concurrent record review, the DON acknowledged Resident A's first neuro check FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 6 of 31 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 01/31/2019 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 not done until 1 hour and 50 minutes after he was found on the floor. On October 30, 2018, at 11 a.m., the DON was further interviewed. She stated neuro checks should be started as soon as the resident was found after a fall. She was unable to find documented indication in the Nurse's Notes to show Resident A's condition during his stay at the facility after an initial assessment on November 19, 2017 at 6:14 p.m. The DON stated RNs are responsible for the "Functional Rehab Documentation...." completed once daily for residents. She further stated the LVNs are responsible for checking resident's tracheostomy sites, G tubes, and administering medications, and documenting this information in the record each shift. LVN 1 was interviewed on October 30, 2018, at 11:50 a.m., . LVN 1 stated she did not remember Resident A but recognized her signature on Resident A's "Neuro Check Flow Sheet." and stated LVNs are supposed to document any changes of condition including 72 hour monitoring after a change of condition on all residents. During a concurrent record review, LVN 1 stated Resident A should have had neuro checks started "ASAP (as soon as possible)." LVN 1 stated Resident A "did hit his head because he was found face down." Resident A's record from HOSP 2 was reviewed. The record indicated Resident A was brought to HOSP 2 by ambulance on November 24, 2017, at 9:19 p.m. ( 23 hours and 19 minutes after he fell). The History and Physical, dated November 24, 2017, at 11:18 p.m., indicated,"...was found on floor, fell off bed at (name of SNF)...family came and noted he was more confused with expressive dysphasia (difficulty understanding and speaking words)..." The record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 7 of 31 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 01/31/2019 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 Resident A became lethargic and nonresponsive on November 25, 2017. The Physician's Progress Note, dated November 25, 2017, at 5:49 a.m., indicated, "...acute traumatic SAH (subarachnoid hemorrhagebleeding into space between brain and tissue that covers brain)...acute encephalopathy (brain injury)..." Resident A's SNF record was further reviewed. The record indicated Resident A was readmitted to the facility from HOSP 2 on November 30, 2017, with diagnoses that included traumatic subarachnoid hemorrhage, chest pain, and weakness. The Physician's Order, dated November 30, 2017, indicated, "Enteral Feed (a liquid nutritional formula provided to the resident via the PEG)...at 85 ml/hr (milliliters per hour a unit of measure) to provide 1020 ml...via enteral pump for tube feeding ON:1800 (6 p.m.) OFF: 0600 (6 a.m.)" The Physician's Order summary for December 2017 indicated Resident A's medications included Aspirin, Plavix, (medications used to prevent stroke or heart attack that may thin blood), Keppra (to prevent seizures) and Duoneb (as needed every 6 hours for shortness of breath). The Nurse's Admission Assessment, dated November 30, 2017, at 2100 (9 p.m.) indicated Resident A was "...Confused...oriented to person (normal is oriented to person, place, time, situation)...weakness...Paralysis Left side..." The SBAR form, dated December 01, 2017, at 4 a.m., indicated, "...CNA (Certified Nursing Assistant) informed CN (charge nurse) pt (Resident A) was found with G-tube FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 8 of 31 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 01/31/2019 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 pole/machine on his chest as it appeared pt pulled it down on himself. CNA stated she picked it up and put it back where it was pt still connected, machine still on. When pt was asked what happened, pt did not wake enough to disclose, pt's roommate (sic) stated he heard a loud crash and pt (name of Resident A) say oh oh...no signs of bruises, abrasions, or bumps...pt's family and Dr will be notified...To be notified by AM shift..." The area of the SBAR form to document Resident A's mental status was marked "NA." There was no documented indication the nurse (LVN 3) evaluated Resident A's level of alertness, oxygen level, pain level, heart and lung sounds, range of motion, PEG tube or tracheostomy sites. There was no documented indication LVN 3 asked the RN on duty to assess Resident A for injuries or changes in his condition. The Nurse's Notes, dated November 30, 2017 through December 7, 2017, were reviewed. There was no documented indication LVN 3 notified Resident A's Physician that Resident A was found with the pump on his chest for an unknown period of time, or requested any additional tests to check for potential injuries. There was no documented indication of Resident A's condition, assessments, or interventions done on December 1, 2017, when Resident A was found. There was no documented indication Resident A's family was notified of the incident. The handwritten Provider's Progress Note, dated December 1, 2017, untimed, found in Resident A's record indicated, "...staff indicates pt pulls lines & PEG...secure PEG..." and had no Resident's name, room number, or medical record number on the Note. There was no documented indication in the Note to indicate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 9 of 31 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 01/31/2019 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 Provider was aware that Resident A was found with the pump on his chest for an unknown period of time. The Nurse's Notes, dated December 7, 2017, at 12:32 p.m., indicated Resident A was found having labored breathing, clammy and sweaty, at 9:30 a.m., and had an oxygen saturation level of 78% (normal is 92-100%). The record indicated Resident A was sent to HOSP 3 by ambulance at 10 a.m. On November 6, 2018, at 2:10 p.m., Resident A's record from HOSP 3 was reviewed. The record indicated Resident A was brought in by ambulance on December 7, 2017, at 10:12 a.m., with complaint of shortness of breath for 30 minutes. The record indicated Resident A was in severe distress, diaphoretic, and unresponsive. The record indicated Resident A had two code blue (life saving measures given) events and passed away at 11:17 a.m. On October 30, 2018, at 2:45 p.m., the Director of Nursing (DON) was interviewed. During a concurrent facility medical record review, the DON verified there was no documented indication Resident A's Physician was immediately notified when Resident A was found with the enteral feeding pump on his chest. The DON was unable to state how the facility's nurses decide when to notify the Physician immediately and when it may be okay to "endorse to the next shift." The DON stated the nurses may have had difficulty reaching the Physician, but she could not find any documentation in the record to support that statement. The DON acknowledged the potential for Resident A to have unseen injuries from the pump laying on his chest. On November 6, 2017, at 11:25 a.m., the Director of Staff Development (DSD) was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 10 of 31 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 01/31/2019 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 interviewed by telephone. The DSD stated the facility's process for falls or changes in condition was: whoever found the resident should stand by and call for help, the nurses should do a "head-to-toe" assessment, try to wake the resident, notify the Physician, and get whatever x-ray or lab tests the Physician orders done. The DSD stated the RN and LVN should both assess the resident including tracheostomy site, PEG tube, Foley catheter, level of alertness, oxygen level, heart and lungs, "a full head to toe assessment." The DSD further stated when the nurses reported the incident to the Physician, the nurse should include all of the information from the assessments, and document the date, time, who was notified, and the Physician's response/orders "verbatim" in the record. The facility policy and procedure, titled, "Condition Change of Resident" last revised October 2017, was reviewed and indicated, "...It is the policy of this facility to observe, record, and report changes in condition to the attending physician...If unable to reach the attending physician or the physician on call, call the facility medical director or 911...Notify resident's representative after the resident is stable...Monitor resident's condition as often as the condition warrants...in accordance with recognizable standards of care...Document per facility policy..." The facility policy and procedure, titled, "Falls/Accident Mitigation and Intervention," last revised October 2017, was reviewed and indicated, "...After a fall or other similar accident...the resident shall have a physical assessment documented in the nursing notes...The attending physician and legal representative...shall be notified...The facility shall begin 72 hour charting...and continue to assess for latent injuries or changes in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 11 of 31 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 01/31/2019 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 condition..." The facility policy and procedure, titled, "Neurological Assessment ( Neuro Checks)," last revised October 2017, was reviewed and indicated, "It is the policy of this facility to provide neurological assessments as indicated for the resident involved in an incident...may include...resident found on floor...Neurological checks are completed within the time frames noted on the Neuro Check Flow Sheet or as ordered by the physician..."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/02/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 12 of 31 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 01/31/2019 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 remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure adequate supervision, was provided and implemented for one of three sampled residents (Resident A) when: a. Resident A fell out of bed and was found face down on the floor; and b. Resident A was found with the G tube pump (mechanical pump used to give enteral/liquid feedings at a specified rate through a tube surgically placed into the resident's stomach) laying on his chest for an unknown period of time. These failures increased the potential for harm to Resident A and may have contributed to the decline in Resident A's overall health. Findings: On October 29, 2018, at 12:55 p.m., the complainant, a family member (FM) 1 of Resident A was interviewed by telephone. FM 1 stated Resident A had a history of multiple strokes, was bedbound, and his left side was paralyzed. FM 1 stated Resident A was sent to the facility for rehabilitation, with a plan for Resident A to return home. FM 1 stated the family requested side rails for Resident A's bed and was told "no." FM 1 stated she received a call from a facility nurse on November 23, 2017, about 10 p.m., who told FM 1 Resident A, "fell out of bed face first," that Resident A was OK, and his vital signs (temperature, heart rate, blood pressure, and respiratory rate) were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 13 of 31 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 01/31/2019 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 fine. FM 1 stated she asked the nurse if the facility called 911 to have Resident A sent to the hospital for further evaluation and was told "no." FM 1 stated she went to see Resident A in the facility the next day, and Resident A was more confused and not responding to them. FM 1 stated Resident A's doctor came to the facility, stated he was not aware of Resident A's fall, and ordered the nurse to call 911. FM 1 further stated Resident A was treated at (name of Hospital 2) HOSP 2 for injuries related to the fall and later returned to the facility. FM 1 stated several days later Resident A was sent to (name of Hospital 3) HOSP 3 and passed away on December 7, 2017. On October 30, 2018, at 9 a.m., an unannounced visit was made to the facility for the investigation of one complaint regarding Resident A. On October 30, 2018, beginning at 9:55 a.m., Resident A's record was reviewed. The record indicated Resident A was admitted to the facility on November 19, 2017, from HOSP 1. The record indicated Resident A had a diagnosis of generalized muscle weakness and was to receive short term rehabilitation. The Physician's Order summary for November 2017 indicated Resident A's medications included Aspirin and Plavix (medications given to prevent stroke or heart attack can cause prolonged bleeding) Keppra (to prevent seizures) and Nitroglycerin (for acute chest pain). The "Physical Therapy Plan of Care," dated November 19, 2018, untimed, indicated Resident A was, "...Unable to maintain balance without mod/max support...dependent for all functional mobility..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 14 of 31 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 01/31/2019 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 "Narrative Nurse Assistant Notes," dated November, 2017 (used to document cares provided by the Certified Nursing Assistant/CNA staff) was reviewed and indicated Resident A required total staff assistance for bed mobility. Resident A's record from the SNF (skilled nursing facility) was further reviewed. The SBAR Note (communication form used to document physician notification of changes in condition) indicated, "...unwitnessed fall...11/23/2017..." The form indicated, "A resident (no name noted) reported to charge nurse that he (Resident A) was on the floor I went in found pt (patient) face down by bedside RN (Registered Nurse) supervisor came in to assist we used hoyer lift to lift pt back to bed this happened at 2200 (10 p.m.)...Doctor was notified we started neurochecks..." The area of the form to document mental status changes was marked "NA." The area of the form for the RN and Licensed Vocational Nurse (LVN) to document Resident A's appearance was blank. The Notes titled, "Functional Rehab Documentation..." dated November 22 and 23, 2017, completed by the RNs, indicated, "Resident alert, awake, verbally responsive and able to make needs known..." The "Functional Rehab Documentation..." form, dated November 24, 2017, at 1515 (17 hours and 15 minutes after Resident A was found face down on the floor) indicated, "Resident is awake, on bed, non-verbal, total care rendered..." The Nurse's Notes for November 19, 2017 to November 24, 2017, were reviewed. There was no documented indication in the Notes of Resident A's fall on November 23, 2017, nursing assessments or interventions done, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 15 of 31 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 01/31/2019 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 notification of Resident A's Physician or if any orders were given to address Resident A's fall. There was no documented indication when Resident A was evaluated or provided care prior to the fall. There was further no documented indication of Resident A's transfer to HOSP 2 on November 24, 2017, his condition at the time, or what time he was transferred. The "Narrative Nurse Assistant Notes" dated November 2017, were further reviewed and the column for cares given on November 23, 2017, evening shift when Resident A fell out of bed was blank. The Progress Notes, dated November 24, 2017, at 10:31 a.m., indicated, "Wife called facility upset pt (Resident A) had un witness (sic) fall, she had been requesting side rails from admission..." On October 30, 2018, beginning at 9:30 a.m., the Director of Nursing (DON) was interviewed. The DON stated when a resident was at risk for falls, the facility used frequent visual checks to monitor the resident, and if the family requested side rails, the nurses should assess the resident and call the physician to request side rails. The DON stated if a resident had an unwitnessed fall, the resident was supposed to be monitored closely for 72 hours and interventions added to the resident's care plan. On October 30, 2018, at 11:50 a.m., LVN 1 was interviewed. LVN 1 stated she did not remember Resident A but recognized her signature on Resident A's "Neuro Check Flow Sheet." LVN 1 stated LVNs are supposed to document for each resident a weekly summary, any changes of condition, and 72 hour monitoring after changes of condition in the record. During a concurrent record review, LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 16 of 31 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 01/31/2019 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 1 stated the LVN who found Resident A on the floor should have started neurochecks "ASAP." LVN 1 stated if a resident is on anti-seizure medications when admitted, the nurse should call the Physician to get orders for padded side rails for the bed. LVN 1 stated after a resident has a fall, the nurse should do a full body assessment, ask the resident if they hit their head, and give the full story to the Physician when reporting the fall. LVN 1 stated Resident A "did hit his head because he was found face down." On October 30, 2018, at 12:20 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she remembered the evening Resident A fell. CNA 1 stated she and another CNA changed Resident A about 9 p.m. and left the room. CNA 1 stated Resident A did not have side rails up on his bed and the family had been asking for them. CNA 1 stated Resident A was a large, big man and required two staff to turn him in bed. CNA 1 stated she later went into Resident A's room and the RN and LVN were there with Resident A on the floor. CNA 1 stated the RN and LVN used the machine lift to get Resident A back into bed. CNA 1 stated Resident A had redness on his forehead. Resident A's record from HOSP 2 was reviewed. The record indicated Resident A was brought to HOSP 2 by ambulance on November 24, 2017, at 9:19 p.m. ( 23 hours and 19 minutes after he was discovered on the floor). The History and Physical, dated November 24, 2017, at 11:18 p.m., indicated,"...was found on floor, fell off bed at (name of SNF)...family came and noted he was more confused with expressive dysphasia (difficulty understanding and speaking words)..." The record indicated Resident A became lethargic and non-responsive on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 17 of 31 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 01/31/2019 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 November 25, 2017. The Physician's Progress Note, dated November 25, 2017, at 5:49 a.m., indicated, "...acute traumatic SAH (subarachnoid hemorrhage-bleeding into space between brain and tissue that covers brain)...acute encephalopathy (brain injury)..." ADD CARE PLAN INFO The "Functional Rehab Documentation for Nursing" dated November 22 and 23, 2017, as noted above indicated Resident A had daily "Safety Awareness" needs. The areas of the forms used to indicate Resident A's specific needs (i.e. bed mobility, balance) and any interventions were blank. The Nurse's Notes, dated November 19 through 24, 2017, were further reviewed. There was no documented indication of interventions including increased visual checks, positioning, side rail assessment, or seizure precautions done to address Resident A's risk for falls and seizures. The "Side Rail Use Assessment Form" dated November 24, 2017, indicated Resident A was assessed for the use of side rails the day after he fell out of bed and was found on the floor, and 5 days after he was admitted to the facility. The facility policy and procedure titled, "Fall/Accident Mitigation and Intervention," last revised October 2017, was reviewed and indicated, "It is the policy of this facility to minimize the risk of falls or accidents, and minimize the risk of serious injury associated with falls or accidents...Residents at risk for falls shall have a care plan that identifies risk factors...and appropriate interventions..." b. Resident A's SNF record was further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 18 of 31 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 01/31/2019 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 reviewed. The record indicated Resident A was re-admitted to the facility from HOSP 2 on November 30, 2017, with diagnoses that included traumatic subarachnoid hemorrhage, chest pain, and weakness. The Physician's Order, dated November 30, 2017, indicated, "Enteral Feed...at 85 ml/hr (milliliters per hour a unit of measure) to provide 1020 ml...via enteral pump for tube feeding ON:1800 (6 p.m.) OFF: 0600 (6 a.m.)" The Nurse's Admission Assessment, dated November 30, 2017, at 2100 (9 p.m.) indicated Resident A was "...Confused...oriented to person (normal is oriented to person, place, time, situation)...weakness...Paralysis Left side..." The "Narrative Nurse Assistant Notes" dated November 30, 2017 through December 6, 2017, indicated Resident A required total assistance from staff for bed mobility. The "Functional Rehab Documentation for Nursing" Notes, dated December 1 through 6, 2017, indicated Resident A had daily "Safety Awareness" needs. The areas of the form used to document Resident A's specific needs and interventions were blank. The Admission Care Plan, dated November 30, 2017, was reviewed. The section titled "Safety Risk...Monitor for behaviors q shift (every shift) and document any noted episodes...Adequate monitoring based on resident condition..." was blank and did not indicate any interventions to monitor Resident A more closely. The Nurse's Notes, dated November 30, through December 1, 2017, and did not indicate any interventions to address Resident A's safety needs before he was found with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 19 of 31 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 01/31/2019 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 G tube pump on his chest. The SBAR form, dated December 01, 2017, at 4 a.m., indicated, "...CNA (Certified Nursing Assistant) informed CN (charge nurse) pt (Resident A) was found with G-tube pole/machine on his chest as it appeared pt pulled it down on himself. CNA stated she picked it up and put it back where it was pt still connected, machine still on. When pt was asked what happened, pt did not wake enough to disclose, pt's roommate (sic) stated he heard a loud crash and pt (name of Resident A) say oh oh...no signs of bruises, abrasions, or bumps...pts family and Dr will be notified...To be notified by AM shift..." The area of the SBAR form to document Resident A's mental status was marked "NA." There was no documented indication the nurse who checked Resident A (LVN 3) evaluated Resident A's level of alertness, oxygen level, pain level, heart and lung sounds, range of motion, PEG tube or tracheostomy sites. There was no documented indication LVN 3 asked the RN to assess Resident A for injuries or changes in his condition. The Nurse's Notes, dated December 1 through December 6, 2017, were reviewed. There was no documented indication of 72 hour monitoring or interventions done from December 1, 2017, at 11:03 p.m. until December 3, 2017 at 11:17 p.m., after Resident A was found with the pump on his chest. The handwritten Provider's Progress note, dated December 1, 2017, untimed, found in Resident A's record indicated, "...staff indicates pt pulls lines & PEG...secure PEG..." and had no resident's name, room number, or medical record number on the note. There was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 20 of 31 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 01/31/2019 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 documented indication in the Note that Resident A was found with the pump on his chest for an unknown period of time. The Nurse's Notes, dated December 7, 2017, at 12:32 p.m., indicated Resident A was found having labored breathing at 9:30 a.m., was clammy and sweaty, and had a oxygen saturation level of 78% (normal is 92-100%). The record indicated Resident A was sent out by ambulance at 10 a.m. On November 6, 2018, at 2:10 p.m., Resident A's record from (name of Hospital 3) HOSP 3 was reviewed. The record indicated Resident A was brought in by ambulance on December 7, 2017, at 10:12 a.m., with complaint of shortness of breath x 30 minutes. The record indicated Resident A was in severe distress, diaphoretic, and unresponsive. The record indicated Resident A had two code blue (life saving measures given) events and passed away at 11:17 a.m. The facility policy and procedure, titled, "Falls/Accident Mitigation and Intervention," last revised October 2017, was reviewed and indicated, "It is the policy of this facility to minimize the risks of falls or accidents, and to minimize the risk of serious injury associated with falls or accidents...After a fall or other similar accident...the resident shall have a physical assessment documented in the nursing notes...The attending physician and legal representative...shall be notified...The facility shall begin 72 hour charting...and continue to assess for latent injuries or changes in condition..."

F842 SS=E Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 03/02/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 21 of 31 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 01/31/2019 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 resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 22 of 31 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 01/31/2019 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 §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure professional standards of documentation were maintained for one of three sampled residents (Resident A) when Resident A: a. fell out of bed and was found face down on the floor; and b. was found with the G-tube pump (mechanical pump used to administer enteral/liquid feedings at specified rate through tube connected to resident) on his chest. These failures caused an incomplete representation of Resident A's care at the facility, and increased the potential for staff who provided care to Resident A to be unaware of his full health status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 23 of 31 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 01/31/2019 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 Findings: a. On October 29, 2018, at 12:55 p.m., the complainant (FM-a family member of Resident A) was interviewed by telephone. FM stated Resident A had a history of multiple strokes and was paralyzed on his left side. FM stated Resident A was admitted to the skilled nursing facility (SNF) from (name of Hospital 1) HOSP 1 after a massive stroke in October 2017. FM stated Resident A fell out of bed in the evening of November 23, 2017, and was sent to the hospital the next day after Resident A's family noted he had increased confusion and was less responsive. On October 30, 2018, at 9 a.m., an unannounced visit was made to the facility for the investigation of one complaint. On October 30, 2018, beginning at 9:55 a.m., Resident A's SNF record was reviewed. The record indicated Resident A was admitted to the facility on November 19, 2017, with a diagnosis of generalized muscle weakness. The record contained multiple entries with Resident A's last name spelled two different ways and no medical record number or date of birth (DOB) listed on multiple documents. Copies of Resident A's record from HOSP 1 were reviewed. The record indicated Resident A was admitted to HOSP 1 on October 14, 2017, for treatment of an acute stroke. The Record indicated Resident A had a tracheostomy (surgical opening in the airway to assist breathing), a PEG tube (Perctaneous Gastrostomy tube-tube surgically placed into the stomach through the abdominal wall used to give liquid nutrition) and a Foley catheter (tube placed into the bladder to drain urine) at the time he was discharged from HOSP 1 to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 24 of 31 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 01/31/2019 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 Resident A's SNF record was further reviewed. The Physician's Order Summary, dated November 19 to 24, 2017, had no Physician's orders in the summary regarding Resident A's fall out of bed on November 23, 2017, or transfer to (name of Hospital 2) HOSP 2 on November 24, 2017. The History and Physical (H & P), dated November 24, 2017, untimed, was reviewed and had no medical record number, room number, or DOB on the form. The H & P indicated "...fall w/ ALOC (altered level of consciousness)..." The document titled, "Certification and Recertification Form" with an admission date of November 19, 2017, signed by the Physician had no date to indicate when it was signed, a different spelling of Resident A's name, and no medical record number on the form. The form titled, "SBAR" (used to document communication with the Physician when a resident had a change in condition) dated November 23, 2017, indicated, "A resident (no name given) reported to charge nurse that he (Resident A) was on the floor I went in and found pt (Resident A) face down by bedside RN Supervisor came in to assist we used hoyer lift (mechanical device used to move resident from one location to another) to lift pt back to bed This happened at 2200 (10 p.m.)..." The area of the form for the Registered (RN) and Licensed Vocational Nurse (LVN) to document Resident A's appearance was blank. There was no documented indication of a comprehensive assessment by the RN or LVN to indicate Resident A's general condition including level of alertness, oxygen level, heart/lung sounds, range of motion (ROM), pain level, tracheostomy, PEG tube, or Foley catheter FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 25 of 31 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 01/31/2019 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 when Resident A was found on the floor. There was no documented indication to specify what information was given to Resident A's Physician by the nurse, the Physician's response, or if any new orders were given to address Resident A's fall. The documents titled, "Functional Rehab Documentation for Nursing...This form is Used for Medicare/MDS Documentation in Support of Skilled Therapy..." completed daily by the RNs for November 22 to 24, 2017, were reviewed. There was no documented indication by the RNs of Resident A's fall on November 23, 2017. The "Functional Rehab..." Notes for November 22 and 23, 2017, further indicated, "Resident showing progress with Safety Awareness but still has difficulty with..." The area of the form used to indicate the tasks Resident A had difficulty with and "Therapy-Suggested ADL Activities..." was blank. The area marked "Other Notes" had no documented indication of Resident A's tracheostomy, PEG, or Foley catheter. The area to mark the time the RN assessed Resident A was blank, and no DOB or medical record number were listed on the forms. The "Functional Rehab..." Note, dated November 24, 2017, at 3:15 p.m., (15 hours and 15 minutes after Resident A was found on the floor indicated, "...Resident showing progress with Bed Mobility..." and had no documented indication of Resident A's fall on November 23, 2017, or transfer to HOSP 2 on November 24, 2017. The form titled, "Narrative Nurse Assistant Notes" (used to document cares provided by the Certified Nursing Assistant or CNA staff), dated November 2017, was reviewed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 26 of 31 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 01/31/2019 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 column for cares given on November 23, 2017, evening shift when Resident A fell was blank. The Nurse's Notes, dated November 19 through November 24, 2017, were reviewed. There were no documented indication of Resident A's on-going condition, cares or evaluations by nursing staff after an admission assessment on November 19, 2017, at 6:14 p.m., including his fall on November 23, 2017, and transfer to (name of Hospital 2) HOSP 2 on November 24, 2017. On October 30, 2018, at 9:30 a.m., the Director of Nursing (DON) was interviewed. The DON stated when a resident had an unwitnessed fall, the LVN should notify the RN to assess the resident, check for injuries, and the RN and LVN should call to notify and get orders from the Physician. On October 30, 2018, at 11 a.m., the DON was further interviewed. During a concurrent record review, the DON verified there was no documented indication in the Nurse's Notes of Resident A's condition after November 19, 2017, at 6:14 p.m. The DON could find no documented indication of a comprehensive nursing assessment or nursing interventions done immediately after Resident A was found on the floor November 23, 2017. On October 30, 2018, at 12:20 p.m., CNA 1 was interviewed. CNA 1 stated she remembered the evening Resident A fell. CNA 1 stated she and another CNA changed Resident A about 9 p.m. and left the room. CNA 1 stated she later went back into Resident A's room and Resident A was on the floor with the RN and LVN there. CNA 1 stated the RN and LVN used the hoyer lift to get Resident A back in bed. CNA 1 stated Resident A had redness on his forehead. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 27 of 31 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 01/31/2019 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 b. Resident A's SNF record was further reviewed. The record indicated Resident A was re-admitted to the facility on November 30, 2017, from HOSP 2 with diagnoses that included traumatic subarachnoid hemorrhage (bleeding into the space between the brain and the tissue that covers the brain caused by head injury), chest pain, and weakness. The SBAR form, dated December 01, 2017, at 4 a.m., indicated, "CNA informed CN (charge nurse) that pt (Resident A) was found with Gtube pole/machine on his chest, as it appeared pt pulled it down on himself CNA stated she picked it up and put it back where it was...When pt was asked what happened, pt did not wake enough to disclose, pts roommate stated he heard a loud crash and pt (name of Resident A) say Oh Oh...pt's family and Dr will be notified...To be notified by AM shift..." The area of the form for the RN and LVN to document Resident A's appearance after he was found was blank. There was no documented indication Resident A's Physician was notified or any additional tests were requested by the nurses. There was no documented indication Resident A's family was notified of the incident. There was no documented indication the RN on duty was informed and asked to do a comprehensive assessment including Resident A's level of alertness, oxygen level, heart/lung sounds, pain level, or ROM. The "Functional Rehab..." Notes for December 1 through December 6, 2017, were reviewed and had no documented indication that Resident A was found with the pump laying on his chest. The Notes indicated Resident A, "...showing progress with safety awareness..." The handwritten Provider's Progress Note, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 28 of 31 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 01/31/2019 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 dated December 01, 2017, untimed, found in the record, had no resident's name, medical record number, DOB, or other identifying information on the Note. The Note indicated, "...staff indicates pt pulls on lines & PEG...secure PEG..." There was no documented indication in the Note that the Provider was aware Resident A was found with the pump laying on his chest for an unknown period of time. The Nurse's Notes, dated November 30 through December 7, 2017, were reviewed. There was no documented indication of Resident A's condition on December 1, 2017, at 4 a.m., when he was found with the pump on his chest or nursing interventions initiated at that time. The Nurse's Notes indicated Resident A was monitored with "frequent visual checks " on December 1, 2017, at 11:03 p.m. (19 hours and 3 minutes after found) and December 3, 2017, at 11:17 p.m. (67 hours and 17 minutes after found). There was no documented indication Resident A's Physician or family were notified of the incident. On October 30, 2018, at 11:50 a.m., LVN 1 was interviewed. LVN 1 stated during her shift, she would check each of her assigned resident's general appearance, breathing, G tube site, feeding pump, rate and connections, and tracheostomy site if the residents had them. She stated LVN staff were supposed to document a weekly summary in residents' records, any change of condition, and 72 hour monitoring after a change in condition. LVN 1 further stated she did not know why LVN staff did not document the routine checks of the residents if they were done each shift. On October 30, 2018, at 2:45 p.m., the DON was interviewed. During a concurrent record review, the DON could find no documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 29 of 31 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 01/31/2019 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 indication that Resident A's Physician or family were notified of the change in condition on December 1, 2017, when Resident A was found with the pump on his chest. The DON could find no documented indication of a comprehensive assessment of Resident A, or that the next shift was informed of the incident by the nurse. On November 6, 2018, at 11:25 a.m., the Director of Staff Development (DSD) was interviewed by telephone. The DSD stated the process for an unwitnessed fall or a change in condition was: whoever found the resident should stand by and call for help, the RN and LVN should do a full "head to toe" assessment for injuries, notify the Physician and obtain whatever tests the Physician ordered. The DSD stated when the nurse notified the Physician, the nurse should give all of the information obtained about the incident including their assessments to the Physician and document the Physician's response "verbatim" in the record. The facility policy and procedure, titled, "Fall/Accident Mitigation and Intervention," last revised October 2017, was reviewed. The policy indicated, "...After a fall or other similar accident...the resident shall have a physical assessment documented in the nursing notes...The attending physician and legal representative...shall be notified...The facility shall begin 72 hour charting after the fall or related accident and continue to assess for latent injuries or changes in condition..." The facility policy and procedure, titled, "General Documentation Guidelines, " last revised October 2017, was reviewed and indicated, "...It is the policy...to document relevant findings in the clinical record specific to each individual resident's needs and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 30 of 31 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 01/31/2019 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 condition...72-hour charting shall be initiated at the following times...A significant change in physical, mental, or psychosocial status of the resident...An extraordinary event...(...fall or injury)..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QMKX11 Facility ID: CA240000057 If continuation sheet 31 of 31