Other·March 14, 2018

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 facility-reported incident. Facility-reported Incident # CA00560469 Representing the California Department of Public Health: Surveyor Federal/State ID# 38478, HFEN The inspection was limited to the specific facility-reported incident investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for facility-reported incident number CA00560469.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/18/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment 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 observation, interview, and record review, the facility failed to ensure safety and supervision was provided for one of three sampled residents (Resident A) when: 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: EQDS11 Facility ID: CA240000095 If continuation sheet 1 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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. Resident A's one-to-one sitter (constant observer for residents requiring direct supervision for safety) was discontinued without a completed evaluation of safety by the interdisciplinary team; 2. Resident A, who was identified with elopement (leaving without accompaniment or knowledge of staff) risks, did not have an elopement evaluation on multiple admissions to the facility; and 3. Resident A's elopement risk care plan to provide a one-to-one sitter was not implemented; This failure resulted in Resident A's attempted elopement by jumping off the facility's entrance porch, causing multiple injuries, rehospitalization, and increased the potential for further harm, injuries, or even death. Findings: On November 20, 2017, at 10:05 a.m., an unannounced visit was made to the facility for the investigation of a facility-reported incident. On November 20, 2017, at 10:12 a.m., Resident A was observed in bed, awake, with a one-to-one sitter at the bedside. In a concurrent interview with Resident A, she stated she jumped over the balcony a few weeks ago. Resident A was able to answer basic questions consistently. She stated, prior to her going out onto the balcony, she was "pissed that day" with some of the nurses because she wanted to go downstairs but they did not allow her to do so. Resident A stated how she got out of her room through the sliding doors, climbed onto the rails of the balcony on the second floor of the building, and walked on the roof of the entrance porch. Resident A pointed out the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 2 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 place where she eventually landed when she fell. The distance where the resident landed (from the roof of the entrance porch to the ground floor) was approximately 10-12 feet high. On November 20, 2017, at 10:51 a.m., Resident B was interviewed. Resident B stated he witnessed the incident on November 12, 2017, "at around 10 a.m.," when Resident A landed on the ground after falling from the roof of the entrance porch. Resident B stated he was sitting in the lobby, looking at the entrance glass doors when he saw a resident falling from the roof next to the bench at the entrance of the facility building. Resident B stated he called one of the staff and told them to call the ambulance. On November 20, 2017, at 11:04 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated she was the charge nurse/treatment nurse on November 12, 2017 for the 8 a.m. to 4:30 p.m. shift. LVN 1 stated Resident A was taken to her room on the second floor after her smoke break ended at around 9:50 a.m. LVN 1 stated Resident A did not have a sitter. LVN 1 stated after "five to ten minutes," at "around 10 a.m.," they received notification that one of their residents was outside of the building after a fall off the balcony. LVN 1 stated she called 911, and immediately assessed Resident A. LVN 1 stated Resident A complained of a headache with a pain level of four out of ten (ten being the worst) and was noted with slurred speech, but had no noted physical injuries. On November 20, 2017, at 11:18 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was working on November 12, 2017. CNA 1 stated CNA 2 took Resident A outside to smoke after breakfast. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 3 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 CNA 1 stated at "around 10 a.m.," Resident A requested to go down, and she told Resident A that she was still "taking care of another resident." CNA 1 stated she told Resident A to give her a couple of minutes to finish. CNA 1 stated she heard on the facility radio a few minutes later that Resident A was already outside of the building. On November 20, 2017, at 11:26 a.m., LVN 2 was interviewed. LVN 2 stated she was the charge nurse for Resident A on November 12, 2017. LVN 2 stated Resident A was "impulsive" and "always" wanted to "get up without thinking." She stated Resident A needed a 24hour sitter. On November 20, 2017, at 11:51 a.m., CNA 2 was interviewed. CNA 2 stated she was working on November 12, 2017, when the incident occurred. CNA 2 stated "around 9:30 a.m.," on November 12, 2017, she took Resident A on a wheelchair outside of the building for a smoke break. CNA 2 stated, after the smoke break, she took Resident A back to her room and endorsed her care to LVN 2. CNA 2 stated Resident A had behavior issues with periods of confusion, and was at "danger" from falls and accidents. CNA 2 stated Resident A needed a sitter. On November 20, 2017, Resident A's record was reviewed. Resident A was initially admitted on October 7, 2017, with diagnoses which included cerebrovascular accident (stroke), history of falls, traumatic hemorrhage of the cerebrum (bleeding in the brain), major depression with bipolar disorder (mood disorder), psychosis (disturbance in thoughts and perception), mild cognitive impairment (decline in memory and thinking skills), alcohol abuse, restlessness and agitation. Resident A was transferred to the acute hospital on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 4 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 October 23, 2017, for further evaluation after a fall incident in the facility. Resident A was readmitted to the facility on October 30, 2017. The "Skilled Nursing Facility History & (and) Physical," dated October 9, 2017, indicated, Resident A had "fluctuating capacity to understand or make decisions...Assessment & Plan...needs sitter this time, monitor..." The plan of care titled, "Elopement risk/wanderer r/t (related to) Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness...Date Initiated: 10/08/2017 (October 8, 2017)," indicated: "Goal...Will not leave facility unattended through the review date...Target Date 01/30/2018 (January 30, 2018). Interventions: 1:1 sitter during daytime hours." The facility's time record for Resident A's sitter indicated a 1:1 sitter was started on October 7, 2017, and was discontinued on October 19, 2017. The "Progress Notes" titled, "Fall Committee IDT (interdisciplinary team)," dated October 31, 2017, indicated, "She was admitted requiring a 1:1 sitter for safety and re-direction. During admission process (resident's name) was found by staff to be crawling on the floor in her room specifically in between her bed and the sliding door..." The "Progress Notes," dated November 5, 2017, at 12:38 p.m., indicated Resident A had "over 10 attempts of getting out of bed and laying on the floor mat...Pt (patient) also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 5 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 continues on crawling outside of her room...Hospice notified that patient requires 1:1 (sitter) for safety." The "Progress Notes" titled, "Fall Committee IDT," dated November 6, 2017, at 3:18 p.m., indicated, "...follow up regarding unwitnessed fall which occurred on 11/04/2017 (November 4, 2017)...She was found by staff to be crawling on the floor in the doorway of her room. She sustained a right elbow abrasion and a right eye discoloration and right sclera (white outer layer of the eyeball) bleed...staff recognized (resident's name) as a high fall risk based on her behaviors, confusion and impaired physical mobility...She required a one on one sitter for safety and re-direction. The sitter was discontinued before resident sustained her fall..." The "Progress Notes," dated November 6, 2017, at 3:29 p.m., indicated, "...Patient with several attempts crawling outside of the door and walking with an unsteady gait. Patient continues as a fall risk with bed and chair alarms that are not effective due to patient's agitation and not staying in one place longer than 2 minutes. Hospice notified of need for 1:1 (sitter) for safety..." The "Progress Notes," dated November 12, 2017, at 11:52 a.m., indicated at "Approximately 1000 (10 a.m.) nursing staff notified that a resident was on the first floor and needed assistance. Nursing staff arrived at scene and found resident sitting on bench, witnesses stated resident had fallen...New orders to send resident to [name of general acute care hospital] for further evaluation." The general acute care hospital's "Neurology Consultation Note," dated November 13, 2017, was reviewed. The notes indicated: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 6 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 "...Per other historians patient climbed over railing and fell from balcony >10 ft (greater than 10 feet) which was unwitnessed. Pt was found sitting on bench with multiple abrasions... ...Noncontrast CT of head (computed tomography scan- use of computer-processed combinations of many x-ray measurements taken from different angles of the brain) showed 3.1 X 2.5 cm (centimeters) L (left) posterior frontal lobe hemorrhage (bleeding in the front part of the brain), increased from previous CT done 2-3 weeks ago, new small subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), new subdural hematomas (pool of blood between the brain and its outermost covering)..." The "Skilled Nursing Facility History & Physical," dated November 17, 2017, indicated, "History: 52 y.o. (year-old) female with rehospitalized for a fall (pt jumped from a second floor balcony)...New subdural hematoma per CT, post frontal hemorrhage..." There was no documented evidence that an elopement evaluation was completed on Resident A's admission and readmission to the facility on October 7, 2017, and October 30, 2017. There was no documented evidence of a safety evaluation for Resident A from the physician or the interdisciplinary team prior to discontinuing the sitter on October 20, 2017. There was no documented evidence Resident A had a sitter from October 31, 2017 to November 12, 2017, the date of the incident, as identified in the plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 7 of 8 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: _______________ 555613 (X3) DATE SURVEY COMPLETED 03/05/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE CARE AND WELLNESS 3401 Lemon St Riverside, CA 92501 (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 On December 19, 2017, at 11:25 a.m., Resident A's record was reviewed with the Director of Nursing (DON). The DON confirmed there was no elopement evaluation completed on Resident A's admission and readmission to the facility on October 7, 2017, and October 30, 2017. The DON confirmed there was no evaluation by the physician or the interdisciplinary team for the safety of Resident A before discontinuing the 1:1 sitter on October 20, 2017. The DON stated the sitter was discontinued due to non-coverage by the insurance, and the care plan for 1:1 sitter was not properly implemented. The facility's policy and procedure titled, "Elopement-Policy and Assessment, revised October 2007," was reviewed. The policy indicated: "It is the policy of this facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to wandering behavior or elopement...elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff... ...Each resident's level of supervision required will be assessed...This information will be documented in the resident's medical record, and used in the care planning process... ...Residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement...If exacerbation of the behavior continues, 1:1 supervision will be considered until the physician can assess the resident for cause..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EQDS11 Facility ID: CA240000095 If continuation sheet 8 of 8